Participants in the FGDs ranged in age from 18 to 37
years. The socio-demographic characteristics of women in the FGDs are shown in Table
. Most of them had some primary education but about one third of them were illiterate. A little less than half of the women in the FGDs (41.5
%) held traditional animist beliefs and the others were Buddhists. Almost all were farmers. The parity ranged from one to seven and the women’s most recent intrapartum experience had occurred between 1 and 12
Characteristics of FGD participants
The women who participated in in-depth interviews (IDI) ranged in age from 17 to 38
years, had husbands between 26 and 46
years old, and mothers and mothers-in-law between 45 and 50
years old. About 37.5
% of husbands and 50
% of mothers were illiterate. The characteristics of the key informants who participated in IDIs are summarized in Table
Socio-demographic characteristics of participants in in-depth interviews
Two women, one in a FGD and one in an interview, had experienced a stillbirth. Two of the women interviewed had had complications: one had had excessive bleeding and the other had lost consciousness during the birth. The woman with bleeding was referred to the provincial hospital and had recovered there. The woman who lost consciousness was assisted by a TBA and recovered without needing to go to hospital. The babies were alive and, aside from the two stillborn children, there were no cases of disabled children or death.
Overall summary of results
The reasons women and men gave for choosing home deliveries had at least as much to do with the perceived advantages of home births – they are convenient, time-tested, and near to family -- as with the perceived disadvantages of hospital births – they involve high costs, make it difficult for family to be present, and require that women give birth in the disliked horizontal position. Women and men recognized the value of the hospital as a place to turn to when a delivery went wrong, but found the home setting fully adequate and preferable for giving birth otherwise (See Table
Results: Why do rural Laotians prefer home delivery, and who decides?
Perceived advantages of home births
Ease, Convenience, and Nearness to Family: Ease, convenience, and nearness to relatives were the most cited reasons for home delivery. Family members noted that with home deliveries they did not need to move from one place to another and they and their relatives did not need to go to hospital for visiting.
"“I preferred to deliver at home because at home it is easier. You can boil the water and cook, and I can accommodate my relatives and husband.” (Woman, 35)"
"“I would like my wife to deliver at home because it is easy and cheap; additionally, I can help my wife during labor by massaging her abdomen during pain.” (Husband, 34)"
The availability of family support was also mentioned by women, mothers and husbands. At home births, mothers and husbands could stay close to the women and provide psychological support as well as physical care, including back massage and gentle touching of the abdomen, soothing the woman in labor and making her feel warm. In hospitals, the husband and other family members are not permitted to enter the delivery room. One husband described how he cared for his wife during labor:
"“I gave psychological support to my wife when she delivered by putting my hand to her hand and gave her emotional support with pushing during labor” (Husband, 31)"
Women themselves also saw the presence of their husbands and other family members as an advantage to giving birth at home:
"“I like to deliver at home because I like my husband staying with me during labor and I feel warmest and I am not afraid. My husband holds my hands and the TBA also stays with me” (Woman, 29)"
In addition to close relatives, other family members and neighbors also pay visits to women giving birth, and giving birth at a health facility makes this impossible, as one woman pointed out:
"“It is impossible to drag my family to visit me at the hospital as I have 3 children and my relatives as well....” (Woman, 30)"
Desirable Birthing Practices at Home: Pregnant women wanted their husbands and mothers to be close to them during labor to give psychological support, but were often also attended by a TBA, in addition to other relatives. Women and their families expressed great confidence in TBA’s, their skills and their knowledge. TBAs supervised deliveries either at their own homes or at the woman’s home. The predominant role of TBAs was to give traditional medicine and “magic water” that has been prayed over by a healer or by lay people to the woman in labor to relieve pain, treat abnormal discharge, and give her energy and strength to push the baby out. TBAs helped women during labor by advising them to walk around during early contractions, and by compressing the abdomen during later stages. One 26-year old woman described the TBA’s role thus:
"“During labor, the TBA suggested that I walk in order to make the head of the baby engaged in my pelvis to make it easy to deliver.”"
Mothers and husbands also provided care and support to women in labor. Mothers gave herbal medicine and coconut milk to their daughters and put eggs on their daughters’ abdomens, all in order to ease delivery. Husbands helped in similar ways:
"“I used an herbal medicine called “wane” mixed in water and I put this water on the head of my wife to help make the labor easy and to reduce pain during labor.” (Husband, 32)"
Participants also mentioned that women in labor normally drank some water that had been blessed with sacred words or had the water put on their abdomen in order to make the birth easier. One TBA noted that,
"“… With a difficult delivery, I blow water from the spiritual healer or use another method such as soap in the vagina to make it an easy delivery and if it is not successful then I suggest that the woman go the hospital.”"
TBAs also advised women on different positions during labor in order to facilitate childbirth, and used other traditional remedies to ease delivery:
"“To support and assist a woman during labor I suggest that she lie down and hold onto a rope and I push her abdomen in order to make the head of the baby come down; then I do a vaginal examination [not as invasive as those done at health facilities] to check the cervical dilatation, and when it’s fully opened I tell her to use her all her energy to push.” (TBA, 38)"
Position of delivery was an important factor in women’s preference for home delivery. At home women give birth in a sitting position with their knees to their chest, holding onto a rope hanging from the ceiling (described above), a position they prefer to the prone position required at the hospital. In addition, at home women can follow the practices of taking a hot bath and of lying over a fire to warm their bodies during the postpartum period, traditional valued practices thought to help heal the body after delivery. As one 28-year old woman explained,
"“After delivery at home, I can take a hot bath so the wounds will heal quickly and the bleeding will stop, and I can lie on a hot bed.”"
Even when TBA’s did not attend a birth, relatives attending the birth saw to it that the practices described above were followed.
Previous positive experiences: Previous positive experience with home delivery was another common reason given for choosing to give birth at home. Most women had already delivered at least one child at home, and if this delivery had gone well there was no reason to change. Even if a woman herself had not delivered previously at home, the delivery experiences of mothers-in-law, mothers, aunts and grandmothers all influenced the place of delivery.
Perceived disadvantages with giving birth at a health facility
Costs and transport: In addition to the social and psychological support available to women who give birth at home, giving birth at home is also cheaper, many participants pointed out. Giving birth at home costs little beyond the obligatory payment to the TBA, while giving birth at a health facility involves paying for the delivery itself, any needed medicines, the hospital room, and transport to the health facility, and food. One 29-year old woman expressed the views of many when she said,
"“I could not afford the hospital delivery due to the high cost of a hospital delivery compared to a home delivery. For the hospital delivery, I had to pay for the rooms and medicine, while for home delivery, I did not pay anything except the gift for TBA’s who assisted my delivery.”"
Physical distance and lack of transportation were also obstacles to delivering at health facilities. In the rural areas there is no public transport between the villages and the health facilities, so people have to rely on their own means of transport, such as motorbikes and small trucks, to get to health centers. One mother described how transportation difficulties prevented her from seeing to it that her daughter gave birth at the health facility as she, the mother, had hoped:
"“My daughter was delivering for the first time, so I wanted her to deliver at the health facilities; however, I waited for a bus or pick-up for two hours; there was not any transport and I did not have my own transport.”"
Sometimes, labor started at night and the family did not want to travel at night; in other cases, families were afraid that labor could start while travelling a long distance to health facilities. In some cases there simply was not time to get to a hospital because of the quick progression of labor.
"“Because the labor was easy and quick and was a short labor, I couldn’t get to the health facilities on time.” (Woman, 26)"
Dislike of position of delivery and medical procedures: Unlike the squatting position that women preferred, health facilities demand that women lie on their backs on a labor bed with their legs strapped to metal stirrups. Women did not like giving birth in this position:
"“I don’t like the birthing position in the health facilities where you have to lie with your legs wide open.” (Woman, 28)"
Some women also noted that they were afraid of some medical procedures commonly performed at the hospital such as episiotomies and suturing after delivery. A 24-year old woman described her dislike of common hospital procedures thus:
"“I did not want to deliver at a hospital because I was afraid that the health staff would cut me and I would not be able to lie over a fire or on a hot bed and I was afraid of bleeding … The other medical procedure I did not want was a vaginal examination, which they do at the health facilities. When I delivered at home where there was no vaginal examination.”"
As this woman explains and as mentioned above, another drawback of giving birth at a hospital is that women cannot follow their traditional birthing practices, considered essential for a woman to recover properly from childbirth. As one 28-year old woman reasoned,
"“If I were to deliver at a hospital, I could not lie on a hot bed immediately after birth because the stitches might come out.”"
Presence of male birth attendants: Another aspect of hospital services that women did not like was that the birth attendant could be a man. Their husbands, interestingly, could accept this, but most of the women felt shy and embarrassed by having a male attendant.
Lack of privacy and confidentiality: Informants also reported that they disliked the lack of privacy and confidentiality at the hospital. The presence of many health staff during delivery coupled with women’s shyness at being naked during delivery made hospital deliveries less appealing than home deliveries:
"“In the health facilities, there are a lot of health staff during the delivery and I am shy, so I prefer to deliver at home” (Woman, 25)"
Previous negative experiences: Previous negative experiences at the health facilities were another reason women and their families chose not to deliver there. Either the women themselves or their mothers described receiving poor service at health facilities when they were ill, and this discouraged them from wanting to give birth there. One mother described how she got worse rather than better when recently treated for an illness at health center:
"“My daughter did not want to deliver at the hospital because I had a bad experience with the health staff. During my previous illness, I went to hospital and the health staff gave me some injections; however, I got worse, so I did not want my daughter go to hospital.”"
Reasons for choosing delivery at the health facilities: skilled birth attendants and high-risk pregnancies
The only reasons informants gave for giving birth at the health facilities were the skill and medical knowledge of trained health professionals and their ability to assist women if complications arose during delivery. If labor was prolonged, there was excess bleeding, or the baby was in a breech presentation, women and their families preferred to give birth under the supervision of trained health workers. As one mother explained,
"“I wanted my daughter to deliver at hospital because I was concerned for my daughter’s health and I wanted health staff supervising and examining her; I felt confident that they could help the mother and baby in time.” (Mother, 54)"
Even though men preferred for their wives to give birth at home, they too recognized the advantages of a hospital delivery if there seemed to be any risk factors in the pregnancy:
"“I talked to my wife and said that if the labor is prolonged or difficult, I will bring her to the hospital.” (Husband, 27)"
Decision-making about place of delivery
The place of delivery was decided by the woman’s husband, mother, grandmother or a TBA, together with the woman herself, but it often seemed that the woman herself had the least say in the matter. As one woman put it,
"“My husband decided where to deliver; however, he also mentioned that it is up to me and I decided to deliver at home.” (Woman, 28)"
"“I consulted with my husband about where to deliver and we decided to deliver at home because my previous delivery also was at home.” (Woman, 35)"
Even if a woman and her husband preferred to have the delivery at a health centre, the mother, mother-in-law, aunt or even neighbors might advise the woman to deliver at home, in accordance with their own past experience of childbirth.
"“My mother always delivered at home, so she advised me to deliver at home and there nothing went wrong.” (Woman, 25)"
TBAs and health care providers were another source of advice and influence. According to some women, their health providers at ANC left it up to them to decide if they wanted to give birth at the health facility or at home. As one husband reported,
"“The nurse did not advise my wife to deliver at the hospital when my wife attended antenatal care. She said that my wife could deliver at home.” (Husband, 27)"
The vast majority of women thus ended up delivering at home with the assistance of a TBA. If the TBA could not help them, the women sought permission from their husbands to go the hospital and get the extra care they needed there.