This study identified four main themes:
- Women chose to deliver at home because of poor quality of care and conduct of skilled birth attendants
- Women preferred home delivery because Traditional Birth Attendants gave better care;
- Women delivered at home due to financial constraints
- Women lacked access to healthcare facilities
Theme 1: Women chose to deliver at home because of poor quality of care and conduct of skilled birth attendants
The participants who delivered at home revealed that though they had wanted to deliver at a health facility, they faced insurmountable barriers to utilise facility-based childbirth., As a result of these barriers, women often had little or no option but to deliver at home. One of the reasons accounting for home birth according to the participants was the poor attitudes of skilled birth attendants and poor quality of skilled birth care at the health care facilities.
"Hmm... (smiling and nodding the head). I must be honest, one of the things that actually made me to deliver at home was the fact that when you go to deliver at the health facility, the nurses would just be insulting you and embarrassing you like that and your colleague pregnant women would just be laughing at you as if you have committed a great crime. So, I 'didn't want to go and deliver in a health facility so that the nurses would insult and laugh at me again" ( IDI,gravida 1 Para 1 woman).
The participants reported that some of the skilled birth attendants exhibited poor conduct such as using harsh words on them during previous childbirth and so 'didn't want to go through a similar experience in their recent childbirth as one of the participants indicated below:
"As for me, I delivered at home because I 'didn't want the nurses/midwives to slap me again. When I went to the hospital to deliver my second child, how the nurses beat me when I was delivering my baby and I 'wasn't pushing well"( IDI,multipara 3 woman)..
Also, the participants reported that another poor conduct of skilled birth attendants that made them deliver at home was that the nurses and midwives neglected them. One participant indicated that she was very close to delivery, only to be told that the midwife has left the ward and went to the market to do shopping.
"After the nurse attended to me and asked that I should go and be walking around, she left the room and went to the market to buy her things, and there was no one in the room except other three women who came and delivered and had not been discharged. When she left, I realised the baby was coming so I called one of the women who had delivered and was in the room with me to come and assist me, so the three of them left their children and quickly came to me and realised that the head of the baby was already out"( IDI,gravida 1 para 1 woman) .
Furthermore, the participants indicated that one of the poor conducts of skilled birth attendants that made them give birth at home was the delay in rendering services to women any time they visited the health care facility. The participants narrated that sometimes when a woman is in labour and visits the health facility for delivery especially on weekends, they 'don't find the skilled birth attendants on duty. If this happens at night, they would be sleeping in their houses. And when they are called to attend to a labouring woman, it would take time before responding to the call as indicated by a participant below:
"Hmm..., the last time I went to deliver at the health centre, when Joe went to call the midwife from her house, she delayed a bit before coming and yet I was in pain. But that is usual them. I mean the nurses will always delay when you get to the health facility to deliver. Sometimes, if it is a weekend, they will not even come to work unless you go to call them from their homes. So, why would you waste your time going there to deliver when labour starts in the night or during weekend" (IDI,gravida 2 para 1 woman).
Also, the participants reported a lack of privacy and confidentiality in the provision of care during childbirth by skilled birth attendants as another poor quality of service. A participant expressed this:
".... I was embarrassed when I realised people could see me from outside when I was in labour. The room where I delivered was very small, and some of the louvre blades were broken. Due to the heat in the room, they normally fold and tie-up the curtains to provide fresh air in the room. However, people who walk around the hospital can easily see you through the window. Sometimes, people walking outside usually see women in labour in the delivery room, and this is very embarrassing"(IDI,multipara 3 woman)..
Participants indicated that some of the skilled birth attendants sometimes abandoned women under their care and go out of the health facility to do their personal things. As one of the participants indicated that she delivered by herself without any assistance of a skilled birth attendant in the health facility because the nurse who was on duty in the night left her and went home.
"As for my case, it was serious. It was God who saved my life because when I went to deliver my second child at the hospital, the nurse who was on duty in the night left me and went home and the baby was coming, so I had to shout for my mother who was outside the ward to run and assist me. By the time my mother could get to the ward, the baby was already out and was on the floor" (IDI,gravida 1 para 1 woman).
One of the participants indicated that when she was in labour and went to the nearest clinic to deliver, she got there and was told the midwife on duty had locked up the maternity ward and went away.
".....We walked from my community to the Health Centre. When we got to the health centre, the midwife was not at post. So, I went back home and was assisted by a TBA to give birth"(IDI,gravida2 para2 woman).
Another important factor expressed by some of the participants as having accounted for their decision to deliver at home was the environmental conditions at the health facilities. The participants indicated they were always expecting the maternity environment in the health facilities to be neat and secured like their various home environments but that was not always the case. One of the participants described the health facility environment as:
"I think the labour room did not smell good. I realised when I entered the delivery room to deliver, somebody had just given birth and they 'didn't clean the room well before I entered so there was still visible blood on the table. As for the bath room, it was full of blood and the toilet was only one so people would defecate everywhere and you 'couldn't even breathe when you entered there" (IDI,multipara 3 woman).
Another thing that created poor quality of care that forced them to deliver at home was lack of basic infrastructure and equipment such as beds and mattresses in most of the health facilities in the district. There were some of the facilities that women were seen lying on the bare floor because all the beds were occupied. One participant had this to say:
"As for the hospital environment, I think the room where women who deliver stayed was just too small and so sometimes, it was just too crowded, and the windows were just too small and anytime there were lights out it was a big problem. Some of the mosquito nets were torn and so the mosquitoes were just disturbing us"(IDI,gravida 2 para 1 woman).
Other participants also reported that some health facilities lacked supplies and equipment to conduct safe delivery. Participants indicated that there were times in some health facilities, where some drugs and other consumables such as disposable gloves were not available. All these make accessing health care in the health facilities the last option for women to consider. This was the comment from a participant:
"……As for the health facility, they are always lacking one thing or the other. Either, they have run out of drugs or intravenous fluids or gloves. How can you go to a health facility to deliver when there are no drugs there"? (IDI,multipara 2 woman).
Theme 2: Women preferred home delivery because traditional Birth Attendants gave better care
The participants reported that they preferred home delivery because they perceived traditional birth attendants gave better care than the services that were rendered at the healthcare facilities by skilled birth attendants. Perception of women regarding the quality of skilled birth care as indicated previously, influence 'women's skilled birth care seeking behaviour. Participants semphasised the close bond they felt with TBAs, due to their status in the community and their trustworthiness. Some participants believed that they received high quality care from TBAs and believed that TBAs played a more supportive role. These descriptions were captured in the quote below:
"If you deliver at home by the assistance a TBA or any relative, they will treat you very well. They will praise you and support you to go through the delivery process without feeling any pain. But in the hospital, the nurses will just be behaving as if they 'don't want you to come to them to deliver. They 'wouldn't help you, yet they will still insult you in addition. Their behaviour scares most women away from delivering in the health facilities" (IDI,multipara 2 woman).
According to the participants, another reason that made them to prefer home delivery to skilled birth attendants was the availability or the opportunity for family members to be with the birthing woman when delivery assistance is being sought from a TBA. However, in health care facilities, family members are not permitted to enter the delivery room to offer support to the labouring woman. This was captured in the quote below:
"When I delivered this my current baby at home, the way they treated me, I 'didn't even feel the pain during the delivery. My mother and other women were with me and they were singing and others were massaging my back and praising me throughout till I delivered" ( IDI,gravida2 para2 woman).
The participants reported that the flexible choice of birthing position was also a factor that made them prefer home delivery with the assistance of TBAs to skilled birth care attendants. Most of the participants reported that unlike the healthcare facilities where women are compelled to adopt only the supine position in giving birth, the TBAs are flexible and a woman could adopt any position she felt comfortable with, provided it would not harm the mother and the unborn child. A participant expressed her view in the following statement:
"One thing I liked about the TBA was that she asked me to sit on a stool and when I realised that I was not comfortable sitting and I told her about it she asked me to squat and see whether that was comfortable for me and I did. She assisted me to squat, I was in that position till I delivered my baby"( IDI,gravida1 para1 woman).
Furthermore, the participants reported that they preferred home delivery because TBAs allowed family members and other relatives to prepare the traditional food, which according to the women are nutritious and good food for a newly delivered woman. A participant described the food as :
"You know after delivery you are always weak and hungry so they need to give you something to eat; not just anything but something that will make you strong again. So, they give you """"zoomkom"""" warm millet water first to give you energy and to cleanse your mouth (meaning appetiser) and to help cleanse your stomach of all the dirt following the delivery, which will be followed with tuozaafi (local diet prepared from cereals), which will further boost your strength. The """"zoomkom"""" also helps you to produce more breast milk for your baby" (IDI,multipara 3 woman).
The participants also reported that TBAs are very good at maintaining confidentiality of the birthing woman and the delivering process such as not exposing them to so many people during childbirth as compared to the health facilities. Participants indicated TBAs are very secretive about what happened during and after delivery and would not permit anybody who was not involved in the delivery process to watch them, unlike in the health facility, where they could allow many people including students to watch their nakedness. A participant noted:
"There is privacy when you deliver at home. As for the hospital, there is no privacy. The last time I delivered my second child at the District Hospital, the nurses who were in the delivery room were more than five. Sometimes in the presence of all these people, they would just be insulting and shouting at you"(IDI,multipara 2 woman).
Theme 3: Women delivered at home due to financial constraints
Some of the participants indicated that they delivered at home due to financial constraints. The participants explained that although they knew about the importance of delivering at a health facility, and probably would have wished to deliver in a health facility, due to financial barriers of seeking care such as money to pay for transportation and other indirect costs involved in seeking skilled birth care, they were unable to utilise skilled birth care during childbirth. Participants expressed their concerns in the following quotes:
"Most of us here deliver at home because of the poverty situation in this village. Majority of us here are not working and our husbands are not equally doing anything meaningful. So, if you 'don't have money, you 'can't go and hire a car to transport you to the health facility and to pay for other costs associated with delivery"(gravida3 para1 woman3).
"…I delivered at home because I 'didn't have money to pay for the cost of delivery, for transport and other things"( IDI,Gravida2 Para2 woman).
The participants in this study indicated that apart from the lack of money to pay for transportation, paying for the cost of prescribed drugs that were not covered by the free maternal health care policy as well as buying food to sustain themselves and their caretakers during the period of stay in the health facility was another reason why women delivered at home. The descriptions of women regarding financial constraints are captured in the quote below:
"As for the women in Amanga here, our problem is not about going to deliver in the health facility. Our main problem is how to get money to pay for drugs that are not given to us and the many things the skilled birth attendants would require of us to buy before we go to deliver in a health facility" (IDI,multipara2 woman).
Another issue that was raised by participants that made them prefer home delivery during the data collection was that they did not have money to buy a delivery pack required by all women as part of their delivery plan. Participants noted that although most of the delivery services were covered under the free maternal healthcare policy, women still needed money to buy the delivery pack. The participants explained that because of their inability to buy the delivery pack, they chose to deliver at home to avoid embarrassment from skilled birth care providers.
"We were told to buy pampers, sanitary pads, rubber (referring to mackintosh), soap, and Dettol (a kind of antiseptic). I 'can't remember all the things we were asked to buy but I think these were some of them and I 'couldn't buy any of them because they were very expensive and because I was not able to buy them I decided to deliver at home" (IDI,multipara 3 woman).
Moreover, some of the participants reported that they did not get financial support from their husbands during their childbirth. They indicated that it was always difficult for them to get money from their husbands to buy the delivery set because according to the participants, the husbands either did not have money or 'didn't see the delivery set necessary. This was what one woman said:
" Yes, I told my husband about those things (the delivery set) and he said he 'didn't have money. They usually do not see those things as important, so they 'wouldn't mind you when you are talking to them about those things. Sometimes, we also understand them because they really 'don't have money. Apart from the petty farming they do during the raining season which cannot even feed us well, they 'don't do anything that can earn any income"( IDI,multipara 4 woman)."
Theme 4: Women lacked access to healthcare facilities
The availability and accessibility of health facilities play an important role in the utilisation of skilled birth care in developing countries like Ghana. According to the participants of this study, issues such as long distance to health facilities, lack of transportation, inadequate skilled birth attendants in health facilities were some of the factors that made them lack access to healthcare facilities during childbirth. Childbirth services were geographically inaccessible to most of the population, as captured in the quote below:
"he distance to the health facility is a major problem for women here in Amanga. Because there is no health facility here, people would have to travel as far as to Namoo to access skilled birth care. The long distances to health facilities discourage women from accessing skilled birth care services in Amanga"(IDI,gravida3 para2 woman).
The participants reported that the problem of long distance was exacerbated by poor roads, rivers and valleys separating some of the communities from the health facilities that provide skilled birth care. For instance, some of the participants indicated that one thing that made it even more difficult accessing health facilities in their community was the fact that women would have to cross two major rivers before they could get to a health centre to access care. As a result, some ended up delivering at the riverside as depicted below:
"The rivers here in Amanga serve as a barrier to accessing care anytime it rains. I even delivered my second child by the riverside because it was in the rainy season and when I was in labour and got there, the river was full and we 'couldn't cross it, so I delivered by the riverside"( IDI, gravida2 para2 woman).
Another problem of access to the healthcare facilities as reported by most participants in this study was lack of means of transport to healthcare facilities. The most common means of transport, usually bicycles, motorbikes or sometimes tricycles which were often the only alternatives were risky and sometimes culturally unacceptable as illustrated below:
"What really informed my decision to deliver at home was the fact that the labour started in the night and I 'didn't have any means of transport to get to the clinic to deliver"(IDI,multipara3 woman).