The following perceived reasons for home delivery, grouped by key topics, emerged from the qualitative dataset. Most women, from nearly all villages, reported that they give birth at home because of lack of money to pay for delivery kits, fare and food. Home delivery cost was said not to exceed 600 Tanzanian shillings (roughly $0.5) for gloves and a razor blade. In some private hospitals they had to pay about 5000 Tanzanian shillings (equivalent to $4). Some health facilities were thought not to discharge women with no money until their debts were paid. When cash was not available for delivery at the heath facility, the options were to borrow money from relatives or friends, to sell land or produce, casual labour, and to offer a valuable object, such as a bicycle to someone in exchange for a temporary loan and reclaim it after returning the money. Availability of cash for transport was an important influence on whether health facility delivery was sought. This was substantiated by the quantitative data showing wealth quintiles as predictors of home births (see below). The following typical statements were recorded:
There was no reason for me to pay for a bed at a health facility while I could give birth for free at home. (Indepth-interview, Chikonji)
I heard from the radio that delivery services for the government health facilities are free of charge but when I went to the health facility for delivery I was asked to buy everything, even a Panadol, so what services are considered to be free of charge? (A mother of a neonate, Maundo)
Women who go to deliver at health facilities usually should have money to buy gloves, food and transport while those who deliver at home need thread and a razor only. (Indepth-interview with MT, Chikonji)
I spent about four thousand shillings to buy gloves, food, and I had to pay for my transport. I used normal transport and I paid one thousand shillings, otherwise I could pay up to twenty thousand shillings for hiring a car. I couldn't manage to eat good food at hospital, so I spent less money on food; one thousand and five hundred shillings. (FGD-Chikonji)
Lack of transport was reported in all villages as a contributing factor for home delivery. In most rural areas, public transport is the only means available and services can be irregular. For example, it was reported in one of the in-depth interviews that public transport was only available at 5 am.
‘If you don't own a bicycle, you should prepare to give birth at home.’ (FGD, Nahukahuka). Other FGD groups made the same comment.
I decided to give birth at home because of the lack of reliable transport to the nearby health facility, two hours walking distance. It is so dangerous to cross the forest at night; there are wild animals such as lions. (A mother of a neonate from Nahukahuka village)
Sometime, one can be referred to the big hospital during labour, but lack of transport can force the mother to deliver at home, lose a baby or die. (FGD-Mtakuja)
Another factor that influenced the choice of place of delivery was sudden onset of labour or short labour. This was mentioned in almost all of villages. Health facility delivery was perceived to be desirable for prolonged labour:
When a woman experiences sudden onset of labour she usually gives birth at home. Those who have given birth before usually give birth at home. (A mother of a neonate from Maundo village)
Health system factors, such as staff attitudes also had an impact on the choice of place of delivery. Poor staff attitude was perceived to exist in most health facilities; including abusive language, denying women service, lacking compassion and refusing to assist properly.
During my last few days before I delivered, I went to the clinic, the midwife advised me to go to the district hospital because the child was too big. The midwife threatened me that I would die if I didn't go to the hospital. Are these words good to tell someone who is pregnant like me? (An in-depth interview, Maundo village)
Another experience from an in-depth interview with a mother who had given birth recently, gave a clear picture of a provider–client relationship.
When I went for ANC (mobile clinic in the village) in the 9th month of my pregnancy, the health worker (nurse) instructed us that she would start with those who came to report their pregnancy for the first time, followed by those who had just delivered, and then with those who are in their last months of pregnancies. She called my name three times, but I couldn't hear because I was outside. She stopped other women who wanted to call me from outside, and instead, she decided to throw my card under a scrap milling machine which is in the same building where we get clinic services. I went inside after been told about this by other women, and she said I would either be the last to be attended, or be obliged to go to the health facility the next day. At the end of the day, she told me to come to the health facility next Tuesday. When I asked her what the reason was, she replied that she was tired. Imagine, I stayed hungry for the whole day, my children hadn't eaten. I didn't understand that it was a crime for not hearing my name. I left with sorrow, and ended up crying at home. I walked to the health facility on Tuesday as instructed, but I was told there was preparation for laboratory day ceremony (special day in the health facility organized for emphasizing importance of clinic diagnostic), I went back and delivered at home the day after. (In-depth interview with mother of neonate, Nahukahuka village)
In general, woman's expectation of the choice of place of delivery was influenced by a positive attitude of staff at the health facility.
When I went to the health facility (X) for delivery, I was impressed by the midwife who cared for me so much. She was so human, polite and sympathetic. (In-depth interview, Maundo)
Lack of privacy in some of the health facilities was also mentioned as a contributing factor for home delivery. Sometimes, older women give birth at home to avoid contact with younger mid-wives at the health facility, who they think of as their children. Some young women also do not deliver at health facilities because of the presence of male health workers during delivery.
Some health facilities have no special room for delivery; the room is small and all treatment for both men and women are taking place in the same room; you can easily be seen while giving birth. (a mother of a neonate, Kilimahewa village)
Traditional beliefs and culture were also mentioned as contributing factors for home delivery. It is perceived that long labour may be caused by extramarital affairs during pregnancy (nunumalila).
One of the reasons for home delivery is to keep the secret. If it is a woman's time for delivery and the child doesn't come out, a woman would be asked to mention all men who she has slept with apart from her husband; she would then be given some water to drink and then she mention that I have slept with so and so…, please my baby come out. She then drinks some water again; and if God wishes, she would deliver her baby safely otherwise, she would be taken to the hospital for major operation. It is the responsibility for all who participated in that delivery process to keep the secret. (FGD, Hingawali)
Some participants mentioned that this tradition is one of the causes of misunderstanding between husband and wife, and has led to many marriage breakdowns. This tradition was reported from most of our study villages but in some places it was said to be disappearing.
Most women who delivered at health facilities did not do so because they wished to, but were persuaded by a nurse, spouse, parents or grandmothers. The major reason given for why they were reluctant to make their own decision was lack of money.
When I went to the clinic in the last month of my pregnancy, the nurse advised me to go to the district hospital because the child was so big. I went to inform my husband and he agreed. It is my husband who decides the place of delivery because he has money. (An in-depth interview, Maundo village)
My last child was born at the health facility because my parents wanted me to deliver at health facility. I couldn't decide on my own because I had no money. (FGD, Nahukahuka village)
The decision for place of delivery was also influenced by the availability of a caregiver, regardless of the distance involved.
I was advised by nurse to go to the district hospital but decided to go to the regional hospital, because I had a relative who lives near the regional hospital. (FGD, Maundo village)
These findings corroborate the result of the quantitative work that women from female headed-households were more likely to deliver in health facilities.
Quality of services
The choice of place of delivery was not only determined by income. Quality of services was perceived to play a major role in choice of place of delivery. Although some government health facilities were equally close to where a majority of women lived, and were free of charge, some women decided to go to more distant private health facilities, despite the user charges involved. In some FGDs, the participants said that they were asked to bring water to clean the labour ward after delivery. Quality of services provided directed most women's choices.
I decided to deliver in that private health facility (X) because they provide good services. They are empathetic and can solve any problem; they have a car and can probably take you to the next level of services if need arises. In addition they don't ask you to bring water. (FGD, Mtakuja village)
Carelessness and lack of education were also perceived to be factors for home delivery. These reasons were mentioned in some FGD sessions.
…Lack of education is another factor for home delivery. Some expectant mothers can just stick to their decision regardless of their condition. (Indepth-interview, Mnolela)
What needs to be done?
Mothers were asked to make their own suggestion concerning improvements of delivery services. The following suggestions were put forward;
Please, remind all health workers, especially nurses, that they deal with fellow women; we can't respect them unless they treat us well too; if they love us we will respect them. (Indepth interview, Nahukahuka village)
Besides qualitative results as shown above, demographic and socio-economic status and place of delivery were also looked at quantitatively and results are presented below.
We visited 21 482 households representing 99% of the 21 600 households expected. A total of 98% of heads of household were present during the survey and only 0.004% refused to take part. A total of 94% of 20 138 women of reproductive age (15–49) visited were interviewed. Data were available for 9152 women who had delivered in the 3 years prior to survey. For their most recent births 5317 (58%) delivered at home and 3835 (42%) at a health facility.
Table 1 presents the predictors of place of delivery. In univariate analysis comparing home and health facility deliveries, differences between subgroups reached statistical significance (P < 0.05) for all variables considered (ethnicity, gender of the household head, mothers education, mothers age at the time of child birth and wealth quintiles).
Table 1. Factors associated with place of delivery in Lindi and Mtwara
|Demographic||Ethnic group||Makonde||2353||62||1359||38||1|| ||<0.001||1|| ||<0.001|
| ||5316||58||3835||42|| || || || |
|Gender of household head||Female||975||53||874||47||1|| ||0.001||1|| ||<0.001|
| ||5312||58||3833||42|| || || || |
|Mothers’ education||None||1730||64||937||36||1|| ||<0.001||1|| ||<0.001|
|Primary and higher education||2773||55||2341||45||1.30||1.23–1.38||1.29||1.20–1.38|
|5314||58||3833||42|| || || || |
|Mother's age at child birth||15–19||1151||54||1017||46||1|| ||0.005||1|| ||<0.001|
| ||5317||58||3835||42|| || || || |
|Social economic status||Wealth quintiles||Poorest||1012||63||634||37||1.07||1.05–1.10||<0.001*||1.08||1.06–1.10||<0.001*|
|Very poor||1219||61||762||39|| || || || |
|Poor||905||59||620||41|| || || || |
|Less poor||1183||61||772||39|| || || || |
|Least poor||940||49||992||51|| || || || |
| ||5259||58||3780||42|| || || || |
There was variation between ethnic groups with respect to place of delivery (P < 0.0001), with the Yao being more likely to deliver at health facility than the Makonde or Mwera (RR 1.48, 95% CI 1.34–1.63). Women who lived in male headed household were less likely to deliver in a health facility (RR 0.86, 95% CI 0.8–0.91). Mothers with primary and higher education were more likely to deliver at health facility than mothers with no education (RR 1.30, 95% CI 1.23–1.38). Younger mothers were more likely to deliver at a health facility than other age groups (RR 0.89, 95% CI 0.83–0.95). The least poor women were more likely to deliver in a health facility than the poorest with a 7% increase in the risk of delivering in health facility for every increase in wealth quintile (RR 1.07, 95% CI 1.03–1.43)
Using a generalized linear regression model, all variables (ethnicity, gender of the household head, mother's education, mother's age at the time of child birth, wealth quintile) remained independently associated with place of delivery. There was no evidence of two-way interaction between the variables. Risk ratio coefficients were similar in adjusted and unadjusted models, and thus there was little evidence of confounding.