title: Exploration of perceptions and decision-making processes related to childbirth in rural Sierra Leone.
abstract: BACKGROUND
  Maternal mortality ratio (MMR) remains high in Sierra Leone. Efforts have been made to reduce MMR by increasing the number of women delivering at a health facility through introduction of the Free Health Care Initiative in 2010. Despite this, utilisation remains lower than aimed for, with marked inequalities between rural and urban settings. This study explores the perceptions and decision-making processes of women and their communities during childbirth in rural Sierra Leone.
  
  
  METHODS
  A qualitative, cross-sectional study employing focus group discussions, in- depth interviews and informal interviews with pregnant women and community members in rural northern Sierra Leone. Data were analysed using systematic text condensation.
  
  
  RESULTS
  Data revealed that the decision-making processes are complex and multi-faceted. Decisions regarding the place of delivery and with whom assisting the birth are often made collectively. A normal delivery is seen as one that occurs within the village. Previous experiences, perceptions and expressions of bodily symptoms as well as the interpretation of different risks affect these decisions. The health seeking behaviours were found to be flexible and dynamic, and the final decisions about where to give birth could be governed by unexpected circumstances.
  
  
  CONCLUSIONS
  Decision-making processes during childbirth in rural Sierra Leone are dynamic and intricate and need to be understood within the broader social context. Future initiatives to improve access and utilisation of safe health services for pregnant women within rural Sierra Leone need to be based on adequate knowledge of women's preferences, cultural-specific traits, capabilities, perceptions of risk and the constraints in which they may live.
authors.affiliation: International Community Health, University of Oslo, P.O box 1130, Blindern, Oslo, 0317, Norway. ltreacy@hotmail.com.
authors.forename: Laura
authors.initials: L
authors.lastname: Treacy
authors.affiliation: Oslo and Akerhus University College, Faculty of Health Sciences, Oslo, Norway. Mette.Sagbakken@hioa.no.|National Center for Minority Health Research (NAKMI), Gullhaugveien 1-3, 0484, Oslo, Norway. Mette.Sagbakken@hioa.no.
authors.forename: Mette
authors.initials: M
authors.lastname: Sagbakken
mesh_terms: D000328:Adult; D001294:Attitude to Health; D016550:Birthing Centers / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D003466:Cultural Characteristics; D003657:Decision Making; D005260:Female; D006301:Health Services Needs and Demand; D006700:Home Childbirth / Q000523:psychology / Q000706:statistics & numerical data; D006801:Humans; D036801:Parturition / Q000523:psychology; D010342:Patient Acceptance of Health Care / Q000208:ethnology / Q000523:psychology; D057240:Patient Preference / Q000208:ethnology / Q000523:psychology; D011247:Pregnancy; D012424:Rural Population / Q000706:statistics & numerical data; D012807:Sierra Leone; D012959:Socioeconomic Factors