title: Exploring the first delay: a qualitative study of home deliveries in Makwanpur district Nepal.
abstract: BACKGROUND
  In many low-income countries women tend to deliver at home, and delays in receiving appropriate maternal care can be fatal. A contextual understanding of these delays is important if countries are to meet development targets for maternal health. We present qualitative research with women who delivered at home in rural Nepal, to gain a contemporary understanding of the context where we are testing the effectiveness of an intervention to increase institutional deliveries.
  
  
  METHODS
  We purposively sampled women who had recently delivered at home and interviewed them to explore their reasons for home delivery. Interviews were recorded, transcribed and analysed using thematic content analysis. We used the 'delays' model discussed in the literature to frame our analysis.
  
  
  RESULTS
  Usually a combination of factors prevented women from delivering in health institutions. Many women were aware of the benefits of institutional delivery yet their status in the home restricted their access to health facilities. Often they did not wish to bring shame on their family by going against their wishes, or through showing their body in a health institution. They often felt unable to demand the organisation of transportation because this may cause financial problems for their family. Some felt that government incentives were insufficient. Often, a lack of family support at the time of delivery meant that women delivered at home. Past bad experience, and poor quality health services, also prevented women from having an institutional delivery.
  
  
  CONCLUSIONS
  Formative research is important to develop an understanding of local context. Sociocultural issues, perceived accessibility of health services, and perceived quality of care were all important barriers preventing institutional delivery. Targeting one factor alone may not be effective in increasing institutional deliveries. Our intervention encourages communities to develop local responses to address the factors preventing institutional delivery through women's groups and improved health facility management. We will monitor perceptions of health services over time to help us understand the effectiveness of the intervention.
authors.affiliation: Institute of Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK. joanna.morrison@ucl.ac.uk.
authors.forename: Joanna
authors.initials: J
authors.lastname: Morrison
authors.forename: Rita
authors.initials: R
authors.lastname: Thapa
authors.forename: Machhindra
authors.initials: M
authors.lastname: Basnet
authors.forename: Bharat
authors.initials: B
authors.lastname: Budhathoki
authors.forename: Kirti
authors.initials: K
authors.lastname: Tumbahangphe
authors.forename: Dharma
authors.initials: D
authors.lastname: Manandhar
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.forename: David
authors.initials: D
authors.lastname: Osrin
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000592:standards*; D005260:Female; D006297:Health Services Accessibility; D006700:Home Childbirth / Q000592:standards*; D006801:Humans; D008427:Maternal Health Services; D008880:Midwifery / Q000592:standards; D009390:Nepal; D011247:Pregnancy; D036301:Qualitative Research; D012189:Retrospective Studies; D012424:Rural Population; D012959:Socioeconomic Factors; D016387:Women's Health