Barriers to Institutional Childbirth in Rumbek North County, South Sudan: A Qualitative Study.

Calistus Wilunda,Ana Pilar Betrán,Chiara Scanagatta,Risa Takahashi,Giovanni Putoto,Francesca Montalbetti,Giulia Segafredo,Abigail Fraser

doi:10.1371/journal.pone.0168083

Abstract

BackgroundSouth Sudan has one of the world’s poorest health indicators due to a fragile health system and a combination of socio-cultural, economic and political factors. This study was conducted to identify barriers to utilisation of institutional childbirth services in Rumbek North County.MethodsData were collected through 14 focus group discussions with 169 women and 45 men, and 18 key informant interviews with community leaders, staff working in health facilities, traditional birth attendants, and the staff of the County Health Department. Data were analysed using inductive content analysis.ResultsThe barriers to institutional childbirth were categorised under four main themes: 1) Issues related to access and lack of resources: long distance to health facilities, lack of transportation means, referral problems, flooding and poor roads, and payments in health facilities; 2) Issues related to the socio-cultural context and conflict: insecurity, influence of the husband, lack of birth preparedness, domestic chores of women, influence of culture; 3) Perceptions about pregnancy and childbirth: perceived benefit of institutional childbirth, low childbirth risk perception, and medicalisation of childbirth including birth being perceived to be natural, undesirable birth practices, privacy concerns, and fear of caesarean section; and 4) Perceptions about the quality of care: inadequate health facility infrastructure and perceived neglect during admission.ConclusionsMultiple factors hinder institutional childbirth in Rumbek North. Some of the factors such as insecurity and poor roads are outside the scope of the health sector and will require a multi-sectoral approach if childbirth services are to be made accessible to women. Detailed recommendations to increase utilisation of childbirth services in the county have been suggested.

Highlights

Reduction in maternal mortality is still a top global development agenda as reflected in the third Sustainable Development Goal [1]
The barriers to institutional childbirth were categorised under four main themes: 1) Issues related to access and lack of resources: long distance to health facilities, lack of transportation means, referral problems, flooding and poor roads, and payments in health facilities; 2) Issues related to the socio-cultural context and conflict: insecurity, influence of the husband, lack of birth preparedness, domestic chores of women, influence of culture; 3) Perceptions about pregnancy and childbirth: perceived benefit of institutional childbirth, low childbirth risk perception, and medicalisation of childbirth including birth being perceived to be natural, undesirable birth practices, privacy concerns, and fear of caesarean section; and 4) Perceptions about the quality of care: inadequate health facility infrastructure and perceived neglect during admission
Barriers to Institutional Childbirth in Rumbek North multi-sectoral approach if childbirth services are to be made accessible to women

Summary

Introduction

Reduction in maternal mortality is still a top global development agenda as reflected in the third Sustainable Development Goal [1]. Some progress was achieved in reducing maternal mortality during the era of Millennium Development Goals, many countries, especially in sub-Saharan Africa, failed to achieve the targets of this goal [2]. In 2015, almost all global maternal deaths (99%) occurred in developing countries, and sub-Saharan Africa alone accounted for 66% of the deaths [3]. About 63% of maternal deaths occur intrapartum or postpartum [4]; access to high quality skilled care around the time of childbirth can reduce maternal mortality. A report by United Nations agencies and the World Bank has shown that maternal mortality ratio (MMR) declined in South Sudan by 54.4% between 1990 and 2015 [3], a different study has shown that MMR increased in the country from 763Á8 per 100,000 births in 1990 to 956Á8 per 100,000 births in 2013 (a 25.3% rise), and is projected to remain in the range of 500–925 per 100,000 livebirths by 2030 [4].

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Discussion

Conclusion