KnE Life Sciences | The 3rd International Meeting of Public Health and the 1st Young Scholar Symposium on Public Health | pages: 243–251


1. Introduction

Maternal Mortality Rate (MMR) is an indicator not only to evaluate the maternal health program but also to asses the public health level. It is because of the sensitivity to health services improvement, both in accessibility and even the quality of health [1]. The Indonesia MMR is still high. Although there was a declining of the MMR from 390/100,000 live births in 1990 become 228/100.000 live births in 2007, this decline was considered very slow [2]. Indeed, in 2012, the MMR increased to be 359/100.000 [1]. Even in 2015, the MMR was decreased to 305/100.000 live birth; this rate remained much higher than the target of MDG's to 110/100.000 live births [3].

There were various efforts that have been made by the Indonesian government to reduce the MMR, such as Safe Motherhood Initiative (1990), Mother-Friendly Movement (1996), Making Pregnancy Safer (2000) and Expanding Maternal and Neonatal Survival (EMAS) (2012) [1]. The Indonesia Ministry of Health emphasized that every delivery was attended by health providers. However, although distribution is assisted by health providers, it was not in health care facilities, it's considered to be one of the causes of the high maternal mortality rate. Therefore, since 2015, the government emphasized that safe delivery was the delivery attended by health providers and placed at health care facilities. The Ministry of Health's Strategic Plan 2015-2019 establishes delivery at health-care facilities as an indicator of maternal health efforts, replacing delivery assistance by health providers [4].

Culture is how individuals learn the values, beliefs, norms, and way of life that influence their thinking, decisions, and actions in certain ways [5]. Pregnancy and childbirth are unique events in the lives of women [6]. The influence of culture in these events is powerful. Childbearing in any society is a biological event, but the birth experience is also socially constructed [7] how a woman decides to choose her helper, where she delivered, linked closely to culture. Although there is a policy that every delivery should be attended by health providers at health facilities, it's not necessarily women will choose it. Although health care facilities were free of charge, it did not mean the woman would accept it necessarily.

Although delivery coverage in health care facilities of West Java reached to 89,94% higher than the Ministry of Health's Strategic Plan that targetted 75%, in rural areas of West Java, the rate of home birth was still high. The births could be attended by village midwife or traditional birth attendant (called paraji). In Campakamulya Village, Campakamulya Sub-district, Cianjur District, the rate of home birth in 2016 reached 87%. Even though in this village was assigned two midwives who resided there. One of them stayed at the village birth center and another at the auxiliary community health center. Besides that, there is a local regulation that if a woman delivered attended by a midwife in a health care facility, it is free of charge because it's covered by health insurance. But if the woman chose to deliver at home, even attended by a health provider, she had to pay.

Nevertheless, this regulation just had a little influence on the mother's choice. Therefore, the primary objective of this study was to determine the reasons for rural women to prefer home birth. This study also wanted to know seeking information before choosing home birth and factors that supported and inhibited for giving birth at home.

2. Methods

This research was conducted in Campakamulya Village, Cianjur District in January 2017. This study chose a qualitative approach as the best design to allow women to describe their opinion. Informants were selected by using purposive sampling. The criteria were women who planned to give birth at home in their current pregnancy and who gave birth at home within the last six months and resided in Campakamulya Village, Cianjur district. Reasons for women choosing home birth were explored by engaging in conversation with them using an interview guide. Before interviewed, the women were asked for informed consent. For anonymization purposes, women were assigned a code that was used for data collection and analysis. Transcript of the interview was analyzed in an open way using content analysis.

3. Results and Discussion

Campakamulya Village is one village in Campakamulya Sub-district, Cianjur District. Distance from this village to Cianjur City is about 55 kilometers which could be reached within 2.5 to 3 hours by car. Some population was about 25.000 people. Their occupation mostly as a peasant. Majority of their last education was an elementary school. Health care facilities in this village were one auxiliary community health center and a village birth center. There were two village midwives who assigned in this village. Besides that, two traditional birth attendant (paraji) were actively to help women during their reproduction cycles.

Some research's respondents were 29 women. Ten of the women were currently pregnant and planning a home birth, while the remainder had scheduled a home birth within the last six months.

Four of the women were primigravidas at the time they planned their home birth, while the remaining women had given birth once to five times. Age of the pregnant women was between 21 to 32 years, during the period of the remainder between 19 to 40 years. The education level of the women were twelve women (41.4%) who finished elementary school, twelve women (41.4%) who completed Junior High School, four women (13.8%) who finished Senior High School and there was a woman who finished university. Almost all of the women worked as a housewife. There was only one woman who worked as a teacher. Most of the pregnant women and the remainder preferred to deliver attended by a midwife and a paraji. There were only four women who have participated in by a midwife. From the interview with the women, some themes emerged. There were reasons to choose home birth, seeking information before choosing home birth and factors supporting and inhibiting home birth.

Reasons for choosing home birth

Several reasons were delivered by the women led to their decision to choose home birth. There were three main reasons rural women choose home birth. The first was a comfort reason. Birthing at home surrounded by family, high autonomy dan readily available birthing equipment and supplies. The women in this village felt more comfortable giving birth at home because they were accompanied and closed to all families. Otherwise, they delivered at a clinic, nobody or maybe only their husband who attended. Birthing at homemade women organizes everything by themselves. If the delivery time was still long, they could take a shower, ate whenever they wanted. Besides that, the equipment was needed available at home. It was different if they delivered at a clinic. Everything was prescribed and arranged by midwives or officers. Also, all supplies must be brought.

“ More comfortable at home. I can arrange everything by myself. I can eat, bath, sleep... In the clinic, I am controlled by the other. I feel clumsy."

“ Many people can accompany if giving birth at home, at the clinic you can not...only one person permit to stay."

“ At home not complicated. Everything available...”

The second reason was a belief in tradition reason. Giving birth at home allowed women to practice their beliefs. Women in Campakamulya Village still believed and practiced childbirth and newborn traditions. These practices were usually led by paraji. It was the reason for women to choose both of the birth attendant, paraji, and also midwife. On the contrary, if the women delivered at a clinic, she could not practice the believes, forbidden by a midwife.

“ At our home, we can practice what we believe, in the clinic does not permit...”

“When born at home, the baby is inserted into a bamboo sieve, startled...but not in the clinic."

The third was a safety reason. Inadequate infrastructure, lack of transportation made the women felt safer to stay at home to give birth. The bad road condition, slippery, narrow and uphill, made the women challenging to access health care facilities. This condition worsened when rain fell. At night, the street was also dark, allowing the women to land. Besides that, most of the women did not have transportation.

“It is safer to give birth at home; I am afraid to go to the clinic, the road is bad..."

“It is difficult to find transportation here. Even there is a motorcycle; I am afraid to fall. The road is up and down".

Seeking information before choosing home birth

Women had looked for and collected information regarding home births, before deciding to give birth at home. Sources of information were their mother, paraji, older women and neighbor women who had experienced in giving birth. They asked for information about the best place to give birth.

“ I asked my mother; she delivered all of her children at home. All was survived."

" My neighbor delivered at a clinic. She said it's uncomfortable... that why I choose to deliver at home.”

Factors supporting and inhibiting home birth

Some elements that helped women to give birth at home came from closed people. They were husbands, family, friend, older women, and paraji. The normal pregnancy condition of the women also a factor that promoted home birth.

“ My family asked me to deliver at home, so my mother can accompany me...”

“ My husband feels safer if I give birth at home. It is easy to ask help."

The emphasis from health care providers to deliver at health care facilities, negative attitude of health care providers, cost of home birth were some factors that inhibited to choose home birth.

“ If delivered at home, we have to pay 500 thousand rupiahs, but at the clinic, it's free

of charge, covered by health insurance.”

“ The midwife will nag to women who deliver at home."

Table 1

Profile of informants.


Age Currently Pregnant Number of birth Education Occupation Birth attended by the/birth attendant plan
25 Six month 1 Elementary Housewife M & P
25 2 Junior HS Housewife M & P
24 2 Junior HS Housewife M & P
21 Seven month 0 Elementary Housewife M & P
25 2 Elementary Housewife M & P
23 1 Senior HS Housewife M & P
33 5 Junior HS Housewife M & P
35 3 Elementary Housewife M & P
30 Six month 2 Junior HS Housewife M & P
33 4 Elementary Housewife M & P
24 1 Senior HS Housewife M
37 3 University Teacher M
37 3 Junior HS Housewife M & P
20 Three month 0 Junior HS Housewife M & P
19 1 Elementary Housewife M & P
32 3 Elementary Housewife M & P
26 Six month 1 Senior HS Housewife M & P
22 Five month 0 Senior HS Housewife M & P
22 Six month 0 Junior HS Housewife M
33 3 Junior HS Housewife M & P
22 1 Junior HS Housewife M
32 Eight month 2 Elementary Housewife M & P
28 Nine month 1 Elementary Housewife M & P
40 3 Elementary Housewife M & P
25 Six month 2 Elementary Housewife M & P
30 3 Junior HS Housewife M & P
26 Junior HS Housewife M & P
33 3 Junior HS Housewife M & P
26 3 Elementary Housewife M & P
Source: Primary Data
M= Midwife, P= Paraji

4. Discussion

The result showed several reasons for women to choose home birth. Being accompanied by the family was a goal. It was similar to another study [8,9]. The birthing surrounded family gave social support for the women. Winson (2003) explained that receiving appropriate support in labor was known to result in a positive experience [10]. This support gave greater satisfaction with birth, longer duration of breastfeeding, decreases in perineal trauma and also less postnatal depression and less difficulty in mothering[11]. Social support was an essential element for pregnancy and delivery. It was also emphasized by Choudhury et al. (2012) that in rural areas family members were found to provide extensive support during pregnancy, transportation, and in the care of the mother and newborn after birth [12].

High autonomy made home birth more comfortable. At a home birth, the attendants are visitors in the cultural context of the family, whereas in the hospital it is the woman who must adapt to the hospital context [13]. The mother's active participation and involvement during labor set the stage for the reception of the baby at birth. Homebirth may offer the optimal setting for early bonding to occur while Rowan concluded that the familiar, safe and relaxed environment, with little or no intervention, allowed natural attachment processes to take place immediately after birth [14].

One reason for women in choosing a home birth was to practice traditional beliefs. Childbirth had a social meaning as part of the more extensive social system. Women in Campakamulya Village believed that birth was a critical phase for a mother and her baby. Birth involves the woman, her family, the community, society and the supernatural world [15]. Thomson (1997) and Andrino et al. [2016] also emphasized that the cultural perspectives of birth could not be ignored [16,17]. The environment will need to be `right' for women to feel free to practice the ceremonies for labor related to her religious or spiritual beliefs [18]. When birth takes place in a hospital, modern birthing techniques are applied, and traditional practices are banned [19]. Health system had a lack of understanding of cultural beliefs and practices [20]. To do the conventional methods, the women were led by paraji. It explained the women are choosing paraji beside midwife as their birth attendant. This condition explained by Atuyambe et al. (2009) that traditional birth attendants respected traditional customs [21].

Bad infrastructure was a barrier for the women in Campakamulya Village to go to the clinic. It was similar to Seljeskog et al. findings stating that transport was an unsatisfactory availability to skilled delivery care [22]. Another study demonstrated the influence of accessibility in choosing a birth attendant and place of birth [23,24].

The problem that is often arising when a woman birth at home is that there is a delay in handling the g emergency condition. It is a reason of policy emphasis to deliver at a health care facility. Therefore Buitendijk (1993) concluded that a successful system of home births would be possible only if appropriate screening for risk could take place, taking care by an obstetrician was available if needed, and if a system of postpartum home care was in place [25].

To encourage women to choose childbirth in health care facilities, there were various aspects that must be considered. Feeling comfortable for women was significant. When the presence of a family was restricted, the midwife has to be with women. Limited skills and approaches will lead to unharmonious relationships [26]. To become culturally competent, the midwife has to embrace skills and knowledge that will enable one to one communication based on an understanding of the social, cultural and religious needs of these women [27].

Respect for traditional believes had to be practiced by a health care provider to encourage women choosing health care facilities for giving birth. Health care providers should provide space for women and family to practice unharmful traditional beliefs. They may also permit paraji to lead the unharmful practices.

Safety Infrastructure facility is an essential factor to access health care facilities easily. Women will feel safe if the road is right. Transportation availability is also necessary. Thus women can go to the clinic every time they get construction.

5. Conclusions

Three main reasons emerged when rural women are choosing home birth. The first was a comfort because giving birth surrounded family and high autonomy. Free to practice their beliefs was the second reason. Women also felt safer to deliver at home. It was because of the inadequate infrastructure and lack of transportation. Before choosing the home birth, women seek information to people that are closed with her. Support from the closed people and the normal condition of their pregnancy were supporting factors to chose home birth while inhibiting factors were cost and attitude of health care providers.

To change the women in choosing a birthplace, the health care providers must have cultural competency besides their professional skills. It will make the women feel comfortable without surrounded by their family. Infrastructure is also necessary to access health care facilities easily.

Acknowledgment

The author would like to thank all of the informants and cadres in Campakamulya Village.

Competing Interest

The author declares that there are no competing interests.

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