A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs—a qualitative study among multiparous women in Somaliland

ABSTRACT

Background

Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women’s choice of place of birth.

Objective

In this study, we explore multipara women’s needs and preferences when choosing the place of birth.

Method

An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years.

Results

The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth.

Conclusion

To meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

KEYWORDS:

• Home-based birth
• facility-based birth
• decision-making
• reproductive agency

RESPONSIBLE EDITOR

Maria Emmelin

RESPONSIBLE EDITOR

Maria Emmelin

Acknowledgments

The authors would like to thank the participants who participated in this study for sharing their experiences. We wish to dedicate this article to the memory of Dr Dirie Erg, Dean of the College of Medicine and Health Sciences at the University of Hargeisa, who passed away in the COVID 19 pandemic, in 2021, and was not able to see this publication come to life.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

Ethics and consent procedure details are documented in the manuscript. Ethical clearance to conduct the study was obtained first from the Somaliland Ministry of Health and Development and second from the research ethics committee of the University of Hargeisa. Approval number Dr: CS/41105/18.

Paper context

Women in low resource settings choose home births with untrained, traditional birth attendants in preference to health authorities’ facility-based maternity services. This study provides a valuable description of why multipara women in low-resource settings choose a home birth.

To meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up at public health facilities. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Additional information

Funding

This study was funded by Dalarna University, Sweden .

Notes on contributors

Jama Ali Egal

All authors have made substantial contributions to the conception and design of this study. All authors have participated in the work to such a degree as to be willing to be responsible and accountable for all aspects of the study, and for ensuring that questions related to the accuracy of any part of the work are appropriately investigated and described.