Treacy, Laura, Håkon A. Bolkan, and Mette Sagbakken, “Distance, Accessibility and Costs. Decision-Making during Childbirth in Rural Sierra Leone: A Qualitative Study,” PLOS One 13, no.2 (February 2018), doi:10.1371/journal.pone.0188280

URL: journals.plos.org/plosone/article?id=10.1371/journal.pone.0188280

Abstract

Background: Sierra 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 findings: Data 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.

Conclusions: Pregnant 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.

Treacy et al. (2018) bring to light the complexity of pregnant women’s autonomy in the decision-making of where to give birth in Sierra Leone. In a culture that emphasizes the husband’s duty to make family decisions, while in contrast also relegating childbirth to “women’s business” and the birthing experience of older women, it is a real challenge to promote the positive impact of giving birth in a health facility and empowering pregnant mothers to do so is a real challenge.