Determinants of health-seeking behavior of people on institutional delivery: evidence from qualitative research

BACKGROUND: Institutional delivery is an evidence-based option that substantially reduces risks to mothers and newborns. However, the existing literature provides an incomplete account of the determinants that influence individuals' choices about institutional delivery. This study explores the determinants (facilitators, barriers) of health-seeking behavior for institutional delivery in Nepal. METHODS: This study employed a focused ethnographic design, which allowed for an in-depth understanding of participants lived experiences in relation to health seeking behavior to institutional delivery. 60 in-depth interviews were conducted among mothers of children under two years, followed by transect walk, informal discussion with community people and field observations. Purposeful sampling included mothers who delivered in health facilities to explore facilitators of institutional delivery and mothers who delivered at home to identify barriers. Primary data were collected from both rural and urban sites across seven provinces of Nepal. All interviews were audio-recorded, transcribed in Nepali, and subsequently translated into English. Codes were generated from the translated transcripts, and those codes were then organized into overarching themes and sub-themes. An inductive approach was employed for data analysis, and R-based Qualitative Data Analysis (RQDA) software was used for data management. RESULTS: The study revealed broad support for antenatal care and health facilities, emphasizing their safety and benefits. Information about institutional delivery was disseminated through multiple channels, although some participants lacked comprehensive knowledge, leading to decisions influenced by personal intuition and cultural beliefs. Household decision-making dynamics, geographic accessibility, and financial considerations were significant factors influencing the selection of delivery location. While some participants valued free services, others experienced financial hardships. Infrastructure limitations and behaviours of health workers also affected health-seeking behaviors. CONCLUSION: Antenatal care and facility-based childbirth are widely accepted among women in Nepal; however, utilization of institutional delivery remains constrained by multiple barriers, including limited maternal knowledge, family decision-making dynamics, distance and transport challenges, hidden costs, shortages of facilities and personnel, disrespectful care, and COVID-19-related disruptions. Addressing these barriers is important to improve access to safe facility-based delivery.