Experienced disrespect & abuse during childbirth and associated birth characteristics: a cross-sectional survey in the Netherlands.

BACKGROUND: Experiencing upsetting disrespect and abuse (D&A) during labour and birth negatively affects women's birth experiences. Knowing in what circumstances of birth women experience upsetting situations of D&A can create general awareness and help healthcare providers judge the need for extra attention in their care to help reduce these experiences. However, little is known about how different birth characteristics relate to the experience of D&A. Previous studies showed differences in birth experiences and experienced D&A between primiparous and multiparous women. This study explores, stratified for parity, (1) how often D&A are experienced in the Netherlands and are considered upsetting, and (2) which birth characteristics are associated with these upsetting experiences of D&A. METHODS: For this cross-sectional study, an online questionnaire was set up and disseminated among women over 16 years of age who gave birth in the Netherlands between 2015 and 2020. D&A was divided into seven categories: emotional pressure, unfriendly behaviour/verbal abuse, use of force/physical violence, communication issues, lack of support, lack of consent and discrimination. Stratified for parity, univariable and multivariable logistic regression analyses were performed to examine which birth characteristics were associated with the upsetting experiences of different categories of D&A. RESULTS: Of all 11,520 women included in this study, 45.1% of primiparous and 27.0% of multiparous women reported at least one upsetting experience of D&A. Lack of consent was reported most frequently, followed by communication issues. For both primiparous and multiparous women, especially transfer from midwife-led to obstetrician-led care, giving birth in a hospital, assisted vaginal birth, and unplanned cesarean section were important factors that increased the odds of experiencing upsetting situations of D&A. Among primiparous women, the use of medical pain relief was also associated with upsetting experiences of D&A. CONCLUSION: A significant number of women experience upsetting disrespectful and abusive care during birth, particularly when medical interventions are needed after the onset of labour, when care is transferred during birth, and when birth takes place in a hospital. This study emphasizes the need for improving quality of verbal and non-verbal communication, support and adequate decision-making and consent procedures, especially before, during, and after the situations of birth that are associated with D&A.

Antenatal cardiotocography in dutch primary midwife-led care: Maternal and perinatal outcomes and serious adverse events. A prospective observational cohort study.

PROBLEM: It is yet unknown whether shifting antenatal cardiotocography (aCTG) from obstetrician-led to midwife-led care leads to a safe reduction in referrals. BACKGROUND: ACTG is used to assess fetal well-being. In the Netherlands, the procedure has until now been performed as part of obstetrician-led care. Developments in E-health facilitates the performance of aCTG outside the hospital in midwife-led care, hereby increasing continuity of care. AIM: To evaluate 1) process outcomes of implementing aCTG for specific indications in primary midwife-led care; 2) maternal and perinatal outcomes of pregnant women receiving aCTG in midwife-led care; 3) serious adverse events (with outcomes, causes, avoidability, and potential prevention strategies) that have occurred during the innovation project 'aCTG in midwife-led care'. METHODS: Prospective observational cohort study and a case series study of serious adverse events. FINDINGS: A total of 1584 pregnant women with a specific aCTG indication were included in this cohort study for whom 1795 aCTGs were performed in midwife-led care. 1591 aCTGs(89.7%) were classified as reassuring. Referral to obstetrician-led care occurred for 234 women(13.0%) after an aCTG in midwife-led care of whom 202(86%) were referred back. Severe neonatal morbidity occurred in 27 neonates (1.7%). In the 5736 aCTGs included in the case series study, one case with a serious neonatal outcome was assessed as a serious adverse event attributable to human factors. DISCUSSION: ACTGs performed in midwife-led care increased continuity of care. In this innovation project, maternal and perinatal outcomes were in the expected range for women in midwife-led care.

(Non-)disclosure of lifetime sexual violence in maternity care: Disclosure rate, associated characteristics and reasons for non-disclosure.

BACKGROUND: In maternity care, disclosure of a past sexual violence (SV) experience can be helpful to clients to discuss specific intimate care needs. Little evidence is available about the disclosure rates of SV within maternity care and reasons for non-disclosure. AIM: The aim of this study was to examine (1) the disclosure rate of SV in maternity care, (2) characteristics associated with disclosure of SV and (3) reasons for non-disclosure. METHODS: We conducted a descriptive mixed method study in the Netherlands. Data was collected through a cross-sectional online questionnaire with both multiple choice and open-ended items. We performed binary logistic regression analysis for quantitative data and a reflexive thematic analysis for qualitative data. RESULTS: In our sample of 1,120 respondents who reported SV, 51.9% had disclosed this to a maternity care provider. Respondents were less likely to disclose when they received obstetrician-led care for high-risk pregnancy (vs midwife-led care for low-risk pregnancy) and when they had a Surinamese or Antillean ethnic background (vs ethnic Dutch background). Reasons for non-disclosure of SV were captured in three themes: 'My SV narrative has its place outside of my pregnancy', 'I will keep my SV narrative safe inside myself', and 'my caregiver needs to create the right environment for my SV narrative to be told'. CONCLUSIONS: The high level of SV disclosure is likely due to the Dutch universal screening policy. However, some respondents did not disclose because of unsafe care conditions such as the presence of a third person and concerns about confidentiality. We also found that many respondents made a positive autonomous choice for non-disclosure of SV. Disclosure should therefore not be a goal in itself, but caregivers should facilitate an inviting environment where clients feel safe to disclose an SV experience if they feel it is relevant for them.

Pregnant women's perceptions of antenatal care and utilisation of digital health tools in Magu District, Tanzania: a qualitative study.

Antenatal care is essential to promote maternal health. Prior research has focused on barriers women face to attending antenatal care, and improving quality of care is seen as a precondition for better attendance. Digital health tools are seen as a promising instrument to increase the quality of healthcare. It is less clear to what extent the use of digital health tools in low- and middle-income counties would be perceived as beneficial by end-users. The aim of this research was to explore women's experiences with antenatal care, and whether digital health tools would change their perceptions of quality of care. This qualitative research utilised an interpretative phenomenological approach on data from semi-structured in-depth interviews collected in 2016 with 19 randomly selected pregnant women from six different dispensaries in Magu District. Findings showed that pregnant women are motivated to attend antenatal care and are grateful for the services received. However, they also articulated a need for improvements in antenatal care services such as the availability of diagnostic tests and more interactions with healthcare workers. Participants indicated that a digital health tool could help in storing patient files and improving communication with health workers. Our results indicate that pregnant women are positive about the use of digital health tools during antenatal care but that the implementation of such a tool should be implemented in parallel to structural service delivery improvements, such as testing availability.

The difficult process of autonomous choice: using I-poems to understand experiences of abortion-seekers in The Netherlands.

While key barriers to abortion care accessibility have been established, little is known about the experiences of people having abortions in the Netherlands. Stories of individual abortion-seekers can help counteract stereotyping, diminish abortion stigma, and improve accessibility. This study's research question is: What experiences do abortion-seekers in the Netherlands have with abortion care and what new insights can the I-poem method of analysis provide? This qualitative feminist study used transcripts of semi-structured, in-depth interviews with abortion-seekers from previous research to create I-poems. Using a grounded theory method, the I-poems were coded deductively to validate previous findings, and inductively to generate new insights. The I-poems revealed that although abortion-seekers felt autonomous, their decision-making was complicated by doubt concerning their partner's views and/or suitability as a parent, feelings of shame, and a lack of support. The abortion-seekers were often slowed by obstacles in policy and care; waiting caused feelings of fear and panic and routine pre-abortion ultrasounds led to anxiety. They often did not know what to expect from their body or the abortion procedure. I-poems show how autonomous choice in abortion care is socially constructed rather than purely individual. Abortion providers must pay special attention to external factors complicating the decision-making process such as partner discordance (even in stable relationships) and anxiety due to waiting times and routine pre-abortion ultrasound. Future action on normalisation of information provided on all aspects of choosing an abortion is necessary to realise informed choice and reduction of abortion stigma.Plain language summary Abortion is a medical procedure that ends a pregnancy. In some countries, people can easily get an abortion. In others, it is illegal or difficult to access. In the Netherlands, abortion is accessible and legal before 24 weeks of pregnancy and can be performed upon request of the abortion seeker. This policy is often seen as liberal, as it allows people to make their own decisions about their bodies. Still, abortion stigma is present in Dutch society. Stigma around abortion refers to negative attitudes and beliefs that society has towards people who have had abortions or are considering having one.Research by Holten et al7 looked at how easy it is for abortion seekers in the Netherlands to access abortion services. The study highlighted that people in the Netherlands still face barriers to accessing abortion services. For example: the law and regulations regarding abortions and the fact that people had difficulty in talking about their abortion due to stigma.The abovementioned study gives a broad view on challenges in the accessibility of abortion in the Netherlands, but the individual experiences are not portrayed.The goal of this study is to learn about the personal experiences of abortion-seekers in the Netherlands. It aims to understand what it's like for these people to access abortion services and what we can learn from their individual stories by using a method of analysis called I-poem. I-poems are a type of poem created by the researcher by looking for sentences using the first-person pronoun "I" in interview texts. I poems show the personal experience or point of view of the person interviewed. This type of poem is often used to express emotions or share personal stories or observations.This study used interviews with people who have had abortions to create I-poems. The grounded theory method was used to analyse the I-poems in two ways: confirming what was found in previous studies, and also providing new insights from the data.The study found that the people contemplating having an abortion had a hard time making the decision to have an abortion because they had doubts, were worried about what their partner would think, felt ashamed to talk about it with friends and family, and didn't have enough support. They also faced challenges like having to wait for the abortion because of clinic schedules and laws and getting ultrasounds before the procedure, which made them anxious. It was also found that the people contemplating abortion were unsure of what to expect from the abortion procedure and how their body would react, which made the decision even harder.The study concludes that even when people felt in control of their decision, the decision-making process was still difficult. The decision is not just personal, but is also affected by society, partners, and healthcare policies. The waiting time and the ultrasound before the abortion made the process harder, and abortion seekers were not aware of what to expect from the procedure. More information and education on all aspects of having an abortion should be provided to help people to make better informed decisions and reduce the abortion stigma. Further research on experiences of routine ultrasound before abortion in the Netherlands is needed to improve abortion care.

Antenatal cardiotocography in primary midwife-led care: Women's satisfaction.

BACKGROUND: In the Netherlands, antenatal cardiotocography (aCTG), used to assess fetal well-being, is performed in obstetrician-led care. To improve continuity of care, an innovation project was designed wherein primary care midwives perform aCTGs for specific indications. The aim of this study was to examine the satisfaction and experiences of pregnant women who received an aCTG in primary midwife-led care and explore which factors were associated with high satisfaction. METHODS: Data were collected through a self-administered questionnaire based on the Consumer Quality Index. The primary outcome was general satisfaction on a 10-point scale, with a score above nine indicating participants were "highly satisfied". RESULTS: In total, 1227 women were included in the analysis. The study showed a mean general satisfaction score of 9.2. Most women were highly satisfied with receiving an aCTG in primary midwife-led care (77.4%). On the Consumer Quality Index, the mean satisfaction level varied from 3.98 (SD ± 0.11) for the subscale "client satisfaction" to 3.87 (SD ± 0.32) for the subscale "information provision" on a 4-point scale. Women at between 33 and 36 weeks' gestation were more likely to be highly satisfied (adjusted OR [aOR] = 3.35). Compared with a completely comfortable position during the aCTG, a mostly comfortable or somewhat comfortable level had decreased odds of being associated with a ranking of highly satisfied (aOR 0.24 and 0.19, respectively). CONCLUSIONS: This study shows that pregnant women are satisfied with having an aCTG in midwife-led care. Providing aCTG in midwife-led care can increase access to continuity of care.

Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands.

BACKGROUND: Informed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter. METHODS: A national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting. RESULTS: 13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54-0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting. CONCLUSIONS: Consent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman's refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.

The ethics of consent during labour and birth: episiotomies.

Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures.

Disrespect and abuse during labour and birth amongst 12,239 women in the Netherlands: a national survey.

BACKGROUND: Women experience disrespect and abuse during labour and birth all over the world. While the gravity of many forms of disrespect and abuse is evident, some of its more subtle forms may not always be experienced as upsetting by women. This study examines (1) how often women experience disrespect and abuse during labour and birth in the Netherlands and (2) how frequently they consider such experiences upsetting. We also examine (3) which respondent characteristics (age, ethnicity, educational level and parity) are associated with those experiences of disrespect and abuse that are upsetting, and (4) the associations between upsetting experiences of disrespect and abuse, and women's labour and birth experiences. METHODS: Women who gave birth up to five years ago were recruited through social media platforms to participate in an online survey. The survey consisted of 37 questions about experiences of disrespect and abuse divided into seven categories, dichotomised in (1) not experienced, or experienced but not considered upsetting (2) experienced and considered upsetting. A multivariable logistic regression analysis was performed to examine associated characteristics with upsetting experiences of disrespect and abuse. A Chi-square test was used to investigate the association between upsetting experiences of disrespect and abuse and overall birth experience. RESULTS: 13,359 respondents started the questionnaire, of whom 12,239 met the inclusion and exclusion criteria. Disrespect and abuse in terms of 'lack of choices' (39.8%) was reported most, followed by 'lack of communication' (29.9%), 'lack of support' (21.3%) and 'harsh or rough treatment/physical violence' (21.1%). Large variation was found in how frequently certain types of disrespect and abuse were considered upsetting, with 36.3% of women experiencing at least one situation of disrespect and abuse as upsetting. Primiparity and a migrant background were risk factors for experiencing upsetting disrespect and abuse in all categories. Experiencing more categories of upsetting disrespect and abuse was found to be associated with a more negative birth experience. CONCLUSIONS: Disrespectful and abusive experiences during labour and birth are reported regularly in the Netherlands, and are often (but not always) experienced as upsetting. This emphasizes an urgent need to implement respectful maternity care, even in high income countries.

Disrespect and abuse during labour and birth is a globally recognized phenomenon and has been linked to traumatic birth experiences and PTSD. In our study, we investigated how often women experience disrespect and abuse during labour and birth in the Netherlands and what proportion of these experiences was found to be upsetting. We also looked at risk factors for experiencing upsetting disrespect and abuse and to what extent upsetting disrespect and abuse influences the overall labour and birth experience.We conducted an online survey, with 12,239 respondents included in the analysis. We found a large variation in how frequently certain types of disrespect and abuse were considered upsetting, with 36.3% of women experiencing at least one situation of disrespect and abuse as upsetting. More subtle forms of disrespect and abuse, such as lack of choice, communication or support, were most prevalent and often considered upsetting. Giving birth for the first time and having a migrant background were risk factors for experiencing upsetting disrespect and abuse. Upsetting disrespect and abuse was found to have a strong impact on the overall labour and birth experience; with every additional experienced category of upsetting disrespect and abuse, the number of (very) positive labour and birth experiences decreases and the number of very negative ones increases.Although disrespect and abuse is a complex issue and its measurement subjective, this study shows that there is still a long way to go before achieving optimal respectful maternity care for all women, even in high income countries.

Client-care provider interaction during labour and birth as experienced by women: Respect, communication, confidentiality and autonomy.

INTRODUCTION: Respectful Maternity Care is important for achieving a positive labour and birth experience. Client-care provider interaction-specifically respect, communication, confidentiality and autonomy-is an important aspect of Respectful Maternity Care. The aim of this study was twofold: (1) to assess Dutch women's experience of respect, communication, confidentiality and autonomy during labour and birth and (2) to identify which client characteristics are associated with experiencing optimal respect, communication, confidentiality and autonomy. METHODS: Pregnant women and women who recently gave birth in the Netherlands were recruited to fill out a validated web-based questionnaire (ReproQ). Mean scores per domain (scale 1-4) were calculated. Domains were dichotomised in non-optimal (score 1, 2,3) and optimal client-care provider interaction (score 4), and a multivariable logistic regression analysis was performed. RESULTS: Of the 1367 recruited women, 804 respondents completed the questionnaire and 767 respondents completed enough questions to be included for analysis. Each domain had a mean score above 3.5. The domain confidentiality had the highest proportion of optimal scores (64.0%), followed by respect (53.3%), communication (45.1%) and autonomy (36.2%). In all four domains, women who gave birth at home with a community midwife had a higher proportion of optimal scores than women who gave birth in the hospital with a (resident) obstetrician or hospital-based midwife. Lower education level, being multiparous and giving birth spontaneously were also significantly associated with a higher proportion of optimal scores in (one of) the domains. DISCUSSION: This study shows that on average women scored high on experienced client-care provider interaction in the domains respect, communication, confidentiality and autonomy. At the same time, client-care provider interaction in the Netherlands still fell short of being optimal for a large number of women, in particular regarding women's autonomy. These results show there is still room for improvement in client-care provider interaction during labour and birth.

Left powerless: A qualitative social media content analysis of the Dutch #breakthesilence campaign on negative and traumatic experiences of labour and birth.

INTRODUCTION: Disrespect and abuse during labour and birth are increasingly reported all over the world. In 2016, a Dutch client organization initiated an online campaign, #genoeggezwegen (#breakthesilence) which encouraged women to share negative and traumatic maternity care experiences. This study aimed (1) to determine what types of disrespect and abuse were described in #genoeggezwegen and (2) to gain a more detailed understanding of these experiences. METHODS: A qualitative social media content analysis was carried out in two phases. (1) A deductive coding procedure was carried out to identify types of disrespect and abuse, using Bohren et al.'s existing typology of mistreatment during childbirth. (2) A separate, inductive coding procedure was performed to gain further understanding of the data. RESULTS: 438 #genoeggezwegen stories were included. Based on the typology of mistreatment during childbirth, it was found that situations of ineffective communication, loss of autonomy and lack of informed consent and confidentiality were most often described. The inductive analysis revealed five major themes: ''lack of informed consent"; ''not being taken seriously and not being listened to"; ''lack of compassion"; ''use of force"; and ''short and long term consequences". "Left powerless" was identified as an overarching theme that occurred throughout all five main themes. CONCLUSION: This study gives insight into the negative and traumatic maternity care experiences of Dutch women participating in the #genoeggezwegen campaign. This may indicate that disrespect and abuse during labour and birth do happen in the Netherlands, although the current study gives no insight into prevalence. The findings of this study may increase awareness amongst maternity care providers and the community of the existence of disrespect and abuse in Dutch maternity care, and encourage joint effort on improving care both individually and systemically/institutionally.

Experiences and views of midwives performing antenatal cardiotocography in Dutch primary care: A qualitative study.

OBJECTIVE: In the current Dutch maternity care system, pregnant women who have an indication for an antenatal cardiotocography (CTG) to be undertaken need to be referred from primary midwife-led care to secondary obstetric-led care. Within three different regions in the Netherlands independent primary care midwives perform antenatal CTG in primary care, introduced as a pilot project. The aim of this study was to evaluate the experiences and views of primary care midwives who perform antenatal CTG in primary care. DESIGN: Using a qualitative approach data were collected by seventeen in depth semi-structured interviews. The interview recordings were transcribed verbatim and analysed using thematic coding. SETTING: Three regions in the Netherlands where midwives carry out antenatal CTG in primary care during this pilot project. PARTICIPANTS: Seventeen primary care midwives were interviewed between July and November 2017. FINDINGS: In general, midwives were satisfied with performing antenatal CTG and felt it contributed positively towards the midwife-client relationship. However, midwives experienced an increased workload, partly due to time-consuming technical difficulties. Furthermore, mixed feelings existed on whether antenatal CTG contributes to a more physiological or to a more pathological approach in midwifery practice. Most midwives believed that performing antenatal CTG contributes to the physiological process: strengthening of their gate-keeper role, increased confidence of their clients and improved midwife-client relationship. In contrast, some midwives believed it contributes to a pathological process: medicalization and relying too much on technical devices. KEY CONCLUSIONS: This study showed an overall positive attitude of primary care midwives towards performing antenatal CTG when required, in primary midwife-led care. However, performing the antenatal CTG can be a challenge for midwives, as midwifery care within this setting is often for healthy women who have a straightforward pregnancy. For some midwives, providing antenatal CTG monitoring in the primary care setting may be seen as using a pathological approach to midwifery care. IMPLICATIONS FOR PRACTICE: There seems to be a place for antenatal CTG in primary midwife-led care. However, further research is needed before this practice can be implemented widely.

Husbands' experiences and perceptions regarding the use of maternity waiting homes in rural Zambia.

OBJECTIVE: To explore men's experience and beliefs regarding the use of maternity waiting homes (MWHs) in Kalomo District, Zambia. METHODS: As part of a qualitative study, in-depth interviews with the husbands/partners of women attending the under-five clinic at a health center with a MWH were conducted between April 1 and May 31, 2014. Men aged 18-50 years whose partner/wife was of reproductive age and who had lived in the area for more than 6 months were eligible for inclusion. RESULTS: Overall, 24 husbands/partners were interviewed in seven rural health centers. Men perceived many potential benefits of MWHs, including improved access to facility-based skilled delivery services and treatment in case of labor complications. Their many roles included decision making and securing funds for transport, food, cleaning materials, and clothes for the mother and the neonate to use during and after labor. However, limited financial resources made it difficult for them to provide for their wives and newborns, and usually led to delays in their decisions about MWH use. Poor conditions in MWHs and the lack of basic social and healthcare needs meant some men had forbidden their wives/partners from using the facilities. CONCLUSION: Important intervention targets for improving access to MWHs and skilled birth attendance have been identified.

Improving access to skilled facility-based delivery services: Women's beliefs on facilitators and barriers to the utilisation of maternity waiting homes in rural Zambia.

BACKGROUND: Maternity waiting homes (MWHs) are aimed at improving access to facility-based skilled delivery services in rural areas. This study explored women's experiences and beliefs concerning utilisation of MWHs in rural Zambia. Insight is needed into women's experiences and beliefs to provide starting points for the design of public health interventions that focus on promoting access to and utilisation of MWHs and skilled birth attendance services in rural Zambia. METHODS: We conducted 32 in-depth interviews with women of reproductive age (15-45 years) from nine health centre catchment areas. A total of twenty-two in-depth interviews were conducted at a health care facility with a MWH and 10 were conducted at a health care facility without MWHs. Women's perspectives on MWHs, the decision-making process regarding the use of MWHs, and factors affecting utilisation of MWHs were explored. RESULTS: Most women appreciated the important role MWHs play in improving access to skilled birth attendance and improving maternal health outcomes. However several factors such as women's lack of decision-making autonomy, prevalent gender inequalities, low socioeconomic status and socio-cultural norms prevent them from utilising these services. Moreover, non availability of funds to buy the requirements for the baby and mother to use during labour at the clinic, concerns about a relative to remain at home and take care of the children and concerns about the poor state and lack of basic social and healthcare needs in the MWHs--such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities as well as failure by nurses and midwives to visit the mothers staying in the MWHs to ensure their safety prevent women from using MWHs. CONCLUSION: These findings highlight important targets for interventions and suggest a need to provide women with skills and resources to ensure decision-making autonomy and address the prevalent gender and cultural norms that debase their social status. Moreover, there is need to consider provision of basic social and healthcare needs such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities, and ensuring that nurses and midwives conduct regular visits to the mothers staying in the MWHs.