Deliver in the right place and get there in time! Healthcare-seeking behaviour for delivery in cases of stillbirths and neonatal deaths in rural Cambodia: a prospective cohort social autopsy study

Introduction Perinatal mortality remains high in low-resource settings, with many deaths preventable. While clinical causes of stillbirths and neonatal deaths are often examined, non-medical factors such as care-seeking behaviour and barriers are less well understood. This study uses social autopsy to explore upstream, social factors associated with stillbirths and neonatal deaths in rural Cambodia.

A prospective, population-based observational study over three years (2019–2022) in Preah Vihear province, Cambodia. A social autopsy questionnaire to examine socio-demographic characteristics, health-seeking behaviours, and delays in healthcare-seeking was developed. The Three Delays model was used to summarise barriers faced by pregnant women at the time of delivery. Social autopsy interviews were conducted for all stillbirths and neonatal deaths. Data were analysed descriptively.

Social autopsy was completed for 315 out of 404 (78.0%) stillbirths and neonatal deaths. Most mothers (87.3%, 275/315) reached a health facility for delivery. However, 20.4% (56/275) of them bypassed their nearest facility. Among women attending their nearest facility, 64.8% (142/219) delivered there, and of these, 69.0% (98/142) delivered within one hour of arrival. In total, nearly half of all deliveries (49.5%) occurred either at home (28/315), enroute (12/315), or within one hour of arrival at the first facility (116/315). Delays to seeking facility-based care for delivery were common: 65.7% (207/315) of women reported experiencing at least one delay type, most often at home (43.5%) or at the facility (36.7%).

Healthcare-seeking behaviour was generally appropriate, but not timely. Deliveries occurring very soon after arrival at health facilities likely limited the quality of care that healthcare workers could provide. Addressing home and facility delays may help to reduce these late-presenting deliveries, as well as reducing non-facility births. To improve the timeliness of facility arrival by pregnant women for delivery, we need to better understand the perspectives of families and healthcare workers. Competing Interest Statement The authors have declared no competing interest. Funding Statement This study is nested in the Saving Babies Lives study, which was supported by funding from Angkor Hospital for Children, Civil Society in Development, Fu Tak Iam Foundation, Manan Trust, T&J Meyer Family Foundation, Vitol Foundation, IF Foundation, and Wellcome Trust [220211]. Angkor Hospital for Children participated in the design of the study, data collection, analysis and interpretation, and in the writing of this manuscript; the other funding bodies did not. This research was funded in part by the Wellcome Trust [220211/Z/20/Z]. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The ethics committees of both the Cambodian National Ethics Committee for Health Research (NECHR, 283) and the Oxford Tropical Research Ethics Committee (OxTREC, 547-17) gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the authors Abbreviations - SA - social autopsy - VA - verbal autopsy - SBL - Saving Babies’ Lives - NGO - non-governmental organisation - CHW - community health worker - NECHR - National Ethics Committee for Health Research - OxTREC - Oxford Tropical Research Ethics Committee - BPCR - birth preparedness and complication readiness