<p>When Women Deliver at Home Without a Skilled Birth Attendant: A Qualitative Study on the Role of Health Care Systems in the Increasing Home Births Among Rural Women in Southwestern Uganda</p>

Abstract

Background: Uganda's maternal mortality remains unacceptably high, with thousands of women and newborns still dying of preventable deaths from pregnancy and childbirth-related complications. Globally, Antenatal care (ANC) attendance has been associated with improved rates of skilled births. However, despite the fact that over 95% of women in Uganda attend at least one ANC, over 30% of women still deliver at home alone, or in the presence of an unskilled birth attendant, with many choosing to come to hospital after experiencing a complication. We explored barriers to women's decisions to deliver in a health care facility among postpartum women in rural southwestern Uganda, to ultimately inform interventions aimed at improving skilled facility births. Methods: Between December 2018 and March 2019, we conducted in-depth qualitative face-to-face interviews with 30 post-partum women in rural southwestern Uganda. The purposeful sample was intended to represent women with differing experiences of pregnancy, delivery, and antenatal care. We included 15 adult women who had delivered from their homes and 15 who had delivered from a health facility in the previous 3 months. Women were recruited from 10 villages within 20 km of a regional referral hospital. Interviews were conducted and digitally recorded in a private setting by a trained native speaker to elicit experiences of pregnancy and birth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Results: Regardless of where they decided to give birth, women wished to deliver in a supportive, respectful, responsive and loving environment. The data revealed six key barriers to women's decisions to deliver from a health care facility: 1) Fear of unresponsive care, fueling a fear of being neglected or abandoned while at the facility; 2) fear of embarrassment and mistreatment by health care providers; 3) low perception of risk associated with pregnancy and childbirth; 4) preferences for particular birthing positions and their outcome expectations; 5) perceived lack of privacy in public facilities; and 6) perceived poor clinical and interpersonal skills of health providers to adequately explain birthing procedures or support expectant or laboring women and their newborn. Conclusion: Anticipation of unsupportive, unresponsive, disrespectful treatment, and a perceived lack of tolerance for simple, non-harmful traditions prevent women from delivering at health facilities. Building better interpersonal relationships between patients and providers within health systems could reinforce trust, improve patient-provider interaction, and facilitate useful information transfer during ANC and delivery visits. These expectations are important considerations in developing supportive health care systems that provide acceptable patient-friendly care. These findings are indicative of the vital need for midwives and other health care providers to have additional training i...

mHealth-Based Health Promotion Intervention to Improve Use of Maternity Care Services Among Women in Rural Southwestern Uganda: Iterative Development Study

“…In addition, 5 key HCPs (2 senior obstetricians—a man aged 44 years and a woman aged 39 years—and 3 experienced female midwives aged 27, 38, and 55 years) were also purposively identified and interviewed during the formative phase. Detailed preliminary findings of these interviews have been documented elsewhere [ 26 , 27 ].…”

“…All messages included both prevention and promotional information. Additional data from the formative interviews on barriers to, and facilitators of, ANC attendance and skilled delivery had been already documented [ 26 , 27 ].…”

“…The women were recruited from 10 villages located within 20 km of Mbarara Regional Referral Hospital (MRRH) with the help of existing village health teams (VHTs). VHTs are composed of community-based volunteers who are identified by community members and given basic training on major health programs to mobilize and sensitize communities to use available health services [ 25 - 27 ]. Eligible women for these predevelopment interviews included adults (1) aged ≥18 years (2) who had delivered a baby within the past 3 months, (3) owned or had access to a mobile phone, and (4) were able and willing to give informed consent.…”

“…The interviews were open-ended and organized to cover predesignated core topics. An interview guide was developed and pilot-tested using the constructs of the Healthcare Service Utilization Model as reported elsewhere [ 26 , 27 ] and the Technology Acceptance Model [ 28 , 29 ] ( Multimedia Appendix 1 ). This open-ended approach ensured systematic coverage of specific areas of interest while allowing for unanticipated content to emerge.…”

Factors associated with home birth in Peru: An analysis of the Demographic and Health Survey, 2019

“…On the other hand, the present study showed that women living in rural areas are more likely to have home births, which is consistent with a recent systematic review (24). One possible explanation lies in the fact that pregnant women in rural areas feel fear that their privacy and traditions are not going to be respected in health facilities, and some indicated that they were afraid of being victims of abuse by health professionals (25)(26)(27), which highlights the marked gap between the rural population and health care.…”