Abstract
BackgroundIn low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal.MethodsWe conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community.ResultsSeveral women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position.ConclusionsOur findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.
Highlights
In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications
To better understand care-seeking patterns and barriers to care for non-cephalic presentation, we describe the intrapartum conditions of women who recently gave non-cephalic birth in rural Sarlahi District, Nepal, and highlight existing perceptions and care-seeking behavior specific to non-cephalic presentation
Non-cephalic presentation is a predictor of adverse pregnancy outcomes, with high associated risk of fetal and neonatal death in low-resource settings
Summary
In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal. Fetuses in non-cephalic presentation (presenting with a body part other than its head first, e.g. breech) have heightened risk of intrapartum-related complications and subsequent fetal and neonatal death [3, 6,7,8]. In the same context in rural Nepal as this paper reports on, non-cephalic births had 13-fold increased risk (adjusted risk ratio 12.52, 95% CI: 7.86–19.95) compared to cephalic births, and a nearly five-fold increased risk (adjusted risk ratio, 4.57, 95% CI: 1.44–14.50) of early neonatal mortality
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