Perceptions and practices related to home based and facility based birth. A qualitative study from Agemssa, Ethiopia

Introduction Despite the indications of sharp declines in maternal mortality rate the past few years, maternal mortality still remains unacceptably high, and many countries are not on track to achieve the aims of the millennium developments goal 5. Ethiopia has one of the highest numbers of maternal deaths in the world, around 20 000 deaths annually. Less then six% of the births in Ethiopia are attended by a skilled birth attendant, a very low figure also in an East African context. In order to enhance our understanding of the very high numbers of home births in Ethiopia, the present study set out to explore perceptions and practices that can help explain the apparent emphasis of home birth and the experienced barriers to birth giving at health facilities. The study draws up the Availability, accessibility, acceptability and quality framework (AAAQ) in the discussion of the findings. Methods To gain in depth get understanding of the study topic a qualitative design was chosen including one community based setting and one health facility based setting. Qualitative data triangulation was applied to collect the data. A total of 31 in-depth interviews, 2 focus group discussions and one observation of a homebirth that ended at a health facility were carried out. The data was transcribed and translated from Afaan Oromo to English. The analysis of the collected data is based on Malterud's Systematic Text Condensation". Results Home birth was perceived to be the normal place to give birth and was highly valued as signifying health among the informants. There was a general scepticism- related to giving birth at health facility that was seen as an option in cases of emergencies only. Regarding the decision-making process it was the husband, who ultimately decided where his wife was going to give birth, but the results of the study revealed that the mother, elderly female family members and neighbours also strongly influenced this decision. Conclusion Homebirths were culturally elaborated and emerged as highly valued as meaningful events and as signs of health and wellbeing. There was a simultaneous scepticism to birth taking place at health facilities indicating a strong emphasis on the acceptability' dimension of the AAAQ framework. There was substantial openness for facility based delivery in cases of emergency, and a call for available emergency obstetric services. A stark difference hence emerged between what was experienced as delays in the care seeking in cases of what was perceived to be normal" deliveries and in cases of more obvious emergency situations where accessibility' and availability' limitations emerged strongly