During the FGDs, we learned that women had many different types of birthing experiences. There were: women who had delivered both at home and in a facility for different pregnancies; women who had exclusively delivered at home or in a facility for all their births; women who had wanted to deliver at a hospital but never made it; and women who had wanted to deliver at home, but had to be taken to a hospital due to a complication. There were also pregnant women who had given birth previously and who wanted to choose their place of birth based on an earlier experience; others who were pregnant for the first time and clear about their place of delivery; and those who did not know yet. In short, we realized that women did not fall into one, single category in terms of where they chose to give birth, or even in terms of the factors leading them to a given decision. We found this to be somewhat surprising, as other studies on maternal health categorized women into groups based on their discrete choices for place of delivery, and presumably the choices were consistent across all pregnancies [28,29,30]. Instead, we found that the same woman may make different choices for different pregnancies, depending on their circumstances and context.
What was most consistent in our study was that the hospital or health center was the preferred option, particularly in cases of suspected and confirmed complications. In those latter instances, women would often seek medical care in response to a complication and then be advised by a provider to deliver at a facility. There was enough trust in and access to a provider to seek care for complications. Further, the women who went to a facility also perceived that the facility would be able to manage their complication(s). Similarly, one study in southern Haiti concluded that prenatal care was associated with the ability of a woman to recognize pregnancy complications, and that women who better perceived symptoms were more likely to seek care [31]. However, the participants in our study also expressed a negative perception of what type of care they would receive in a facility. The anecdotal report from one woman about being physically immobilized was extreme, but it fit within the premise that there is an overall lack of attention and compassionate care for birthing women in a facility. Thus, women appeared to be consistently weighing the pros and cons of giving birth in a facility, e.g., a safer birth but in a colder and less compassionate environment, versus at home, surrounded by loved ones and the dedicated attention of a fanm chay. Women’s autonomy in decision-making to seek care has been associated with higher hospital birth rates, but it is possible that negative experiences dampen this association if women perceive the choice to be a poor one [32].
Although we found that the rural/urban division was relevant in some respects (e.g., costs and challenges of transportation and concerns about crime and insecurity, which are beyond the scope of this paper), women’s preferences for or experiences of place of birth did not vary across urban and rural settings. Some urban women did express that they had a choice in health-care facilities and that they had compared delivery services between different hospitals, whereas the rural women did not suggest that they had choices or that they compared facilities. The city of Port-au-Prince has more than twice as many health facilities, more than three times as many nurses, and over seven times as many midwives as the entire southern department [33]. Nonetheless, we found the aversion to isolation in hospitals to be common across urban and rural groups and to be reported for multiple facilities in Port-au-Prince.
The 2016–17 Haitian Demographic Health Survey found transportation cost and distance to facilities to be the major obstacles for women to deliver in health facilities, i.e., the first and second delays [3]; however, this survey did not report directly on the hospital-birth experience. Our study found compassionate maternity care to be an important factor in the decision about where to give birth. We found that the experience of isolation negatively affected women’s perceptions of the hospital birth; it also eroded confidence in choosing a hospital for the location of future births. Negative perceptions of facility-based maternity care can also have a psychological impact that affects future reproductive health decisions, such as seeking antenatal or postnatal care [34]. Distinct from women’s feelings about isolation is also the implication that isolation indicates a monitoring delay in the timely detection of complications and in appropriate interventions to prevent or treat a life-threatening complication, such as preeclampsia. Certainly, the issue of isolation is not attributable to provider attitude or behavior alone. As has been noted in several studies, Haitian facilities are understaffed, overcrowded, and lack basic supplies that cause further delays in the administration of appropriate care [35, 36]. We argue, however, that it would be possible to address these issues (without additional significant financial resources) if the clinical training curriculum were to include respectful and compassionate care as an integral part of the current standard of maternal care in Haitian facilities.
Women expressed a preference for home births over facility births, based on the physical support and care they receive during labor and delivery. They noted a lack of care, leading to emotionally and physically isolating experiences in facilities. Having continuous social support during birth is also recognized as an important intervention by the WHO [37]. Research shows that women with continuous support are less likely to use any intrapartum analgesia, are more likely to have a spontaneous vaginal birth, and are less likely to report negative ratings of or feelings about their childbirth experience. They also tend to have shorter labors and are less likely to have a cesarean or a baby with a low Apgar score [38]. Prata and colleagues recommend training traditional birth attendants or community health workers to deliver life-saving interventions during home births, but this approach is currently not supported by Haiti’s public health ministry (Ministère de la Santé Publique et de la Population, or MSPP) [39]. MSPP’s program for maternal and newborn health in Haiti exclusively advocates for facility births with skilled birth attendants [40]. Therefore, within the context of this policy and our data from this study, it would be more feasible to identify and integrate interventions that would encourage facility births by improving the overall experience of the facility birth.
One realistic recommendation for immediately improving the facility birth experience would be to allow the women to have a labor companion. Labor companions could help provide information and bridge communication with providers; advocate on behalf of the women; and provide physical and emotional support [41]. While our research did not focus specifically on solutions, we find women’s isolating facility birth experiences to suggest a need for a labor companion who can provide similar support to what they most value in home births; however, at the same time, we are aware that such a person should be trained, prepared, and have an approved role in a clinical setting. In high-volume maternity wards, for instance, a care navigator would be helpful during the labor and delivery, as well as in the postpartum period, to provide clinical observation, communicate with family, and help the patient through the labor and delivery process [42, 43]. The WHO’s recommendations on Intrapartum Care for a Positive Childbirth include choice of birth position and mobility for low-risk births in the facility setting—a recommendation that is highly applicable for Haitian facilities, given that women in both rural and urban areas noted the inability to move and having to lie down for delivery as important constraints in facility births [44]. Another approach would be to focus on staff training, particularly on staff empowerment, to address structural restrictions that impede better patient-provider interactions. For example, a comparison of two hospitals in Tanzania showed that, in similarly constrained circumstances, providers’ and women’s experiences were much more positive when nurse-midwives and nurse managers felt they were effective in influencing their environment and outcomes in the hospital [45]. Other policy-driven approaches may be enacted for a more systematic impact, such as the specific inclusion of respectful maternity care in the quality-of-care standards for maternal health [46]. In Brazil, for example, a national law allows all women in the public and private sectors to have a labor companion of their choice during all antenatal, labor, delivery, and postpartum care visits to a facility [47].
Strengths and limitations
We note that national survey data have documented financial barriers to facility delivery in Haiti, including cost of medical care, facility fees, and cost of transportation [3]. In other settings, the expectation of disrespect from physicians and hospital staff has been shown to impede hospital births [15,16,17, 41]. Yet, few studies have analyzed women’s perspectives on the facility birth experience in Haiti and, to our knowledge, none have identified the role that isolation plays in that experience versus a home birth in both urban and rural settings. Given that this is a qualitative study with a limited sample size, and that there is limited standardization of medical care in Haiti, the experiences of isolation (detailed above) may not necessarily be transferable to all facility settings, such as those that are private, well-funded, or uncongested. The women we spoke with were poor and relied on public sector facilities; however, one cannot assume that the private sector necessarily has different outcomes. For example, one study from India found that the private sector was even stricter about allowing companions during delivery [16]. Future studies that focus on Haitian women with higher incomes or with access to a range of public and private hospital facilities would supplement our findings. The significance that a supportive environment plays in a woman’s assessment of her birthing experience(s) reinforces current modifications to global health policy. Our findings reinforce the goal, adopted by the WHO and others, to provide women in labor with a “humane, supportive” environment [13, 48]. We hope that our study will motivate Haitian practitioners to address the experience of isolation as contradictory to a humane and supportive environment. We expect that additional research into this area will further define factors that contribute to feelings of isolation and will further evaluate evidence-based procedures to address isolation, while also acknowledging and accounting for the pressures placed on facilities in terms of space, crowding, and costs.
We also note a few further limitations of our study. We did not distinguish between the types of facilities women visited for deliveries. While women always used the word “hospital,” some of these were health centers, which would have varying staff capacity and offer different obstetric services than hospitals [49]. We could not say from the focus groups whether the comments were primarily about health centers or hospitals and, therefore, refer to the place of delivery using “facility” as a unified term. We also are aware that, in a group setting, women may have preferred to express a preference for a facility birth since facility births tend to indicate higher socioeconomic status in Haiti. In addition, although it is culturally appropriate to begin conversations by asking how one is doing and what one is doing, this may have elicited information about mood, source of income, and family life that biased the respondents toward demonstrating a certain socioeconomic status. However, we believe that this introduction was essential, because it served to create camaraderie among the group and to aid women in their ability to connect with one another; for instance, as they were able to connect over their shared experiences as mothers without formal employment. We also understand that women’s preferences for facility births and their complaints about facility births may have been shaped by their relationships with the public health clinic and our role as foreign researchers tied to health projects. In other words, the women could ascertain that we were both interested in both encouraging facility births and improving the facility birth experience, which is why we also chose to include women who gave birth at home and those who were currently pregnant. Notably, while most women expressed a preference for a facility birth when asked directly, it was interesting that they tended to modify their preference over the course of discussing their facility-birth experiences with others. As noted, first-time pregnant women were included to understand where they were planning to deliver and why. While this added an interesting perspective to the discussion, we realize that their understanding was not based on their own experiences and that the data they provided reflected impressions they gained from other women in their families or communities; however, their impressions did not contradict the experience of others.
Another limitation could have been the group format, which may have amplified the discussion towards women’s shared experiences. Despite this, we believe the focus group format was the best approach, as it allowed us to establish shared experiences for a diverse group of women in a relatively short timeframe and helped us to identify overarching themes that could form the basis for targeted research in the future. In cases of emotionally sensitive outcomes (such as a severe complication, stillbirth, or a neonatal death), an in-depth interview format would be more appropriate. We also note that we may have some bias in the sample since participants were selected by the clinic staff, and they could have chosen women who were more likely to come for antenatal care, were closer in proximity to the clinic, or who had not experienced a severe complication or death in their most recent pregnancy. This could have biased the sample toward healthier women; however, we do not think it biased the sample to share different stories than what they had experienced. We did observe that the urban sample tended to be younger and quieter, needing more promoting than the rural sample.
We did not provide participants with an opportunity to review transcripts and provide feedback, in part due to concerns over low rates of literacy in the rural setting and in part due to difficulties in locating participants again, especially in the urban setting. We would have valued the chance to work more closely with the participants. We did provide the transcripts to the local clinical staff, with whom we worked closely. We plan to continue our collaboration toward determining how our findings can inform practice and policy, such as presenting the findings to the MSPP.
