Distance, accessibility and costs. Decision-making during childbirth in rural Sierra Leone: A qualitative study

Abstract

BackgroundSierra Leone has one of the highest maternal mortality ratios in the world. Efforts to reduce maternal mortality have included initiatives to encourage more women to deliver at health facilities. Despite the introduction of the free health care initiative for pregnant women, many women still continue to deliver at home, with few having access to a skilled birth attendant. In addition, inequalities between rural and urban areas in accessing and utilising health facilities persist. Further insight into how and why women make decisions around childbirth will help guide future plans and initiatives in improving maternal health in Sierra Leone. The objective of this study was to explore the perceptions and decision-making processes of women and their communities during childbirth in rural Sierra Leone.Methods and findingsData were collected through seven focus group discussions and 22 in-depth interviews with recently pregnant women and their community members in two rural villages. Data were analysed using systematic text condensation. Findings revealed that decision-making processes during childbirth are dynamic, intricate and need to be understood within the broader social context that they take place. Factors such as distance and lack of transport, perceived negative behaviour of hospital staff, direct and indirect financial obstacles, as well as the position of women in society all interact and influence how and what decisions are made.ConclusionsPregnant women face multiple interacting vulnerabilities that influence their healthcare-seeking decisions during pregnancy and childbirth. Future initiatives to improve access and utilisation of safe healthcare services for pregnant women need to be based on adequate knowledge of structural constraints and health inequities that affect women in rural Sierra Leone.

Women’s economic empowerment and health related decision-making in rural Sierra Leone

“…FHCI evaluations are promising, showing associated improvements in service use, particularly amongst the most disadvantaged in rural areas, despite the shocks of the 2014 Ebola crisis (Witter, Wurie, and Bertone 2016). Furthermore, the 2013 DHS indicated that 97% of women had attended at least one antenatal care appointment with a skilled provider during their last pregnancy (Treacy, Bolkan, and Sagbakken 2018;Statistics Sierra Leone (SSL) and ICF International 2014). However, information about the quality of care received is not provided.…”

“…For individuals and households, there are still costs associated with accessing care such as transport, informal charges or contributions to health care staff, official user fees and lost income. These factors can considerably affect household financial security, with multiple difficult financial decisions often needing to be made about household health (Treacy, Bolkan, and Sagbakken 2018;McNamee, Ternent, and Hussein 2009).…”

Does free of charge policy increase care-seeking for children under five in Sierra Leone? Evidence from population-based studies from 2008-2016

“…During these outbreaks, the northern and western regions were the most affected [28,29], and population in these regions could have avoided health centers for fear of contamination, this could explain the low prevalence of care-seeking in children under ve in the context of free health care observed in our study. In addition, poor road conditions, availability of affordable and reliable transport means, and physical inaccessibility in the rains may contribute to explain the persisting low prevalence in care seeking in these regions despite the free-of-charge policy [30].…”

“…Using fever as an indicator of morbidity in children under ve this study aims to evaluate the trend in the prevalence of care-seeking for fever as well as to identify determinants of utilization of healthcare services by U5 caregivers in the context of FHCI. Independent variables included those for the description of the socio-demographic and those for the assessment of the determinants of the care-seeking for fever: the respondent's age ( [15][16][17][18][19][20][21][22][23][24], [25][26][27][28][29][30][31][32][33][34], and ≥35 years); the level of education of the mother of the child (none formal level of education, primary, and secondary or higher level of education); the number of children ever born in the household ( [1][2], [3][4] and 5≥children); the gender of the household head of the child; the age of the head of the household of the child ( [15][16][17][18][19][20][21][22][23][24], [25][26][27][28][29][30][31][32][33][34], and ≥35 years); the wealth index (richest, richer, middle, poor and poorest); the regions (east, north, south, and west)...…”

Assessing the need for surgical treatments in Sierra Leone

“…Approximately one in seventeen women die from pregnancy or childbirth-related causes, with similar high rates of neonatal mortality (36). The poor access to surgical care is regarded as one of the major causes of these poor health parameters (37,38).…”