Why institutional delivery is still the last option to rural women in North West Ethiopia: Qualitative study

Background: Whatever the actions has been implemented, home delivery preference in Ethiopia is still over 72%. To date, no studies explored why institutional delivery is still the last option to rural women in Ethiopia. This study was conducted to explore the reason why institutional delivery is still the last option to rural women in Awi Zone Northwest Ethiopia. Methods : An explanatory qualitative study was conducted from February to March 2014. Participants were selected purposively and written informed consent was sought. Twelve reproductive aged females, ten religious and twelve community leaders and sixteen key informants were participated. Data were collected by using semi-structured questionnaire using focused group discussion and in-depth interview guides. Thick description and peer debriefing were applied to assure data quality. Thematic analysis framework was used to analyse the data. Results : The study revealed that institutional delivery is still the last option to the study area. Individual related factors like information gap, low risk Perception to pregnancy and delivery have been mentioned as drive factors for not using institutional delivery. Community related factors of women’s poor position to decision, beliefs and cultural practices for home delivery preference affects institutional delivery. In addition, health facility related barriers like inaccessibility of health facility, infrastructure, lack of privacy during delivery, misconducts of health care providers and high risk perception to health facility delivery were repeated raised as reasons of last option of institutional delivery. Conclusion: This study elucidated that home delivery preference was existed, given high social and cultural price for home delivery and misconceptions towards institutional delivery. Thus, the Ethiopian government together with its partners should focus on accessing health facilities, infrastructure, equipping health facilities with essential materials and skilled health professionals and increasing knowledge of the community, avert communities’

misconceptions and deep-rooted socio-cultural beliefs towards institutional delivery.

Background
Globally, 216 women are still dying from pregnancy and delivery related complications in a day [1]. More than 70% of deaths are due to post-partum haemorrhage, infection, unsafe abortion; pregnancy induced hypertensive and obstructed labour complications. More than 75% of maternal deaths are occurred during postnatal period and more than half deaths take place within 24 hours of delivery [2]. Except pregnant induced hypertension, all major causes of deaths are easily avoidable and 99% of the event has been in the developing countries [3,4].
Maternal death could be prevented more than 75%, if skill care during childbirth [5]. Yet, in Ethiopia majority of mothers are not beneficiary in use of health facility where skilled birth attendants and adequate supplies are guarantee of quality care [6].
Home delivery is still common, primarily in hard-to-reach areas. The study area was known as low institutional delivery utilization about 18% only but the delivery service is free from payment of governmental institution. Institutional delivery for rural and urban women were 20% and 79% according to 2016 EDHS in Ethiopia. About 78% women who undertook home delivery was attended by traditional birth attendants [1,[6][7][8][9][10]. According to EDHS thereby suggesting potential remedies for programme planners, policymakers and other responsible bodies for intervention. Moreover, the study design of qualitative nature is better measuring the individual and community perspectives, misconceptions, sensitive issues and cultures of rural Ethiopia adding to its creditability [7,16,17].

Study design and setting
Qualitative study was conducted in Ankasha Guagussa district of Awi zone, in Amhara region from February to March, 2014 which is 463 km far from Addis Ababa, Ethiopia. The study area was known as low institutional delivery utilization (18%) [6]. According to 2007 census, the total population of the district is expected to be 221,796 with an area of 79,881 km 2 . The population were Agew in ethnic origin and speak both Agewugna and Amharic languages. Agricultural products such as Maize, Teff, Red pepper, wheat ... , were the main source of income for the community [6].

Study participants and sampling technique
Overall, 34 individuals participated in the three FGDs: FGD-1 comprised of 10 religious leaders, FGD-2 involved 12 community leaders and FGD-3 included 12 reproductive-aged females. In addition, 16 key informant's interviews were conducted. For this study, Health Care Providers other than health extension workers labelled as KI-1; health extension workers labelled as KI-2 and other than health professionals labelled as KI-3. Purposive sampling technique was used to select participants for both FGDs and KIIs. With the help of local Health Extension Workers and leaders, study participants were selected for FGDs and KII depending on the potential relevance of the participants in delivering rich information about why institutional delivery is still the last option to rural women.

Data collection methods and tools
FGD and IDI were the data collection methods. Semi structured FGD guide and key informant interview guide was used for collecting the data. FGD and IDI guides were developed firstly in English and translated in to Amharic to collect the data and then translated back to English to check consistency. The tool was pretested in similar context to the study area and necessary adjustments were performed based on the result of the pre-test. During discussion, codes was given to each participants and profile was registered. A principal investigator moderated each discussion. One note taker was assigned for each interview. Each participant was encouraged to talk and control participants' dominance during focus group discussion. All discussions and interviews were digitally tape-recorded. All FGDs and individual depth interview were conducted in a place free from disturbance.

Data analysis
Data analysis was done side by side of the data collection. Widening approach was used for analysis of data from key informants. For all independently recorded FGDs and indepth interviews, data were transcribed word by word at each step after a repeated listening. The transcripts were cross checked with recordings. Analysis was begun with coding of respondent's words, phrases and sentences related and relevant to the area of the study. Then after, transcribed data were coded in to related themes and sub-themes.
Verbatim quotations are used to show their responses to vital issues and themes.

Trustworthiness
Developed data collection tools were pretested in similar context. Thick description during analysis were considered as data quality measurements and assuring trustworthiness of the data. Throughout the study, bracketing of preconceptions of the investigator was employed in order to minimize the investigator's bias and the risk of reactivity whereby participants could withhold information to; so that anticipated to assure credibility. The emerging findings during analysis were shared to experienced qualitative researchers for peer debriefing before synthesizing the final outputs.

Characteristics of the participants
The study participant mean age was 39.8 year. Out of 34 focused group discussion participants, 8 female participants were illiterate and 15 participants were can read and write ( Table-1).
Out of 16 individual depth interview participants; 10 participants were health care providers and 6 informal participants who came at Health facility for scheduled child immunization and family planning. More than three quarter of in-depth interviewees were found on mean age of 29 (Table-2).

Institutional delivery Practices and Barriers
The study revealed various reasons that favour home delivery to be first in the selected district. The three main themes: the individual, community and facility factors were come out to show how the pregnant women is affected to use skilled birth attendants and quality of health care.

Category-1: Information gap
Illiteracy and information gap to identify risks and benefits of home delivery were among reasons of low skilled birth attendance. Majority of the participants had no interest to attend their delivery in health facilities unless complication faced.
"Institutional delivery is the last option for us…we can manage everything without any challenges using our traditional birth attendants." (FGD_3 Participant)

Category-2: Low risk perception to pregnancy and delivery
"…in my life I know one woman who gave birth in her home more than 12 times without any health risks or complications. So, why you forced us to go and give birth in health facility. As you observed; there is no road, transport and is very difficult to reach to nearby health facility due to flooding, filled river and mud." (FGD_3 Participant)

Category-1: Women's poor position to decision
Majority of health care providers said that husbands are considered influential in deciding the whole process at home and dependency on husbands' financial support is one of the reason for poor provision of skilled care during pregnancy and delivery.

During birth
Religious acts conducted during childbirth were among reasons to retain labouring women in home. If the first trial were failed, other options will be attempted. For instance, Fenugreek in local language, "Abash" will take the place of coffee to be roasted.

After birth
All participants mentioned that when women faced lost her consciousness after delivery in local language 'Sereka', they immerse in a river to make her conscious. Besides, poorly had a habit of putting Maria Teresa in between the victim upper and lower teeth to prevent clinch and sometimes people made postnatal mothers to catch mirror in front of her face to prevent eye closure.
All participants said that in addition if the postnatal mother loses her consciousness, we start knocking tin, whipping whip, installing spear parallel to the pillar of the house to prevent entrance of 'Sereka' and firing gun near her ear to make her wake up so far nowadays there is improvement. All religious leaders believed that they had traditional medicine to remove retained placenta. They also claimed that local language 'Adefe/yhuala leje' or retained placenta could be remove if a script from 'Melke Rufaele' or religious book is read. Most of the participants said that, 'the placenta is buried inside home because the community is considered it as second child.
All FGD participants said that If it is throwaway home, the women might be suffering from severe abdominal pain called as local name "Marate". So, the placenta should be buried inside home by the husband's left hand using spear. Most respondents knew that laboring women do not allow go out of home before the baby is baptized with holy water which is supposed to protect them from evil or devil spirit

"...in our health Centre, there is no water and light. You can imagine without water how could we manage laboring women and with no light most investigations can't be done and sterilization is difficult for delivery sets." (KI-1 participant)
In addition to this all healthcare providers worry about patients or client health due to shortage of basic needs of the health facility.

Category-3: Lack of privacy
The health extension workers indicated that, lack of privacy at health facility during delivery is one of the reasons for home delivery.
"Most of the time we prefer to deliver in home than health institution. This is because of not exposing our bodies to an outsider including students that touches repeatedly for learning-teaching process. But, in our home no one can touch us except female family members." (FGD_3 Participant)

Category-4: Misconducts of health providers'
Most participants revealed that, health providers are generally criticized, distrusted and not accepted by their approaches. They usually serve by focusing on urban dwellers and relatives.

Category-6: Community's misconception towards health facility
Majority of participants had misconceptions towards health facility delivery. If the baby nose is broad and short and the forehead is protruded, the communities think that the existence of such body structure is due to healthcare provider mistakes.

Discussion
According to the current study, health facility was not first option for delivery as they consider themselves low risks to pregnancy and delivery. This is highly consistent with research conducted in different low and middle income countries [16,[19][20][21][22]. This might be due to knowledge gaps to recognize pregnancy and delivery related danger signs and symptoms.
Women's poor position to decision is one contributing factor for not using institutional delivery. Beliefs and cultural practices at home delivery affects institutional delivery. In addition, health facility related barriers like inaccessibility of health facility, lack of privacy during delivery, misconducts of health care providers and high risk perception to health facility delivery were raised as reasons of last option of institutional delivery. This might have implicated that there is gap in implementing health promotion strategies that are applied practically to anticipate the importance of institutional delivery and risk of home childbirth. This could be addressed in antenatal follow-up which was effective occasion in enhancing the use of trained delivery attendants during parturition.
This study showed that majority of mothers didn't consider institutional delivery, unless they faced complication during labor and they like the naturalness of home delivery rather than institutional delivery. This is recognized for all people with which they were deeply embedded with socio-cultural problems and misconceptions as these findings supported by other studies as well. [18,23].
Consist with previous studies [2, 3,18,20], our finding indicted that most ladies lack decision making power in paying to household materials, maternal health looking for. The problems are not only for the Ethiopians, but for the majority of low and middle income countries that education is unaddressed equally and adequately.
This study showed that husbands are the decision makers for selecting place of delivery.
Husbands believed that labouring mums should be giving birth in their home as previous experienced mothers can manage every problem. The wide prevalent control of economy of the household by husbands' may also contribute for home delivery.
Our findings comparable to various studies [3,7,16,24], Beliefs and misconceptions were another non-touched community related barriers that hold back mothers in house during delivery. Besides, similar with other few studies, postnatal mothers forbidden and protected in home until baby baptism and the placenta is not thrown away home. In addition to this result, many religious acts conducted during and after delivery such as, preparing porridge, massaging the labouring abdomen with Fenugreek dough and performing homemade ceremony were among concealed reasons lack safe care during labor [17,25].
Similar with least and middle income countries [6,15,18] this study district mothers of Ethiopia had been still challenging on benefits of modern health facility delivery. Among challenges were issues related with availability and distribution of modern health facility with its communications. Modern health facility is a type of facility where basic essential obstetric cares are provided; infrastructures including with skilled workers equipped [15].
As shown in study setting, in the study district only seven health centres were available and planned to give services for estimated, 221,798 inhabitants [6]. One health centre established to serve four to five Keeble's. In these Keeble estimated, 5, 000 dwellers were resided. Of the total health centres, only two health centres were modern health centres found in urban comparatively adequate infrastructure. The remaining five health centres found in five clusters were highly marginalized in all rounds and located at least 20km at most 70km far from the capital of the district was Gemjabet.
Moreover, the Ankasha Guagussa district was extremely disadvantageous in means of transportation, distributions of health institutions and infrastructure similar with study done in different countries. In general, all villages are connected to health posts and modern facilities only by footpaths. Achieving any kind of facility was a challenge, and this had a contradictory effect on the user and provider of health services [18,26].
This result is in line with the previous studies [7,16,17] as scatter population settlement contribute to long distance to reach to nearby health centre. There is also a long distance to referral hospitals. In addition, health providers' competencies issued by the community, unavailability of infrastructure and ambulance service are highly contributors for home delivery preference.
Another notable finding in the study was that lack of privacy play a prominent role in home delivery preference. This is because of fear of exposing their bodies to the outsider even they did not want to be touched with their respected husbands' as this finding is supported by other studies. [18,27,28].

Conclusion
Home delivery preference existing in the study setting. High socio-cultural value and misconceptions towards health facility delivery, knowledge gap, distrust, need privacy, poor women's decision, infrastructure and financial constraints were reported as main contributing factors for institutional delivery. Thus, efforts should be made to resolve the low institutional delivery by considering the above main contributing factors. Health, Addis Ababa University, and support letter was obtained from the District Management Council. The purpose of the study was explained to all participants and the study was begun after obtaining verbal consent. They were assured their anonymity and privacy and informed that they can discontinue at any time.

Consent for publication
No individual persons' data was reported in this manuscript and the authors declare that they have agreed to publish on this journal