Elsevier

Midwifery

Volume 28, Issue 5, October 2012, Pages 554-560
Midwifery

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: An empirical study

https://doi.org/10.1016/j.midw.2011.12.004Get rights and content

Abstract

Objective

to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available.

Design

a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires.

Setting

the service area of Matlab, Bangladesh.

Participants

women 18–49 years who had an uncomplicated pregnancy and delivery resulting in a live birth.

Findings

a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use.

Key conclusions

the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.

Introduction

The World Health Organization (WHO) estimates that worldwide 358,000 women die annually from pregnancy- and childbirth-related complications; with sub-Saharan Africa and South Asia accounting for 87% of these deaths (World Health Organization, 2010; UNICEF, UNFPA, & The World Bank). The United Nations (2006) Millennium Development Goal 5 (MDG-5) has identified the reduction of maternal mortality by three quarters, between 1990 and 2015, as a global public health priority. The most effective, internationally recognized strategy to reduce maternal mortality is for every woman to be assisted by a skilled birth attendant (SBA) who is supported or backed by emergency obstetric care (De Brouwere and Van Lerverghe, 2001, Paxton et al., 2003, Paxton et al., 2005, Cambell and Graham, 2006).

SBAs are accredited health professionals, such as a midwife, doctor or nurse, who are educated and trained to proficiency in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns (Thomson, 2005). The proportion of births attended by skilled health personnel is one of the indicators of progress towards MDG-5. The successes of strategies that promote SBAs are dependent on both their availability and use during childbirth. In developing countries worldwide lack of availability of SBAs restricts use, however, data from India (Griffiths and Stephenson, 2001, Sunil et al., 2006), China (Anson, 2004), Vietnam (Duong et al., 2004), Uganda (Amooti-Kaguna and Nuwaha, 2000) Guatemala (Glei et al., 2003) and Nigeria (Esimai et al., 2002) indicate women choose homebirth with lay attendants despite the availability of SBA services. Although, numerous reasons contribute to the observed under utilization of SBAs (Koblinsky et al., 2008), their role and relative importance in decision-making, particularly among women who do not experience complications, is not clear. Gabrysch and Campbell's (2009) review of determinants of delivery service use in low and middle income countries yielded no studies that distinguished preventive (i.e., precautionary seeking of a SBA for anticipated normal delivery) and emergency (i.e., seeking of a SBA in the event of complications) care-seeking despite the global emphasis that SBAs attend all deliveries.

Here we describe a study designed to test the predictive power of women's reasons for delivering at home or in a facility (henceforth, referred to as decision criteria) in the event of uncomplicated childbirth in a area where SBAs are available. We conducted a retrospective, cross-sectional study in two phases: (i) the first qualitative phase used data from in-depth interviews of 25 women to identify the criteria used in the decision-making process, (ii) the second quantitative phase used data from structured questionnaires of 246 women to test the predictive capability of the decision criteria identified from the first phase.

Section snippets

Analytical approach

Ethnographic decision modelling, a context-sensitive cognitive modelling strategy, was employed (Gladwin, 1989). The approach uses in-depth interviewing to elicit from individuals their decision criteria within a narrative about the decision making process itself (Bernard, 2006). Categorical criteria are identified and then combined, clustered, and ordered by the researcher in the form of a composite decision tree based on individual decision processes. After construction, the criteria and

Participants

Key characteristics of the participants in the qualitative and quantitative study phases were comparable in that they did not significantly differ with regard to age (p=.58), education (p=.27), parity (p=.77), and asset score (p=.34). Table 1 lists the characteristics of phase two participants. The average age of participants was 24.68 (SD=5.1) years. The average asset quintile, a proxy measure of wealth, was 3 (SD=1.4). Nearly all of the women were married (99.2%) and the mean marital age was

Discussion

The study contributes to research on place of birth decisions in low-resource settings in two important ways. First, the study focused on the determinants of place of birth decisions for preventive as opposed to emergent purposes. Through sampling and screening procedures we were able to isolate a representative sample of women who did not experience childbirth complications. Decisions about place of birth, namely seeking care from a SBA, typically follow perceived complications during

Limitations

Limitations relevant to the conduct of this study include the use of a retrospective, cross-sectional design and self-report. The data were collected at one time point, give no indication of the sequence of events, and inference of causality is not possible. As with all retrospective self-reports recall bias is a concern. However, some research findings suggest that long term maternal recall of pregnancy related events is both reproducible and accurate, including mode of delivery, onset of

Conclusion

In many rural, low-resource areas worldwide, SBA services do not exist and women have no choice but to deliver at home without a SBA. Yet, our results show that access to SBA services does not guarantee use. Instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to

Acknowledgments

Acknowledgements: The study is a result of collaboration between Emory University and the International Center for Diarrheal Disease Research: Center for Health and Population Research. Grant Number F31NR010650 from the National Institute of Nursing Research and a research grant from the American Nurses Foundation supported this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies. The authors are grateful

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