“Midwives do not appreciate pregnant women who come to the maternity with torn and dirty clothing”: institutional delivery and postnatal care in Torit County, South Sudan: a mixed method study

Abstract

Background: South Sudan has one of the highest maternal mortality ratios in the world, at 789 deaths per 100,000 live births. The majority of these deaths are due to complications during labor and delivery. Institutional delivery under the care of skilled attendants is a proven, effective intervention to avert some deaths. The aim was to determine the prevalence and explore the factors that affect utilization of health facilities for routine delivery and postnatal care in Torit County, South Sudan.Methods: A convergent parallel mixed method design combined a community survey among women who had delivered in the previous 12 months selected through a multistage sampling technique (n = 418) with an exploratory descriptive qualitative study. Interviews (n = 19) were conducted with policymakers, staff from nongovernmental organizations and health workers. Focus group discussions (n = 12) were conducted among men and women within the communities. Bivariate and multivariate logistic regression were conducted to determine independent factors associated with institutional delivery. Thematic analysis was undertaken for the qualitative data.Results: Of 418 participants who had delivered in the previous 12 months, 27.7% had institutional deliveries and 22.5% attended postnatal care at least once within 42 days following delivery. Four or more antenatal care visits increased institutional delivery 5 times (p < 0.001). The participants who had an institutional delivery were younger (mean age 23.3 years old) than those who had home deliveries (mean age 25.6 years). Any previous payments made for delivery in the health facility doubled the risk of home delivery (p = 0.021). Women were more likely to plan and prepare for home delivery than for institutional delivery and sought institutional delivery when complications arose. Perceived poor quality of care due to absence of health staff and lack of supplies was reported as a major barrier to institutional delivery. Women emphasized fear of discrimination based on social and economic status. Unofficial payments such as soap and sweets were reported as routine expectations and another major barrier to institutional delivery.

Inequality in institutional delivery of the recent birth among married women in Nepal: a trend analysis

“…Our study also highlights the importance of completing four or more ANC visits for greater utilization of institutional delivery aswomen completing four or more ANC visits were nearly three times more likely to deliver in health facility. This nding is in-line with the ndings of studies conducted inChitwan 20 and Kavrepalanchowk 31 districts of Nepal and also in Ethiopia 32 and Sudan 33 .Other different studies 25, 34,35 ,36 also showed that improving ANC practices can help increase institutional delivery. This can be justi ed by the fact that women are women are also counseled for institutional delivery in their ANC check-up as birth-preparedness is also a component of ANC.Similarly, women having more number of children were also less likely to practice institutional delivery in our study which is in accordance with the ndings of studies in Bangladesh 37,38 , and Nepal 26 .…”

Confronting the culture of care: a call to end disrespect, discrimination, and detainment of women and newborns in health facilities everywhere

“…Further, the link has been shown, in many regions of the world, between perceived quality of care and families' decisions about when and where to seek obstetric and postpartum care [4][5][6][7]. A new study from Bayo et al [8], is no exception: perceived poor quality, including the threat of small or in-kind payment for services, was found to be a main driver in the incredibly low institutional delivery rates in one region in South Sudan.…”

“…How can improving quality of care and client experiences be used as an 'accelerant' instead of a deterrent to care-seeking? While health care workers and policymakers often attribute low facility utilization to "traditions" and "culture," women themselves often place primacy on the perceived quality of care and will overcome barriers of gender inequity, decision-making power, cultural norms, transport, and geography to access what they perceive as high-quality care [8].…”

“…While the level of complexity and need for significant investment may stultify efforts to enact immediate change, starting at the facility door may be a crucial first step. Care-seekers perceive the culture of a health facility, and the expectations on how one must present may be insurmountable for many [8]. Care-seekers are often required to bring items that are lacking in the facility, like soap, clean sheets, or even living blood donors, all of which may even be in addition to payments, or in contexts where health care is supposed to be free at the point of service.…”

Disrespect and Abuse During Facility‐Based Childbirth in North Showa Zone, Ethiopia

“…This indicates the prevailing social attitudes towards people from lower socioeconomic backgrounds. Studies from different contexts have also revealed likewise (25,48).…”