A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs—a qualitative study among multiparous women in Somaliland

Abstract

Background Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women’s choice of place of birth. Objective In this study, we explore multipara women’s needs and preferences when choosing the place of birth. Method An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years. Results The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth. Conclusion To meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Why do women still give birth at home; perceptions of Pakistani women and decision-makers from marginalized communities

“…Our findings are in concordance with previous literature that suggests that women value a supportive and familiar environment during childbirth. A recent study in Somaliland has shown that home births are believed to make it easier to manage women's concerns about privacy and psychosocial support during childbirth [20]. Similarly, an interpretive synthesis of literature relating the concepts of "place" and "space" to childbirth suggests that providing women with a familiar and home-like environment can increase feelings of comfort, control, and autonomy during labor and delivery, which plays a significant role in shaping positive experiences with childbirth [21].…”

Incidence and causes of severe maternal outcomes in Somaliland using the sub‐Saharan Africa maternal near‐miss criteria: A prospective cross‐sectional study in a national referral hospital

“…The present study has shown that at HGH, around 70% of women gave birth without complications and that most women bypassed the primary healthcare level (self‐referred) during the study period. In Somaliland, most women (80%) deliver at home supported by a traditional birth attendant and the rest deliver at a healthcare facility 20 . This indicates that a considerable proportion of women with normal pregnancies and uncomplicated deliveries attend the referral hospital instead of a primary healthcare center, resulting in overcrowding and suboptimal care.…”

“…In Somaliland, most women (80%) deliver at home supported by a traditional birth attendant and the rest deliver at a healthcare facility. 20 This indicates that a considerable proportion of women with normal pregnancies and uncomplicated deliveries attend the referral hospital instead of a primary healthcare center, resulting in overcrowding and suboptimal care. A recent qualitative study among multiparous women in Somaliland found that a lack of reproductive agency in facility‐based births makes home births their first choice, regardless of medical need.…”

“…A recent qualitative study among multiparous women in Somaliland found that a lack of reproductive agency in facility‐based births makes home births their first choice, regardless of medical need. 20 Inadequate quality of care for women and neonates in low‐ and middle‐income countries is evident, and different solutions have been proposed, such as scaling up access to hospital care. 21 However, to meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a scalable, context‐specific, midwife‐led continuity of care model.…”

“…This indicates that a considerable proportion of women with normal pregnancies and uncomplicated deliveries attend the referral hospital instead of a primary healthcare center, resulting in overcrowding and suboptimal care. A recent qualitative study among multiparous women in Somaliland found that a lack of reproductive agency in facility‐based births makes home births their first choice, regardless of medical need 20 . Inadequate quality of care for women and neonates in low‐ and middle‐income countries is evident, and different solutions have been proposed, such as scaling up access to hospital care 21 .…”