Factors Influencing Decision-making for Institutional Delivery in Rural Nepal: A Qualitative Study

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Nepal, recording 151 maternal deaths per 100,000 live births in 2021, faces significant challenges despite efforts to increase institutional deliveries. This study examines the decision-making processes surrounding childbirth, in the rural districts of Nepal, focusing on the roles of family and community members and factors influencing the decision-making choice for utilization of institutional delivery. Using purposive sampling technique, the study conducted thirty-four semi-structured interviews with women who had recently given birth, along with their husband and mothers-in-law. Additionally, nine key informant interviews with health workers and local authorities, and eight focus group discussions were held with women, men, health workers and local stakeholders. Thematic (Bottom-up) approach was employed to identify relevant themes and sub-themes initiated by codes and categories. The study found that decision-making about seeking care is dynamic and influenced by various factors throughout pregnancy and labour. While women are increasingly involved in decision-making during the pregnancy, the responsibility often shifts to family members, particularly husbands and mothers-in-law, once labour begins. Key factors influencing care-seeking decisions included fear of complications, previous obstetric experiences, perceived competence of healthcare providers, and role of community people. Despite birth preparedness plans, many women still failed to reach health facilities on time. The findings highlight the need to include husbands and family members in birth preparedness counselling and awareness programs to ensure timely care-seeking decisions. Emphasizing the urgency of timely care, building trust between healthcare providers and families, and improving service quality are crucial for promoting institutional deliveries. Decision-making 3 delays model maternal health service utilization institutional delivery complications Plain English summary In 2020, around 800 women died daily due to the pregnancy and childbirth related reasons. Most of them were from developing countries like Nepal. Deaths during pregnancy, and around delivery can be prevented if women receive quality services timely. The Nepal Government provide free delivery services and cash incentive when women deliver in a public health facility. However, many women do not use these services as they experience delays in deciding to use health service. This study tried to learn how women and their families make decisions about using delivery services during pregnancy and how those decisions play out during actual birth. In order to explore what things, influence such decisions, we interviewed total thirty-four women from two rural districts of Nepal, who had recently given birth (at home or in health facilities); her family members (husbands, mothers-in-laws); nine health workers and local leaders; and eight group discussions with community people to better understand their opinions. We found that during the labour process, decision-making, previous arrangements and choices along with decision-makers changed and women depended on others to decide. When their husbands were aware of signs of labor or potential dangers, they were quicker to decide to use health facility. However, low confidence in health facilities’ staff and service quality reduced likelihood of going including the woman’s past experiences, the level of support from the community, and availability of transportation. Therefore, health programs should focus on including husbands and family members in pre-delivery birth preparation to increase timely healthcare-seeking practice. Background Maternal mortality remains a significant public health challenge, with approximately 800 preventable deaths occurring daily as of 2020, primarily in in low- and lower-middle-income Countries (LMICs) which accounted for 95% of total maternal deaths worldwide ( 1 ). Sub-Saharan Africa and Southern Asia account for around 87% of these deaths, highlighting persistent disparities in maternal health outcomes in 2020, among which Sub-Saharan Africa alone accounted for around 70% while Southern Asia accounted for around 16% of total maternal deaths ( 1 ). In 2016, Nepal reported Maternal Mortality Ratio (MMR) of 239 deaths per 100,000 live births ( 2 )which was reduced to 151 deaths per 100,000 live births in 2021( 3 ). While this indicates progress it highlights the ongoing challenges it faces in achieving the Sustainable Development Goals (SDGs) target of reducing the MMR to less than 70 per 100,000 live births by 2030 ( 1 , 3 ). Despite efforts to improve Maternal, Neonatal, and Child Health (MNCH) outcomes, delays in accessing obstetric care remain a critical issue in Nepal. Notably, the First Delay- referring to the time taken to recognize the complications and decide to seek care- accounted for 57% of maternal deaths, as indicated by a verbal autopsy of 611 maternal deaths reported in the 2021 census ( 3 ). Numerous studies have highlighted barriers to maternal health service utilization in LMICs—such as difficult geography, financial constraints, cultural norms, and women's low autonomy ( 4 – 7 ). The complexity of seeking maternal and neonatal care is shaped by multiple factors. Barriers like transportation difficulties, financial limitations, nighttime onset of labor, and the distance to health facilities intensify these challenges ( 8 – 11 ). Thaddeus and Maine had recognized that prompt and sufficient treatment for obstetric complications plays a crucial role in lowering maternal mortality. Their research introduced a new perspective on analyzing maternal deaths, utilizing a three-phase framework to identify shortcomings in access to proper care for obstetric emergencies ( 12 ). Thaddeus and Maine's framework identifies three levels of delay contributing to maternal deaths: delays in recognizing risks and deciding to seek care (First Delay), delays in reaching a health facility (Second Delay), and delays in receiving appropriate care upon arrival (Third Delay) ( 13 ). Although all these factors important, decision making can have a huge influence that occurs before and during labor( 4 , 14 – 19 ). Factors like educational level, economic status, ethnicity, and place of residence play crucial roles in determining whether women choose institutional delivery or not ( 17 , 18 ). In Nepal, qualitative studies reveal that socio-cultural norms, concerns about healthcare quality, and logistical barriers further complicate this decision-making process ( 2 , 8 , 10 ). In rural Chitwan, evidence suggests socio-cultural norms favoring home births are reinforced by concerns about healthcare quality, deterring women from choosing institutional deliveries, even when birthing centers are nearby ( 14 ). Similarly, in Sarlahi District, concerns about the quality of public health facilities and delays in receiving appropriate care deter women from seeking institutional delivery services ( 8 ). From this literature review, there is a need to delve deeper into the decision-making processes that occur before and during labor( 4 ). While previous studies have examined the barriers to institutional delivery in general and extensively examined structural determinants ( 9 , 10 )the specific decision-making process before and during labor remains underexplored. To support fulfilling this gap, this study seeks to understand the decision-making processes prior to, at the onset of labour and during labour, focusing on determinants of the first delay, which include factors and individuals influencing women’s decision whether or not to attend a health facility at childbirth. By gaining insight into these household-level dynamics, strategies can be developed to better inform and involve family members in the decision-making process while respecting the woman’s preferences during delivery ( 17 , 18 ). Focusing on these factors, overall, this study aims to promote positive shifts in maternal health outcomes inNepal. Method Study design This is a qualitative study using semi structured interviews (SSI), key informant interviews (KII) and focus group discussion (FGD). Qualitative research explores the perceptions, beliefs and motivations behind observed behavior from the perspectives of those experiencing the phenomena of interest (20). This study tries to understand birth-related healthcare decisions as taken by pregnant women and those who influence them based on their own interpretations of recent experiences. Study setting The study was conducted in Banglachuli rural municipality (Dang district) and Tribeni rural municipality (Rukum-west district) of Province 5 -Lumbini and Province 6 -Karnali respectively. These sites, part of the Nepal Red Cross Society’s Community Empowerment for Health Promotion program, were selected purposively due to their rural location having low maternal health service utilization rates (as shown in table) and mixed ethnicity. Although Dang is a Terai district (plain geography), the study site of Dang was remote and had diverse socio-economic status, ethnic composition (i.e mixed community of so-called advantaged caste groups like Bhramin and Chettri and so-called disadvantaged caste groups like Dalit and others). Rukum-west represents a typical hilly district of Nepal. Catchment area of Hansipur Health Post with birthing center of Banglachuli RM of Dang (ward 7,8) and catchment area of Simrutu Health Post with birthing center of Tribeni RM of West Rukum (ward 1, 2) were the selected data collection sites. Table 1 MNCH service use as per HMIS indicators (21) Indicators Dang Rukum-West Nepal % of Institutional delivery 57.4 73.8 65.5 % of pregnant women who had four ANC check-ups (as per protocol*) 51.4 65.1 52.6 % of SBA delivery 56.3 65 62.3 *ANC protocol as per MoHP during the time of study- ANC visit at 4 th , 6 th , 8 th and 9 th months Percentage of institutional delivery, ANC check-ups, and SBA delivery as per HMIS indicators in shown in the table 1 which shows the lower percentage of these indicators compared to national average in Dang district, whilst that of Rukum-west are slightly higher than the national average however still far behind in reaching the SDG goals. Study population Semi-structured interviews (SSIs) were conducted with women who had delivered at home or in a facility within the last six months and their family members (husbands or mothers-in-law), and KII with healthcare providers, and local authorities. FGDs were conducted with groups of community people ie, women, men, healthcare providers and other stakeholders such as community leaders, teachers, traditional healers, and Female Community Health Volunteers (FCHVs). Sampling method Purposive sampling was used to select participants with a range of birth experiences, including those who had experienced complications and referrals. Participants were identified by the local health worker, FCHVs, Health Mothers' group members who were familiar with women/households who experienced pregnancy outcomes/care engagement. Diversity in ethnicity and economic status, and in the case of key informants, a range of roles and positions of authority was sought. The selection of study cluster/communities for FGDs was based on local diversity, socio-economic differences and vulnerability, ethnicity representing diverse background and knowledge about decision making and different social dynamics. Sampling framework Altogether 4 group discussions were conducted in each site where 8-12 participants were present in each group. Total 22 SSIs and KIIs were conducted in Dang whereas 21 SSIs and KIIs were conducted in Rukum-West. Table 2 Sample Frame for Individual Interviews Description Number of interviews (N= 43) District Place and type of birth Women Husbands Mother-in-law Health workers Local authority Dang Normal delivery at facility 3 1 1 2 2 Delivery at facility with complications 2 3 0 Normal delivery at home 3 3 1 Delivery at home with complications 1 0 0 Rukum West Normal delivery at facility 3 2 0 3 2 Delivery at facility with complications 2 1 0 Normal delivery at home 5 3 0 Delivery at home with Complications 0 0 0 Total 19 13 2 5 4 As shown in table 2, total 19 women participants were interviewed. Besides women, total 13 husbands, 2 mother-in-laws, 5 health workers and 4 local authorities were also interviewed. Data collection tools Data collection tools included interview guides for FGDs, SSI, and KIIs. FGDs were facilitated according to specific guidelines detailing the three above-mentioned research techniques and moderation process. SSI and KII guidelines featured questions tailored to different interviewee types (women, husbands, mothers-in-law) and focused on decision-making and service utilization during pregnancy, childbirth, and the postnatal period. All tools were translated into Nepali to ensure clarity and appropriateness for the participants. Data collection techniques All study participants were approached by the data collectors and asked for their consent to be interviewed. Subsequently, data collectors arranged a convenient time and private place for the SSIs, KIIs and FGDs. All data collection was conducted by 4 local research assistants trained in FGD and interview methods. The research officers supervised the fieldwork, including daily reviews of digital recordings, verification of data completeness, and transcription assessments. Daily team meetings were held to discuss preliminary findings and refine the data collection process. SSIs allowed respondents to share their personal experiences and perspectives on decision-making and barriers in accessing health services in a semi-structured narrative format. KIIs offered perspectives from healthcare providers and local authorities on the supply-side aspects of maternal health, and their perceptions of low rates of delivery service uptake. Focus Group Discussions, each lasting 90-120 minutes, were conducted in three phases: Community Mapping, where participants developed a visual map of maternal health services; Pregnancy Pathway, where they outlined potential maternal experiences from pregnancy detection to delivery; and Barrier/Facilitator Identification, where they used a "Horse & Cart" metaphor to identify factors that “pull forward” or “hold back” likelihood of women delivering in a facility. Pretesting Tools were pretested in Rolpa District from March 22-23, 2021, to adapt them to local contexts and literacy levels. Insights from the pretest led to modifications of the tools, such as adding more probing questions and numbering participants in the FGD to facilitate notetaking. In a review meeting the question flow was refined and probing techniques improved. Data collection timeline Data was collected from March 26 th to April 9 th , 2021. Data analysis Interviews and FGDs were audio-recorded, transcribed and translated from Nepali to English. Thematic analysis was conducted using both ‘bottom-up’ and ‘top-down’ coding approaches, meaning open-ended identification of codes emerging from the data were added to codes based on the topic guide questions. Following coding, the team analyzed the data by grouping codes into categories and/or breaking them down into sub-codes and developed themes based around factors affecting women's decision-making prior to and at the time of giving birth. The analysis was done using the following steps in two phases: Primary analysis: (1) familiarization of the data by the researchers by reading and rereading the transcribed data and the notes. (2) discussion within the study team to develop a framework for primary analysis using MS Excel. (3) agreement of an initial coding framework for general emerging themes (4) three separate analysis sheets for SSI of community people, KII of stakeholders, and FGD were used. Transcripts and notes were categorized in the data according to the stages of pregnancy and categories of questions asked. Secondary analysis: (5) data from FGD and SSIs were analyzed in the different rows of the same excel sheet in order to triangulate the information. (6) code generation by team members and comparison of coding for consistency. (7) discussion of main codes and then grouping them into themes and/or sub-dividing them into sub-codes/categories. (8) checking for outliers and rechecking the transcripts to ensure there aren’t examples of data that contradict or challenge the main findings. Results The results of the study are grouped, starting with a summary of participants’ demographic characteristics and then reflecting different themes as facilitators and barriers in decision-making for institutional delivery. Demographic characteristics Among the women interviewed, most belonged to the Janajati and Brahmin/Chettri ethnic group, whereas very few represented Dalit ethnic group (Note: Brahmin/Chettri considered as higher class followed by Janajati (indigenous groups) and Dalits considered as lower class in traditional belief system of caste hierarchy). The representation of people who live in a joint family setting was slightly higher than that of a small family-type. Table 3 Age of women respondents Age group Frequency of women (n = 19) ≤ 19 1 20–29 16 30–49 2 Total 19 Table 3 shows that most women were aged 20–29, followed by those ≤ 19, and then 30–39. This indicates the persistence of early marriage and pregnancy in the study areas. Over half of the women had two children, with the rest having one child. The study also found a slightly higher number of respondents with experience of institutional deliveries compared to home deliveries. Most husbands were migrant workers, mainly in India, with nearly half being seasonal migrants who returned home during critical periods such as pregnancy, delivery, or postnatal phases to provide financial and workload support. The major occupation of the women and other family members was agriculture and farming; therefore, mostly the women were involved in household chores, agriculture, and farming activities along with child-rearing. Thematic findings Theme 1: Factors influencing decision-making choice of pregnant women for institutional delivery 1.1 Previous experiences Previous positive experience as facilitator for institutional delivery Many women, who already delivered at least once in a health facility had positive delivery experiences, which further reinforced their preference. Nearly all respondents from Rukum-West and over half from Dang preferred health facilities for delivery, often citing positive past experiences as a key factor in their decision. “It was already planned that the delivery would be in a HF. We knew it was safe to do so, there might be complications at home”. (Dang -facility delivery normal /Woman) “I advise others to go to a nearby health facility if it seems that a normal delivery would happen. If it looks like a normal delivery would not happen then I would advise to go to a higher-level facility.” (Rukum-West- facility delivery normal/Husband) The quality health services and facilities provided at birthing center also influenced women’s decision making to deliver at health facility which was also quoted by healthcare provider that the facilities such as accommodation influenced their positive decision-making. “We have arranged lodging and food at the HF for women and one companion as some might have to stay for 2/3 days. Some can arrange it by themselves, but it is not possible for everyone. Some can’t afford to stay and eat at a hotel.” (KII_Dang-healthcare provider) “They do regular checkups once in a month for mother and baby. If there is any problem, the staff also visit mothers at home. All services provided from this health facility are good.” (Rukum-West-Health Facility delivery/Husband) However, previous positive experience in home birth also influenced the decision to deliver a subsequent child at home, despite advice from the health workers. The perceived hassle of traveling to a health facility for a 'normal birth’ influenced their decision. “I preferred to deliver at home than go to the doctors. Health workers at the health facility had suggested giving birth at the facility and they gave me a number to contact them in case of labor pain. But, as I delivered my first child at home, I didn’t feel it necessary to seek service at the Health Facility”. (Dang-Home Delivery with Complication/ Women) Previous negative experiences as barrier of institutional delivery Similarly, negative past experiences influenced the decision-making in favor of delivering at home. Some women opted for home births, especially in Dang, due to concerns about body exposure. “I had thought that I would deliver my child at home and would not go to a Health Facility. But everybody forced me to go even though I didn’t want to. My first child was delivered at home. And when I was pregnant with my second child, I thought of delivering the child at home as well. It’s shy to go to the doctor and expose oneself, that’s why I didn’t want to go”. (Dang-Facility Delivery Normal /Woman) Negative past experiences included dissatisfaction with the quality of infrastructure and amenities at health posts. The perceived negative experience with facility deliveries, such as prolonged labor and discomfort, led some women to prefer home births since they could have facility of fire for warmth at home which lacked in health facilities. “There are no facilities of warming like fire at home, there is not heater in health facility for pregnant women hence they shiver from the cold. During the delivery of my first child too, I had prolonged labor pain due to a cold at HF. So, we had to take her (child) to a higher-level health facility in the city. This is the reason, most of the women usually like home delivery rather than institutional delivery”. (Rukum-West-Home Delivery Normal/ Woman) The behavior of the healthcare staff experienced by themselves or by the other women in the community significantly influenced women’s decisions and their choice of delivery location. “At first, we had doubts regarding Health Facility delivery. Additionally, when other women share their experience about the treatment done in the Health Facility like scolding, if we cry during delivery, then we feel like delivering at home rather than being scolded at Health Facility.” (Dang-Women Group FGD) 1.2 Fear of complications Women who chose to deliver at health facilities often did so due to concerns about potential complications and previous difficult childbirth experiences. Both women and some husbands expressed fears about possible complications and viewed health facilities as safer options for childbirth. Awareness of the ability of health facilities to manage complications strongly influenced their preference for these settings. “We had planned and prepared for HF delivery. Joint decision making was done with the family members because there were complications during the delivery of the first child. We sought advice from the family members this time”. (Rukum-West-Facility Delivery with Complication/ Woman) “I was aware about the danger signs during delivery; therefore, we had planned to deliver at Hansipur” HP. (Dang- home delivery normal /Woman) “Actually, I wanted a doctor’s attended delivery rather than delivering alone at home. I was afraid. I always wanted to go to a HF for delivery because I believe that they would save me if any complications arrive. There are people who don’t want to seek such service, but for me, I wanted to go”. (Dang-Home Delivery Normal /Woman) 1.3 Family's Support for Women’s Choice of Institutional Delivery Many respondents regardless of their actual place of delivery during the course of pregnancy, stated that they had initially preferred to deliver at a health facility. While planning for birth, decisions about delivery location were often made jointly with their husbands, sometimes with additional input from other family members. “First of all, I planned it and discussed it with my family members as well.” (Rukum-Facility Delivery with Complication /Women) “My wife told me that the delivery should be done at a HF. There were no objections from my parents”. (Dang-Facility Delivery Normal /Husband) “My husband is the only person I share opinions with. I told my husband and in-laws that there might be complications at home, so it is better to deliver at a health facility. (Dang-Facility Delivery Normal /Women) “Everyone in the family suggested we go to HF for delivery. They suggested that the time has changed, and people need to seek a safe delivery at the HF. They said that it was not safe to deliver at home as complications may arise. Therefore, we went to the health facility for delivery”. (Rukum-West-Facility Delivery Normal/ Women) However, in some cases, decision-making power appeared situated more with husbands or other family members, which stood as a barrier to institutional delivery. “There was no one at home, only my young son. I talked (with my husband) over the telephone. He said if the baby is born normally at home, then it is good but if not then go to a health facility. My sister-in-law also said the same thing. If the delivery happens at home, she will look after me and support me. It would be good if it happens at home. If there is difficulty, then we should go to a health facility.” (Rukum-West-home delivery normal/Women) Theme 2: Factors influencing family’s decision making after the onset of labor 2.1 Influence of people present at labour: shifts in decision-making Women who successfully followed their plan to deliver at a health facility often had supportive husbands and family members who helped ensure timely arrival at the facility. However, decision-making authority sometimes shifts during labor. Despite prior discussions with their husbands or family about the delivery location, decisions could change once labor began. Exhausted from labor pains and reliant on family members for care, the individuals present during labor played a crucial role in determining the delivery location. The outcome depended on the caregivers' knowledge and understanding of emergency obstetric services. For example, some women who initially planned home births ended up delivering at health facilities, while others who had intended to deliver at a health facility chose home births instead, based on assurances of comfort from their family. “It was nighttime when she (daughter-in-law) started to have labor pain. We told her that we were calling an ambulance to go to the health facility, but she didn’t want to go. But we took her anyway. She didn’t have long labor as it started at 5.00am and the baby was born at around 7.30 am”. (Dang-Facility Delivery Normal /Mother-in-law) “I started to have labor pain at 4.00am and the baby was born at around 7.00am. When I started to have labor pain, I also had slight bleeding. I called my sister and shared this with her. She said that it is better to have the baby at home, if not we need to go to the Health Facility. I also called my sister-in law and shared this with her then she came to us. She also said if I delivered at home, it is good if not then we will go to the Health Facility. She gave me an oil massage. Then the baby was born at home”. (Rukum-West-Home Delivery Normal/ Woman) “I was having labor pain, but I didn’t go to the health facility. I wanted to deliver at home only. But my husband didn’t agree, and he called for an ambulance. I thought I will be able to give birth, but I couldn't, so we walked further up, then I gave birth on the way”. (Rukum-Home Delivery Normal/ Woman) When I gave birth to this child, I started having labor pain at 2 am in the morning. I told my mother-in-law about it. I went to the health facility in an ambulance. My mother-in-law called a community mobilizer who works in a community-based nutrition project and gave her our location as she was there at the health facility. However, I did not want to go to health facility, I wanted to give birth at home. I went there because everyone (family members) wanted me to go.” (Dang-Facility Delivery Normal /Woman) 2.2 Influence of the time of onset of labour: hesitancy to act upon promptly Some women faced challenges in enacting their decision to deliver in an institution when labor pain began at night. Labor starting at night often led to delays in seeking care until morning, because some women were hesitant to inform their husband and family members until daytime, in order to not disturb their sleep or give them a hard time. “I started to have labor pain at 2:00 AM at night. It was rainy season, and no transportation would have come though it used to come during the dry season. I was alone at home, and it was difficult to call for help as all the men had migrated to India and there were only older people at home. I was waiting and gave birth at 5.00am. I didn’t call at the time of delivery but I called them after delivery in the morning”. (Rukum-West-Home Delivery Normal /Woman) Alerting family members late, further postponed arranging transportation. Mobilizing community support and accessing ambulance services at night proved challenging compared to daytime, complicating the process of reaching a health facility. “Her labor pain had started at midnight and the baby was born at 12 in the afternoon the next day. She was having labor pain since midnight, but she only told me in the morning. Then I tried to call (for an ambulance) but the number was not reachable. And while I was trying to contact the health facility, she already gave birth at home.” (Dang-Home Delivery Normal /Husband) “It was already late by the time we could arrange for all materials and vehicles. It took time to arrange everything. My labor pain started at midnight and the baby was born in an hour.” (Rukum-West-Home Delivery Normal /Woman) 2.3 Timely recognition of signs of labor Female respondents, who had delivered in a health facility reported that they were able to promptly recognize the onset of labor and initiate their journey to the facility. In contrast, those families where the woman did not deliver at a health facility or had experienced complications, often struggled to identify true labor pains or determine the right time to seek care. “She (wife) said that she had a slight pain in the abdomen around 9–10 pm at night. I had no idea whether the abdomen pain was normal regular pain or it’s a labor pain and hence I was confused whether to take her to HF or not.” (Dang Home Delivery Normal /Husband) Some women were reluctant to go to a health facility timely due to concerns about waiting for labor to progress. “I recognized very little pain. I had a similar pain during the birth of my first baby. I thought about why to visit the Health Facility during minimal labor pain and stay all day at the Health Facility, so I didn’t visit Health Facility earlier and decided to go when there will be more labor pain”. (Rukum-West-Facility Delivery with Complication /Woman) “Now it is better to go to the health facility as soon as possible if there is labor pain. I have seen pregnant women who have been kept at home for two or three days in some places”. (Rukum-West-Facility Delivery with Complication/ Husband) 2.4 Cultural and traditional beliefs delayed timely decision-making Families with strong cultural beliefs sometimes prioritized traditional healers, which delayed seeking professional medical care. Beliefs in supernatural causes for prolonged labor and pain, especially if symptoms appeared before the expected delivery date, also influenced decisions. These cultural beliefs impacted healthcare choices, causing delays in consulting healthcare providers and arranging transportation, whether the delivery occurred at a health facility or at home. “I went to see a traditional healer to know if there is any lagat (bad spirit). I came to know there is a bad spirit. The healer came home and did his ritual, but she didn’t get better. He did the same on the next day then she got better”. (Dang-Facility Delivery with Complication/ Husband) Theme 3: Factors influencing the actualization of plan for institutional delivery 3.1 Birth preparedness: Are women and their families truly prepared? Despite birth preparedness plans, many women still failed to reach health facilities on time due to various reasons. Respondents described their efforts to prepare for safe childbirth beyond decision-making, including securing funds for medical expenses, arranging transportation, providing nutritious food for the mother, and preparing clothing for the baby. “My husband was working in India during my delivery. He had sent home some money to use if needed while delivering the baby.” (Dang-Facility Delivery Normal /Woman) “I had already packed some clothes for the child and for myself in a bag. My mother-in-law had borrowed ten thousand Nepalese Rupees from the mothers’ group. My husband also had around ten-eleven thousand. We went to a health facility with this money.” (Dang-Facility Delivery with Complication /Woman) “We have to carry women in stretchers from here. We had prepared clothes and other materials needed for delivery. There is a stretcher at the school which was given by the health post for emergency use. I had also prepared for money. My brothers had sent it from abroad (India). I had kept it separately almost one and half months before delivery.” (Rukum-West-Home Delivery Normal /Husband) Family members thought they were prepared for what was needed like (stretchers and resources like money and people). Despite birth preparations, many women still struggled to reach health facilities in a timely manner due to lacking of understanding of onset of labor pain, prompt action, complemented by structural determinants. “While we were trying to search for previous documents (ANC cards, reports) and call for an ambulance, the baby was already born. The labor pain started at around 8PM and the baby was born after half an hour.” (Dang-Home Delivery Normal /Woman) “We have to carry women in stretcher from here. We had prepared for clothes and other materials needed for delivery. There is a stretcher at the school which was given by the health post for emergency use. I had also prepared for money. My brothers had sent it from abroad (India). I had kept it separately almost one and half month before delivery.” (Rukum-Home Delivery Normal /Husband) “Vehicles do come here but not all the time. So, we had to carry her. I had requested my friends and brothers in the village for support. I also consulted with FCHV. We had also prepared some money, clothes and foods like ghee, honey and chickens for mother.” (Rukum-Home Delivery Normal /Husband) “She (wife) said that she had a slight pain in the abdomen around 9–10 pm at night. I had no idea whether the abdomen pain was normal regular pain or it’s a labor pain and hence I was confused whether to take her to HF or not. At the same time there was a heavy rainfall and there were no one to leave small kid. There is not delivery facility nearby, to take Hansipur, road access was problem due to rain and raised level of river and it was difficult to manage people to carry as they were busy in agricultural work at daytime and didn’t feel comfortable to call at mid of night.” (Dang Home Delivery Normal /Husband) 3.2 Social cohesion and community support Decision making is supported by community members and support groups. Besides, financial assistance and help with transportation, the advice from community members plays a role in deciding the place of delivery in both positive and negative ways. “People around us (neighbors) used to suggest her to go to the health facility. My wife was experienced and was aware about it. We decided to ask for suggestions from an FCHV. She then suggested to visit HF. Therefore, we did as per the community people suggested”. (Dang- facility-based delivery with complication /Husband) “We seek support from our own community. We seek financial support as well as human resource support if the woman has to be carried on a stretcher. They also support communication with the health worker in times of emergency”. (Dang-Community Male FGD) One woman reported that despite being prepared, the community did not support her in manifesting her decision to deliver in a health facility. Since she was living alone with her husband working abroad, she faced challenges. She and her husband’s decision to deliver at a health facility was overruled when labor began at night, and the immediate supporter did not honor the decision of the couple. “I was sleeping when I started to have labor pain. My husband (in India) was saying that we should call the neighbors and go to the health facility as there is no facility in the village. But no one called the ambulance. Neighbors were getting ready to take me to the health facility. I started to have pain at 9pm and the baby was delivered at 1.00am at home. There were sisters helping me at the time of delivery, they were giving hot oil massages and hot water with sugarcane. I was saying it would be easy if I would have been taken to a health facility. But they said that we continue the oil massage and if you have difficulties then we will take you. Then I had to wait 3 hours”. (Rukum-West Home Delivery Normal /Woman) Discussions This study aimed to explore the decision-making process by women before and during labor regarding their place of birth and what affected them. The decision for institutional delivery tended to be dynamic throughout pregnancy and multiple factors affected the decision of seeking care contributing to the first delay. During the period prior to labor, women’s decision to have (or not to have) institutional delivery was shaped by their past experiences either at home or health facility, their understanding of birth complications, and the support of husbands and family members. Whereas after the onset of labor, the decision to seek care was influenced by the family and relatives’ attitude towards having institutional delivery, time of onset of labor, timely recognition of signs of labor, and cultural beliefs similar to other studies done in Nepal as well as in other countries like Ghana, Indonesia and Ethiopia ( 14 – 19 ). Women’s decisions and preference for place of birth prior to labor were based on their past birth experiences, either at home or the health facility. Women who previously had a normal delivery at home were more inclined to choose home birthing again, and this choice is reinforced by the negative experiences resulting from the poor attitude of care providers, lack of competence, lack of infrastructure, and overall low quality of service at health facilities as delineated by a meta-synthesis of qualitative studies from across Africa, Asia, and South America ( 22 ). Improving the quality of maternal health services has been brought into focus globally to increase utilization and receiving of appropriate care ( 23 – 25 ). While national programs such as the Minimum Service Standards Package are being rolled out in Nepal to improve service quality and accountability in the health system, localized efforts for competency building and fostering trust between healthcare providers and the community could promote the general preference for institutional delivery from the early stage of decision making ( 26 ). Past experiences of difficult birth inclined women and their families to decide on institutional delivery in their subsequent births, and more so if the use of health services had resulted in a positive birth outcome. Apart from difficult experiences, perceived urgency and fear of developing complications was another factor in encouraging women to choose facility-based delivery. Even women who preferred home birth vocalized that they would go to a health facility if normal birth did not happen while at home. However, their approach of ‘wait and watch’ significantly delays care seeking( 12 ). Well-informing women and their families about the possible complications and reaching health facilities at the earliest to ensure safety is valuable in reducing such delays. One of the critical findings in this study is that the families and community members influenced care-seeking decisions more often during labor. While decision-making prior to labor often involved the woman and her husband, after the onset of the labor women relied on their family, relatives, or community members for decision-making, to the point, where the initial decision of the woman is not honored any longer. Female relatives, in particular, played a crucial role in either facilitating or delaying care, even though they were not involved in prenatal decision-making( 16 , 27 ). The shifts in decision-making authority from the woman to those around her were similar to the patterns observed in Tanzania ( 28 ). Although this study does not examine women’s decision-making autonomy, the findings of the study highlight the role of husbands and family members in supporting women to use health services corroborating with the findings of a bi-variate analysis study from Ghana that shows women living in a community supportive of institutional delivery to be more likely to deliver at health facility despite their level of autonomy ( 15 ). The household dynamics, open communication, and circumstances during labor were unique to each woman in this study which underscores the need for health programs to adopt a family-centered approach, actively involving husbands and other key family members from the antenatal period. The increase in the use of ANC-services across Nepal ( 2 , 29 ) presents opportunities to go beyond regular health education to reduce the barriers posed by distrust and negative perceptions about local health services. Family-centric antenatal education promoting better spousal and family level communication could also address other barriers identified in this study such as delayed recognition of signs of labor, hesitancy to alert family members about labor pain at night, or seeking traditional healers, ultimately preventing the first delays. However, further study is needed to explore the quality and content of ANC-counseling and how a family-centric approach can be integrated into current ANC-service practices. Furthermore, community programs should expand their coverage to include males as well as general community members to develop positive community attitudes towards facility-based delivery and harness more social cohesion to support every women to actualize their decision of institutional delivery. Apart from factors influencing the decision to have facility birth, findings reported in theme 3 flag the structural barriers faced by women and families when choosing institutional delivery. Although financial difficulties were less vocalized in this study, the migration of husbands for work opportunities reduced the availability of support for women during labor making them less likely to go to a health facility. Distance, unreliable transportation, communication service, and difficult geography continue to challenge the actualization of the decisions to deliver at a health facility adding to previous studies in Nepal and many other LMICs ( 7 , 9 , 10 , 30 – 32 ). The interventions addressing the barriers contributing to the first delay can only be as effective as interventions addressing others. Addressing the barriers to decision-making can only be effective when efforts are present to reduce the structural barriers. While addressing these challenges requires significant resources and government commitment, a thorough birth and complication readiness plan considering the local context should be emphasized during antenatal education. Strengths and limitations of the study Strengths This qualitative study explores perspectives of women and family members on maternal health services during delivery including experiences with complications in both homes as well as facility-based births. It incorporates viewpoints from women who have delivered either at home or in health facilities, family members along with healthcare providers, and local authorities. Analysis of these perspectives revealed facilitators and barriers to maternal service utilization that are valuable in guiding the strategies aimed at improving maternal and neonatal health outcomes. The study aimed to minimize bias by including women who had delivered within the last 12 months, thus reducing recall bias. Interviews were conducted in the original language to maintain the authenticity of respondents' experiences. Limitations While the efforts were made to limit bias through study design and methodology, the purposive sample selection in a small area may have introduced sampling and geographical bias. The narratives from healthcare providers and local authorities did not generate novel perspectives and insights as per the objective of the study, and was not mentioned in detailed in this paper. The majority of mentioned findings presented are based on women’s and husband’s perspectives. Conclusion The study found that decision-making about place of birth is dynamic and influenced by various factors throughout pregnancy and labour. Positive experience of using health services, fear of developing complications, support from family encouraged women to choose institutional birth whereas distrust in health services, delay in recognizing signs of labor, hesitancy to seek care at night, ‘wait and watch’ attitude of family members hindered timely decision for seeking care. While women are increasingly involved in decision-making during the pregnancy, the responsibility often shifts to family members, particularly husbands and mothers-in-law, once labour begins. The decision-making process around maternal health services evolves dynamically with progression of pregnancy. Husbands and family members often play pivotal roles specifically after onset of labor when women depend upon them to reach the health service. The family-centric antenatal education and involvement of male in community awareness programs should be prioritized to improve general community’s attitude of institutional delivery and improve spousal communication to reduce the delay in decision-making at family level. Health programs should focus on including husbands and family members in pre-delivery birth preparation to increase timely healthcare-seeking practice. Additionally, it would require further studies to fully explore what strategies can be adopted to effectively engage with family members taking in account localized context such migration and nuclear families. Low confidence in health facilities’ staff and service quality affected the preference of giving birth at health facility. Building trust between healthcare providers and families, and improving service quality are crucial for promoting institutional deliveries. Despite birth preparedness, many women failed to reach health facilities on time. The findings highlight the need to address structural barriers at community level such as reliable transportation and communication services to actualize the decision of facility-based delivery. Abbreviation ANC Antenatal Care FCHVs Female Community Health Volunteers FGDs Focus Group Discussions GoN Government of Nepal HMIS Health Management Information System KII Key Informant Interview LMCs Low and Lower Middle-Income Countries MMR Maternal Mortality Ratio MNCH Maternal, Neonatal and Child Health PNC Postnatal care SBA Skilled Birth Attendants SDGs Sustainable Development Goals SSI Semi-Structured Interviews Declarations Ethical approval and consent to participate Ethical approval for the study was granted by the Nepal Health Research Council (NHRC), Reference Number 153 of 28 July 2020. During data collection, strict ethical standards regarding privacy and confidentiality were upheld. Written approvals were obtained from respective municipality authorities as part of the NHRC ethical approval process. Before data collection began, courtesy meetings were conducted with Rural Municipality authorities and health units to explain the study objectives and procedures, and to share NHRC ethical approval. All study participants provided written consent before participating in interviews and discussions. For participants unable to read or sign, consent was obtained verbally and confirmed with a thumbprint. Field researchers ensured participants understood the study objectives, information usage, and provided contact details for further inquiries. Participation was voluntary, and participants could withdraw at any time. Anonymity was maintained through a code-to-name matching system. Data collectors were trained to recognize mental distress of study participants and, in case of any mental distress, to immediately stop the interview, ask if the person needs support and call the immediate supervisor to liaise with the respective focal person on mental health and psycho-social support of the Nepal Red Cross Society. Consent for publication The authors have provided their individual consent for the publication. Availability of data and materials This study applied a standardized methodology used similar data collection tools for all four countries that were adapted to each local context. The data used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study was conducted by the Nepal Red Cross funded by Swiss Red Cross in Nepal. It is a part of broader research conducted by the Swiss Red Cross in Nepal, Pakistan, Bangladesh, and Laos. All four countries experienced stagnant rates of institutional deliveries over two program cycles, prompting an investigation into MNCH decision-making processes in the project areas. Authors' contributions S.A. contributed during data management, analysis, manuscript writing and substantively did revision and finalization of manuscript. A.G. contributed during the proposal development, analysis, substantially during manuscript writing and its revision. T.B. contributed during the proposal development, data collection, analysis, and during the manuscript writing and revision. J.B. supported the methodological design of the work, data analysis and interpretation; manuscript review. M.C.K. contributed to the conception and design of the work, the data analysis and interpretation; supported in manuscript writing and its revision. All authors reviewed the manuscript. Acknowledgements The authors of the study would like to thank the Country Coordinator of SRC Nepal Kamal Baral for his overall guidance and support. We would like to acknowledge the whole team of Community Empowerment for Health Promotion (CEHP) of Nepal Red Cross Society specially Mr. Raj Kumar Kshetri, Mr. Amulya Vaish for overall finance, administrative and logistics management, Mr. Resham Khadka for his support during the trainings provided to the research assistants, and Mr. Jagannath Chaudhary for his support during analysis of the study. We would like to provide our immense gratitude towards the CEHP project’s field staffs of Dang, West Rukum, and Rolpa for their support during the process of pretesting and data collection. We would like to extend our sincere thanks to all the four research assistants: Sailendra Gartaula, Keshab Raj Joshi, Anzela Sapkota, and Prasamsha Thapa who were involved in the data collection of the research. Our special thanks to all women, men and community members, local authorities, health managers and health professionals of the respective study municipality for their participation in this study and their open and valuable sharing of experiences. The authors of this study would like to thank the teams of the remaining three countries Laos, Pakistan and Bangladesh, for their peer support during the design of this research, the data collection and report writing process. Authors' information 1. Consultant, Helen Keller International, Lalitpur, Nepal ( [email protected] ) 2. Independent Consultant, Kathmandu, Nepal ( [email protected] ) 3. Previous Senior Health Programme Officer, Swiss Red Cross, Kathmandu, Nepal ( [email protected] ) 4. Independent Consultant, Fajara, The Gambia ( [email protected] ) 5. Senior Health Advisor, Swiss Red Cross, Bern, Switzerland ( [email protected] ) References WHO. World Health Statistics 2023 Monitoring health for the SDGs Sustainable Development Goals HEALTH FOR ALL [Internet]. 2023. Available from: https://www.who.int/publications/book-orders. MoH Nepal; New Era and ICF. Nepal Demographic and Health Survey 2016. Kathmandu; 2016. MoHP N. National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021. Kathmandu; 2022. Rahman MA, Rahman MA, Rawal LB, Paudel M, Howlader MH, Khan B, et al. Factors influencing place of delivery: Evidence from three south-Asian countries. PLoS One. 2021 Apr 1;16(4 April). Sharma G, Molla YB, Budhathoki SS, Shibeshi M, Tariku A, Dhungana A, et al. Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- And middle-income countries: Lessons from Ethiopia and Nepal. PLoS One. 2021 Oct 1;16(10 October). Gupta I, William J, Rudra S. Demand side financing in health. How far can it address the issue of low utilization in developing countries? World health report [Internet]. 2010;1–34. Available from: http://www.who.int/entity/healthsystems/topics/financing/healthreport/27DSF.pdf Tegegne TK, Chojenta C, Loxton D, Smith R, Kibret KT. The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis. PLoS One. 2018 Aug 1;13(8). Lama T, Khatry S, Katz J, LeClerq S, Mullany LC. Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Nepal. 2017;1–12. Shah R, Rehfuess EA, Paudel D, Maskey MK, Delius M. Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: A qualitative study. Reprod Health. 2018;15(1):1–13. Tey NP, Lai SL. Correlates of and barriers to the utilization of health services for delivery in South Asia and Sub-Saharan Africa. The Scientific World Journal. 2013;2013. Lusambili AM, Muriuki P, Wisofschi S, Shumba CS, Mantel M, Obure J, et al. Male Involvement in Reproductive and Maternal and New Child Health: An Evaluative Qualitative Study on Facilitators and Barriers From Rural Kenya. Front Public Health. 2021 Apr 21;9. Pacagnella RC, Cecatti JG, Osis MJ, Souza JP. The role of delays in severe maternal morbidity and mortality: Expanding the conceptual framework. Reprod Health Matters. 2012 Jun;20(39):155–63. Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context [Internet]. 1994. Available from: https://www.researchgate.net/publication/11134243 Lama TP, Khatry SK, Katz J, LeClerq SC, Mullany LC. Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal. J Health Popul Nutr. 2017;36(Suppl 1):45. Speizer IS, Story WT, Singh K. Factors associated with institutional delivery in Ghana: the role of decision-making autonomy and community norms [Internet]. 2014. Available from: http://www.biomedcentral.com/1471-2393/14/398 Simkhada B, Porter MA, Van Teijlingen ER. The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study [Internet]. Vol. 10, BMC Pregnancy and Childbirth. 2010. Available from: http://www.biomedcentral.com/1471-2393/10/34 Rizkianti A, Afifah T, Saptarini I, Rakhmadi MF. Women’s decision-making autonomy in the household and the use of maternal health services: An Indonesian case study. Midwifery. 2020 Nov 1;90. Kebede AA, Cherkos EA, Taye EB, Eriku GA, Taye BT, Chanie WF. Married women’s decision-making autonomy in the household and maternal and neonatal healthcare utilization and associated factors in Debretabor, northwest Ethiopia. PLoS One. 2021 Sep 1;16(9 September). Zhang Z, Cunningham K, Adhikari RP, Yogi S, Manandhar S, Rana PP, et al. Maternal Decision-Making Input and Health-Seeking Behaviors Between Pregnancy and the Child’s Second Birthday: A Cross-Sectional Study in Nepal. Matern Child Health J. 2020 Sep 1;24(9):1121–9. Kielmann K, Cataldo F, Seeley J. Introduction to Qualitative Research Methodology: A Training Manual, produced with the support of the Department for International Development (DfID), UK, under the Evidence for Action Research Programme Consortium on HIV Treatment and Care [Internet]. 2012. Available from: http://www.dfid.gov.uk/R4D/Output/188391/Default.aspx DOHS/MOHP. Annual Report 2076/77 (2019/20). 2077;78(December):2–2. Available from: https://sec.gov.gh/wp-content/uploads/Annual-Reports/2019-Annual-Report.pdfFF Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: Results from a randomized controlled trial. Health Educ Res. 2007 Apr;22(2):166–76. WHO. Standards for improving quality of maternal and newborn care in health facilities. 2016. Nepal Helath Sector Support Program (NHSSP). Improving the quality of pre-discharge postnatal care. Nucl Phys. 1959;13(1):104–16. Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: An overview of the evidence. Reprod Health. 2014 Sep 4;11. Minimum Service Standards (MSS) Tool for Health Post_2076. 2076; Paul PL, Pandey S. Factors influencing institutional delivery and the role of accredited social health activist (ASHA): a secondary analysis of India human development survey 2012. BMC Pregnancy Childbirth. 2020 Aug 5;20(1). Kohi TW, Mselle LT, Dol J, Aston M. When, where and who? Accessing health facility delivery care from the perspective of women and men in Tanzania: A qualitative study. Vol. 18, BMC Health Services Research. BioMed Central Ltd.; 2018. Ministry of Health and Population (MOHP). NDHS Key findings. NDHS survey key findings 2022. 2022; Chukuezi C. Socio-cultural Factors Associated with Maternal Mortality in Nigeria. Vol. 1, Research Journal of Social Sciences. 2010. Mgawadere F, Unkels R, Kazembe A, van den Broek N. Factors associated with maternal mortality in Malawi: Application of the three delays model. BMC Pregnancy Childbirth. 2017 Jul 12;17(1). Alvarez JL, Gil R, Hernández V, Gil A. Factors associated with maternal mortality in Sub-Saharan Africa: An ecological study. BMC Public Health. 2009;9. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files BMCListoftablesSA.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5335904","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371585047,"identity":"028f8f6d-3dee-4e17-8133-9aaa8bbeaf87","order_by":0,"name":"Shijan Acharya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYDACCcYGAxANJhgqgJiZuYEULWdAWhgJaYHSYC2MbWASvxb52c0NBT932Mmbs599JvFzXm00fztQy4+KbTi1GNw52GDYeybZcGdPuplk77bjuTMOMzYw9py5jVuLRGKDAW8bc4LBgTQ2Cd5tx3IbgFqYGdtwa5Gfkdhg+LetPsHg/DM2yb9zjuXOJ6SF4UZigzFv2+EEgxtpbNK8DTW5GwhpMQBpkW07brjhxjNma5ljB3I3ArUcxOcX+RnpzwzftlXLG5xPY7z5pqYud975wwcf/KjA4zAGBjYDKIMFGEeHwawD+NQDAfMDGOMDA0MdAcWjYBSMglEwEgEAAExeB1qSoK8AAAAASUVORK5CYII=","orcid":"","institution":"Helen Keller International Nepal","correspondingAuthor":true,"prefix":"","firstName":"Shijan","middleName":"","lastName":"Acharya","suffix":""},{"id":371585048,"identity":"c7d96bc7-a85d-40be-9ce5-beaa5cc5f824","order_by":1,"name":"Anju Gautam","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Anju","middleName":"","lastName":"Gautam","suffix":""},{"id":371585049,"identity":"4d3eb2c1-1718-4741-8e42-1c09ce4e1dcd","order_by":2,"name":"Tulasa Bharati","email":"","orcid":"","institution":"Swiss Red Cross, Nepal","correspondingAuthor":false,"prefix":"","firstName":"Tulasa","middleName":"","lastName":"Bharati","suffix":""},{"id":371585050,"identity":"d5ff1bdb-9be0-4053-8904-008a8f4435a0","order_by":3,"name":"Joanna Busza","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Busza","suffix":""},{"id":371585051,"identity":"aeb946a4-cbcf-47e8-ac70-62d5195c06ea","order_by":4,"name":"Monika Christofori-Khadka","email":"","orcid":"","institution":"Swiss Red Cross","correspondingAuthor":false,"prefix":"","firstName":"Monika","middleName":"","lastName":"Christofori-Khadka","suffix":""}],"badges":[],"createdAt":"2024-10-26 06:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5335904/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5335904/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87541706,"identity":"559d8949-abb9-4eb3-81b5-519edfdf110d","added_by":"auto","created_at":"2025-07-25 03:46:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1193679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5335904/v1/8effedc9-e002-4329-a346-d8152052786f.pdf"},{"id":68478248,"identity":"615f9271-f47b-4ed6-a6c7-9146bcd6737f","added_by":"auto","created_at":"2024-11-07 16:29:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23832,"visible":true,"origin":"","legend":"","description":"","filename":"BMCListoftablesSA.docx","url":"https://assets-eu.researchsquare.com/files/rs-5335904/v1/158e6fedf71a9461e20fb5af.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Influencing Decision-making for Institutional Delivery in Rural Nepal: A Qualitative Study","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eIn 2020, around 800 women died daily due to the pregnancy and childbirth related reasons. Most of them were from developing countries like Nepal. Deaths during pregnancy, and around delivery can be prevented if women receive quality services timely. The Nepal Government provide free delivery services and cash incentive when women deliver in a public health facility. However, many women do not use these services as they experience delays in deciding to use health service.\u003c/p\u003e\n\u003cp\u003eThis study tried to learn how women and their families make decisions about using delivery services during pregnancy and how those decisions play out during actual birth. In order to explore what things, influence such decisions, we interviewed total thirty-four women from two rural districts of Nepal, who had recently given birth (at home or in health facilities); her family members (husbands, mothers-in-laws); nine health workers and local leaders; and eight group discussions with community people to better understand their opinions.\u003c/p\u003e\n\u003cp\u003eWe found that during the labour process, decision-making, previous arrangements and choices along with decision-makers changed and women depended on others to decide. When their husbands were aware of signs of labor or potential dangers, they were quicker to decide to use health facility. However, low confidence in health facilities’ staff and service quality reduced likelihood of going including the woman’s past experiences, the level of support from the community, and availability of transportation. Therefore, health programs should focus on including husbands and family members in pre-delivery birth preparation to increase timely healthcare-seeking practice.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eMaternal mortality remains a significant public health challenge, with approximately 800 preventable deaths occurring daily as of 2020, primarily in in low- and lower-middle-income Countries (LMICs) which accounted for 95% of total maternal deaths worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Sub-Saharan Africa and Southern Asia account for around 87% of these deaths, highlighting persistent disparities in maternal health outcomes in 2020, among which Sub-Saharan Africa alone accounted for around 70% while Southern Asia accounted for around 16% of total maternal deaths (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2016, Nepal reported Maternal Mortality Ratio (MMR) of 239 deaths per 100,000 live births (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)which was reduced to 151 deaths per 100,000 live births in 2021(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While this indicates progress it highlights the ongoing challenges it faces in achieving the Sustainable Development Goals (SDGs) target of reducing the MMR to less than 70 per 100,000 live births by 2030 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite efforts to improve Maternal, Neonatal, and Child Health (MNCH) outcomes, delays in accessing obstetric care remain a critical issue in Nepal. Notably, the First Delay- referring to the time taken to recognize the complications and decide to seek care- accounted for 57% of maternal deaths, as indicated by a verbal autopsy of 611 maternal deaths reported in the 2021 census (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNumerous studies have highlighted barriers to maternal health service utilization in LMICs\u0026mdash;such as difficult geography, financial constraints, cultural norms, and women's low autonomy (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The complexity of seeking maternal and neonatal care is shaped by multiple factors. Barriers like transportation difficulties, financial limitations, nighttime onset of labor, and the distance to health facilities intensify these challenges (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThaddeus and Maine had recognized that prompt and sufficient treatment for obstetric complications plays a crucial role in lowering maternal mortality. Their research introduced a new perspective on analyzing maternal deaths, utilizing a three-phase framework to identify shortcomings in access to proper care for obstetric emergencies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Thaddeus and Maine's framework identifies three levels of delay contributing to maternal deaths: delays in recognizing risks and deciding to seek care (First Delay), delays in reaching a health facility (Second Delay), and delays in receiving appropriate care upon arrival (Third Delay) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough all these factors important, decision making can have a huge influence that occurs before and during labor(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Factors like educational level, economic status, ethnicity, and place of residence play crucial roles in determining whether women choose institutional delivery or not (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Nepal, qualitative studies reveal that socio-cultural norms, concerns about healthcare quality, and logistical barriers further complicate this decision-making process (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In rural Chitwan, evidence suggests socio-cultural norms favoring home births are reinforced by concerns about healthcare quality, deterring women from choosing institutional deliveries, even when birthing centers are nearby (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Similarly, in Sarlahi District, concerns about the quality of public health facilities and delays in receiving appropriate care deter women from seeking institutional delivery services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom this literature review, there is a need to delve deeper into the decision-making processes that occur before and during labor(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). While previous studies have examined the barriers to institutional delivery in general and extensively examined structural determinants (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)the specific decision-making process before and during labor remains underexplored.\u003c/p\u003e \u003cp\u003eTo support fulfilling this gap, this study seeks to understand the decision-making processes prior to, at the onset of labour and during labour, focusing on determinants of the first delay, which include factors and individuals influencing women\u0026rsquo;s decision whether or not to attend a health facility at childbirth. By gaining insight into these household-level dynamics, strategies can be developed to better inform and involve family members in the decision-making process while respecting the woman\u0026rsquo;s preferences during delivery (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Focusing on these factors, overall, this study aims to promote positive shifts in maternal health outcomes inNepal.\u003c/p\u003e"},{"header":"Method","content":"\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis is a qualitative study using semi structured interviews (SSI), key informant interviews (KII) and focus group discussion (FGD). Qualitative research explores the perceptions, beliefs and motivations behind observed behavior from the perspectives of those experiencing the phenomena of interest (20). This study tries to understand birth-related healthcare decisions as taken by pregnant women and those who influence them based on their own interpretations of recent experiences.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in Banglachuli rural municipality (Dang district) and Tribeni rural municipality (Rukum-west district) of Province 5 -Lumbini and Province 6 -Karnali respectively. These sites, part of the Nepal Red Cross Society\u0026rsquo;s Community Empowerment for Health Promotion program, were selected purposively due to their rural location having low maternal health service utilization rates (as shown in table) and mixed ethnicity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough Dang is a Terai district (plain geography), the study site of Dang was remote and had diverse socio-economic status, ethnic composition (i.e mixed community of so-called advantaged caste groups like Bhramin and Chettri and so-called disadvantaged caste groups like Dalit and others). Rukum-west represents a typical hilly district of Nepal. Catchment area of Hansipur Health Post with birthing center of Banglachuli RM of Dang (ward 7,8) and catchment area of Simrutu Health Post with birthing center of Tribeni RM of West Rukum (ward 1, 2) were the selected data collection sites.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1\u0026nbsp;MNCH service use as per HMIS indicators\u0026nbsp;(21)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndicators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDang\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRukum-West\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNepal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e% of Institutional delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e73.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e65.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e% of pregnant women who had four ANC check-ups (as per protocol*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e51.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e65.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e% of SBA delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e56.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1919%;\"\u003e\n \u003cp\u003e62.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*ANC protocol as per MoHP during the time of study- ANC visit at 4\u003csup\u003eth\u003c/sup\u003e, 6\u003csup\u003eth\u003c/sup\u003e, 8\u003csup\u003eth\u003c/sup\u003e and 9\u003csup\u003eth\u003c/sup\u003e months\u003c/p\u003e\n\u003cp\u003ePercentage of institutional delivery, ANC check-ups, and SBA delivery as per HMIS indicators in shown in the table 1 which shows the lower percentage of these indicators compared to national average in Dang district, whilst that of Rukum-west are slightly higher than the national average however still far behind in reaching the SDG goals.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews (SSIs) were conducted with women who had delivered at home or in a facility within the last six months and their family members (husbands or mothers-in-law), and KII with healthcare providers, and local authorities. FGDs were conducted with groups of community people ie, women, men, healthcare providers and other stakeholders such as community leaders, teachers, traditional healers, and Female Community Health Volunteers (FCHVs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to select participants with a range of birth experiences, including those who had experienced complications and referrals. Participants were identified by the local health worker, FCHVs, Health Mothers\u0026apos; group members who were familiar with women/households who experienced pregnancy outcomes/care engagement. Diversity in ethnicity and economic status, and in the case of key informants, a range of roles and positions of authority was sought. The selection of study cluster/communities for FGDs was based on local diversity, socio-economic differences and vulnerability, ethnicity representing diverse background and knowledge about decision making and different social dynamics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAltogether 4 group discussions were conducted in each site where 8-12 participants were present in each group. Total 22 SSIs and KIIs were conducted in Dang whereas 21 SSIs and KIIs were conducted in Rukum-West.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2\u0026nbsp;Sample Frame for Individual Interviews\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 388px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of interviews (N= 43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistrict\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePlace and type of birth\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eHusbands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMother-in-law\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003eLocal authority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDang\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNormal delivery at facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDelivery at facility with complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNormal delivery at home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDelivery at home with complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRukum West\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNormal delivery at facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDelivery at facility with complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNormal delivery at home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDelivery at home with Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs shown in table 2, total 19 women participants were interviewed. Besides women, total 13 husbands, 2 mother-in-laws, 5 health workers and 4 local authorities were also interviewed.\u003c/p\u003e\n\u003cp\u003eData collection tools\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection tools included interview guides for FGDs, SSI, and KIIs. FGDs were facilitated according to specific guidelines detailing the three above-mentioned research techniques and moderation process. SSI and KII guidelines featured questions tailored to different interviewee types (women, husbands, mothers-in-law) and focused on decision-making and service utilization during pregnancy, childbirth, and the postnatal period. All tools were translated into Nepali to ensure clarity and appropriateness for the participants.\u003c/p\u003e\n\u003ch3\u003eData collection techniques\u003c/h3\u003e\n\u003cp\u003eAll study participants were approached by the data collectors and asked for their consent to be interviewed. Subsequently, data collectors arranged a convenient time and private place for the SSIs, KIIs and FGDs. All data collection was conducted by 4 local research assistants trained in FGD and interview methods. The research officers supervised the fieldwork, including daily reviews of digital recordings, verification of data completeness, and transcription assessments. Daily team meetings were held to discuss preliminary findings and refine the data collection process.\u003c/p\u003e\n\u003cp\u003eSSIs allowed respondents to share their personal experiences and perspectives on decision-making and barriers in accessing health services in a semi-structured narrative format. KIIs offered perspectives from healthcare providers and local authorities on the supply-side aspects of maternal health, and their perceptions of low rates of delivery service uptake. Focus Group Discussions, each lasting 90-120 minutes, were conducted in three phases: \u0026nbsp;Community Mapping, where participants developed a visual map of maternal health services; Pregnancy Pathway, where they outlined potential maternal experiences from pregnancy detection to delivery; and Barrier/Facilitator Identification, where they used a \u0026quot;Horse \u0026amp; Cart\u0026quot; metaphor to identify factors that \u0026ldquo;pull forward\u0026rdquo; or \u0026ldquo;hold back\u0026rdquo; likelihood of women delivering in a facility. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePretesting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTools were pretested in Rolpa District from March 22-23, 2021, to adapt them to local contexts and literacy levels. Insights from the pretest led to modifications of the tools, such as adding more probing questions and numbering participants in the FGD to facilitate notetaking. In a review meeting the question flow was refined and probing techniques improved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection timeline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected from March 26\u003csup\u003eth\u003c/sup\u003e to April 9\u003csup\u003eth\u003c/sup\u003e, 2021.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews and FGDs were audio-recorded, transcribed and translated from Nepali to English. Thematic analysis was conducted using both \u0026lsquo;bottom-up\u0026rsquo; and \u0026lsquo;top-down\u0026rsquo; coding approaches, meaning open-ended identification of codes emerging from the data were added to codes based on the topic guide questions. Following coding, the team analyzed the data by grouping codes into categories and/or breaking them down into sub-codes and developed themes based around factors affecting women\u0026apos;s decision-making prior to and at the time of giving birth. The analysis was done using the following steps in two phases:\u003c/p\u003e\n\u003cp\u003ePrimary analysis:\u003c/p\u003e\n\u003cp\u003e(1)\u0026nbsp;\u0026nbsp;familiarization of the data by the researchers by reading and rereading the transcribed data and the notes.\u003c/p\u003e\n\u003cp\u003e(2)\u0026nbsp;\u0026nbsp;discussion within the study team to develop a framework for primary analysis using MS Excel.\u003c/p\u003e\n\u003cp\u003e(3)\u0026nbsp;\u0026nbsp;agreement of an initial coding framework for general emerging themes\u003c/p\u003e\n\u003cp\u003e(4)\u0026nbsp;\u0026nbsp;three separate analysis sheets for SSI of community people, KII of stakeholders, and FGD were used. Transcripts and notes were categorized in the data according to the stages of pregnancy and categories of questions asked.\u003c/p\u003e\n\u003cp\u003eSecondary analysis:\u003c/p\u003e\n\u003cp\u003e(5)\u0026nbsp;\u0026nbsp;data from FGD and SSIs were analyzed in the different rows of the same excel sheet in order to triangulate the information.\u003c/p\u003e\n\u003cp\u003e(6)\u0026nbsp;\u0026nbsp;code generation by team members and comparison of coding for consistency.\u003c/p\u003e\n\u003cp\u003e(7)\u0026nbsp;\u0026nbsp;discussion of main codes and then grouping them into themes and/or sub-dividing them into sub-codes/categories.\u003c/p\u003e\n\u003cp\u003e(8) \u0026nbsp;checking for outliers and rechecking the transcripts to ensure there aren\u0026rsquo;t examples of data that contradict or challenge the main findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e The results of the study are grouped, starting with a summary of participants\u0026rsquo; demographic characteristics and then reflecting different themes as facilitators and barriers in decision-making for institutional delivery.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics\u003c/h2\u003e \u003cp\u003eAmong the women interviewed, most belonged to the Janajati and Brahmin/Chettri ethnic group, whereas very few represented Dalit ethnic group \u003cem\u003e(Note: Brahmin/Chettri considered as higher class followed by Janajati (indigenous groups) and Dalits considered as lower class in traditional belief system of caste hierarchy).\u003c/em\u003e The representation of people who live in a joint family setting was slightly higher than that of a small family-type.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge of women respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency of women (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that most women were aged 20\u0026ndash;29, followed by those\u0026thinsp;\u0026le;\u0026thinsp;19, and then 30\u0026ndash;39. This indicates the persistence of early marriage and pregnancy in the study areas. Over half of the women had two children, with the rest having one child. The study also found a slightly higher number of respondents with experience of institutional deliveries compared to home deliveries. Most husbands were migrant workers, mainly in India, with nearly half being seasonal migrants who returned home during critical periods such as pregnancy, delivery, or postnatal phases to provide financial and workload support. The major occupation of the women and other family members was agriculture and farming; therefore, mostly the women were involved in household chores, agriculture, and farming activities along with child-rearing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThematic findings\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eTheme 1: Factors influencing decision-making choice of pregnant women for institutional delivery\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section4\"\u003e \u003ch2\u003e1.1 Previous experiences\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003ePrevious positive experience as facilitator for institutional delivery\u003c/strong\u003e \u003cp\u003eMany women, who already delivered at least once in a health facility had positive delivery experiences, which further reinforced their preference. Nearly all respondents from Rukum-West and over half from Dang preferred health facilities for delivery, often citing positive past experiences as a key factor in their decision.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was already planned that the delivery would be in a HF. We knew it was safe to do so, there might be complications at home\u0026rdquo;. (Dang -facility delivery normal /Woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I advise others to go to a nearby health facility if it seems that a normal delivery would happen. If it looks like a normal delivery would not happen then I would advise to go to a higher-level facility.\u0026rdquo; (Rukum-West- facility delivery normal/Husband)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e The quality health services and facilities provided at birthing center also influenced women\u0026rsquo;s decision making to deliver at health facility which was also quoted by healthcare provider that the facilities such as accommodation influenced their positive decision-making.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We have arranged lodging and food at the HF for women and one companion as some might have to stay for 2/3 days. Some can arrange it by themselves, but it is not possible for everyone. Some can\u0026rsquo;t afford to stay and eat at a hotel.\u0026rdquo; (KII_Dang-healthcare provider)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They do regular checkups once in a month for mother and baby. If there is any problem, the staff also visit mothers at home. All services provided from this health facility are good.\u0026rdquo; (Rukum-West-Health Facility delivery/Husband)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, previous positive experience in home birth also influenced the decision to deliver a subsequent child at home, despite advice from the health workers. The perceived hassle of traveling to a health facility for a 'normal birth\u0026rsquo; influenced their decision.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I preferred to deliver at home than go to the doctors. Health workers at the health facility had suggested giving birth at the facility and they gave me a number to contact them in case of labor pain. But, as I delivered my first child at home, I didn\u0026rsquo;t feel it necessary to seek service at the Health Facility\u0026rdquo;. (Dang-Home Delivery with Complication/ Women)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePrevious negative experiences as barrier of institutional delivery\u003c/strong\u003e \u003cp\u003eSimilarly, negative past experiences influenced the decision-making in favor of delivering at home. Some women opted for home births, especially in Dang, due to concerns about body exposure.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had thought that I would deliver my child at home and would not go to a Health Facility. But everybody forced me to go even though I didn\u0026rsquo;t want to. My first child was delivered at home. And when I was pregnant with my second child, I thought of delivering the child at home as well. It\u0026rsquo;s shy to go to the doctor and expose oneself, that\u0026rsquo;s why I didn\u0026rsquo;t want to go\u0026rdquo;. (Dang-Facility Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eNegative past experiences included dissatisfaction with the quality of infrastructure and amenities at health posts. The perceived negative experience with facility deliveries, such as prolonged labor and discomfort, led some women to prefer home births since they could have facility of fire for warmth at home which lacked in health facilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are no facilities of warming like fire at home, there is not heater in health facility for pregnant women hence they shiver from the cold. During the delivery of my first child too, I had prolonged labor pain due to a cold at HF. So, we had to take her (child) to a higher-level health facility in the city. This is the reason, most of the women usually like home delivery rather than institutional delivery\u0026rdquo;. (Rukum-West-Home Delivery Normal/ Woman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe behavior of the healthcare staff experienced by themselves or by the other women in the community significantly influenced women\u0026rsquo;s decisions and their choice of delivery location.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;At first, we had doubts regarding Health Facility delivery. Additionally, when other women share their experience about the treatment done in the Health Facility like scolding, if we cry during delivery, then we feel like delivering at home rather than being scolded at Health Facility.\u0026rdquo; (Dang-Women Group FGD)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Fear of complications\u003c/h2\u003e \u003cp\u003eWomen who chose to deliver at health facilities often did so due to concerns about potential complications and previous difficult childbirth experiences. Both women and some husbands expressed fears about possible complications and viewed health facilities as safer options for childbirth. Awareness of the ability of health facilities to manage complications strongly influenced their preference for these settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We had planned and prepared for HF delivery. Joint decision making was done with the family members because there were complications during the delivery of the first child. We sought advice from the family members this time\u0026rdquo;. (Rukum-West-Facility Delivery with Complication/ Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was aware about the danger signs during delivery; therefore, we had planned to deliver at Hansipur\u0026rdquo; HP. (Dang- home delivery normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Actually, I wanted a doctor\u0026rsquo;s attended delivery rather than delivering alone at home. I was afraid. I always wanted to go to a HF for delivery because I believe that they would save me if any complications arrive. There are people who don\u0026rsquo;t want to seek such service, but for me, I wanted to go\u0026rdquo;. (Dang-Home Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Family's Support for Women\u0026rsquo;s Choice of Institutional Delivery\u003c/h2\u003e \u003cp\u003eMany respondents regardless of their actual place of delivery during the course of pregnancy, stated that they had initially preferred to deliver at a health facility. While planning for birth, decisions about delivery location were often made jointly with their husbands, sometimes with additional input from other family members.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;First of all, I planned it and discussed it with my family members as well.\u0026rdquo; (Rukum-Facility Delivery with Complication /Women)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My wife told me that the delivery should be done at a HF. There were no objections from my parents\u0026rdquo;. (Dang-Facility Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My husband is the only person I share opinions with. I told my husband and in-laws that there might be complications at home, so it is better to deliver at a health facility. (Dang-Facility Delivery Normal /Women)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Everyone in the family suggested we go to HF for delivery. They suggested that the time has changed, and people need to seek a safe delivery at the HF. They said that it was not safe to deliver at home as complications may arise. Therefore, we went to the health facility for delivery\u0026rdquo;. (Rukum-West-Facility Delivery Normal/ Women)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, in some cases, decision-making power appeared situated more with husbands or other family members, which stood as a barrier to institutional delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There was no one at home, only my young son. I talked (with my husband) over the telephone. He said if the baby is born normally at home, then it is good but if not then go to a health facility. My sister-in-law also said the same thing. If the delivery happens at home, she will look after me and support me. It would be good if it happens at home. If there is difficulty, then we should go to a health facility.\u0026rdquo; (Rukum-West-home delivery normal/Women)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Factors influencing family\u0026rsquo;s decision making after the onset of labor\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e2.1 Influence of people present at labour: shifts in decision-making\u003c/h2\u003e \u003cp\u003eWomen who successfully followed their plan to deliver at a health facility often had supportive husbands and family members who helped ensure timely arrival at the facility. However, decision-making authority sometimes shifts during labor. Despite prior discussions with their husbands or family about the delivery location, decisions could change once labor began. Exhausted from labor pains and reliant on family members for care, the individuals present during labor played a crucial role in determining the delivery location.\u003c/p\u003e \u003cp\u003eThe outcome depended on the caregivers' knowledge and understanding of emergency obstetric services. For example, some women who initially planned home births ended up delivering at health facilities, while others who had intended to deliver at a health facility chose home births instead, based on assurances of comfort from their family.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was nighttime when she (daughter-in-law) started to have labor pain. We told her that we were calling an ambulance to go to the health facility, but she didn\u0026rsquo;t want to go. But we took her anyway. She didn\u0026rsquo;t have long labor as it started at 5.00am and the baby was born at around 7.30 am\u0026rdquo;. (Dang-Facility Delivery Normal /Mother-in-law)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I started to have labor pain at 4.00am and the baby was born at around 7.00am. When I started to have labor pain, I also had slight bleeding. I called my sister and shared this with her. She said that it is better to have the baby at home, if not we need to go to the Health Facility. I also called my sister-in law and shared this with her then she came to us. She also said if I delivered at home, it is good if not then we will go to the Health Facility. She gave me an oil massage. Then the baby was born at home\u0026rdquo;. (Rukum-West-Home Delivery Normal/ Woman)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was having labor pain, but I didn\u0026rsquo;t go to the health facility. I wanted to deliver at home only. But my husband didn\u0026rsquo;t agree, and he called for an ambulance. I thought I will be able to give birth, but I couldn't, so we walked further up, then I gave birth on the way\u0026rdquo;. (Rukum-Home Delivery Normal/ Woman)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen I gave birth to this child, I started having labor pain at 2 am in the morning. I told my mother-in-law about it. I went to the health facility in an ambulance. My mother-in-law called a community mobilizer who works in a community-based nutrition project and gave her our location as she was there at the health facility. However, I did not want to go to health facility, I wanted to give birth at home. I went there because everyone (family members) wanted me to go.\u0026rdquo; (Dang-Facility Delivery Normal /Woman)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Influence of the time of onset of labour: hesitancy to act upon promptly\u003c/h2\u003e \u003cp\u003eSome women faced challenges in enacting their decision to deliver in an institution when labor pain began at night. Labor starting at night often led to delays in seeking care until morning, because some women were hesitant to inform their husband and family members until daytime, in order to not disturb their sleep or give them a hard time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I started to have labor pain at 2:00 AM at night. It was rainy season, and no transportation would have come though it used to come during the dry season. I was alone at home, and it was difficult to call for help as all the men had migrated to India and there were only older people at home. I was waiting and gave birth at 5.00am. I didn\u0026rsquo;t call at the time of delivery but I called them after delivery in the morning\u0026rdquo;. (Rukum-West-Home Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlerting family members late, further postponed arranging transportation. Mobilizing community support and accessing ambulance services at night proved challenging compared to daytime, complicating the process of reaching a health facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Her labor pain had started at midnight and the baby was born at 12 in the afternoon the next day. She was having labor pain since midnight, but she only told me in the morning. Then I tried to call (for an ambulance) but the number was not reachable. And while I was trying to contact the health facility, she already gave birth at home.\u0026rdquo; (Dang-Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It was already late by the time we could arrange for all materials and vehicles. It took time to arrange everything. My labor pain started at midnight and the baby was born in an hour.\u0026rdquo; (Rukum-West-Home Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e2.3 Timely recognition of signs of labor\u003c/h2\u003e \u003cp\u003eFemale respondents, who had delivered in a health facility reported that they were able to promptly recognize the onset of labor and initiate their journey to the facility. In contrast, those families where the woman did not deliver at a health facility or had experienced complications, often struggled to identify true labor pains or determine the right time to seek care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;She (wife) said that she had a slight pain in the abdomen around 9\u0026ndash;10 pm at night. I had no idea whether the abdomen pain was normal regular pain or it\u0026rsquo;s a labor pain and hence I was confused whether to take her to HF or not.\u0026rdquo; (Dang Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome women were reluctant to go to a health facility timely due to concerns about waiting for labor to progress.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I recognized very little pain. I had a similar pain during the birth of my first baby. I thought about why to visit the Health Facility during minimal labor pain and stay all day at the Health Facility, so I didn\u0026rsquo;t visit Health Facility earlier and decided to go when there will be more labor pain\u0026rdquo;. (Rukum-West-Facility Delivery with Complication /Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Now it is better to go to the health facility as soon as possible if there is labor pain. I have seen pregnant women who have been kept at home for two or three days in some places\u0026rdquo;. (Rukum-West-Facility Delivery with Complication/ Husband)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Cultural and traditional beliefs delayed timely decision-making\u003c/h2\u003e \u003cp\u003eFamilies with strong cultural beliefs sometimes prioritized traditional healers, which delayed seeking professional medical care. Beliefs in supernatural causes for prolonged labor and pain, especially if symptoms appeared before the expected delivery date, also influenced decisions. These cultural beliefs impacted healthcare choices, causing delays in consulting healthcare providers and arranging transportation, whether the delivery occurred at a health facility or at home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I went to see a traditional healer to know if there is any lagat (bad spirit). I came to know there is a bad spirit. The healer came home and did his ritual, but she didn\u0026rsquo;t get better. He did the same on the next day then she got better\u0026rdquo;. (Dang-Facility Delivery with Complication/ Husband)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Factors influencing the actualization of plan for institutional delivery\u003c/h2\u003e \u003cdiv id=\"Sec26\" class=\"Section4\"\u003e \u003ch2\u003e3.1 Birth preparedness: Are women and their families truly prepared?\u003c/h2\u003e \u003cp\u003eDespite birth preparedness plans, many women still failed to reach health facilities on time due to various reasons. Respondents described their efforts to prepare for safe childbirth beyond decision-making, including securing funds for medical expenses, arranging transportation, providing nutritious food for the mother, and preparing clothing for the baby.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My husband was working in India during my delivery. He had sent home some money to use if needed while delivering the baby.\u0026rdquo; (Dang-Facility Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I had already packed some clothes for the child and for myself in a bag. My mother-in-law had borrowed ten thousand Nepalese Rupees from the mothers\u0026rsquo; group. My husband also had around ten-eleven thousand. We went to a health facility with this money.\u0026rdquo; (Dang-Facility Delivery with Complication /Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have to carry women in stretchers from here. We had prepared clothes and other materials needed for delivery. There is a stretcher at the school which was given by the health post for emergency use. I had also prepared for money. My brothers had sent it from abroad (India). I had kept it separately almost one and half months before delivery.\u0026rdquo; (Rukum-West-Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFamily members thought they were prepared for what was needed like (stretchers and resources like money and people). Despite birth preparations, many women still struggled to reach health facilities in a timely manner due to lacking of understanding of onset of labor pain, prompt action, complemented by structural determinants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;While we were trying to search for previous documents (ANC cards, reports) and call for an ambulance, the baby was already born. The labor pain started at around 8PM and the baby was born after half an hour.\u0026rdquo; (Dang-Home Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have to carry women in stretcher from here. We had prepared for clothes and other materials needed for delivery. There is a stretcher at the school which was given by the health post for emergency use. I had also prepared for money. My brothers had sent it from abroad (India). I had kept it separately almost one and half month before delivery.\u0026rdquo; (Rukum-Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Vehicles do come here but not all the time. So, we had to carry her. I had requested my friends and brothers in the village for support. I also consulted with FCHV. We had also prepared some money, clothes and foods like ghee, honey and chickens for mother.\u0026rdquo; (Rukum-Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;She (wife) said that she had a slight pain in the abdomen around 9\u0026ndash;10 pm at night. I had no idea whether the abdomen pain was normal regular pain or it\u0026rsquo;s a labor pain and hence I was confused whether to take her to HF or not. At the same time there was a heavy rainfall and there were no one to leave small kid. There is not delivery facility nearby, to take Hansipur, road access was problem due to rain and raised level of river and it was difficult to manage people to carry as they were busy in agricultural work at daytime and didn\u0026rsquo;t feel comfortable to call at mid of night.\u0026rdquo; (Dang Home Delivery Normal /Husband)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e3.2 Social cohesion and community support\u003c/h2\u003e \u003cp\u003eDecision making is supported by community members and support groups. Besides, financial assistance and help with transportation, the advice from community members plays a role in deciding the place of delivery in both positive and negative ways.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;People around us (neighbors) used to suggest her to go to the health facility. My wife was experienced and was aware about it. We decided to ask for suggestions from an FCHV. She then suggested to visit HF. Therefore, we did as per the community people suggested\u0026rdquo;. (Dang- facility-based delivery with complication /Husband)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We seek support from our own community. We seek financial support as well as human resource support if the woman has to be carried on a stretcher. They also support communication with the health worker in times of emergency\u0026rdquo;. (Dang-Community Male FGD)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne woman reported that despite being prepared, the community did not support her in manifesting her decision to deliver in a health facility. Since she was living alone with her husband working abroad, she faced challenges. She and her husband\u0026rsquo;s decision to deliver at a health facility was overruled when labor began at night, and the immediate supporter did not honor the decision of the couple.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was sleeping when I started to have labor pain. My husband (in India) was saying that we should call the neighbors and go to the health facility as there is no facility in the village. But no one called the ambulance. Neighbors were getting ready to take me to the health facility. I started to have pain at 9pm and the baby was delivered at 1.00am at home. There were sisters helping me at the time of delivery, they were giving hot oil massages and hot water with sugarcane. I was saying it would be easy if I would have been taken to a health facility. But they said that we continue the oil massage and if you have difficulties then we will take you. Then I had to wait 3 hours\u0026rdquo;. (Rukum-West Home Delivery Normal /Woman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussions","content":"\u003cp\u003eThis study aimed to explore the decision-making process by women before and during labor regarding their place of birth and what affected them. The decision for institutional delivery tended to be dynamic throughout pregnancy and multiple factors affected the decision of seeking care contributing to the first delay.\u003c/p\u003e \u003cp\u003eDuring the period prior to labor, women\u0026rsquo;s decision to have (or not to have) institutional delivery was shaped by their past experiences either at home or health facility, their understanding of birth complications, and the support of husbands and family members. Whereas after the onset of labor, the decision to seek care was influenced by the family and relatives\u0026rsquo; attitude towards having institutional delivery, time of onset of labor, timely recognition of signs of labor, and cultural beliefs similar to other studies done in Nepal as well as in other countries like Ghana, Indonesia and Ethiopia (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s decisions and preference for place of birth prior to labor were based on their past birth experiences, either at home or the health facility. Women who previously had a normal delivery at home were more inclined to choose home birthing again, and this choice is reinforced by the negative experiences resulting from the poor attitude of care providers, lack of competence, lack of infrastructure, and overall low quality of service at health facilities as delineated by a meta-synthesis of qualitative studies from across Africa, Asia, and South America (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Improving the quality of maternal health services has been brought into focus globally to increase utilization and receiving of appropriate care (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). While national programs such as the Minimum Service Standards Package are being rolled out in Nepal to improve service quality and accountability in the health system, localized efforts for competency building and fostering trust between healthcare providers and the community could promote the general preference for institutional delivery from the early stage of decision making (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePast experiences of difficult birth inclined women and their families to decide on institutional delivery in their subsequent births, and more so if the use of health services had resulted in a positive birth outcome. Apart from difficult experiences, perceived urgency and fear of developing complications was another factor in encouraging women to choose facility-based delivery. Even women who preferred home birth vocalized that they would go to a health facility if normal birth did not happen while at home. However, their approach of \u0026lsquo;wait and watch\u0026rsquo; significantly delays care seeking(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Well-informing women and their families about the possible complications and reaching health facilities at the earliest to ensure safety is valuable in reducing such delays.\u003c/p\u003e \u003cp\u003eOne of the critical findings in this study is that the families and community members influenced care-seeking decisions more often during labor. While decision-making prior to labor often involved the woman and her husband, after the onset of the labor women relied on their family, relatives, or community members for decision-making, to the point, where the initial decision of the woman is not honored any longer. Female relatives, in particular, played a crucial role in either facilitating or delaying care, even though they were not involved in prenatal decision-making(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The shifts in decision-making authority from the woman to those around her were similar to the patterns observed in Tanzania (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough this study does not examine women\u0026rsquo;s decision-making autonomy, the findings of the study highlight the role of husbands and family members in supporting women to use health services corroborating with the findings of a bi-variate analysis study from Ghana that shows women living in a community supportive of institutional delivery to be more likely to deliver at health facility despite their level of autonomy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The household dynamics, open communication, and circumstances during labor were unique to each woman in this study which underscores the need for health programs to adopt a family-centered approach, actively involving husbands and other key family members from the antenatal period.\u003c/p\u003e \u003cp\u003eThe increase in the use of ANC-services across Nepal (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) presents opportunities to go beyond regular health education to reduce the barriers posed by distrust and negative perceptions about local health services. Family-centric antenatal education promoting better spousal and family level communication could also address other barriers identified in this study such as delayed recognition of signs of labor, hesitancy to alert family members about labor pain at night, or seeking traditional healers, ultimately preventing the first delays. However, further study is needed to explore the quality and content of ANC-counseling and how a family-centric approach can be integrated into current ANC-service practices.\u003c/p\u003e \u003cp\u003eFurthermore, community programs should expand their coverage to include males as well as general community members to develop positive community attitudes towards facility-based delivery and harness more social cohesion to support every women to actualize their decision of institutional delivery.\u003c/p\u003e \u003cp\u003eApart from factors influencing the decision to have facility birth, findings reported in theme 3 flag the structural barriers faced by women and families when choosing institutional delivery. Although financial difficulties were less vocalized in this study, the migration of husbands for work opportunities reduced the availability of support for women during labor making them less likely to go to a health facility. Distance, unreliable transportation, communication service, and difficult geography continue to challenge the actualization of the decisions to deliver at a health facility adding to previous studies in Nepal and many other LMICs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe interventions addressing the barriers contributing to the first delay can only be as effective as interventions addressing others. Addressing the barriers to decision-making can only be effective when efforts are present to reduce the structural barriers. While addressing these challenges requires significant resources and government commitment, a thorough birth and complication readiness plan considering the local context should be emphasized during antenatal education.\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis qualitative study explores perspectives of women and family members on maternal health services during delivery including experiences with complications in both homes as well as facility-based births. It incorporates viewpoints from women who have delivered either at home or in health facilities, family members along with healthcare providers, and local authorities. Analysis of these perspectives revealed facilitators and barriers to maternal service utilization that are valuable in guiding the strategies aimed at improving maternal and neonatal health outcomes.\u003c/p\u003e \u003cp\u003eThe study aimed to minimize bias by including women who had delivered within the last 12 months, thus reducing recall bias. Interviews were conducted in the original language to maintain the authenticity of respondents' experiences.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhile the efforts were made to limit bias through study design and methodology, the purposive sample selection in a small area may have introduced sampling and geographical bias. The narratives from healthcare providers and local authorities did not generate novel perspectives and insights as per the objective of the study, and was not mentioned in detailed in this paper. The majority of mentioned findings presented are based on women\u0026rsquo;s and husband\u0026rsquo;s perspectives.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study found that decision-making about\u0026nbsp;place of birth\u0026nbsp;is dynamic and influenced by various factors throughout pregnancy and labour.\u0026nbsp;Positive experience of using health services, fear of developing complications, support from family encouraged women to choose institutional birth whereas distrust in health services, delay in recognizing signs of labor, hesitancy to seek care at night, ‘wait and watch’ attitude of family members hindered timely decision for seeking care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile women are increasingly involved in decision-making during the pregnancy, the responsibility often shifts to family members, particularly husbands and mothers-in-law, once labour begins. The decision-making process around maternal health services evolves dynamically with progression of pregnancy. Husbands and family members often play pivotal roles specifically after onset of labor when women depend upon them to reach the health service.\u0026nbsp;The family-centric antenatal education and involvement of male in community awareness programs should be prioritized to improve general community’s attitude of institutional delivery and improve spousal communication to reduce the delay in decision-making at family level.\u003c/p\u003e\n\u003cp\u003eHealth programs should focus on including husbands and family members in pre-delivery birth preparation to increase timely healthcare-seeking practice. Additionally, it would require further studies to fully explore what strategies can be adopted to effectively engage with family members taking in account localized context such migration and nuclear families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLow confidence in health facilities’ staff and service quality affected the preference of giving birth at health facility. Building trust between healthcare providers and families, and improving service quality are crucial for promoting institutional deliveries. Despite birth preparedness, many women failed to reach health facilities on time. The findings highlight the need to address structural barriers at community level such as reliable transportation and communication services to actualize the decision of facility-based delivery.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviation","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eANC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAntenatal Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFCHVs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale Community Health Volunteers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocus Group Discussions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGovernment of Nepal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHMIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth Management Information System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKey Informant Interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLMCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow and Lower Middle-Income Countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaternal Mortality Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMNCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaternal, Neonatal and Child Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostnatal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSBA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSkilled Birth Attendants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSDGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSemi-Structured Interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval for the study was granted by the Nepal Health Research Council (NHRC), Reference Number 153 of 28 July 2020. During data collection, strict ethical standards regarding privacy and confidentiality were upheld. Written approvals were obtained from respective municipality authorities as part of the NHRC ethical approval process. Before data collection began, courtesy meetings were conducted with Rural Municipality authorities and health units to explain the study objectives and procedures, and to share NHRC ethical approval.\u003c/p\u003e\n\u003cp\u003eAll study participants provided written consent before participating in interviews and discussions. For participants unable to read or sign, consent was obtained verbally and confirmed with a thumbprint. Field researchers ensured participants understood the study objectives, information usage, and provided contact details for further inquiries. Participation was voluntary, and participants could withdraw at any time. Anonymity was maintained through a code-to-name matching system.\u003c/p\u003e\n\u003cp\u003eData collectors were trained to recognize mental distress of study participants and, in case of any mental distress, to immediately stop the interview, ask if the person needs support and call the immediate supervisor to liaise with the respective focal person on mental health and psycho-social support of the Nepal Red Cross Society. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eThe authors have provided their individual consent for the publication.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThis study applied a standardized methodology used similar data collection tools for all four countries that were adapted to each local context. The data used and analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was conducted by the Nepal Red Cross funded by Swiss Red Cross in Nepal. It is a part of broader research conducted by the Swiss Red Cross in Nepal, Pakistan, Bangladesh, and Laos. All four countries experienced stagnant rates of institutional deliveries over two program cycles, prompting an investigation into MNCH decision-making processes in the project areas.\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\n\u003cp\u003eS.A. contributed during data management, analysis, manuscript writing and substantively did revision and finalization of manuscript. A.G. contributed during the proposal development, analysis, substantially during manuscript writing and its revision. T.B. contributed during the proposal development, data collection, analysis, and during the manuscript writing and revision. J.B. supported the methodological design of the work, data analysis and interpretation; manuscript review. M.C.K. contributed to the conception and design of the work, the data analysis and interpretation; supported in manuscript writing and its revision. All authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors of the study would like to thank the Country Coordinator of SRC Nepal Kamal Baral for his overall guidance and support. We would like to acknowledge the whole team of Community Empowerment for Health Promotion (CEHP) of Nepal Red Cross Society specially Mr. Raj Kumar Kshetri, Mr. Amulya Vaish for overall finance, administrative and logistics management, Mr. Resham Khadka for his support during the trainings provided to the research assistants, and Mr. Jagannath Chaudhary for his support during analysis of the study. We would like to provide our immense gratitude towards the CEHP project’s field staffs of Dang, West Rukum, and Rolpa for their support during the process of pretesting and data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to extend our sincere thanks to all the four research assistants: Sailendra Gartaula, Keshab Raj Joshi, Anzela Sapkota, and Prasamsha Thapa who were involved in the data collection of the research. Our special thanks to all women, men and community members, local authorities, health managers and health professionals of the respective study municipality for their participation in this study and their open and valuable sharing of experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors of this study would like to thank the teams of the remaining three countries Laos, Pakistan and Bangladesh, for their peer support during the design of this research, the data collection and report writing process.\u003c/p\u003e\n\u003ch2\u003eAuthors' information\u003c/h2\u003e\n\u003cp\u003e1. Consultant, Helen Keller International, Lalitpur, Nepal ([email protected])\u003c/p\u003e\n\u003cp\u003e2. Independent Consultant, Kathmandu, Nepal (\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e)\u003c/p\u003e\n\u003cp\u003e3. Previous Senior Health Programme Officer, Swiss Red Cross, Kathmandu, Nepal ([email protected])\u003c/p\u003e\n\u003cp\u003e4. Independent Consultant, Fajara, The Gambia (\u003ca href=\"mailto:[email protected]\" target=\"_blank\"\[email protected]\u003c/a\u003e)\u003c/p\u003e\n\u003cp\u003e5. Senior Health Advisor, Swiss Red Cross, Bern, Switzerland ([email protected])\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWHO. World Health Statistics 2023 Monitoring health for the SDGs Sustainable Development Goals HEALTH FOR ALL [Internet]. 2023. Available from: https://www.who.int/publications/book-orders.\u003c/li\u003e\n \u003cli\u003eMoH Nepal; New Era and ICF. Nepal Demographic and Health Survey 2016. Kathmandu; 2016.\u003c/li\u003e\n \u003cli\u003eMoHP N. National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021. Kathmandu; 2022.\u003c/li\u003e\n \u003cli\u003eRahman MA, Rahman MA, Rawal LB, Paudel M, Howlader MH, Khan B, et al. Factors influencing place of delivery: Evidence from three south-Asian countries. PLoS One. 2021 Apr 1;16(4 April).\u003c/li\u003e\n \u003cli\u003eSharma G, Molla YB, Budhathoki SS, Shibeshi M, Tariku A, Dhungana A, et al. Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- And middle-income countries: Lessons from Ethiopia and Nepal. PLoS One. 2021 Oct 1;16(10 October).\u003c/li\u003e\n \u003cli\u003eGupta I, William J, Rudra S. Demand side financing in health. How far can it address the issue of low utilization in developing countries? World health report [Internet]. 2010;1\u0026ndash;34. Available from: http://www.who.int/entity/healthsystems/topics/financing/healthreport/27DSF.pdf\u003c/li\u003e\n \u003cli\u003eTegegne TK, Chojenta C, Loxton D, Smith R, Kibret KT. The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis. PLoS One. 2018 Aug 1;13(8).\u003c/li\u003e\n \u003cli\u003eLama T, Khatry S, Katz J, LeClerq S, Mullany LC. Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Nepal. 2017;1\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eShah R, Rehfuess EA, Paudel D, Maskey MK, Delius M. Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: A qualitative study. Reprod Health. 2018;15(1):1\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eTey NP, Lai SL. Correlates of and barriers to the utilization of health services for delivery in South Asia and Sub-Saharan Africa. The Scientific World Journal. 2013;2013.\u003c/li\u003e\n \u003cli\u003eLusambili AM, Muriuki P, Wisofschi S, Shumba CS, Mantel M, Obure J, et al. Male Involvement in Reproductive and Maternal and New Child Health: An Evaluative Qualitative Study on Facilitators and Barriers From Rural Kenya. Front Public Health. 2021 Apr 21;9.\u003c/li\u003e\n \u003cli\u003ePacagnella RC, Cecatti JG, Osis MJ, Souza JP. The role of delays in severe maternal morbidity and mortality: Expanding the conceptual framework. Reprod Health Matters. 2012 Jun;20(39):155\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eThaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context [Internet]. 1994. Available from: https://www.researchgate.net/publication/11134243\u003c/li\u003e\n \u003cli\u003eLama TP, Khatry SK, Katz J, LeClerq SC, Mullany LC. Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal. J Health Popul Nutr. 2017;36(Suppl 1):45.\u003c/li\u003e\n \u003cli\u003eSpeizer IS, Story WT, Singh K. Factors associated with institutional delivery in Ghana: the role of decision-making autonomy and community norms [Internet]. 2014. Available from: http://www.biomedcentral.com/1471-2393/14/398\u003c/li\u003e\n \u003cli\u003eSimkhada B, Porter MA, Van Teijlingen ER. The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study [Internet]. Vol. 10, BMC Pregnancy and Childbirth. 2010. Available from: http://www.biomedcentral.com/1471-2393/10/34\u003c/li\u003e\n \u003cli\u003eRizkianti A, Afifah T, Saptarini I, Rakhmadi MF. Women\u0026rsquo;s decision-making autonomy in the household and the use of maternal health services: An Indonesian case study. Midwifery. 2020 Nov 1;90.\u003c/li\u003e\n \u003cli\u003eKebede AA, Cherkos EA, Taye EB, Eriku GA, Taye BT, Chanie WF. Married women\u0026rsquo;s decision-making autonomy in the household and maternal and neonatal healthcare utilization and associated factors in Debretabor, northwest Ethiopia. PLoS One. 2021 Sep 1;16(9 September).\u003c/li\u003e\n \u003cli\u003eZhang Z, Cunningham K, Adhikari RP, Yogi S, Manandhar S, Rana PP, et al. Maternal Decision-Making Input and Health-Seeking Behaviors Between Pregnancy and the Child\u0026rsquo;s Second Birthday: A Cross-Sectional Study in Nepal. Matern Child Health J. 2020 Sep 1;24(9):1121\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eKielmann K, Cataldo F, Seeley J. Introduction to Qualitative Research Methodology: A Training Manual, produced with the support of the Department for International Development (DfID), UK, under the Evidence for Action Research Programme Consortium on HIV Treatment and Care [Internet]. 2012. Available from: http://www.dfid.gov.uk/R4D/Output/188391/Default.aspx\u003c/li\u003e\n \u003cli\u003eDOHS/MOHP. Annual Report 2076/77 (2019/20). 2077;78(December):2\u0026ndash;2. Available from: https://sec.gov.gh/wp-content/uploads/Annual-Reports/2019-Annual-Report.pdfFF\u003c/li\u003e\n \u003cli\u003eMullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: Results from a randomized controlled trial. Health Educ Res. 2007 Apr;22(2):166\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eWHO. Standards for improving quality of maternal and newborn care in health facilities. 2016.\u003c/li\u003e\n \u003cli\u003eNepal Helath Sector Support Program (NHSSP). Improving the quality of pre-discharge postnatal care. Nucl Phys. 1959;13(1):104\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eAustin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: An overview of the evidence. Reprod Health. 2014 Sep 4;11.\u003c/li\u003e\n \u003cli\u003eMinimum Service Standards (MSS) Tool for Health Post_2076. 2076;\u003c/li\u003e\n \u003cli\u003ePaul PL, Pandey S. Factors influencing institutional delivery and the role of accredited social health activist (ASHA): a secondary analysis of India human development survey 2012. BMC Pregnancy Childbirth. 2020 Aug 5;20(1).\u003c/li\u003e\n \u003cli\u003eKohi TW, Mselle LT, Dol J, Aston M. When, where and who? Accessing health facility delivery care from the perspective of women and men in Tanzania: A qualitative study. Vol. 18, BMC Health Services Research. BioMed Central Ltd.; 2018.\u003c/li\u003e\n \u003cli\u003eMinistry of Health and Population (MOHP). NDHS Key findings. NDHS survey key findings 2022. 2022;\u003c/li\u003e\n \u003cli\u003eChukuezi C. Socio-cultural Factors Associated with Maternal Mortality in Nigeria. Vol. 1, Research Journal of Social Sciences. 2010.\u003c/li\u003e\n \u003cli\u003eMgawadere F, Unkels R, Kazembe A, van den Broek N. Factors associated with maternal mortality in Malawi: Application of the three delays model. BMC Pregnancy Childbirth. 2017 Jul 12;17(1).\u003c/li\u003e\n \u003cli\u003eAlvarez JL, Gil R, Hern\u0026aacute;ndez V, Gil A. Factors associated with maternal mortality in Sub-Saharan Africa: An ecological study. BMC Public Health. 2009;9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Decision-making, 3 delays model, maternal health service utilization, institutional delivery, complications","lastPublishedDoi":"10.21203/rs.3.rs-5335904/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5335904/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMaternal mortality is a critical global issue, with approximately 800 preventable deaths occurring daily in 2020, predominantly in low and lower middle-income countries. Nepal, recording 151 maternal deaths per 100,000 live births in 2021, faces significant challenges despite efforts to increase institutional deliveries. This study examines the decision-making processes surrounding childbirth, in the rural districts of Nepal, focusing on the roles of family and community members and factors influencing the decision-making choice for utilization of institutional delivery.\u003c/p\u003e \u003cp\u003eUsing purposive sampling technique, the study conducted thirty-four semi-structured interviews with women who had recently given birth, along with their husband and mothers-in-law. Additionally, nine key informant interviews with health workers and local authorities, and eight focus group discussions were held with women, men, health workers and local stakeholders. Thematic (Bottom-up) approach was employed to identify relevant themes and sub-themes initiated by codes and categories.\u003c/p\u003e \u003cp\u003eThe study found that decision-making about seeking care is dynamic and influenced by various factors throughout pregnancy and labour. While women are increasingly involved in decision-making during the pregnancy, the responsibility often shifts to family members, particularly husbands and mothers-in-law, once labour begins. Key factors influencing care-seeking decisions included fear of complications, previous obstetric experiences, perceived competence of healthcare providers, and role of community people. Despite birth preparedness plans, many women still failed to reach health facilities on time.\u003c/p\u003e \u003cp\u003eThe findings highlight the need to include husbands and family members in birth preparedness counselling and awareness programs to ensure timely care-seeking decisions. Emphasizing the urgency of timely care, building trust between healthcare providers and families, and improving service quality are crucial for promoting institutional deliveries.\u003c/p\u003e","manuscriptTitle":"Factors Influencing Decision-making for Institutional Delivery in Rural Nepal: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-07 16:29:21","doi":"10.21203/rs.3.rs-5335904/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"25a80219-cb42-4daa-be5e-e474e432c777","owner":[],"postedDate":"November 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-25T03:38:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-07 16:29:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5335904","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5335904","identity":"rs-5335904","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}