Why do women prefer home births in Ethiopia?

Background: Skilled attendants during labor, delivery, and in the early postpartum period, can prevent up to 75% or more of maternal death. However, in many developing countries, very few mothers make at least one antenatal visit and even less receive delivery care from skilled professionals. The present study reports findings from a region where key challenges related to transportation and availability of obstetric services were addressed by an ongoing project, giving a unique opportunity to understand why women might continue to prefer home delivery even when facility based delivery is available at minimal cost.Methods: The study took place in Ethiopia using a mixed study design employing a cross sectional household survey among 15-49 year old women combined with in-depth interviews and focus group discussions.Results: Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) for their most recent birth in the one year preceding the survey. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. The most important reasons for not seeking institutional delivery were the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). The group discussions and interviews identified several reasons for the preference of traditional birth attendants over health facilities. Traditional birth attendants were seen as culturally acceptable and competent health workers. Women reported poor quality of care and previous negative experiences with health facilities. In addition, women’s low awareness on the advantages of skilled attendance at delivery, little role in making decisions (even when they want), and economic constraints during referral contribute to the low level of service utilization.Conclusions: The study indicated the crucial role of proper health care provider-client communication and providing a more client centered and culturally sensitive care if utilization of existing health facilities is to be maximized. Implications of findings for maternal health programs and further research are discussed. © 2013 Shiferaw et al.; licensee BioMed Central Ltd.

The study took place in a predominantly rural area (Kembatta-Tembaro) in Ethiopia. The area has an estimated total population of 1,266,275 people at the time of the study. There were 11 Health centers (9 public, 2 Non Governmental Organization), 126 Health Posts and 13 private clinics (medium and small including drug stores) within the area. A health center is a midlevel health facility catering for a population of approximately 25,000 while a health post is the smallest publicly owned health facility serving up to 5,000. Worth to note is the fact that the study was conducted around a health facility which was upgraded to provide comprehensive emergency obstetric care to the surrounding population. Specifically, the renovated health center had an experienced obstetrician-gynecologist and an ambulance that provided 24 h service either free or at minimal charge which was made available through a project support [19]. The Health center has 15 nurses (including one midwife), one public health officer, one laboratory and pharmacy technician, one anesthetist, one pediatrician and a Gynecologist/obstetrician. Most health centers in Ethiopia (including those around the study area) are staffed by health officers, nurses/midwives and laboratory and pharmacy technicians and generally have no specialists in Gynecology/obstetrics or pediatrics. The study used a mixed study design employing a cross sectional household survey among 15–49 year old women combined with qualitative approaches (in-depth interviews and focus group discussions (FGDs)). The quantitative survey employed a cluster sampling scheme selecting representative samples from each of the three districts using the probability proportional to sample (PPS) technique. Key informants and focus group discussion participants were selected purposively and saturation of information was used to decide on adequacy of the samples. The study got ethical clearance from the respective Health Bureau, and informed verbal consent was obtained from all participants. A pre-tested structured questionnaire developed in the local language was used to collect information on awareness about and utilization of maternity care services (antenatal, delivery and postnatal) and reasons for not seeking delivery care. The questions were adapted from previous surveys [2]. Overall, a total of three focus group discussions were conducted. The discussions involved three separate groups with women, men and community health workers who opted for institutional or home delivery for the most recent births. As shown in Table ​Table1,1, a total of 23 people participated in the three focus group discussions. Additionally, in-depth interviews were held with six health care providers (physician, nurses, and a health officer) and two TBAs. Characteristics of participants in focus group discussions and in-depth interviews The questions included, among others, issues affecting institutional delivery including how and who makes decisions regarding place of delivery, perceived barriers to skilled attendance at delivery, experiences in relation to the behavior and competency of the health care providers, satisfaction with quality of the service, as well as relationships between traditional birth attendants and the formal health system. The study teams consisted of three graduate students in public health and 30 experienced enumerators who have completed at least 12 years of secondary education. The research teams participated in a two-days training session that included: study overview, ethical conduct of research, role play and pre-testing the study instruments. Interviewers took extensive notes, in addition to tape recording and transcribing the interviews. The transcripts were reviewed by the research team. All FGDs and in-depth interviews were translated into English by the research assistants who led the interviews/discussions. Qualitative data were analyzed through thematic analysis using OpenCode software [20,21]. Coding of the transcriptions line by line was done by the Principal Investigator and the second co-author who had previous research experience in maternal health and qualitative data analysis. In many instances, verbatim quotations (sometimes slightly modified from the original translation to make the English more understandable) are used to illustrate responses on relevant issues and themes. A total of 909 women in the age group 15–49 years participated in the household survey. As Table ​Table22 shows, the majority of respondents was married (75%), less than 30 years of age (54%) with only primary level of education (50%). Socio-demographic profile of respondents, Kenbata-Tembaro zone, Southern Ethiopia Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) at least once for their most recent birth in the one year preceding the survey. On average, pregnant women made 3 antenatal care visits. As shown in Table ​Table3,3, the overwhelming majority of births (84%) in the one year preceding the survey were delivered at home. The proportion of mothers delivering at home did not differ significantly by educational status or household decision making capacity, though women with at least secondary education were more likely to deliver in an institution (p-value > 0.05). Women who reported that they were able to decide about household expenditure by themselves or jointly with their husbands were also slightly more likely to deliver in a health facility, though this was not statistically significant (p-value > 0.05). Percentage distribution of births in the last one year preceding the survey by type of professionals and place of delivery, according to background characteristics * – Traditional Birth Attendant ** – HEWs – Health Extension Workers. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. As showed in Table ​Table3,3, Health Extension Workers (HEWs) attend only a small percentage (2.4%) of deliveries. Health Extension Workers are female community health workers with one year training and work at local health posts providing a package of essential interventions to meet the community health needs at the village level. Two HEWs are assigned in each village (which on average has 1000 households) and are assisted by voluntary community health workers who are expected to serve 50 households. Births to younger mothers (less than 30) and those with a higher level of education were more likely to be assisted by trained health professionals. Women who reported to make joint decisions on household expenses were more likely to have skilled attendance at delivery compared to women who reported that their husbands (or by themselves) make such decisions (20% versus 14% respectively). However, the associations between education and women’s decision making capacity and delivery by health professionals were not statistically significant (p-value > 0.05). Women who gave birth outside health institutions were asked whether any of the following factors might be concerns; obtaining money for the service fee, distance to a health facility or lack of transportation, getting permission from husband/family to go for treatment, trust in service quality, belief that it may not be necessary or customary. Figure ​Figure11 shows that the most important reasons for not seeking institutional delivery are the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). Percentage of women with specific reasons for giving birth outside Health Institutions, (n =215), Kenbata -Tembaro Zone, Southern Ethiopia**. As shown in Table ​Table4,4, recurring themes that evolved from the group discussions and interviews were related to perception of traditional birth attendants as culturally acceptable and competent health workers, perceived quality of care and previous negative experiences with health facilities, low awareness and less empowered women, as well as economic constraints during referral. Themes and sub-themes emanating from FGDs and in depth interviews about barriers to delivery in health facilities Findings from the group discussions indicate that many families opt for traditional birth attendants as their first line of care for delivery unless they believe that labor is not normal. The fact that they are familiar and have trust in the traditional birth attendants’ ability to handle ‘normal’ deliveries was an important consideration in deciding place of delivery. If my wife goes into labor, the first thing I would do is call a traditional birth attendant. If she (traditional birth attendant) believes that the labor can be managed at home, we will stay at home. We will go to a health center only if the traditional birth attendant says so. We have confidence in them. Hence I comply with whatever the traditional birth attendant tells me to do to save the life of my wife. Male FGD participant 3 It is interesting to note that one of the reasons for preferring traditional birth attendants is the fact that mothers get the much needed support from their spouses and families’ presence in home deliveries. Besides, some traditional birth attendants attend to some of the longstanding traditional practices which are rooted in the beliefs and cultures of the society (such as massaging the abdomen with butter and burying the placenta around home). Discussions with both mothers and fathers suggest that traditional birth attendants’ approach fulfils the expectations of laboring mothers and their immediate families in a way the modern health system does not. According to our tradition, the placenta should be buried around our home. It (the placenta) should by no means be thrown out everywhere. However, if mothers deliver in health facilities, the health professionals will not give us the placenta. Hence, most of us do not prefer to go to health facilities. Male FGD participant 7 Women prefer the traditional birth attendants than going to health facility because when they attend deliveries…. First, they will examine the abdomen of pregnant mothers and if they found out that the baby is not in the ‘right position’, they apply butter and do massage on the abdomen to bring the baby to its ‘normal position’ which facilitates smooth delivery. Female FGD participant 6 The interviews reflected that there is no clear relationship between traditional birth attendants and the formal health system. As the following quote shows, traditional birth attendants rely on the respect and trust earned from their communities through their service. We don’t have any relationship with health workers in health centers and health posts. They don’t want us.…And we don’t get any support from them. However, the community believes in us and that is our major source of support and motivation to continue the work we are doing. Traditional birth attendant 1 Women who preferred to deliver at home indicated that some health professionals are not sensitive to their privacy and care little to give them psychological support when they need it most. As the following quote illustrates, families seem to value the more supportive and comfortable care that they get from traditional birth attendants. I am afraid of delivering in a health facility. They [health professionals] don’t allow my family members (who are the main source of psychological support and comfort) to accompany me in the labor ward. They leave us alone on the delivery couch and everybody who comes in and out of the delivery room watches our naked body which is quite embarrassing. We also get little respect from health workers. I won’t have these problems if I go to a traditional birth attendant. I seek help from a health facility only as a last resort (.i.e., if I encounter difficulty to deliver in my home). Female FGD participant 2 Comments from group discussion participants point to concerns about quality of care at health facilities and the lack of confidence in health workers’ ability to deal with pregnant and laboring mothers. Besides, many of the discussants mentioned that the health centers may not be open during nights and weekends. My last child was born at home and I didn’t take my wife to any health facility. This is because of what happened during her pregnancy check up. We were told that it was twin pregnancy which, to our surprise, was later confirmed to be ‘single’ in a different facility… Fortunately, she delivered at home safely and her mother attended the labor. Male FGD participant 4 I had repeated antenatal visits during my first pregnancy. In one of my visits (at the ninth month of pregnancy), I experienced a severe crampy abdominal pain for which the health care provider advised me to take medications assuming it is caused by intestinal worms. Lately, I realized that I was actually in true labor and was thus forced to have my first child delivered at home. That experience eroded my confidence and trust on health professionals’ competence as a result of which I decided to deliver at home for all of my subsequent children. Female FGD participant 1 As it is known, labor often comes during the night. People coming from rural villages pay a lot of money for transportation. However, when we reach there, it is possible that the facility is closed. Even if they are open, medications and equipment are often in short supply. Eventually, we end up taking prescriptions to buy from private pharmacies. Some health workers who are on night duty are also not competent enough to manage deliveries. Many times, they refer all laboring mothers to other hospitals. We face similar problems during weekends. These are serious problems which discourage us from going to a health facility in the first place. Male FGD participant 1 Although many of the study participants pointed out the advantages of traditional birth attendants, a few participants were critical of their service mainly because of safety concerns. I prefer to deliver my children in a health facility. Because the traditional birth attendants do not wear gloves and they may not as well use clean equipments. In contrast, health care providers wear gloves, use clean equipments and medications for delivery. Female FGD participant 7 All my children were born in a health facility. Health facility delivery will benefit mothers as well as their children. In contrary, traditional birth attendants can sometimes be careless in managing deliveries which could endanger the health of mothers and their babies. That is why I preferred to deliver my last child in health facility. Female FGD participant 8 Interviews with health care providers indicate that some of the reasons for not coming to health facilities are results of unfounded rumors about quality of care at health facilities. We learned that there are rumors in the community claiming that every mother who goes to a health facility gets operated. Of course this kind of misperception is improving from time to time and we are getting the publics’ trust as witnessed by a lot of mothers coming to us. Many people are now convinced that we make decisions depending on the kind of problem the mothers are facing. Health care provider 1 There seems consensus among the health workers that knowledge about the importance of delivering in health facilities is fairly low. Communities often use their uneventful previous experiences to strengthen their claim that modern health care may not be necessary for delivery. All my children were born at home assisted by traditional birth attendants. In this locality, once a woman delivers her first child at home, the rest of her children will also be delivered at home. This is because mothers believe that once they are able to give their first birth at home nothing will happen to them in their consecutive home deliveries. In general, in this area mothers deliver their children in their home and no woman wants to deliver her child in health facility unless they face difficulty. Female FGD participant 2 It was suggested that many elderly women promote traditional health care at times advising against services at health facilities. As opinion leaders especially on matters related to labor, their position influences the care seeking behavior of particularly young mothers. We still have many elderly people who discourage going to a health facility for labor claiming that they used to have a better past when there were no modern healthcare services including vaccination, and family planning. For them the health facilities have little impact, if any. These influential people need to be engaged if we are to improve the health seeking behavior of others. Volunteer Community health worker 6 In most situations, it is relatives and neighbors (including traditional birth attendants) who are the main decision makers in this community. And this is one of the reasons why laboring mothers stay at home during delivery. The discussions also point that the community’s awareness is improving from time to time. As the following participant explains more and more women are going to health facilities with increasing awareness and better access to health posts in their own villages. Women in our area usually deliver at their home. One of the reasons is the fact that there were very few health facilities in our locality which provide delivery service. However, currently health posts are being constructed in many villages (‘kebeles’) and there is also ongoing education by different health workers about the importance of delivery at health institutions which improved service utilization in recent times. Male FGD participant 1 Cost is a significant deterrent of maternity service seeking in many rural settings. Where distance to the next level of care is a barrier, indirect cost to cover transportation and lodging expenses become particularly important. As illustrated by the following quotes, one of the reasons for not going to the closest health centers appears to be the anticipation of inadequately equipped facilities and further referrals to more distant hospitals which is hardly affordable. If a laboring mother is referred to other hospitals, she needs to have at least 800 Ethiopian birr for transportation. Most people cannot afford this amount of money. It is usually during this time that the fetus dies due to ‘distress’ and the mother also gets extremely weak. Health facilities are not well equipped with facilities and there is also shortage of essential drugs. Male FGD participant 1 One of the major factors which hinder women from going to health facilities is their financial problem. Even though they know the importance of institutional delivery, they may not go to health facilities as they know they will be referred. Most of the time, they borrow money from their relatives. However, getting that money takes days and it’s during this time that the labor goes into complications. Male FGD participant 2 Even when families know that the labor is not progressing well and the laboring mother is not doing well, they stay up to 3 days until they exhaust all possibilities (before they sell assets to cover transportation and accommodation expenses). Such financial constraints often prevent mothers from seeking timely care. Community health volunteer 1

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