Abstract
Introduction
Sub-Saharan Africa and Sierra Leone bear one of the world’s highest maternal mortality rates. In rural Sierra Leone, 19% of births occur at home, contributing to high maternal mortality ratios. This study aims to identify characteristics and reasons for home births among women in the rural Mathonkara Catchment area in Sierra Leone.
Methods
A cross-sectional survey was conducted among 555 women of childbearing age in the Mathonkara Catchment area, Tonkolili district. Data was collected between February 25 and May 12, 2023. A structured questionnaire assessed birthplaces, demographic characteristics, maternal health indicators, care seeking behaviours, and previous experiences of care at health facilities.
Results
The prevalence of home births was 26.67%. Characteristics associated with home births include the experience of feeling like health care workers did not care about your life (AOR = 19.11; 95% CI:1.57-799.61), a distance of > 1 km to the nearest health facility (AOR = 7.15; 95% CI:3.12–16.51), ≤ 3 antenatal care visits (AOR = 4.84; 95% CI:2.37–10.14), and previous homebirths (AOR = 4.17; 95% CI:2.42–7.30). Common reasons for home births were labour occurring at nighttime, transportation costs and availability, and health care service costs.
Conclusions for Practice
The factors influencing home births in rural Sierra Leone are multifaceted. To improve maternal outcomes, it is crucial to address the challenges that impede facility-based births, including quality of care and respectful care at health facilities, distance, economic costs of reaching facilities, and transportation challenges such as quality of roads and availability of transportation.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10995-026-04277-w.
Keywords: Maternal Health, Sierra Leone, Home Birth, Antenatal care, Tonkolili
Significance
What is already known?
What does this study add?
Home births are common in Sub-Saharan Africa and are associated with increased maternal mortality due to limited access to skilled care. Factors such as distance, socioeconomic challenges, and prior experiences with health care impact the decision to give birth at home.
This study identifies that in rural Sierra Leone, home births are significantly associated with negative health care experiences, long distances to health facilities, and low antenatal care attendance. This suggests that addressing these factors, especially respectful maternity care and logistical barriers, is crucial to reducing home births and improving maternal health outcomes in similar settings.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10995-026-04277-w.
Introduction
Sub-Saharan Africa (SSA) bears a disproportionate maternal mortality burden, encompassing 70% of all maternal deaths. Despite a 34% decline in maternal mortality ratios between 2000 and 2020, 287,000 maternal deaths occur annually, with progress stagnating since 2016 (WHO, 2023). This places SSA at risk of not achieving United Nations’ Sustainable Development goals on reducing global maternal mortality rates to less than 70 in 100,000 live births (UN, 2024). Most maternal fatalities are preventable and occur during childbirth, emphasising the critical need for skilled care and timely access to emergency obstetric care (WHO, 2023).
The prevalence of home births stands at 31% in SSA (Hernández-Vásquez et al., 2021). They are often attended by non-skilled health professionals such as family members and traditional birth attendants (Gabrysch & Campbell, 2009; Hernández-Vásquez et al., 2021). These births carry an increased risk of complications and maternal mortality in low- and middle-income countries (LMICs) (Hernández-Vásquez et al., 2021), where emergency obstetric care is often beyond reach (Gabrysch & Campbell, 2009; Thaddeus & Maine, 1994).
Sierra Leone (SL), a low-income West African country, bears one of the world’s highest maternal mortality ratios at 443 maternal deaths per 100,000 live births (WHO, 2023). In 2022, SL had a total of 51 hospitals and 1,250 Peripheral Health Units (PHUs), providing primary and secondary care (WHO Sierra Leone, 2022). PHUs are divided into maternal and child health posts (MCHPs), community health posts (CHPs), and community health centres (CHCs). Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) is only accessible at hospitals. Basic Emergency and Neonatal Care (BEmONC) is available at hospitals and designated CHCs (Ministry of Health and Sanitation, 2015).
Despite a decline in home birth prevalence from 72% in 2008 to 16% in 2019, rural areas, where 62% of the population resides, still report a 19% prevalence (Statistics Sierra Leone & ICF, 2019; Statistics Sierra Leone & World Bank, 2019). Accessing CEmONC in rural SL remains hindered by distance, and infrastructural and financial barriers (Ministry of Health and Sanitation, 2017). Qualitative studies with women from rural Tonkolili, SL, found that a higher number of pregnancies, poverty, distance, transportation availability and costs, collective decision-making, perceiving home births as the norm, and previous experiences with the health care sector influence the choice of birthplace (Treacy et al., 2018; Treacy & Sagbakken, 2015). Better understanding of the magnitude of these factors and exploring women’s health care seeking behaviour is needed to develop effective interventions to further increase facility births in rural SL.
The aim of this study was to (i) assess the prevalence of home births in the rural Mathonkara Catchment area in Tonkolili district, SL, (ii) identify characteristics associated with home births, and (ii) explore barriers for giving birth at a health facility.
Methods
Research Site and Study Population
This study was conducted in villages in the Mathonkara CHC catchment area in Tonkolili district, rural SL. Tonkolili has 756,425 inhabitants (Statistics Sierra Leone & World Bank, 2019). The district is among the poorest and most deprived districts in SL with overall poor health outcomes (Elston et al., 2017; Statistics Sierra Leone & World Bank, 2019). A total of 23 villages with an estimated population size ranging from 100 to 2,000 were visited (Fig. 1). The area was chosen due to its poor health outcomes and rural, hard-to-reach location, particularly during the rainy season. The area is characterised by long distances, impassable rivers and river-crossings, mountainous terrain, and poor road conditions. Average travel time to the villages took one to two hours travelling on narrow dirt roads with motorbikes from the closest CEmONC, Masanga Hospital. Several villages were only accessible by traveling part of the way on foot or by boat (information acquired through field visits).
Fig. 1.
Overview of Study Site
We included women of reproductive age who gave birth, miscarried, or had an abortion between February 1st 2022 and January 31st 2023, and lived in one of the villages for at least six months during this pregnancy.
Sample Size
The required sample size was calculated to estimate the prevalence of home births in the study population. With a confidence level of 95% (Zα/2 = ± 1.96), a margin of error of 5%, and an expected prevalence of home births of 16% based on the Sierra Leone Demographic Health Survey (SLDHS) (Statistics Sierra Leone & ICF, 2019), the minimum required sample size was calculated at 207.
Study Design and Data Collection
The study was conducted as part of an antenatal care intervention aiming to increase maternal health led by the Wouter Nolet Foundation. A structured questionnaire was developed, consisting of both single answer and multiple answer close-ended and open-ended questions (Supplementary 1). Data was collected from February 25th to May 12th, 2023. Questionnaires were administered through individual, structured interviews and entered into KoboToolbox (Kobo Organization, USA). Six local research assistants were recruited for the data collection and underwent a week of training led by two international MSc students.
Prior to data collection, a meeting was held with village officials from each village to explain the purpose of the study and obtain their support, building on the prior-standing relationship between the Mathonkara CHC and Masanga Outreach Team. The study was also endorsed by the Tonkolili District Medical Officer. Women were identified by going door-to-door. Those meeting the inclusion criteria were invited to be interviewed at home or another private place. Interviews were conducted in Krio or the local language Temne. Two to three revisits were done to all villages to interview women who were absent at the initial data collection. Quality control measures included supervision during field trips, cross-checking for missing data, outliers, and inconsistencies within 48 h of data collection, and two refresher sessions for research assistants.
Study Variables
The outcome variable was place of birth in the latest pregnancy. Home births included any births occurring outside of a health facility, referring to home, at another house in the village, in the nature or on the road while travelling, in line with the definition for unplanned home births used in literature (Vedam, 2003). Facility births were separated into births at hospitals and PHUs.
The explanatory variables included demographic characteristics (distance to nearest health care facility, maternal age, education, literacy), maternal health indicators (parity, pregnancy-related complications), care seeking behaviours (number of ANC visits, previous place of birth, uptake, timing, and outcome of ultrasound scans), and previous experiences of care at health facilities (feeling safe, respected, well taken care of, like health care workers cared about women’s life, like health care workers cared about the infant’s life).
Literacy was defined as being able to read or write. Distances to the nearest facility were acquired through Google Maps’ driving directions, measured from the village centre to the closest health facility. For villages without available driving directions on Google Maps, or where a river separated the village from the nearest facility, distance was measured manually by tracing roads on Google Maps Satellite view. Due to the low number of women that attended the recommended eight ANC visits in the study sample, the separation was set at ≥ 4 for the logistic regression analyses.
Data Analysis
Statistical analysis was conducted in three steps using R-4.3.2 (R Foundation, Austria). Data was checked for missing values and outliers. First, we performed descriptive analyses of demographical data, calculating frequencies (N) and percentages (%).
The next step was an explorative investigation of associations between the dependent variable (place of birth) and independent variables using bivariate logistic regression analysis. Odds Ratios (OR) were calculated for each variable. P-values < 0.05 were considered significant.
Lastly, we investigated the influence of multiple independent variables on the dependent variable using multivariate logistic regression analysis to account for potential confounders. Independent variables were included in the multivariate logistic regression model if they were statistically significant in the bivariate analysis with a cut off p-value of < 0.05. Adjusted Odds Ratios (AOR) were calculated for each variable. The statistical significance level was set at 5% with a 95% confidence interval (CI).
Ethical Considerations
This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was granted by the Sierra Leone Ethics and Scientific Review Committee (SLESRC No: 018/02/2023). Informed written consent was obtained from all study participants prior to inclusion, either signed or by providing their thumbprint for illiterate respondents. All data was de-identified and informed written consent stored in a locked room.
Results
Descriptive Statistics
A total of 555 women completed the face-to-face administered questionnaire, with all respondents eligible for the final analysis. Approximately a quarter (26.7%, 148/555) of the women gave birth at home (Table 1). Of these women, 91.2% (135/148) gave birth at their own home, 6.1% (9/148) elsewhere in the village, and 2.7% (4/148) in the nature or bush. Of the 73.3% (407/555) of women who gave birth at a health facility, 43% (175/407) gave birth at a hospital and 57% (232/407) at a PHU. Generally, in villages with a PHU, the majority of women gave birth at a facility (91.9%, 136/148), while those with a further distance to the nearest health facility portrayed higher home birth rates. A description regarding the proportion of home and facility births for each village can be found in Supplementary 2. Most women were aged 18–40 years (89.2%, 495/555) while 5.4% (30/555) were 14–17 years. More than half of the respondents were illiterate (57.8%, 321/555) and/or did not receive formal education (53.1%, 295/555). The majority had a parity of 2–6 (67.8%, 376/555) while 9.5% (53/555) had a parity of ≥ 7. Only 4.7% (26/555) women attended eight ANC visits as recommended by the World Health Organization’s (WHO) (WHO, 2016). One woman did not attend any ANC visits. More than half (61.8%, 343/555) of the women received at least one ultrasound scan during the last pregnancy. Less than a tenth (8.5%, 47/555) lived ≥ 9 km from the nearest health facility. A quarter (26.7%, 148/555) lived in a village with a PHU (Additional information in Supplementary 2).
Table 1.
Demographic Characteristics of Study Population
| Characteristics | Home Birth N (%) 148 (26.7) |
Facility Birth N (%) 407 (73.3) |
Total N (%) 555 (100) |
|---|---|---|---|
| Ag e groups (years) | |||
| ≤ 17 | 7 (4.7) | 23 (5.7) | 30 (5.4) |
| 18–40 | 131 (88.5) | 364 (89.4) | 495 (89.2) |
| ≥ 41 | 4 (2.7) | 5 (1.2) | 9 (1.6) |
| Unknown | 6 (4.1) | 15 (3.7) | 21 (3.8) |
| Relati onship status | |||
| Single/ Widowed | 5 (3.4) | 26 (5.4) | 31 (5.6) |
| Married/Relationship | 143 (96.6) | 381 (93.6) | 524 (94.4) |
| Liter acy | |||
| Literate | 48 (32.4) | 186 (45.7) | 234 (42.2) |
| Illiterate | 100 (67.6) | 221 (54.3) | 321 (57.8) |
| Highest level of education | |||
| None | 90 (60.8) | 205 (50.4) | 295 (53.1) |
| Primary | 22 (14.9) | 54 (13.3) | 76 (13.7) |
| Junior Secondary | 27 (18.2) | 75 (18.4) | 102 (18.4) |
| Senior Secondary | 9 (6.1) | 71 (17.4) | 80 (14.4) |
| Higher | 0 (0.0) | 2 (0.5) | 2 (0.4) |
| Occup ation 1 | |||
| Employed | 138 (93.2) | 371 (91.2) | 509 (91.7) |
| Unemployed | 10 (6.8) | 36 (8.8) | 46 (8.3) |
| Distance to closest health facility | |||
| In the village (0 km) | 12 (8.1) | 136 (33.4) | 148 (26.7) |
| 1–4 km | 61 (41.2) | 133 (32.7) | 194 (34.9) |
| 5–8 km | 57 (38.5) | 109 (26.8) | 166 (29.9) |
| ≥ 9 km | 18 (12.2) | 29 (7.1) | 47 (8.5) |
| Age at time of first pregnancy (N = 548) | |||
| ≤ 17 | 77 (53.1) | 179 (44.4) | 256 (46.7) |
| ≥ 18 | 60 (41.4) | 213 (52.9) | 273 (49.8) |
| Unknown | 8 (5.5) | 11 (2.7) | 19 (3.5) |
| Parity | |||
| 1–2 | 53 (35.8) | 179 (44.0) | 126 (22.7) |
| 2–6 | 82 (55.4) | 188 (46.2) | 376 (67.8) |
| ≥ 7 | 13 (8.8) | 40 (9.8) | 53 (9.5) |
| Complications during last pregnancy (N = 553) 2 | |||
| Yes | 67 (45.9) | 185 (45.5) | 252 (45.6) |
| No | 79 (54.1) | 221 (54.30) | 300 (54.2) |
| Refusal | 0 (0.00) | 1 (0.2) | 1 (0.2) |
| ANC visits | |||
| ≤ 3 visits | 44 (29.7) | 33 (8.1) | 77 (13.9) |
| 4–7 visits | 100 (67.6) | 348 (85.5) | 448 (80.7) |
| ≥ 8 visits | 3 (2.0) | 23 (5.7) | 26 (4.7) |
| Unknown | 1 (0.7) | 3 (0.7) | 4 (0.7) |
| Ultrasound in last pregnancy | |||
| Yes | 75 (50.7) | 268 (65.9) | 343 (61.8) |
| No | 73 (49.3) | 139 (34.1) | 212 (38.2) |
| Outcome of scan (N = 343) 3 | |||
| Any Problem | 5 (6.7) | 28 (10.54) | 33 (9.6) |
| No problem | 61 (81.3) | 225 (83.9) | 286 (83.4) |
| I don’t know | 9 (12.0) | 15 (5.60) | 24 (7.00) |
N number of individuals, SD standard deviation
1Multiple answers/occupations were possible. Housework was not considered to be an occupation. Occupations included: student, miner, farmer, trader, teacher, self-employment, driver, government employee, other (free text)
2Multiple complications were possible. Complications included: Hypertension, anaemia, vaginal bleeding, fever, malaria, urinary tract infection, seizure/convulsions (eclampsia), mental health challenges, vomiting/nausea, other (free text)
3Multiple outcomes were possible. Problems included: Placenta praevia, multiple gestation, uterine scar, intrauterine foetal death, previous caesarean section, breech presentation or unstable lie, foetal abnormalities, serotinicity, ectopic pregnancy, other (free text)
Characteristics Associated with Home Births
The bivariate analysis demonstrated a significant association between home births and the independent variables low education level, illiteracy, long distance to nearest health facility, high parity, low ANC attendance, absence of ultrasound scans in the last pregnancy, previous home birth, and previous experiences of care at health facilities (Table 2).
Table 2.
Bivariate and Multivariate Logistic Regression Analysis
| Characteristics | Demographics | Bivariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| Home Birth (%) | Facility Birth (%) | Unadjusted OR (95% CI) | P-value | AOR (95% CI) |
P-value | |
| 1. Demographic characteristics | ||||||
| Age Groups | ||||||
| ≤ 17 | 7 (4.7) | 23 (5.7) | 0.85 (0.33–1.92) | 0.705 | ||
| 18–40 | 131 (88.5) | 364 (89.4) | Ref. | |||
| ≥ 41 | 4 (2.7) | 5 (1.2) | 2.22 (0.54–8.52) | 0.239 | ||
| Unknown | 6 (4.1) | 15 (3.7) | 1.11 (0.39–2.80) | 0.831 | ||
| Educ ation 1 | ||||||
| None | 90 (60.8) | 205 (50.4) | Ref. | Ref. | ||
| Primary | 22 (14.9) | 54 (13.3) | 0.93 (0.53–1.60) | 0.792 | 1.03 (0.31–3.33) | 0.958 |
| Junior Secondary | 27 (18.2) | 75 (18.4) | 0.82 (0.49–1.35) | 0.441 | 1.94 (0.59–6.31) | 0.267 |
| Senior Secondary | 9 (6.1) | 71 (17.4) | 0.29 (0.13–0.58) | < 0.001 | 1.72 (0.35–7.12) | 0.462 |
| Literacy | ||||||
| Literate | 48 (32.4) | 186 (45.7) | Ref. | Ref. | ||
| Illiterate | 100 (67.6) | 221 (54.3) | 1.75 (1.19–2.62) | 0.005 | 1.79 (0.58–5.51) | 0.304 |
| Distance to closest Health Facility | ||||||
| 0 km | 12 (8.1) | 136 (33.4) | Ref. | Ref. | ||
| 1–4 km | 61 (41.2) | 133 (32.7) | 5.05 (2.67–10.27) | < 0.001 | 7.15 (3.12–18.14) | < 0.001 |
| 5–8 km | 57 (38.5) | 109 (26.8) | 6.06 (3.21–12.33) | < 0.001 | 8.84 (3.87–22.43) | < 0.001 |
| ≥ 9 km | 18 (12.2) | 29 (7.1) | 7.03 (3.09–16.57) | < 0.001 | 5.56 (1.71–18.19) | 0.004 |
| 2. Maternal Health Indicators | ||||||
| Parity | ||||||
| 1–2 | 53 (35.8) | 179 (44.0) | Ref. | Ref. | ||
| 2–6 | 82 (55.4) | 188 (46.2) | 2.03 (1.24–3.45) | 0.006 | 1.33 (0.12–16.51) | 0.813 |
| ≥ 7 | 13 (8.8) | 40 (9.8) | 1.54 (0.69–3.31) | 0.278 | 0.62 (0.05–8.17) | 0.701 |
| Complications during last pregnancy (N = 553) | ||||||
| Yes | 67 (45.9) | 185 (45.6) | 1.02 (0.70–1.50) | 0.902 | ||
| No | 79 (54.1) | 221 (54.4) | Ref. | |||
| 3. Care-Seeking behaviours | ||||||
| ANC groups | ||||||
| ≤ 3 | 44 (29.7) | 33 (8.1) | 4.80 (2.92–7.98) | < 0.001 | 4.84 (2.37–10.14) | < 0.001 |
| ≥ 4 | 103 (69.6) | 371 (91.20) | Ref. | Ref. | ||
| Unknown2 | 1 (0.7) | 3 (0.7) | 1.20 (0.06–9.49) | 0.875 | ||
| Ultrasound in last pregnancy | ||||||
| Yes | 75 (50.7) | 268 (65.9) | Ref. | Ref. | ||
| No | 73 (49.3) | 139 (34.1) | 1.88 (1.28–2.75) | < 0.001 | 1.59 (0.93–2.69) | 0.088 |
| Place of Birth in first pregnancy (N = 435) 2 | ||||||
| Home | 74 (57.8) | 87 (28.3) | 3.47 (2.26–5.35) | < 0.001 | 4.17 (2.42–7.30) | < 0.001 |
| Facility | 54 (42.2) | 220 (71.7) | Ref. | Ref. | ||
| 4. Previous experience of care at health facilities 3 | ||||||
| Health care workers cared about your life (N = 541) | ||||||
| Yes | 117 (86.7) | 403 (99.3) | Ref. | Ref. | ||
| No | 18 (13.3) | 3 (0.7) | 20.67 (6.85–89.32) | < 0.001 | 19.11 (1.57-799.61) | 0.046 |
| Safety (N = 530) | ||||||
| Yes | 128 (92.8) | 389 (99.2) | Ref. | |||
| No | 10 (7.2) | 3 (0.8) | 10.49 (3.16–47.34) | < 0.001 | 1.89 (0.03–69.67) | 0.719 |
| Respect (N = 542) | ||||||
| Yes | 135 (99.3) | 403 (99.3) | Ref. | |||
| No | 1 (0.7) | 3 (0.7) | 1.00 (0.05–7.85) | 0.997 | 0.0049 (0.00-0.62) | 0.043 |
| Health care workers cared about your infant’s life (N = 538) | ||||||
| Yes | 120 (90.2) | 399 (98.5) | Ref. | Ref. | ||
| No | 13 (9.8) | 6 (1.5) | 7.20 (2.78–20.88) | < 0.001 | 0.62 (0.02–9.90) | 0.759 |
| Health care workers responded to your needs (N = 537) | ||||||
| Yes | 116 (87.9) | 398 (98.3) | Ref. | Ref. | ||
| No | 16 (12.1) | 7 (1.7) | 7.84 (3.26–20.83) | < 0.001 | 0.77 (0.03–7.92) | 0.845 |
| Well taken care of (N = 543) | ||||||
| Yes | 126 (92.0) | 402 (99.0) | Ref. | Ref. | ||
| No | 11 (8.0) | 4 (1.0) | 8.77 (2.94–32.10) | < 0.001 | 4.99 (0.48–58.06) | 0.170 |
N number of individuals, OR odds ratio, AOR adjusted odds ratio, CI confidence interval, Ref. reference, km kilometre, ANC antenatal Care
Multivariate analysis carried out with independent variables with a cut off p-value of ≤ 0.05 in the bivariate analysis. Multivariate regression adjusted for education levels, literacy, distance, parity, ANC uptake, ultrasound uptake, previous place of birth, and previous experiences of care at health facilities
1Not enough observations in higher education group to perform analysis
2Not enough observations to perform multivariate analysis
3Variable I don’t know taken out as too little observations to carry out analysis
4Data also collected for second to sixth pregnancy, which also yield for significant results in the bivariate analysis
Multivariate analysis only carried out for one variable due to high potential of multicollinearity and correlation
Further details on previous pregnancies can be found in Supplementary 3
The multivariate analysis demonstrated a significant association between home births and long distance to the nearest health facility, low ANC attendance, previous home birth, and previous experiences of care at health facilities. The AOR for having a home birth was 7.15 [3.12–18.14], 8.84 [3.87–22.43], and 5.56 [1.71–18.19] for those living 1–4, 5–8 and ≥ 9 km away from the nearest health facility. Women who received ≤ 3 ANC visits during their last pregnancy were four times more likely (AOR = 4.84 [2.37–10.14]) to give birth at home compared to those with ≥ 4 ANC visits. Further, women who gave birth at home in their first pregnancy were four times more likely to give birth at home (AOR = 4.17 [2.42–7.301]) in subsequent pregnancies. Those who felt like health care workers did not care about their lives were 19 times more likely to give birth at home for subsequent pregnancies (AOR = 19.11 [1.57-799.61]).
Results on ultrasounds during the last pregnancy, level of education, literacy, and parity did not yield statistically significant results.
Barriers for Home Births
The most prevalent barriers for home births were nighttime (24.3%, 36/148), time constraints (22.3%, 33/148), and transportation issues (16.2%, 24/148) (Table 3). Most common reasons hindering women from giving birth at a health facility in the future were financial issues (31.1%, 37/119), transportation issues (27.7%, 33/119), and nighttime (16.0%, 19/119).
Table 3.
Reasons for Home Births
| Question | Total N (%) |
|---|---|
| Why did you not give birth at a health facility? (N = 148) 1 | |
| Nighttime | 36 (24.3) |
| Time constraints | 33 (22.3) |
| Transportation2 | 24 (16.2) |
| No money for hospital expenses | 12 (8.1) |
| Preference for home births | 11 (7.4) |
| Fast labour | 10 (6.8) |
| Unexpected Miscarriage | 9 (6.1) |
| Financial issues | 3 (2.0) |
| Distance | 2 (1.4) |
| Poor road conditions | 2 (1.4) |
| Other | 13 (8.8) |
| What could prevent you from going to a health facility in the future? (N = 119) 1, 3 | |
| Financial issues | 37 (31.1) |
| Transportation2 | 33 (27.7) |
| Nighttime | 19 (16.0) |
| Fast labour | 9 (7.6) |
| Unexpected Miscarriage | 7 (5.9) |
| Distance | 6 (5.0) |
| Poor road conditions | 4 (1.7) |
| Giving birth on the way to the health facility | 2 (1.7) |
| Other | 11 (9.2) |
N number of individuals, PHU peripheral health unit
1Open ended free text, multiple answers were possible
2Includes both unavailability of and no money for transportation
3Only asked to women who indicated that they could imagine giving birth at a health facility in a subsequent pregnancy
Discussion
Home birth prevalence was 26.67% (148/555) among the study population. Factors associated with home births included previous experience of care at health facilities, distance to health facilities, and low ANC attendance. Despite efforts to increase access to care such as the National Emergency Medical Service (Doctors with Africa, 2018), distance and financial constraints still prevent women from their right to adequate care. Our findings suggest that previous experiences highly influence women’s choices and respectful care appears crucial in motivating women to give birth at health facilities (Treacy et al., 2018; Treacy & Sagbakken, 2015).
Findings in Light of Other Evidence
The most significant association was a 19-fold increase in home births following negative experiences of care at health facilities, consistent with findings from SL (Theuring et al., 2018; Treacy et al., 2018; Treacy & Sagbakken, 2015). Negative encounters with health facilities and low quality of care have shown to influence a woman’s decision-making across West Africa (Moore et al., 2011; Theuring et al., 2018). This may also explain why previous home births increase the likelihood of subsequent ones (Bohren et al., 2014; Gabrysch & Campbell, 2009). Bribes, verbal and physical abuse during labour, widely reported in LMICs (Bohren et al., 2014; Gabrysch & Campbell, 2009; Thaddeus & Maine, 1994) and SL (Theuring et al., 2018; Treacy et al., 2018; Treacy & Sagbakken, 2015), exacerbate these decisions. Conversely, uneventful facility births have also been linked to increased home births (Moore et al., 2011). However, the WHO and Sierra Leonean Ministry of Health recognise the high level of abuse and importance of improving birth experiences with a focus on attainable birth environments and respectful maternity care as a central component of reducing home births (Ministry of Health and Sanitation, 2023; WHO, 2015).
Distance to the nearest health facility was the second strongest barrier, with women living 4–8 km away from a health facility being almost eight times more likely to give birth at home. This aligns with findings from SL (Statistics Sierra Leone & ICF, 2019; Theuring et al., 2018; Treacy et al., 2018). Contributing factors include cost of transportation (Bayo et al., 2020; Gabrysch & Campbell, 2009; Moore et al., 2011; Thaddeus & Maine, 1994; Theuring et al., 2018; Treacy et al., 2018), poor road conditions, particularly during the rainy season (Moore et al., 2011; Thaddeus & Maine, 1994; Treacy et al., 2018), nighttime travel (resulting in unsafe roads, hindering transportation availability and increasing costs of transportation) (Bohren et al., 2014; Gabrysch & Campbell, 2009; Kawakatsu et al., 2014; Moore et al., 2011; Thaddeus & Maine, 1994; Theuring et al., 2018), and fear of giving birth along the way (Treacy et al., 2018), as also indicated by our study participants. These barriers underscore the structural and logistic challenges related to overcoming distances in rural LMICs (Gabrysch & Campbell, 2009; Thaddeus & Maine, 1994). A study from Northern SL reports an impressive increase in facility-based births (from 63.2% to 81.0%) in communities after exposure to infrastructural improvements such as road development (Knoblauch et al., 2014). This shows reducing distances to health facilities alongside improving road conditions and transportation availability to lower travel time remains a crucial priority in LMICs (Bright et al., 2017), yet improving road infrastructure often remains neglected. Scaling up on health facilities is not effective when human resources are scarce, potentially resulting in unstaffed, low-quality facilities. Furthermore, availability of transportation around the clock and financial support are vital in reducing home births. While maternity waiting homes have been suggested and could explain why the observed AOR is lower in the ≥9 km group, they are challenged by, among other, financial means of women (Treacy et al., 2018). Further, women are often not in charge of finances and transportation, highlighting the importance of community and partner involvement (Ladur et al., 2021).
Low uptake of ANC was associated with a higher likelihood of home births in our population, a trend supported by research in LMICs (Bohren et al., 2014), SSA (Bayo et al., 2020; Kawakatsu et al., 2014) and SL (Statistics Sierra Leone & ICF, 2019). This relationship might be explained by increases in maternal health-related knowledge (Bayo et al., 2020; Kawakatsu et al., 2014), facilitation of more comfortable interactions with health facilities during antenatal care visits (Bayo et al., 2020; Kawakatsu et al., 2014), and common underlying factors facilitating both ANC and facility births like distance, road conditions and transportation availability to the closest health facility. Inadequate and inaccessible ANC can lead to missed opportunities for early detection and management of pregnancy-related complications, contributing to home births and associated risks (Bohren et al., 2014; Thaddeus & Maine, 1994). Improving ANC services by addressing transportation, skilled health care provider availability, and financial barriers is essential. Community-based interventions that educate and empower women about the importance of ANC and facility births can play a vital role (Lassi et al., 2016).
Although lower education levels and illiteracy were significantly associated with home births in the bivariate analysis, they were not significant in the multivariate analysis. Nevertheless, a clear association between lack of education and home births was found across SSA (Ahinkorah, 2020; Bayo et al., 2020; Kawakatsu et al., 2014; Moore et al., 2011; Regassa et al., 2022) and SL (Statistics Sierra Leone & ICF, 2019). Educated women may be more concerned for their health status and more attentive to available health resources, difficulties and complications during pregnancy and childbirth (Bayo et al., 2020; Kawakatsu et al., 2014; Moore et al., 2011; Regassa et al., 2022). Conversely, two studies have suggested a general awareness regarding the importance of facility-based births among women of all education and literacy levels (Theuring et al., 2018), which could explain the lack of significance in the multivariate analysis. Additionally, our lack of findings may be influenced by the homogeneity of our sample, as a large proportion of participants had no or low education levels. Improving access to education and empowering women with the knowledge and confidence to seek facility-based births through community outreach and support systems is therefore a crucial tool to reduce home births (Kerber et al., 2007; Lassi et al., 2016).
Higher parity as a determinant for home births did not reach statistical significance in the multivariate analysis, but data suggest that women with higher parity are more likely to give birth at home. Several studies, including the SLDHS (Statistics Sierra Leone & ICF, 2019), linked high parity to home births across LMICs (Gabrysch & Campbell, 2009) and SSA (Ahinkorah, 2020; Regassa et al., 2022) as childbirth becomes normalised and perceived as less risky (Gabrysch & Campbell, 2009; Regassa et al., 2022). Community education programs and family planning initiatives that support women’s autonomy in health care decisions could help shift perceptions and encourage safer birthing practices (Kerber et al., 2007; Lassi et al., 2016).
Limitations and Strengths
This study is the first to present evidence on characteristics and determinants of home births among women from rural SL. The sample size is large enough to ensure statistical power, and the study is representative of Tonkolili, and possibly other rural districts in SL. To the best of our knowledge, it was also the first to include the variables previous home births and previous experiences of care at health facilities in a quantitative study of this nature.
However, the cross-sectional design limits causal inference and may be subject to residual confounding. The exclusive reliance on quantitative data reduces the depth of insights, in particular in capturing women’s experiences at health care facilities. Furthermore, while some data was obtained from relatively reliable sources such as the women’s ANC card, clinic book, or child health card, it is important to note that these were often not available, making data dependent on self-reports prone to recall bias. Social desirability bias may have also influenced responses, as participants knew the researchers worked at health facilities. Efforts to mitigate this bias included training research assistants to ensure neutrality and confidentiality and effectively communicating this to respondents.
Further research exploring home births in SL could include media usage (Regassa et al., 2022), wealth status (Ahinkorah, 2020; Regassa et al., 2022), and traditional beliefs (Bohren et al., 2014; Gabrysch & Campbell, 2009; Thaddeus & Maine, 1994), whose relevance has been noted in research from other SSA countries. Finally, while factors influencing home births are largely understood, intervention research to ensure innovative, cost-effective solutions to reduce home births is crucially needed.
Conclusions for Practice
Our findings underscore the complex decision-making processes influencing the choice of home births in the Mathonkara Catchment Area in rural SL. Despite efforts to improve uptake of facility-based births, 26% of women in the Mathonkara Catchment area still give birth at home. The strongest association was observed for negative experiences of care at health facilities, yielding for a 19-fold increase of home births. Barriers such as experience at health facilities, distances and road conditions to reach, difficulties in accessing transportation, particularly at night when travelling may be unsafe, financial constraints, and low ANC attendance remain key barriers for facility-based births. Ensuring respectful maternity care is both overdue and crucial for motivating women to overcome these barriers and choose facility-based births. To meet SDG targets on maternal mortality and promote facility-based births in rural SL and potentially other SSA countries, we advocate for evidence-based interventions that address these barriers and prioritise respectful maternity care.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to thank all women who supported this study with their participation. We would also like to thank all research assistants for their hard work as well as all staff members from the Masanga Hospital, who contributed to this study. Finally, we would also like to thank the Wouter Nolet Foundation for their financial support and dedication to increase maternal health in SL.
Author Contributions
M.L.K., T.D.F., R.R.: conceived the study and wrote the protocol. J.Wu., T.D.F., S.S., R.R., H.A.B., J.We., R.J., L.S.A., M.L.K., A.W.B.: conceptualization and methodology. J.Wu., S.S.: coordination and supervision of data collection. M.I.C., I.A.K., H.S.S., A.B.D., Z.M.S.: data acquisition. T.D.F., R.R., M.L.K., L.S.A.: Supervision. T.D.F., S.S., R.R., A.W.B., H.A.B., J.We., R.J., L.S.A., M.L.K., M.I.C., I.A.K., H.S.S., A.B.D., Z.M.S., J.Wu.: writing: review and editing. J.Wu.: formal analysis, data interpretation and writing: original draft. M.L.K.: funding acquisition. All authors participated in the revision of the manuscript, contributed with important intellectual content, and approved the final version.
Funding
The research project was funded by the Wouter Nolet Foundation. The foundation was not involved in the study design, data collection, data analysis, and data interpretation.
Data Availability
The dataset is available from the corresponding author on reasonable request.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
Ethical approval was granted by the Sierra Leone Ethics and Scientific Review Committee (SLESRC No: 018/02/2023).
Consent to Participate
Informed written consent was obtained from all study participants, either signed or by providing their thumbprint for illiterate respondents.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset is available from the corresponding author on reasonable request.