Essay: Dissertation: Women's Experiences and Reasons for Preference to Home Delivery

Women’s Experiences and Reasons for Preference to Home Delivery: A Phenomenological Theory based Qualitative study in Tembaro District, Southern Nations, Nationalities and People’s Region (SNNPR), Ethiopia
Summary
Background: Homebirth is defined as giving birth to a baby in the place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians. Worldwide women who experience childbirth at home are at high risk of approximately 60% of death, and illness and delivery associated health squeal. In Ethiopia, majority (90%) childbirths reported at home. Tembaro is one of the districts in SNNPR, Ethiopia where still home delivery is taken as normal place of delivery. Hence, this study tries to attempt such issues.
Aim: to explore women’s childbirth experiences and reasons for preference to home delivery from women delivered at home in Tembaro district.
Methods: A descriptive phenomenological approach qualitative study will be employed. Using combined maximum variation and stratified purposive sampling technique a twenty-five women who were delivered at home from January 2013 to January 2014 in Tembaro District, SNNPR, Ethiopia will be participated. Data collection using in-depth interviews with open-ended questions on women’s childbirth experiences and reasons for preference to home delivery will be examined in detail by the researcher from March to April 2014. Colaizzi’s method will be used to guide the data analysis process. Applying simultaneous data collection and analysis, audio taped data and field notes will be transcribed in English by the researcher; and reading and re-reading transcriptions, extracting significant statements, categorizing into cluster themes and phenomenological thematic analysis will be assisted by Atlas ti vers.7 software. The trustworthiness will be ensured by validating participants’ agreement on the findings. Data management will be ensured by inserting data to computer using password and securely owned by the researcher and used for only the research purpose. The study findings will be presented, communicated and disseminated to the relevant organizations at the end of the study. Proposed budget planned to accomplish the expected result for personnel expenses 13,075.00 Ethio. Birr; and for transport and materials 2,347.00 Ethio. Birr are required.
Keywords: Women experiences, Reasons for preference, Home delivery, phenomenological approach, Qualitative study.
List of Abbreviations
EDHS-Ethiopian demographic survey
Ethio- Ethiopia
Feb- February
FMoH- Federal ministry of health
IPA- interpretative phenomenological analysis
ID- identification
HE-HP- health education and health promotion
MDG- millennium developmental goal
MPH- master of public health
PI- principal investigator
SBA- skilled birth attendant
SNNPRG- South Nations and Nationalities of peoples Regional state Government
SSA- Sub-Saharan African
TBA- traditional birth attendant
WHO- World Health Organization
CHAPTER ONE: INTRODUCTION
1.1 Background
Homebirth is defined as giving birth to a baby in your place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians(1). Since the women’s experiences and reasons for preference of homebirth vary throughout the world, this study tries to attempt such issues in detail.
Worldwide women who experience labor and delivery alone, with a family members, traditional birth attendants, community health workers, or other unskilled birth attendance occur at home and are at high risk of approximately 60% of death, illness and delivery associated health squeal(2). However, the amount of risk related to childbirth among developed countries compared to developing is very low (2%). For example in the US, about 98.7% of births were delivered in hospitals and only 1.3% of births that were delivered out of hospitals. The majority(98%) of childbirth risk is found in developing countries, where every year an estimated 60 million women give birth outside health facilities, mainly at home, and 52 million births occur without a skilled birth attendant (SBA)(3). Among these, the proportion of the poorest women reporting home delivery is highest in Sub-Saharan Africa(SSA), which is also the region with world’s highest rates of maternal and child mortality(4). Ethiopia is one of SSA countries where majority(90%) childbirth were reported still at home and assisted by non health professionals(TBA, relatives or alone) and only(10%) by skilled health professionals(5). EDHS 2011report shows that in the SNNP region the proportion of births assisted by a skilled provider were only 6.3 percent and 93.5% delivery service were given at home. Thus, it shows that in SNNPR maternal mortality related to childbirth remain the highest(93.5% of childbirth is at risk of deaths, illness and delivery associated health squeal)(5). Tembaro is one of the districts in SNNPR in which also shares similar contribution to the maternal problems related to childbirth.
1.2 Problem Statement
Maternal mortality is unacceptably high and about 800 women die from preventable causes related to pregnancy- or childbirth-related complications around the world every day. 99% of all maternal deaths occur in developing countries and more than half of these deaths occur in sub-Saharan Africa. Maternal mortality is higher in women living in rural areas and among poorer communities. Some childbirth related complication like severe bleeding after birth can kill a healthy woman within two hours if she is unattended(6). Most of home deliveries may be unattended by skilled health professionals.
Currently WHO recommended all delivery services should be attended at health facility to be assisted by skilled birth attendance. However, almost 60 percent of African women give birth without a skilled attendant, 18 million a year at home and during the last 10 years, the average coverage of births with a skilled attendant on the continent has not increased significantly(7).
Similarly, a study conducted in Nepal indicates that 94.7 percent delivered at home with no trained assistance, 114 women were brought to the hospital after home delivery, majority of the women (72.8%) were brought with retained placenta or excessive bleeding. Manipulations at home (abdominal pressure, pulling the cord, tying heavy objects in the cord for traction etc.) were done in some cases(8).
In Ethiopia, the majorities of rural women give childbirth at home and assisted by Traditional Birth Attendants (84%). Due to this reason most of time home deliveries are at risk of deaths, illnesses and the development of complications related to delivery makes childbirth problematic(9,10).
In the recent study in Gondar, Ethiopia in 2013 shows that experiences of complications among 1,668 eligible women about 476 (28.5%) of women were reported that they have some kind of complication related to childbirth. The most common reported complications were excessive bleeding (58.4%), and prolonged labor (23.7%). Thus, this shows that nearly half of the women who faced complications are reported outside health facilities(most likely home setting) at the time of obstetric complications(11).
In Ethiopia maternal and newborn health are questionable especially at the time of delivery because home births are high (90%). These indicates that many of women are delivered at home, which has the implication of high maternal illness, complications and death related to childbirth(12).
The Federal Ministry of Health in Ethiopia(FMoH) aims for 40% of deliveries to be attended by a skilled attendant by 2015(13) and currently required zero home delivery; which is very far to accomplish with in similar manner.
Despite the fact that, the service of home delivery in the study area in 2012/13 was very high(14) shows that still many women delivered at home. In Tembaro district, the lack of studies about women’s views on the reasons why women prefer home for childbirth and therefore home delivery remained the normal place of option they expect. Despite, both trained and untrained TBAs are assisting at delivery services in home level in the study area, which may have its own impact to influence women’s decision of delivery place and it has its own side effects due to lack of any delivery care materials for TBAs at hand and their inadequate skill to manage. Many of women delivering at health facility after delay at home and such women most of time are exposed to some complications related to childbirth. If they were brought to health facility immediately after first initiation of labor, it can be preventable and manageable through assistance of skilled birth attendants. In many developing countries like Ethiopia, it is known that home is not safe place for delivery service and not accessible for skilled birth attendants. Women’s childbirth experiences and reasons for preference to home are not addressed in the study area because no much study was found. Further exploration of the factors contributing to home delivery practice is very important to improve delivery services.
1.3 Research Paradigm and Theoretical Perspectives
A paradigm is essentially a worldview to the research, a whole framework of beliefs, values and methods with in which research takes place. A research paradigm is a set of fundamental assumptions and beliefs as to how the world is perceived which then serves as a thinking framework that guides the behavior of the researcher. The researcher’s ontological and epistemological positions form the philosophical basis of our research project. Ontology refers to our assumptions about how we see the world, e.g., Does the world consist mostly of social order or constant change? Epistemology refers to our assumptions about the best way to study the world, e.g., Should we use an objective or subjective approach to study social reality? This philosophical foundation affects every aspect of the research process, including topic selection, question formulation, method selection, sampling, and research design(15,16). Thus, it is why I am interested to see about the paradigm.
For instance, describing about all paradigms here will be beyond the scope of this study I brief only a paradigm and selected approach through which this study follows.
For this study, an interpretive paradigm was chosen. Interpretive paradigm attempts subjective meanings and social phenomena; focus upon the details of situation, the reality behind these details on knowledge. Assumptions of the Interpretivist Paradigm: share the following beliefs about the nature of knowing and reality: Relativist ontology – assumes that reality as we know it is constructed inter-subjectively through the meanings and understandings developed socially and experientially; and Transactional or subjectivist epistemology – assumes that we cannot separate ourselves from what we know. The investigator and the object of investigation are linked such that who we are and how we understand the world is a central part of how we understand others, the world and ourselves. By positing, a reality that cannot be separated from our knowledge of, the interpretivist paradigm posits that researchers’ values are inherent in all phases of the research process. Interpretivist positions are founded on the theoretical beliefs that reality is socially constructed and fluid. Thus, what we know is always negotiated within cultures, social settings, and relationship with other people. From this perspective, validity or truth cannot be grounded in an objective reality(17,18).
Among interpretive paradigm approaches, phenomenological approach was chosen for this study because it focuses on the understanding of a phenomenon from the point of view of the lived experience of participants in order to be able to discover the meaning of phenomenon to address in this study. Phenomenology is as a qualitative research approaches is based on the philosophy in the early twentieth century’s, in particular the ideas of the mathematician and philosopher Edmund Husserl(1859-1938), who believed that human experience is the source of all knowledge(19).
Among phenomenological approaches, for this study a descriptive phenomenological approach will be followed because it is used when the researcher wants to describe the phenomenon under study and brackets his/her previous knowledge about the phenomenon of interest. Hence, once a Husserlian descriptive phenomenological philosophy will be followed as a basis for a phenomenological theory of science, in order to achieve rigor both the data collection and the data analysis will be needed to follow the same approach(20).
In this study, the descriptive approach was adopted for collecting data to the experiential meaning of childbirth experiences of women delivered at home. Its advantage, in data collection gives the ability to collect accurate data and provide a clear picture of the phenomenon under study. Streubert Speziale and Carpenter stated that a descriptive method in data collection in a qualitative research is central to open-ended unstructured qualitative research interview investigations(21).
Due to its descriptive nature of Husserl’s phenomenology, it became known as descriptive phenomenology. It is important to note that descriptive phenomenology assumes an objective truth actually exists. Husserl stated that this truth was the human experiences that existed in the pre-reflective nature of individual experiences(22). This is just to show that the findings of this study may help to describe the commonality of experiences and reasons obtained from study participants.
1.3.1 Appropriateness of phenomenological approach
Phenomenology focus on an individual experiences, beliefs, and perceptions; and text used as a proxy for human experiences. It also focuses on the processes and experiences one goes through the study of phenomena or the things we experience and the ways we experience such things. Experience is a complex concept and not directly observable by an external observable. It may be difficult to study such a complex experiences in a concrete way because it is subjective. However, inter-subjectivity is often used as a mechanism for understanding how people give meaning or interpret their experiences. In addition to, Choice of an appropriate phenomenological research method underlying philosophical tenets of Husserl’s descriptive phenomenology is found vital to the credibility of the nurse interested to understand how nurses make meaning of their experience of being in nurse patient interactions. In addition, phenomenology is commonly used in the social and human sciences including sociology, education, psychology, nursing and health sciences. Hence, phenomenologists are interested in how people put together the phenomena they experience in such a way as to make sense of the world and develop a worldview. They assume commonality in human experience and focus on meaning making as the essence of human experience. In general phenomenology is a highly appropriate approach to researching human experience; and as a research method, it is a rigorous, critical and systematic investigation of phenomena(19,23). Therefore, I found phenomenological approach is preferred for the study of interest in this study.
1.3.2 Qualitative epistemology
While reflecting up on my experiences, when I was working as a health staff in Tembaro district health bureau, in many informal conversations with women who delivered at home two divergent experiences in my mind always have been at the fore and pushed me to attempt these issues. Firstly, Some women who delivered at home told me that giving birth at home radiated them harmony and happiness and their homebirth experience has had a great positive influence on them. Secondly, I had also encountered women who told me that giving birth at home was their worst experience in their life; a terrifying experience with fear of death, which they hope they will never experience again. Therefore, studying on home delivery has been of immense interest to me because in Tembaro district still majority of women were reported at home delivery that they are at risk of deaths and illnesses associated to childbirth at home. Thus, based on these the following question was attempted:
Why do some women still prefer to home delivery?
1.3.3 Positionality
My epistemological position regarding this study, I place myself in an interpretivist paradigm, while ontologically I would say I am a relativist.
Here, in this study my perceived identity as a university researcher, not as a district health office health staff, will be appeared to make participants feel safe to express their views. In the information sheet, however, the researcher’s background as a health professional will be fully disclosed and therefore there will be no deception.
Since in most qualitative research, health professionals conduct research as a means to understanding a health, as well as for developing their profession and improving health care. I believe that my background as a health professional enables me the conduct of this study on women’s home delivery experiences through qualitative health research; and will help me to gain knowledge working with women, their knowledge and perspective expand from health professional closeness and care provider role(24).
CHAPTER TWO: SIGNIFICANCE OF THE STUDY
This study is expected to have the following significances:
Home delivery has high risk of maternal illnesses, complications and mortality related to childbirth. So appropriately focused interventions on the improvement of delivery service will have high contribution to achieve the MDG 5. This requires preventing of factors contributing to home delivery through detail understanding of practices and reasons for preference to home delivery. Thus, this study attempts to address these issues.
To gain the best knowledge, this study is the first to use a qualitative approach to study the behavior of interest in Tembaro district, specifically acquiring a deep understanding of the reason why women prefer to home delivery rather than health facility. Based on it gathering qualitative data to improve understanding of home delivery could help to determine what draws women to partake childbirth at home. Hence, phenomenological approach has double benefits on addressing those lived experience and reasons as a meaning of participants that cannot much be addressed in quantitative research.
Findings of this study will help to influence decision makers and planners for taking appropriate actions for the improvement of delivery service.
Since not much study were found on the intended study area the study findings on home delivery will help to as a basis to stimulate and provide information for interested researchers to conduct further studies.
CHAPTER THREE: OBJECTIVE OF THE STUDY
3.1 General Objective
To explore women’s childbirth experiences and reasons(causes, explanations or justifications related to childbirth at individual level) for preference to home delivery on women’s delivered at home from January 2013 to January 2014 in Tembaro district, SNNPRG, Ethiopia from March to April, 2014.
3.2 Specific Objectives
1. To investigate the childbirth experiences of women who were delivered at home in Tembaro district.
2. To explore the reasons for preference towards home delivery from women delivered at home in Tembaro district.
CHAPTER FOUR: METHODS
4.1 Study area and period
The study will be conducted in Tembaro district, Southern Nations, Nationalities and People’s Region (SNNPRG), Ethiopia from February to March 2014. Out of the four health centers under Tembaro district, the catchment area of all health centers will be included for this study because many women from those areas delivered at home with non-skilled birth attendants as revealed by district health office report of the previous year (2012/13). The report showed that the district had the number of expected pregnancies of 4148, but low skilled deliveries of 1384 representing 33.4%. Here, we can see the majorities of women were giving birth at home. Data will be collected from mothers who were delivered at home from January 2013 to January 2014. Tembaro district is one of the eight districts in Kembata Tembaro zone, which is located in SNNPRG. It is one of the districts in which a total of 129,421 population lives and its main town is Mudulla. It is far from Addis Ababa, Hawassa and Durame 400km, 185kms, and 60kms respectively. It is bordered: by North Hadiya zone, West Omo river, East Hadero Tunto Zuria District, South Wolaita zone. In Tembaro district there are a total land area of 27,917 Hectare, 20 rural and 3 semi-urban kebeles; twenty health posts, four health centers and four Private health facilities are found. The overall potential health coverage of the district is 80%. The rest Background Information of the study area is given in Appendix A(14).
4.2 Study Design
A phenomenological approach especially descriptive Husserlian’s Phenomenology will be employed to explore women’s childbirth experiences and reasons of women’s delivered at home.
4.3 Study population
Women who have delivered child at home from January 2013 to January 2014 in Tembaro district.
4.4 Inclusion and Exclusion Criteria
4.4.1 Inclusion Criteria
Participants will be eligible for this study, when women who were delivered at home from January 2013 to January 2014 period and have been residing in Tembaro district for at least 6 months (because those less than six months were assumed not familiar to their living society), age in between 15year to 49year old (childbearing age groups) and in condition to the study will be included.
4.4.2 Exclusion Criteria
Eligible participants in the inclusion criteria, who are very sick or not in condition to give interview will be excluded.
4.5 Sample size determination, Sampling Technique and Procedures
4.5.1 Sample size determination
A maximum of twenty-five women of eligible groups will be participated. This is based on the Polkinghorne(1989) recommended for the phenomenological studies consisting of in-depth interviews that researchers interview from 5 to 25 individuals who have all experienced the phenomenon of interest(25). However, based on the purpose of the qualitative study data saturation (redundancy of emergent ideas) the number of sample size will be determined(less than 25).
4.5.2 Sampling Technique
A Combination of stratified purposeful and maximum variation sampling technique will be used. Stratified Purposeful Sampling- will be used in order to obtain the eligibles from different health center catchments, for addressing all the four-health center catchments stratification and to select kebeles from each catchment. Such a sampling technique can facilitate all eligible group comparisons with in the district. According to Patton, maximum variation sampling attempts to study a phenomenon by seeking out settings or persons that represent the greatest differences in that phenomenon(23). Therefore, a maximum variation sampling technique will be used together with stratified purposeful sampling technique just to get diverse variations and identifying important common patterns by representing diverse participants to obtain fully multiple perspectives about the home delivery. This means that the participants will be sampled based on particular predetermined criteria in order to cover a range of constituencies, such as different age, frequency of delivery at home and access to health facility(23).
4.5.3 Sampling Procedure
Before participant selection and data collection permission obtained by consulting, discussing and seeking advice from relevant woreda focal persons like woreda council office, women’s affairs and health office.
At district level, sampling frame will be obtained from district health office data (the number of home delivery report in each kebele of the target 12 months) and discussing the issue with the responsible person the selection of 09 kebeles and number of participants from each health center catchment will be identified.
Similarly, at selected kebele level permission and agreement will be obtained from kebele leaders, women’s affairs and health extension workers. Here, by discussing the issue together with health extension workers, leaders of kebele and women affairs information related to eligible women will be gathered. For participant women selection some criteria related to age of women, number of delivery at home and access to health facility will be taken into consideration. Then, from each selected kebele two or three women of eligible participants, who are willing to participate and getting consent will be purposely selected and used for data collection.
Figure 1: Sampling Procedures Using Combined or Mixed Purposeful Sampling Techniques
4.6 Data Collection Method and Process
4.6.1 Data Collection Process
Data collection process includes activities like selecting kebeles and participants, gaining access and building rapport, sampling purposefully, collecting relevant data, expanding notes and storing/saving it on computer securely. The collection process will be done using an in-depth interview guide with open-ended questions. The interview will be taped. The place of interview will be decided with participant interest in order to obtain rich data on the way of safe environment. Initially researcher attitude of openness needs to be empathic, meeting and being with the participants in a non-censorial manner in order to gain access to the participants’ reality as understood by them. It is a matter of encouraging participants to tell their story of experience in as much detail as they wish and are able to(26).
4.6.2 Data collection method
4.6.2.1 In-depth interview
After receiving approval for ethical clearance and getting individual consent, the researcher will continue data collection. The researcher will be engaged with participants posing questions in a neutral manner, listening attentively to participants’ responses and asking follow up and probes questions based on participants’ response. The interview will be conducted face to face and will be involved one interview with one participant at a time. The eligible women will be interviewed what they experienced and the reasons for preference to home delivery. They are preferred because first person reports of life experiences are what makes phenomenological research valid and experiences cannot be felt to be known in advance or felt to be known by other person rather than experienced. For each participant the interviews will be conducted at the range of 1 to 2 hours. All interviews will be tape recorded and transcribed verbatim by the researcher in English. The interviews will be conducted in the local language, Tembaregna, using the English version open-ended interview guide(27,28).
Audiotaping of interviews will be used after obtaining participant’s permission. There may be a tendency for some interviewees to forget that they are being audio taped. Therefore, the tape recorder will be placed in full view of the participant. In addition to, short field notes, non-verbal (facial, head nodding, etc.) expressions will be used as a means of data collection through active interaction with researcher-participants.
Generally, the interview will be conducted within the participants’ choice of favorable place or their home. This may help them to create feel free, equality and the interviewer-participant interactions to be safe.
4.6.3 Data collection tools
4.6.3.1 In-depth interview guide
For in-depth interview open-ended questions was preferred because it allow people to give their preferred responses. These questions will be flexible and allow the interviewer to probe and to seek clarification. Therefore, in addition to these follow-up questions using probes will be asked in order to acquire a deeper understanding when an explanation was unclear. Open-ended questions will supply a frame of reference for the participants’ answers. Questions focus on perceptions, feelings, experiences and reasons for preference related to home delivery, assistance of birth attendants, and impacts of home delivery on participants’ lives. They are open ended and oriented to gathering personal descriptions of lived human experience. The focus is usually more on a particular aspect of human experience as it occurs in several people rather than on describing in a total manner the experience of one person. The advantage of an interview guide is that it helps the interviewer pursue the same basic lines of inquiry with each person interviewed and manage the interviews in a more systematic and comprehensive way(23,27)
The interview guide including consent form will be used for the respective participants intended to be included in this study (given at Appendix C.
4.6.4 Pre -test
A pre- test study will be conducted for in-depth interviews. One to two interviews with women delivered at home and residing in neighboring district (HaderoTunto zuria) will be conducted to check the appropriateness of the guide to obtain the required information, modify interview guide and to ensure the total management of the whole interview session. Based on the pre test corrections will be made soon and the updated one will be used for the actual interview.
4.7 Data Analysis
Each interview (tape records, and body languages, facial expressions, head nodding, etc.) including field notes will be changed in to written form texts. In addition to this, conveying styles through transcribing choices (including pauses/silence, condensing, etc.) will be employed.
Schools of Phenomenology have developed different approaches to data analysis. Three frequently used methods of data analysis for descriptive phenomenology are the methods of Colaizzi (1978), Giorgi (1978), and Van Kaam (1966). Colaizzi’s method will be applied in this study because it allows the researcher to use a structured approach to data analysis and to expand their understanding of the meaning within the participants’ responses. In addition, Colaizzi’s procedural analysis is a well established and proven method that has been used extensively in qualitative research literature(29). The rigorous analysis of the descriptive phenomenological investigation by Colaizzi’s method of data analysis is preferred to be an appropriate method for this study with its focus on finding the essence and expanding meaning of the experience of women’s in home delivery. This method consists of six steps: dwelling with the data, extracting significant statements, formulating meanings into clusters or themes, creating an exhaustive description of the phenomenon, and reducing the description to a statement of the fundamental structure of the phenomenon(30).
As all qualitative data, based on the above processes as extracting significant statements, formulating meanings, categorizing into clusters and making sense of the essential meanings of the phenomenon and phenomenological thematic analysis will be assisted by Atlas ti vers.7 software(31).
Finally, to validate study findings using “member checking” technique will be undertaken.
That means through returning the research final (significant) statement given to participant to verify researcher’s description with them. If any comments, corrections given will be corrected based on their response(30).
4.8 Research quality
By its nature, a phenomenological study is associated with description and verbatim quotes will be utilized in reports of the findings to further enhance credibility. The participants of this study will be included because of their home delivery experiences. In order to attempt the required high quality of the study findings maximum efforts will be made to improve trustworthiness(32).
To enhance trustworthiness of this study the following points will be maintained:
1) Credibility: interviews will be supported by observation of non-verbal expressions, photo, tape record, and visual aids to strengthen truthiness of the study findings.
2) Applicability (fittingness): checking these understandings with the original informants or others similar to them
3) Consistency (audit ability): all participants will be seen equally by using a similar format for all participants. Oral text and the written text will be compared to ensure that the way and their interpretation were actual, not fabricated accounts, and ensuring their consistency. In addition to this, decisions about the research will be open for the study participants.
4) Neutrality (confirmability): it will be aided by blind reading of the interview texts by second readers (who have no connection to the study setting where the research occurs).
In addition, to the above to keep the truths of participants own meaning I will bracket myself consciously in order to understand, in terms of the perspectives of the participants will be interviewed, the phenomenon that I will be studying, that is the focus will be on participants views(33).
Since this study is intended for analysis through following the method of Colaizzi’s data analysis strategy, it is the only phenomenological analysis that calls for the validation of results by returning to study participants will be employed. This procedure helps the participants to ascertain if their answers to any questions need to be rectified, and ensures that the researcher has not misinterpreted the data(30).
4.9 Definition of terms
Bracketing: is a means of demonstrating the validity of the data collection and analysis
process through researchers putting aside their previous knowledge, beliefs, values and experiences in order to accurately describe participants’ life experiences(33).
Home birth: is as giving birth to a baby in your place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians. In developing countries, homebirth is considered risky place for childbirth related complications(1).
Home delivery: assumed similar to home birth.
Inter-subjectivity: The process of several, or many people, coming to know a common phenomenon, each through his or her subjective experience(34)
Natural settings: the ordinary settings in which people live and work, and/or uses interviews that are designed to approximate to ordinary conversations in key respects(35).
Phenomenology: A qualitative study design that represents an approach to enquiry that emphasizes the complexity of human experience and the need to understand that experience holistically, as it is actually lived(36).
Saturation: the point at which no further themes are generated when data from more participants are included in the analysis(37).
Skilled birth attendant: is a qualified health professionals(midwife, doctor, nurse or health officer) who has the skills needed to manage normal (uncomplicated) childbirth and the identification, management and referral of complications in women(10).
Subjectivities: describe the interaction of the researcher’s subject positions that informs her/his study(38)
Traditional Birth Attendant (TBA): is a person usually woman with or without training, who has no qualified skills(not licensed) to assist a mother in a childbirth(39).
4.10 Ethical Consideration
After approval of my thesis proposal, support letter will be taken from Research Ethics committee of Jimma University, College of Public Health and Medical Sciences; and permission will be obtained from relevant respective bodies accordingly.
Written consent will be obtained from participants after they were informed about the study and their right to withdraw from the study any time they wished too.
Anonymity and confidentiality will be ensured by not using the real names of the participants, in order to prevent emotional harm.
Permission for audio recording and photo taking will be obtained from the participants. Field notes and tape recordings will be kept under lock and key for three years and destroyed by fire after publishing the study findings.
4.11 Dissemination the study findings
The study findings will be presented and communicated at the end the study in the Department of Health Education and Behavioral Sciences, College of Public Health and Medical Sciences, Jimma University. The findings of the study will be disseminated to the relevant organization that can make use of these findings, including the Regional health bureaus, districts of health offices, health institution, community leaders & relevant non-government organizations.
4.13 Role of the Researcher
As being the researcher of this study, my background is BSc in Environmental health. The aim of current study is to explore women’s childbirth experiences and reasons for their preference to home delivery.
I believe that these experiences enhance my awareness, knowledge, and sensitivity to the issues being addressed and assist me in working with the participants of this study. I recognize the need to be open to the thoughts and opinions of participants and to set aside my experiences in order to understand and not to interfere preconceptions to those of the participants in the study(33). Therefore, as being human instrument an iterative and active communication will be made through the data collection period in order to obtained rich data on the topic of this study.
4.14 Limitations of the study
From the nature of human being, some participants may not describe their actual lived experiences rather than explaining only to what they want to say.
The limitations of this study exist in the means of resource and time constraints which may limit this study from further triangulation with different qualitative research methods such as focus group discussion and observational.
CHAPTER FIVE: OVERALL RESEARCH WORK PLAN
Table 1 Work plan
Sn
Activities
Physical year of time
2013 2014
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June
1 Topic selection
2 Preparation for proposal
3 Preparing proposal
4 Defense
5 Obtaining ethical clearance
6 Preliminary work before data collection
7 Pre-testing
8 Data collection and Analysis
9 Data entry and analysis
10 Draft analysis writing
11 Final analysis writing
12 Defense and submission
CHAPTER SIX: BUDGET PLAN
6.1 Personal Cost
Table 2 Personnel cost break down
S/N Personal involved Qualification Responsibility Total No. Working days Perdiem/day Total birr
1 Participants – Attending and giving response 25 2 25*2*50 2,500.00
2 Investigator HE-HP Data collector 1 30 30*195 5,850.00
3 motorist Driver Driving 1 15 15*120 1,800.00
4 Investigator HE-HP Investigator 1 15 15*195 2,925.00
5 Total 13,075.00
Note: Perdiem/incentives will be paid for participants of this study is based on WHO stated as a reimbursement for expenses incurred as a result of travel costs and reimbursement for time lost and its amount based on current context(40).
6.2 Transport and Materials Cost
Table 3 Transport and supply cost break down
S/n Item Unit Quantity Unit price Total price
1 Transport from/to JU to Tembaro district Birr 2 400 800.00
1 Computer paper Ream 1 100 100.00
2 Tape caset pcs 30 15 450.00
3 Battries for tape recorder Pair 10 10 100.00
4 CD-RW PCS 4 25 100.00
5 Note book Number 3 15 45.00
6 Pencil Number 2 1.00 2.00
7 pen Packet 1 50 50.00
8 Telephone card 4 100 400.00
9 Printing and binding of documents number 10 30 300.00
Total 2347.00
a) Personnel cost 13,075.00 b) Transport and Materials 2,347.00
Total Cost required 15,422.00
N/B: Tape-recorder is expected to obtain from the dep’t of HEBs, College of PH and Medical Sciences of Jimma University.
References
1. Rebecca Dekker. What is Home Birth [Internet]. 2012 p. 2. Available from: http://evidencebasedbirth.com/what-is-home-birth/
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22. Mottern R. Teacher-Student Relationships in Court-Mandated Adult Education’: A Phenomenological Study. Qual. Rep. [Internet]. 2013;18(Art.13):7. Available from: http://www.nova.edu/ssss/QR/QR18/mottern13.pdf
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29. Lockie BNM, Lanen RJ Van. Impact of the Supplemental Instruction Experience on Science SI Leaders. J. Dev. Educ. 2008;31(3):2.
30. Gharibpoor M, Allameh SM, Abrishamkar MM. New Concept of Social Network Citizenship Behavior’: Definition and Elements. Aust. J. Basic Appl. Sci. [Internet]. 2012;6(9):6. Available from: http://www.ajbasweb.com/ajbas/2012/Sep%25202012/154-163.pdf
31. Friese DS. ATLAS . ti 7 User Guide and Reference. Trade marks of Microsoft Corporation in United States; 2013. p. 14’20, 189.
32. Mackenzie N. CLINICAL PAPER A phenomenological study of women who presented to a physiotherapy-led continence service with dyspareunia and were treated with trigger point massage. J. Assoc. Chatered Physiother. Women’s Heal. 2009;105:3.
33. Chan ZCY, Fung Y, Chien W. Bracketing in Phenomenology’: Only Undertaken in the Data Collection and Analysis Process’? Qual. Rep. [Internet]. 2013;18(Article 59):2,5,6. Available from: http://www.nova.edu/ssss/QR/QR18/chan59.pdf
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40. WHO. Informed Consent Form Template for Qualitative Studies [Internet]. Geneva, SWITZERLAND; p. 5. Available from: HTTP://www.who.int/RPC/RESEARCH_ETHICS
Appendices
Appendix A: Additional Background Information of the Study Area
Table 4: Back ground information of the study area
1. Population
2. Available Health Facilities
4. Major Interventions and Their Achievement in 2005 E.C
Population profile Year, 2006
REMARK
Type of Health Facility Number of Health
Total population 129,421 Health center 4 Type of Activity Coverage
(%)
Male 63,416 Health posts 20 Open Defecation Free Kebele 100
Female 66,005 Hospital under construction 01, BCG 101
Estimated Households /4.9%/ 26,412 Private health facilities and 04 Pentavalent1 102
Estimated live birth/3.26% 4219 The overall Potential health coverage is 80%. Pentavalent3 101
Estimated surviving infants /3.07% 3844
3. Available Human power Measles 102
Estimated pregnancy/3.6% 4,646 Type of Profession Number available Fully Vaccinated 100
Pneumococcal vaccine1 102
HO/BScN 09
Estimated deliveries 4,219 Mid wife nurse 04 Pneumococcal vaccine3 103
Antenatal care 4 times and above 77
Urban HEWs 06
Under 3 yr age group 10,755 Health development army leaders 4174 Postnatal care 102
Women in reproductive age (15 -49 years) 30,155 Health development army followers 52614 Protected at Birth 105
TBA Trained 24 women received tetanus toxoid all 74
Non-pregnant women in fertile age 25,509 TBA not Trained 18 Delivery by HEW 36.5
By TBA 30.1
By SBA 33.4
Appendix B: English version letter of invitation and Consent form for in-depth interview participants
In-Depth Interview Participants Agreement Form in Kembata Tembaro Zone Tembaro District on Women Delivered at Home During January 2013 to January 2014
Hello, how are you?
My name is Getachew Shamebo; I am from Jimma University research team, where I am studying my master degree on public health. You have been identified as relevant respondent for this study. Therefore, I would like to interview you about your experiences/views on home delivery. The general purpose of this study is to explore women’s experiences and reasons for preference to home delivery. The aim of the interview is to obtain rich information from the residents like you. The interview will last approximately for 1 to 2 hours. The information you provide is confidential (will not conveyed to others unless you permit to do so) and will only be used for the above-mentioned objective of this study. A code /ID number will identify every participant and no names will be used. Participation is voluntary; you have the right to participate, or not to participate or refuse at any time during the interview. Your refusal will not have any effect on services that you or any member of your family receives. However, your participation is very important for the success of this study. There may be a possibility of being upset if the issue raised during discussion is related to personal experiences. There is no direct benefit for the participation of this study for his/her being participated rather than the result of findings will help to improve the whole community delivery services. For further information, my address is Tele 251- 09-16-84-06-19. Email shamebog@yahoo.com.
Would you like to participate in the study?
If yes, continue to the next page.
If no, skip to the other participant.
Informed consent form
I am, _______________________, being asked to participate in the study of women’s experiences and reasons for preference to home delivery. Getachew Shamebo, a student in Jimma University College of public health and medical sciences, is conducting this study. Understood that the general purpose of the study is to explore women’s experiences and reasons for preference to home delivery.
The researcher hopes to gain in-depth understanding of the issues by interviewing individuals knowledgeable of the topic. I understood that as a participant, I have the right to withdraw from the interview process for any reason. I understood that I would participate in an interview that will take an average one hour. The interviewer will ask me my experiences and reasons I have had and recommendations for change of delivery services. I understood that my involvement and sharing information would assist the study in making recommendations as to how future delivery services can better meet the needs of planners and health message developers. No harm is apparent because of participating in this research. If I am unable to continue an interview, I may stop the interview process at any time. I understood that I would share information and option with researcher. Great precaution will be taken to ensure that this information will remain confidential. Any reports or a recommendation that are written because of the study will never refer to specific individuals by name. Participation in this study is voluntary. Refusal to participate will involve no penalty or loss of benefits to which I am otherwise entitled. I understood that I may discontinue participation any time with no penalty to me. I have given the opportunity to ask any questions, and I have received a copy of this consent form. I read completely before interview, and I (study participant) freely and voluntary agreed to participate in the project and I agreed up on audio taping the discussion I will have with the researcher and I ascertained my agreement by signing this document.
Signature of the participant ___________________Date __________________
Signature of Witness _______________________ Date___________
Name of the interviewer ———————————-Signature———–Date—————
Name of Kebele————-Kebele Code———— Nominal code——–Age—–Years
Thank you for your valuable contribution!
Appendix C: English version in-depth interview guide
This list of topics and questions will guide the researcher. It does not have to be adhered to completely; instead, the participants’ response will guide the questions.
Project Name:————————-
Interviewer:—————————-
Name of kebele—————
Name of Village—————–
Nominal name(Id): —————–
Age:———–
Date:————————
Current occupation:—————
Educational status(completed grade):—————–
Monthly income:————-Birr
Location of home Distance from nearest HF:——km
Total number of births:————
Number of births at health facility:—————————–
Number of births at home:————
Started time:——————-
Ended time:——————–
1.Please would you describe the home delivery experience in as much detail as you can and provide some specific examples of your childbirth experience?
Probing questions
‘ Tell me about a time when you first experienced a home delivery?
‘ Can you describe a typical day in your life that happiness/fear felt?
‘ Would you tell me your reasons for preferring a delivery at home?
‘ Can you describe the obstacles you faced when delivering at home?
2.Please would you share me all your thoughts, feelings and perceptions about your experience?
Probing questions
‘ Would you tell me about your family support during home delivery?
‘ Can you tell me about your decision making on delivery places?
‘ Would you tell me about traditional practices and beliefs you are using during delivery?
4. Would you tell me about the use of traditional birth attendants at childbirth?
Probing questions
‘ What are your reasons for preferring traditional birth attendant services?
‘ What are the obstacles you faced when using traditional birth attendant services?
5. Would you tell me about institutional delivery services?
Probing questions
‘ What are your major reasons for not using facility-based delivery services?
‘ Would you tell me the use of skilled attendants’ services?
‘ Would you tell me the obstacles you thought when using skilled attendants’ services?
6. What did that your delivering childbirth at home looks like for you?
Probing questions
‘ Can you remember what you said then?
‘ what did it mean delivering child at home for you?
‘ What else additional comments and recommendations do you have on home delivery? Thank you for your valuable contribution!
Table 5 Socio-demographic data of study participants
SN Nominal
Name Age Kebele
/village Current
Occupat Education
(Completed Grade) Income Distance from the nearest HF
(km) Number
Delivery
given Date Time started Time stopped
At HF At Home
Women’s Experiences and Reasons for Preference to Home Delivery: A Phenomenological Theory based Qualitative study in Tembaro District, Southern Nations, Nationalities and People’s Region (SNNPR), Ethiopia
By
Getachew Shamebo (BSc in Env’tal H)
A Thesis Proposal to be Submitted to Department of Health Education and Behavioral Sciences, College of Public Health and Medical Sciences, Jimma University in Partial Fulfillment for the Requirements of a Masters of Public Health in Health Education and Promotion
February 2014
Jimma, Ethiopia
Women’s Experiences and Reasons for Preference to Home Delivery: A Phenomenological Theory based Qualitative study in Tembaro District, Southern Nations, Nationalities and People’s Region (SNNPR), Ethiopia
By: Getachew Shamebo (BSc in Env’tal H)
Advisors:
1. LAKEW ABEBE (MPH, Assist. Professor)
2. MORANKAR SUDHAKAR (PhD)
February 2014
Jimma, Ethiopia
Summary
Background: Homebirth is defined as giving birth to a baby in the place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians. Worldwide women who experience childbirth at home are at high risk of approximately 60% of death, and illness and delivery associated health squeal. In Ethiopia, majority (90%) childbirths reported at home. Tembaro is one of the districts in SNNPR, Ethiopia where still home delivery is taken as normal place of delivery. Hence, this study tries to attempt such issues.
Aim: to explore women’s childbirth experiences and reasons for preference to home delivery from women delivered at home in Tembaro district.
Methods: A descriptive phenomenological approach qualitative study will be employed. Using combined maximum variation and stratified purposive sampling technique a twenty-five women who were delivered at home from January 2013 to January 2014 in Tembaro District, SNNPR, Ethiopia will be participated. Data collection using in-depth interviews with open-ended questions on women’s childbirth experiences and reasons for preference to home delivery will be examined in detail by the researcher from March to April 2014. Colaizzi’s method will be used to guide the data analysis process. Applying simultaneous data collection and analysis, audio taped data and field notes will be transcribed in English by the researcher; and reading and re-reading transcriptions, extracting significant statements, categorizing into cluster themes and phenomenological thematic analysis will be assisted by Atlas ti vers.7 software. The trustworthiness will be ensured by validating participants’ agreement on the findings. Data management will be ensured by inserting data to computer using password and securely owned by the researcher and used for only the research purpose. The study findings will be presented, communicated and disseminated to the relevant organizations at the end of the study. Proposed budget planned to accomplish the expected result for personnel expenses 13,075.00 Ethio. Birr; and for transport and materials 2,347.00 Ethio. Birr are required.
Keywords: Women experiences, Reasons for preference, Home delivery, phenomenological approach, Qualitative study.
ACKNOWLEDGEMENT
My special gratitude and appreciation go to Jimma University’s College of Public Health and Medical Science, Department of Health Education and Behavioral Sciences for giving me the chance of conducting this study.
I would like to extend my heartfelt grateful to my advisors Lakew Abebe (MPH, Assistant Professor) and Morankar Sudhakar (PhD) for their unreserved sharing necessary materials, encouragements, precious times, guidance and constructive suggestions and comments in conducting this thesis proposal.
I would also like to acknowledge Tembaro district health office staffs for their sharing necessary background information to develop the study setting.
I would also like to acknowledge my wife Rawuda Ali for sharing her being constructive ideas and motivating me to work hard on this proposal.
Finally but not the least I would like to acknowledge my colleagues of this final year all MPH students especially for those who contribute financially as well as morally at the time my laptop was stolen by thief for their valuable role in my thesis proposal development.
Table of Contents
Summary I
ACKNOWLEDGEMENT II
Table of Contents III
List of Figures VII
List of Abbreviations VIII
CHAPTER ONE: INTRODUCTION 1
1.1 Background 1
1.2 Problem Statement 2
1.3 Research Paradigm and Theoretical Perspectives 4
1.3.1 Appropriateness of phenomenological approach 5
1.3.2 Qualitative epistemology 6
CHAPTER TWO: SIGNIFICANCE OF THE STUDY 8
CHAPTER THREE: OBJECTIVE OF THE STUDY 9
3.1 General Objective 9
3.2 Specific Objectives 9
CHAPTER FOUR: METHODS 10
4.1 Study area and period 10
4.2 Study Design 10
4.3 Study population 10
4.4 Inclusion and Exclusion Criteria 11
4.5 Sample size determination, Sampling Technique and Procedures 11
4.5.1 Sample size determination 11
4.5.2 Sampling Technique 11
4.5.3 Sampling Procedure 12
4.6 Data Collection Method and Process 14
4.6.1 Data Collection Process 14
4.6.2 Data collection method 14
4.6.3 Data collection tools 15
4.6.4 Pre -test 15
4.7 Data Analysis 16
4.8 Research quality 17
4.9 Definition of terms 18
4.10 Ethical Consideration 19
4.11 Dissemination the study findings 20
4.13 Role of the Researcher 21
4.14 Limitations of the study 22
CHAPTER FIVE: OVERALL RESEARCH WORK PLAN 23
CHAPTER SIX: BUDGET PLAN 24
References 25
Appendix A: Additional Background Information of the Study Area 28
Appendix B: English version letter of invitation and Consent form for in-depth interview participants 30
Appendix C: English version in-depth interview guide 32
List of Tables
Table 1 Work plan 23
Table 2 Personnel cost break down 24
Table 3 Transport and supply cost break down 24
Table 4: Back ground information of the study area 28
Table 5 Socio-demographic data of study participants 34
List of Figures
Figure 1: Sampling Procedures Using Combined or Mixed Purposeful Sampling Techniques 13
List of Abbreviations
EDHS-Ethiopian demographic survey
Ethio- Ethiopia
Feb- February
FMoH- Federal ministry of health
IPA- interpretative phenomenological analysis
ID- identification
HE-HP- health education and health promotion
MDG- millennium developmental goal
MPH- master of public health
PI- principal investigator
SBA- skilled birth attendant
SNNPRG- South Nations and Nationalities of peoples Regional state Government
SSA- Sub-Saharan African
TBA- traditional birth attendant
WHO- World Health Organization
CHAPTER ONE: INTRODUCTION
1.1 Background
Homebirth is defined as giving birth to a baby in your place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians(1). Since the women’s experiences and reasons for preference of homebirth vary throughout the world, this study tries to attempt such issues in detail.
Worldwide women who experience labor and delivery alone, with a family members, traditional birth attendants, community health workers, or other unskilled birth attendance occur at home and are at high risk of approximately 60% of death, illness and delivery associated health squeal(2). However, the amount of risk related to childbirth among developed countries compared to developing is very low (2%). For example in the US, about 98.7% of births were delivered in hospitals and only 1.3% of births that were delivered out of hospitals. The majority(98%) of childbirth risk is found in developing countries, where every year an estimated 60 million women give birth outside health facilities, mainly at home, and 52 million births occur without a skilled birth attendant (SBA)(3). Among these, the proportion of the poorest women reporting home delivery is highest in Sub-Saharan Africa(SSA), which is also the region with world’s highest rates of maternal and child mortality(4). Ethiopia is one of SSA countries where majority(90%) childbirth were reported still at home and assisted by non health professionals(TBA, relatives or alone) and only(10%) by skilled health professionals(5). EDHS 2011report shows that in the SNNP region the proportion of births assisted by a skilled provider were only 6.3 percent and 93.5% delivery service were given at home. Thus, it shows that in SNNPR maternal mortality related to childbirth remain the highest(93.5% of childbirth is at risk of deaths, illness and delivery associated health squeal)(5). Tembaro is one of the districts in SNNPR in which also shares similar contribution to the maternal problems related to childbirth.
.
1.2 Problem Statement
Maternal mortality is unacceptably high and about 800 women die from preventable causes related to pregnancy- or childbirth-related complications around the world every day. 99% of all maternal deaths occur in developing countries and more than half of these deaths occur in sub-Saharan Africa. Maternal mortality is higher in women living in rural areas and among poorer communities. Some childbirth related complication like severe bleeding after birth can kill a healthy woman within two hours if she is unattended(6). Most of home deliveries may be unattended by skilled health professionals.
Currently WHO recommended all delivery services should be attended at health facility to be assisted by skilled birth attendance. However, almost 60 percent of African women give birth without a skilled attendant, 18 million a year at home and during the last 10 years, the average coverage of births with a skilled attendant on the continent has not increased significantly(7).
Similarly, a study conducted in Nepal indicates that 94.7 percent delivered at home with no trained assistance, 114 women were brought to the hospital after home delivery, majority of the women (72.8%) were brought with retained placenta or excessive bleeding. Manipulations at home (abdominal pressure, pulling the cord, tying heavy objects in the cord for traction etc.) were done in some cases(8).
In Ethiopia, the majorities of rural women give childbirth at home and assisted by Traditional Birth Attendants (84%). Due to this reason most of time home deliveries are at risk of deaths, illnesses and the development of complications related to delivery makes childbirth problematic(9,10).
In the recent study in Gondar, Ethiopia in 2013 shows that experiences of complications among 1,668 eligible women about 476 (28.5%) of women were reported that they have some kind of complication related to childbirth. The most common reported complications were excessive bleeding (58.4%), and prolonged labor (23.7%). Thus, this shows that nearly half of the women who faced complications are reported outside health facilities(most likely home setting) at the time of obstetric complications(11).
In Ethiopia maternal and newborn health are questionable especially at the time of delivery because home births are high (90%). These indicates that many of women are delivered at home, which has the implication of high maternal illness, complications and death related to childbirth(12).
The Federal Ministry of Health in Ethiopia(FMoH) aims for 40% of deliveries to be attended by a skilled attendant by 2015(13) and currently required zero home delivery; which is very far to accomplish with in similar manner.
Despite the fact that, the service of home delivery in the study area in 2012/13 was very high(14) shows that still many women delivered at home. In Tembaro district, the lack of studies about women’s views on the reasons why women prefer home for childbirth and therefore home delivery remained the normal place of option they expect. Despite, both trained and untrained TBAs are assisting at delivery services in home level in the study area, which may have its own impact to influence women’s decision of delivery place and it has its own side effects due to lack of any delivery care materials for TBAs at hand and their inadequate skill to manage. Many of women delivering at health facility after delay at home and such women most of time are exposed to some complications related to childbirth. If they were brought to health facility immediately after first initiation of labor, it can be preventable and manageable through assistance of skilled birth attendants. In many developing countries like Ethiopia, it is known that home is not safe place for delivery service and not accessible for skilled birth attendants. Women’s childbirth experiences and reasons for preference to home are not addressed in the study area because no much study was found. Further exploration of the factors contributing to home delivery practice is very important to improve delivery services.
1.3 Research Paradigm and Theoretical Perspectives
A paradigm is essentially a worldview to the research, a whole framework of beliefs, values and methods with in which research takes place. A research paradigm is a set of fundamental assumptions and beliefs as to how the world is perceived which then serves as a thinking framework that guides the behavior of the researcher. The researcher’s ontological and epistemological positions form the philosophical basis of our research project. Ontology refers to our assumptions about how we see the world, e.g., Does the world consist mostly of social order or constant change? Epistemology refers to our assumptions about the best way to study the world, e.g., Should we use an objective or subjective approach to study social reality? This philosophical foundation affects every aspect of the research process, including topic selection, question formulation, method selection, sampling, and research design(15,16). Thus, it is why I am interested to see about the paradigm.
For instance, describing about all paradigms here will be beyond the scope of this study I brief only a paradigm and selected approach through which this study follows.
For this study, an interpretive paradigm was chosen. Interpretive paradigm attempts subjective meanings and social phenomena; focus upon the details of situation, the reality behind these details on knowledge. Assumptions of the Interpretivist Paradigm: share the following beliefs about the nature of knowing and reality: Relativist ontology – assumes that reality as we know it is constructed inter-subjectively through the meanings and understandings developed socially and experientially; and Transactional or subjectivist epistemology – assumes that we cannot separate ourselves from what we know. The investigator and the object of investigation are linked such that who we are and how we understand the world is a central part of how we understand others, the world and ourselves. By positing, a reality that cannot be separated from our knowledge of, the interpretivist paradigm posits that researchers’ values are inherent in all phases of the research process. Interpretivist positions are founded on the theoretical beliefs that reality is socially constructed and fluid. Thus, what we know is always negotiated within cultures, social settings, and relationship with other people. From this perspective, validity or truth cannot be grounded in an objective reality(17,18).
Among interpretive paradigm approaches, phenomenological approach was chosen for this study because it focuses on the understanding of a phenomenon from the point of view of the lived experience of participants in order to be able to discover the meaning of phenomenon to address in this study. Phenomenology is as a qualitative research approaches is based on the philosophy in the early twentieth century’s, in particular the ideas of the mathematician and philosopher Edmund Husserl(1859-1938), who believed that human experience is the source of all knowledge(19).
Among phenomenological approaches, for this study a descriptive phenomenological approach will be followed because it is used when the researcher wants to describe the phenomenon under study and brackets his/her previous knowledge about the phenomenon of interest. Hence, once a Husserlian descriptive phenomenological philosophy will be followed as a basis for a phenomenological theory of science, in order to achieve rigor both the data collection and the data analysis will be needed to follow the same approach(20).
In this study, the descriptive approach was adopted for collecting data to the experiential meaning of childbirth experiences of women delivered at home. Its advantage, in data collection gives the ability to collect accurate data and provide a clear picture of the phenomenon under study. Streubert Speziale and Carpenter stated that a descriptive method in data collection in a qualitative research is central to open-ended unstructured qualitative research interview investigations(21).
Due to its descriptive nature of Husserl’s phenomenology, it became known as descriptive phenomenology. It is important to note that descriptive phenomenology assumes an objective truth actually exists. Husserl stated that this truth was the human experiences that existed in the pre-reflective nature of individual experiences(22). This is just to show that the findings of this study may help to describe the commonality of experiences and reasons obtained from study participants.
1.3.1 Appropriateness of phenomenological approach
Phenomenology focus on an individual experiences, beliefs, and perceptions; and text used as a proxy for human experiences. It also focuses on the processes and experiences one goes through the study of phenomena or the things we experience and the ways we experience such things. Experience is a complex concept and not directly observable by an external observable. It may be difficult to study such a complex experiences in a concrete way because it is subjective. However, inter-subjectivity is often used as a mechanism for understanding how people give meaning or interpret their experiences. In addition to, Choice of an appropriate phenomenological research method underlying philosophical tenets of Husserl’s descriptive phenomenology is found vital to the credibility of the nurse interested to understand how nurses make meaning of their experience of being in nurse patient interactions. In addition, phenomenology is commonly used in the social and human sciences including sociology, education, psychology, nursing and health sciences. Hence, phenomenologists are interested in how people put together the phenomena they experience in such a way as to make sense of the world and develop a worldview. They assume commonality in human experience and focus on meaning making as the essence of human experience. In general phenomenology is a highly appropriate approach to researching human experience; and as a research method, it is a rigorous, critical and systematic investigation of phenomena(19,23). Therefore, I found phenomenological approach is preferred for the study of interest in this study.
1.3.2 Qualitative epistemology
While reflecting up on my experiences, when I was working as a health staff in Tembaro district health bureau, in many informal conversations with women who delivered at home two divergent experiences in my mind always have been at the fore and pushed me to attempt these issues. Firstly, Some women who delivered at home told me that giving birth at home radiated them harmony and happiness and their homebirth experience has had a great positive influence on them. Secondly, I had also encountered women who told me that giving birth at home was their worst experience in their life; a terrifying experience with fear of death, which they hope they will never experience again. Therefore, studying on home delivery has been of immense interest to me because in Tembaro district still majority of women were reported at home delivery that they are at risk of deaths and illnesses associated to childbirth at home. Thus, based on these the following question was attempted:
Why do some women still prefer to home delivery?
1.3.3 Positionality
My epistemological position regarding this study, I place myself in an interpretivist paradigm, while ontologically I would say I am a relativist.
Here, in this study my perceived identity as a university researcher, not as a district health office health staff, will be appeared to make participants feel safe to express their views. In the information sheet, however, the researcher’s background as a health professional will be fully disclosed and therefore there will be no deception.
Since in most qualitative research, health professionals conduct research as a means to understanding a health, as well as for developing their profession and improving health care. I believe that my background as a health professional enables me the conduct of this study on women’s home delivery experiences through qualitative health research; and will help me to gain knowledge working with women, their knowledge and perspective expand from health professional closeness and care provider role(24).
CHAPTER TWO: SIGNIFICANCE OF THE STUDY
This study is expected to have the following significances:
Home delivery has high risk of maternal illnesses, complications and mortality related to childbirth. So appropriately focused interventions on the improvement of delivery service will have high contribution to achieve the MDG 5. This requires preventing of factors contributing to home delivery through detail understanding of practices and reasons for preference to home delivery. Thus, this study attempts to address these issues.
To gain the best knowledge, this study is the first to use a qualitative approach to study the behavior of interest in Tembaro district, specifically acquiring a deep understanding of the reason why women prefer to home delivery rather than health facility. Based on it gathering qualitative data to improve understanding of home delivery could help to determine what draws women to partake childbirth at home. Hence, phenomenological approach has double benefits on addressing those lived experience and reasons as a meaning of participants that cannot much be addressed in quantitative research.
Findings of this study will help to influence decision makers and planners for taking appropriate actions for the improvement of delivery service.
Since not much study were found on the intended study area the study findings on home delivery will help to as a basis to stimulate and provide information for interested researchers to conduct further studies.
CHAPTER THREE: OBJECTIVE OF THE STUDY
3.1 General Objective
To explore women’s childbirth experiences and reasons(causes, explanations or justifications related to childbirth at individual level) for preference to home delivery on women’s delivered at home from January 2013 to January 2014 in Tembaro district, SNNPRG, Ethiopia from March to April, 2014.
3.2 Specific Objectives
1. To investigate the childbirth experiences of women who were delivered at home in Tembaro district.
2. To explore the reasons for preference towards home delivery from women delivered at home in Tembaro district.
CHAPTER FOUR: METHODS
4.1 Study area and period
The study will be conducted in Tembaro district, Southern Nations, Nationalities and People’s Region (SNNPRG), Ethiopia from February to March 2014. Out of the four health centers under Tembaro district, the catchment area of all health centers will be included for this study because many women from those areas delivered at home with non-skilled birth attendants as revealed by district health office report of the previous year (2012/13). The report showed that the district had the number of expected pregnancies of 4148, but low skilled deliveries of 1384 representing 33.4%. Here, we can see the majorities of women were giving birth at home. Data will be collected from mothers who were delivered at home from January 2013 to January 2014. Tembaro district is one of the eight districts in Kembata Tembaro zone, which is located in SNNPRG. It is one of the districts in which a total of 129,421 population lives and its main town is Mudulla. It is far from Addis Ababa, Hawassa and Durame 400km, 185kms, and 60kms respectively. It is bordered: by North Hadiya zone, West Omo river, East Hadero Tunto Zuria District, South Wolaita zone. In Tembaro district there are a total land area of 27,917 Hectare, 20 rural and 3 semi-urban kebeles; twenty health posts, four health centers and four Private health facilities are found. The overall potential health coverage of the district is 80%. The rest Background Information of the study area is given in Appendix A(14).
4.2 Study Design
A phenomenological approach especially descriptive Husserlian’s Phenomenology will be employed to explore women’s childbirth experiences and reasons of women’s delivered at home.
4.3 Study population
Women who have delivered child at home from January 2013 to January 2014 in Tembaro district.
4.4 Inclusion and Exclusion Criteria
4.4.1 Inclusion Criteria
Participants will be eligible for this study, when women who were delivered at home from January 2013 to January 2014 period and have been residing in Tembaro district for at least 6 months (because those less than six months were assumed not familiar to their living society), age in between 15year to 49year old (childbearing age groups) and in condition to the study will be included.
4.4.2 Exclusion Criteria
Eligible participants in the inclusion criteria, who are very sick or not in condition to give interview will be excluded.
4.5 Sample size determination, Sampling Technique and Procedures
4.5.1 Sample size determination
A maximum of twenty-five women of eligible groups will be participated. This is based on the Polkinghorne(1989) recommended for the phenomenological studies consisting of in-depth interviews that researchers interview from 5 to 25 individuals who have all experienced the phenomenon of interest(25). However, based on the purpose of the qualitative study data saturation (redundancy of emergent ideas) the number of sample size will be determined(less than 25).
4.5.2 Sampling Technique
A Combination of stratified purposeful and maximum variation sampling technique will be used. Stratified Purposeful Sampling- will be used in order to obtain the eligibles from different health center catchments, for addressing all the four-health center catchments stratification and to select kebeles from each catchment. Such a sampling technique can facilitate all eligible group comparisons with in the district. According to Patton, maximum variation sampling attempts to study a phenomenon by seeking out settings or persons that represent the greatest differences in that phenomenon(23). Therefore, a maximum variation sampling technique will be used together with stratified purposeful sampling technique just to get diverse variations and identifying important common patterns by representing diverse participants to obtain fully multiple perspectives about the home delivery. This means that the participants will be sampled based on particular predetermined criteria in order to cover a range of constituencies, such as different age, frequency of delivery at home and access to health facility(23).
4.5.3 Sampling Procedure
Before participant selection and data collection permission obtained by consulting, discussing and seeking advice from relevant woreda focal persons like woreda council office, women’s affairs and health office.
At district level, sampling frame will be obtained from district health office data (the number of home delivery report in each kebele of the target 12 months) and discussing the issue with the responsible person the selection of 09 kebeles and number of participants from each health center catchment will be identified.
Similarly, at selected kebele level permission and agreement will be obtained from kebele leaders, women’s affairs and health extension workers. Here, by discussing the issue together with health extension workers, leaders of kebele and women affairs information related to eligible women will be gathered. For participant women selection some criteria related to age of women, number of delivery at home and access to health facility will be taken into consideration. Then, from each selected kebele two or three women of eligible participants, who are willing to participate and getting consent will be purposely selected and used for data collection.
Figure 1: Sampling Procedures Using Combined or Mixed Purposeful Sampling Techniques
4.6 Data Collection Method and Process
4.6.1 Data Collection Process
Data collection process includes activities like selecting kebeles and participants, gaining access and building rapport, sampling purposefully, collecting relevant data, expanding notes and storing/saving it on computer securely. The collection process will be done using an in-depth interview guide with open-ended questions. The interview will be taped. The place of interview will be decided with participant interest in order to obtain rich data on the way of safe environment. Initially researcher attitude of openness needs to be empathic, meeting and being with the participants in a non-censorial manner in order to gain access to the participants’ reality as understood by them. It is a matter of encouraging participants to tell their story of experience in as much detail as they wish and are able to(26).
4.6.2 Data collection method
4.6.2.1 In-depth interview
After receiving approval for ethical clearance and getting individual consent, the researcher will continue data collection. The researcher will be engaged with participants posing questions in a neutral manner, listening attentively to participants’ responses and asking follow up and probes questions based on participants’ response. The interview will be conducted face to face and will be involved one interview with one participant at a time. The eligible women will be interviewed what they experienced and the reasons for preference to home delivery. They are preferred because first person reports of life experiences are what makes phenomenological research valid and experiences cannot be felt to be known in advance or felt to be known by other person rather than experienced. For each participant the interviews will be conducted at the range of 1 to 2 hours. All interviews will be tape recorded and transcribed verbatim by the researcher in English. The interviews will be conducted in the local language, Tembaregna, using the English version open-ended interview guide(27,28).
Audiotaping of interviews will be used after obtaining participant’s permission. There may be a tendency for some interviewees to forget that they are being audio taped. Therefore, the tape recorder will be placed in full view of the participant. In addition to, short field notes, non-verbal (facial, head nodding, etc.) expressions will be used as a means of data collection through active interaction with researcher-participants.
Generally, the interview will be conducted within the participants’ choice of favorable place or their home. This may help them to create feel free, equality and the interviewer-participant interactions to be safe.
4.6.3 Data collection tools
4.6.3.1 In-depth interview guide
For in-depth interview open-ended questions was preferred because it allow people to give their preferred responses. These questions will be flexible and allow the interviewer to probe and to seek clarification. Therefore, in addition to these follow-up questions using probes will be asked in order to acquire a deeper understanding when an explanation was unclear. Open-ended questions will supply a frame of reference for the participants’ answers. Questions focus on perceptions, feelings, experiences and reasons for preference related to home delivery, assistance of birth attendants, and impacts of home delivery on participants’ lives. They are open ended and oriented to gathering personal descriptions of lived human experience. The focus is usually more on a particular aspect of human experience as it occurs in several people rather than on describing in a total manner the experience of one person. The advantage of an interview guide is that it helps the interviewer pursue the same basic lines of inquiry with each person interviewed and manage the interviews in a more systematic and comprehensive way(23,27)
The interview guide including consent form will be used for the respective participants intended to be included in this study (given at Appendix C.
4.6.4 Pre -test
A pre- test study will be conducted for in-depth interviews. One to two interviews with women delivered at home and residing in neighboring district (HaderoTunto zuria) will be conducted to check the appropriateness of the guide to obtain the required information, modify interview guide and to ensure the total management of the whole interview session. Based on the pre test corrections will be made soon and the updated one will be used for the actual interview.
4.7 Data Analysis
Each interview (tape records, and body languages, facial expressions, head nodding, etc.) including field notes will be changed in to written form texts. In addition to this, conveying styles through transcribing choices (including pauses/silence, condensing, etc.) will be employed.
Schools of Phenomenology have developed different approaches to data analysis. Three frequently used methods of data analysis for descriptive phenomenology are the methods of Colaizzi (1978), Giorgi (1978), and Van Kaam (1966). Colaizzi’s method will be applied in this study because it allows the researcher to use a structured approach to data analysis and to expand their understanding of the meaning within the participants’ responses. In addition, Colaizzi’s procedural analysis is a well established and proven method that has been used extensively in qualitative research literature(29). The rigorous analysis of the descriptive phenomenological investigation by Colaizzi’s method of data analysis is preferred to be an appropriate method for this study with its focus on finding the essence and expanding meaning of the experience of women’s in home delivery. This method consists of six steps: dwelling with the data, extracting significant statements, formulating meanings into clusters or themes, creating an exhaustive description of the phenomenon, and reducing the description to a statement of the fundamental structure of the phenomenon(30).
As all qualitative data, based on the above processes as extracting significant statements, formulating meanings, categorizing into clusters and making sense of the essential meanings of the phenomenon and phenomenological thematic analysis will be assisted by Atlas ti vers.7 software(31).
Finally, to validate study findings using “member checking” technique will be undertaken.
That means through returning the research final (significant) statement given to participant to verify researcher’s description with them. If any comments, corrections given will be corrected based on their response(30).
4.8 Research quality
By its nature, a phenomenological study is associated with description and verbatim quotes will be utilized in reports of the findings to further enhance credibility. The participants of this study will be included because of their home delivery experiences. In order to attempt the required high quality of the study findings maximum efforts will be made to improve trustworthiness(32).
To enhance trustworthiness of this study the following points will be maintained:
1) Credibility: interviews will be supported by observation of non-verbal expressions, photo, tape record, and visual aids to strengthen truthiness of the study findings.
2) Applicability (fittingness): checking these understandings with the original informants or others similar to them
3) Consistency (audit ability): all participants will be seen equally by using a similar format for all participants. Oral text and the written text will be compared to ensure that the way and their interpretation were actual, not fabricated accounts, and ensuring their consistency. In addition to this, decisions about the research will be open for the study participants.
4) Neutrality (confirmability): it will be aided by blind reading of the interview texts by second readers (who have no connection to the study setting where the research occurs).
In addition, to the above to keep the truths of participants own meaning I will bracket myself consciously in order to understand, in terms of the perspectives of the participants will be interviewed, the phenomenon that I will be studying, that is the focus will be on participants views(33).
Since this study is intended for analysis through following the method of Colaizzi’s data analysis strategy, it is the only phenomenological analysis that calls for the validation of results by returning to study participants will be employed. This procedure helps the participants to ascertain if their answers to any questions need to be rectified, and ensures that the researcher has not misinterpreted the data(30).
4.9 Definition of terms
Bracketing: is a means of demonstrating the validity of the data collection and analysis
process through researchers putting aside their previous knowledge, beliefs, values and experiences in order to accurately describe participants’ life experiences(33).
Home birth: is as giving birth to a baby in your place of residence and which can be planned or unplanned, attended by a midwife, physician or others such as family members or emergency medical technicians. In developing countries, homebirth is considered risky place for childbirth related complications(1).
Home delivery: assumed similar to home birth.
Inter-subjectivity: The process of several, or many people, coming to know a common phenomenon, each through his or her subjective experience(34)
Natural settings: the ordinary settings in which people live and work, and/or uses interviews that are designed to approximate to ordinary conversations in key respects(35).
Phenomenology: A qualitative study design that represents an approach to enquiry that emphasizes the complexity of human experience and the need to understand that experience holistically, as it is actually lived(36).
Saturation: the point at which no further themes are generated when data from more participants are included in the analysis(37).
Skilled birth attendant: is a qualified health professionals(midwife, doctor, nurse or health officer) who has the skills needed to manage normal (uncomplicated) childbirth and the identification, management and referral of complications in women(10).
Subjectivities: describe the interaction of the researcher’s subject positions that informs her/his study(38)
Traditional Birth Attendant (TBA): is a person usually woman with or without training, who has no qualified skills(not licensed) to assist a mother in a childbirth(39).
4.10 Ethical Consideration
After approval of my thesis proposal, support letter will be taken from Research Ethics committee of Jimma University, College of Public Health and Medical Sciences; and permission will be obtained from relevant respective bodies accordingly.
Written consent will be obtained from participants after they were informed about the study and their right to withdraw from the study any time they wished too.
Anonymity and confidentiality will be ensured by not using the real names of the participants, in order to prevent emotional harm.
Permission for audio recording and photo taking will be obtained from the participants. Field notes and tape recordings will be kept under lock and key for three years and destroyed by fire after publishing the study findings.
4.11 Dissemination the study findings
The study findings will be presented and communicated at the end the study in the Department of Health Education and Behavioral Sciences, College of Public Health and Medical Sciences, Jimma University. The findings of the study will be disseminated to the relevant organization that can make use of these findings, including the Regional health bureaus, districts of health offices, health institution, community leaders & relevant non-government organizations.
4.13 Role of the Researcher
As being the researcher of this study, my background is BSc in Environmental health. The aim of current study is to explore women’s childbirth experiences and reasons for their preference to home delivery.
I believe that these experiences enhance my awareness, knowledge, and sensitivity to the issues being addressed and assist me in working with the participants of this study. I recognize the need to be open to the thoughts and opinions of participants and to set aside my experiences in order to understand and not to interfere preconceptions to those of the participants in the study(33). Therefore, as being human instrument an iterative and active communication will be made through the data collection period in order to obtained rich data on the topic of this study.
4.14 Limitations of the study
From the nature of human being, some participants may not describe their actual lived experiences rather than explaining only to what they want to say.
The limitations of this study exist in the means of resource and time constraints which may limit this study from further triangulation with different qualitative research methods such as focus group discussion and observational.
CHAPTER FIVE: OVERALL RESEARCH WORK PLAN
Table 1 Work plan
Sn
Activities
Physical year of time
2013 2014
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June
1 Topic selection
2 Preparation for proposal
3 Preparing proposal
4 Defense
5 Obtaining ethical clearance
6 Preliminary work before data collection
7 Pre-testing
8 Data collection and Analysis
9 Data entry and analysis
10 Draft analysis writing
11 Final analysis writing
12 Defense and submission
CHAPTER SIX: BUDGET PLAN
6.1 Personal Cost
Table 2 Personnel cost break down
S/N Personal involved Qualification Responsibility Total No. Working days Perdiem/day Total birr
1 Participants – Attending and giving response 25 2 25*2*50 2,500.00
2 Investigator HE-HP Data collector 1 30 30*195 5,850.00
3 motorist Driver Driving 1 15 15*120 1,800.00
4 Investigator HE-HP Investigator 1 15 15*195 2,925.00
5 Total 13,075.00
Note: Perdiem/incentives will be paid for participants of this study is based on WHO stated as a reimbursement for expenses incurred as a result of travel costs and reimbursement for time lost and its amount based on current context(40).
6.2 Transport and Materials Cost
Table 3 Transport and supply cost break down
S/n Item Unit Quantity Unit price Total price
1 Transport from/to JU to Tembaro district Birr 2 400 800.00
1 Computer paper Ream 1 100 100.00
2 Tape caset pcs 30 15 450.00
3 Battries for tape recorder Pair 10 10 100.00
4 CD-RW PCS 4 25 100.00
5 Note book Number 3 15 45.00
6 Pencil Number 2 1.00 2.00
7 pen Packet 1 50 50.00
8 Telephone card 4 100 400.00
9 Printing and binding of documents number 10 30 300.00
Total 2347.00
a) Personnel cost 13,075.00 b) Transport and Materials 2,347.00
Total Cost required 15,422.00
N/B: Tape-recorder is expected to obtain from the dep’t of HEBs, College of PH and Medical Sciences of Jimma University.
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Appendices
Appendix A: Additional Background Information of the Study Area
Table 4: Back ground information of the study area
1. Population
2. Available Health Facilities
4. Major Interventions and Their Achievement in 2005 E.C
Population profile Year, 2006
REMARK
Type of Health Facility Number of Health
Total population 129,421 Health center 4 Type of Activity Coverage
(%)
Male 63,416 Health posts 20 Open Defecation Free Kebele 100
Female 66,005 Hospital under construction 01, BCG 101
Estimated Households /4.9%/ 26,412 Private health facilities and 04 Pentavalent1 102
Estimated live birth/3.26% 4219 The overall Potential health coverage is 80%. Pentavalent3 101
Estimated surviving infants /3.07% 3844
3. Available Human power Measles 102
Estimated pregnancy/3.6% 4,646 Type of Profession Number available Fully Vaccinated 100
Pneumococcal vaccine1 102
HO/BScN 09
Estimated deliveries 4,219 Mid wife nurse 04 Pneumococcal vaccine3 103
Antenatal care 4 times and above 77
Urban HEWs 06
Under 3 yr age group 10,755 Health development army leaders 4174 Postnatal care 102
Women in reproductive age (15 -49 years) 30,155 Health development army followers 52614 Protected at Birth 105
TBA Trained 24 women received tetanus toxoid all 74
Non-pregnant women in fertile age 25,509 TBA not Trained 18 Delivery by HEW 36.5
By TBA 30.1
By SBA 33.4
Appendix B: English version letter of invitation and Consent form for in-depth interview participants
In-Depth Interview Participants Agreement Form in Kembata Tembaro Zone Tembaro District on Women Delivered at Home During January 2013 to January 2014
Hello, how are you?
My name is Getachew Shamebo; I am from Jimma University research team, where I am studying my master degree on public health. You have been identified as relevant respondent for this study. Therefore, I would like to interview you about your experiences/views on home delivery. The general purpose of this study is to explore women’s experiences and reasons for preference to home delivery. The aim of the interview is to obtain rich information from the residents like you. The interview will last approximately for 1 to 2 hours. The information you provide is confidential (will not conveyed to others unless you permit to do so) and will only be used for the above-mentioned objective of this study. A code /ID number will identify every participant and no names will be used. Participation is voluntary; you have the right to participate, or not to participate or refuse at any time during the interview. Your refusal will not have any effect on services that you or any member of your family receives. However, your participation is very important for the success of this study. There may be a possibility of being upset if the issue raised during discussion is related to personal experiences. There is no direct benefit for the participation of this study for his/her being participated rather than the result of findings will help to improve the whole community delivery services. For further information, my address is Tele 251- 09-16-84-06-19. Email shamebog@yahoo.com.
Would you like to participate in the study?
If yes, continue to the next page.
If no, skip to the other participant.
Informed consent form
I am, _______________________, being asked to participate in the study of women’s experiences and reasons for preference to home delivery. Getachew Shamebo, a student in Jimma University College of public health and medical sciences, is conducting this study. Understood that the general purpose of the study is to explore women’s experiences and reasons for preference to home delivery.
The researcher hopes to gain in-depth understanding of the issues by interviewing individuals knowledgeable of the topic. I understood that as a participant, I have the right to withdraw from the interview process for any reason. I understood that I would participate in an interview that will take an average one hour. The interviewer will ask me my experiences and reasons I have had and recommendations for change of delivery services. I understood that my involvement and sharing information would assist the study in making recommendations as to how future delivery services can better meet the needs of planners and health message developers. No harm is apparent because of participating in this research. If I am unable to continue an interview, I may stop the interview process at any time. I understood that I would share information and option with researcher. Great precaution will be taken to ensure that this information will remain confidential. Any reports or a recommendation that are written because of the study will never refer to specific individuals by name. Participation in this study is voluntary. Refusal to participate will involve no penalty or loss of benefits to which I am otherwise entitled. I understood that I may discontinue participation any time with no penalty to me. I have given the opportunity to ask any questions, and I have received a copy of this consent form. I read completely before interview, and I (study participant) freely and voluntary agreed to participate in the project and I agreed up on audio taping the discussion I will have with the researcher and I ascertained my agreement by signing this document.
Signature of the participant ___________________Date __________________
Signature of Witness _______________________ Date___________
Name of the interviewer ———————————-Signature———–Date—————
Name of Kebele————-Kebele Code———— Nominal code——–Age—–Years
Thank you for your valuable contribution!
Appendix C: English version in-depth interview guide
This list of topics and questions will guide the researcher. It does not have to be adhered to completely; instead, the participants’ response will guide the questions.
Project Name:————————-
Interviewer:—————————-
Name of kebele—————
Name of Village—————–
Nominal name(Id): —————–
Age:———–
Date:————————
Current occupation:—————
Educational status(completed grade):—————–
Monthly income:————-Birr
Location of home Distance from nearest HF:——km
Total number of births:————
Number of births at health facility:—————————–
Number of births at home:————
Started time:——————-
Ended time:——————–
1.Please would you describe the home delivery experience in as much detail as you can and provide some specific examples of your childbirth experience?
Probing questions
‘ Tell me about a time when you first experienced a home delivery?
‘ Can you describe a typical day in your life that happiness/fear felt?
‘ Would you tell me your reasons for preferring a delivery at home?
‘ Can you describe the obstacles you faced when delivering at home?
2.Please would you share me all your thoughts, feelings and perceptions about your experience?
Probing questions
‘ Would you tell me about your family support during home delivery?
‘ Can you tell me about your decision making on delivery places?
‘ Would you tell me about traditional practices and beliefs you are using during delivery?
4. Would you tell me about the use of traditional birth attendants at childbirth?
Probing questions
‘ What are your reasons for preferring traditional birth attendant services?
‘ What are the obstacles you faced when using traditional birth attendant services?
5. Would you tell me about institutional delivery services?
Probing questions
‘ What are your major reasons for not using facility-based delivery services?
‘ Would you tell me the use of skilled attendants’ services?
‘ Would you tell me the obstacles you thought when using skilled attendants’ services?
6. What did that your delivering childbirth at home looks like for you?
Probing questions
‘ Can you remember what you said then?
‘ what did it mean delivering child at home for you?
‘ What else additional comments and recommendations do you have on home delivery? Thank you for your valuable contribution!
Table 5 Socio-demographic data of study participants
SN Nominal
Name Age Kebele
/village Current
Occupat Education
(Completed Grade) Income Distance from the nearest HF
(km) Number
Delivery
given Date Time started Time stopped
At HF At Home