Barriers to institutional delivery in rural areas of Chitwan district, Nepal: A qualitative study

Aim:

Though delivery services are free in Nepal, cash incentives are given and institutions are within reachable distance, about 50% of the women deliver at home. This qualitative study explores socio-cultural and health-service related barriers to institutional delivery.

Methods:

In Chitwan district in Nepal six villages in hilly and plain areas were selected. A total of 10 focus-group-discussions and 12 in-depth-interviews with relevant stakeholders, including mothers, husbands, mothers-in-law, traditional birth-attendants, female community-health-volunteers, health-service providers and district health-managers were conducted. Data were analyzed inductively using thematic analysis.

Results:

Three main themes triggered the decision over the place of delivery: Socio-cultural norms and values, access to birthing-facilities, and perceptions regarding the quality of health services. Socio-cultural barriers to an institutional delivery were mainly found in traditions and cultural rules which are difficult to follow properly in health facilities. Included are the wish to be cared by family members, freedom of movement and decision making within family hierarchies. Cultural norms define birth as a cold body-state, where heat has to be applied. After birth a warm environment and the possibility to obtain appropriate “hot” food are essential, which is usually not possible in birthing-centers. Accessibility and quality of health services also represented important barriers, including insufficient financial incentives for transportation and poor infrastructure at birthing centers.

Conclusion:

The study suggests that a combination of upgrading birthing-centers with embracing and addressing deeply rooted cultural values and traditions can improve existing programmes and further increase institutional delivery rates.