Peer-reviewed article
From Decision to Delivery: A Qualitative Study of Non-Institutional Birth Pathways in Northern India.
Singh M, Sharma N, Arsenault C, Yang WC, Baumann SG et al. ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This qualitative study explored why some women in northern India give birth outside health facilities rather than in hospitals or clinics. Researchers interviewed 50 women who had non-institutional deliveries to understand their decision-making during pregnancy and labour. The study found that women's choices were shaped by mistrust of healthcare systems, difficulties accessing care during labour, reliance on informal birth attendants, and concerns about respectful treatment. Improving institutional delivery rates requires addressing trust and quality of care, not just building more facilities.
Key points
- Of 2000 women enrolled, 75 (3.8%) experienced non-institutional delivery; 50 were interviewed (19 planned, 31 unplanned)
- Planned non-institutional deliveries were driven by mistrust in healthcare, institutional avoidance, and reliance on informal maternity care systems
- Unplanned non-institutional deliveries resulted from delays in obtaining care, physical access barriers, and reliance on informal birth assistance
- Trust, respectful maternity care, timely responsiveness during labour, and birth preparedness strongly influence women's ability to reach and use institutional delivery services
- Many women who had unplanned non-institutional deliveries still accessed health system services for post-delivery or newborn care
Limitations
This qualitative study describes experiences and perceptions rather than measuring health outcomes for mothers or newborns. The findings are specific to one site in northern India and may not generalise to other regions or countries with different healthcare systems.
Abstract
Background: Determinants of non-institutional delivery, particularly in the antenatal period, have been described previously, but less is known about the sequence of events during pregnancy and decision-making processes occurring between labour onset and birth. Aim: We explored reasons for non-institutional births and pathways leading to home and in-transit deliveries in a north Indian setting, with the aim of identifying context-specific, actionable recommendations. Methods: Participants were women from the north Indian site of the Redefining Maternal Anemia in Pregnancy and Postpartum (ReMAPP) cohort who experienced non-institutional delivery. We conducted an exploratory qualitative study using a semi-structured in-depth interview guide. An a priori conceptual framework was developed based on existing continuum-of-care literature and structured around the antenatal, intrapartum, and postnatal phases of care. The framework focused on the "decision-to-delivery pathway" and was subsequently iteratively refined and elaborated based on the thematic findings. Findings: Of the 2000 women enrolled at the north Indian site of the ReMAPP study, 75 (3.8%) experienced non-institutional delivery; among these, 50 participants were interviewed. Among those interviewed, 19 had planned, and 31 had unplanned non-institutional deliveries. Themes identified for planned non-institutional deliveries included perceived mistrust in healthcare, institutional avoidance, reliance on informal maternity care systems, and decision-making uncertainty. For unplanned non-institutional deliveries, themes included intention to institutional delivery, delay in obtaining appropriate maternity care, physical access barriers, reliance on informal birth assistance, and opportunities to avail health system services for post-delivery or newborn care. Conclusions: Our findings suggest that improving institutional delivery coverage requires more than physical access to facilities. Trust, respectful maternity care, timely responsiveness during labour, and birth preparedness appear to strongly influence whether women are able to reach and utilise institutional delivery services.