An insight into birthing and EmONC service utilisation for making birthing safe: a qualitative study in underdeveloped districts of Punjab, Pakistan.

Abstract Background: The qualitative study was conducted to understand the socio-cultural factors (challenges and enabling factors) those influence the decisions and ability of the pregnant women and their families to make better use of the available safe birthing and EmONC services in two districts (Khanewal and Jhang) of Punjab, Pakistan. Objectives: To explore the key social, personal and professional considerations (factors) that influence the women (and family) decision and ability to utilise various birthing and EMONC services and to understand care providers interest and ability to offer these safe birthing services in the districts of Jhang and Khanewal in Pakistan. Study Design: The qualitative study was conducted, during the year 2013/14, on three rural health centers and two district headquarter hospitals in Kanewal and Jhang districts in Punjab. Through purposive sampling, 42 registered clients were interviewed to explain the different birthing experience along with 15 service providers, 2 district level programme managers and 2 transport vendors. The collected qualitative data from interviews were transcribed, and key emerging concepts/ themes were identified. A range and continuum of coded responses/ comments were compiled and discussed under each theme. Results: Main themes were structured birth planning; antenatal at health centres; skilled birth attendance; emergency obstetric and neonatal care (EmONC); and EmONC travel. The study found that pregnant women consult their husbands and mother in laws for taking birthing decisions; consult the skilled birth attendant for management of complication; private clinics are preferred for various social and logistic reasons; many private clinics doing caesarean are not adequately equipped; male reluctance (for cultural reasons) to make in-advance transport arrangement for possible EmONC; travel voucher utilisation remained low because of limited coverage and less-friendly procedures. Conclusion: Safe birthing decisions could be complex; and influenced by multiple social, cultural, economic, service access and quality considerations. Safe birthing practices can be improved if interventions remain sensitive to these preferences and realities. Keywords: Skilled birth attendance, social determinants, lady health workers, birth planning