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Original Article

Studying the decision making process for giving birth at tertiary health facility of Sub
Himalayan region

Dr. Mitasha Singh1, Dr. Shailja Sharma2, Dr. Dinesh Kumar3, Dr. Ashok Kumar Bhardwaj4.
Junior Resident, 2Professor and Head, 3Assistant Professor, 4Professor & Head.
Department of Community Medicine, Dr. RPGMC Tanda
M.O. RHFWTC Cheb Kangra


Background: Increasing rates of institutional deliveries in primary care delivery system has been
evident with the significant contribution of tertiary care medical institutions. Preference for
tertiary care over secondary and primary health care institutions needs to be looked in to ensure
accountable and efficient primary health care delivery system. Objective: To assess the factors
influencing decision making process for giving birth at tertiary care facility. Methodology: A
qualitative study design using a semi structured questionnaire was administered among 71
women in two months study period at Dr. RPGMC. Females of age 18 years and above, those
who delivered through normal vaginal delivery (NVD) without any associated morbidity and
complication were interviewed postpartum. Thematic analysis done on qualitative data and the
quantitative data was presented through proportion and means. Results: Majority of women
(54.9%) belonged to middle class according to Uday Pareekh scale and about 77% have obtained
education up to level of matriculation and above. All underwent NVD and also had a primary or
secondary health centre near their place of residence. As reported, major factors which came out
after interview were either referral by the health professional or self mainly due to the absence of
a doctor or specialist or deficient infrastructure for conducting delivery or resuscitation of a
newborn in the vicinity. “Medical college as a higher and accessible facility” or “came here for
previous pregnancy and was satisfied” or “do not want to take risk since it is first pregnancy”
and “less reliance on primary and secondary health care facilities” were also some of the factors
which emerged from the interview. Conclusion: Accessible tertiary care institution with
confidence for better quality of care to prevent and manage expected complications positively
influences decision for child birth.

Keywords: qualitative, overutilization, tertiary care, decision making process


The concept of primary health care guides for better accessible and affordable services to the
people. The care is comprehensive in nature to deal early with common morbidities and to
reduce the unwanted referrals. In India, the primary health care services are planned for the
convenience of the people as a three tier system.1 This system has gained its experience from
provision of maternal and child health services, which were promotive, preventive and curative
in nature. Ensuring safe delivery of a child has remained an agenda for primary health care;
hence efforts are guided to reduce the delivery at home. This is ensured by encouraging delivery
by the Skilled Birth Attendant (SBA) who maybe a doctor or a nurse.2 SBAs at primary health
facility are equipped for essential obstetric and initial emergency obstetric services. We have
witnessed improvement in institutional delivery, which is 77.8% in Himachal Pradesh against the
target of 100.0%, though still majority of deliveries occurred at tertiary/secondary than at
primary facility.3 This suggests overutilization of high order health institutions with
underutilization of primary health care institutions mainly the primary and community health
centers. With the background of choice of health facility for health services as a patient’s right,
the present study was conducted to identify the related factors influencing the decision making
process of a woman, preferring the tertiary care institution for delivering the child.


A qualitative study design was conducted in Dr. RP Government Medical College of Himachal
Pradesh in which postnatal women of more than 18 years of age with normal vaginal delivery
(NVD) irrespective of parity were interviewed. Women with high risk pregnancies were
excluded. After approval by the Institute’s Research Ethics Committee, eligible women were
enlisted from the case records of the obstetrics ward by the interviewer. Study participants, after
an informed consent, were recruited conveniently during May 2015. The interview was
conducted after the delivery of baby using a semi structured interviewer introduced
questionnaire. The quantitative data was presented through proportion and means. The narrative
responses were recorded as such and then responses were categorized into the epidemiological
triad related factors; Agent (health system), Environment (availability and accessibility of
services) and host (risk perception). (Figure: 1)
A total of 71 women were included in the study, of which about half (50.7%) of the study
participants were below 25 years of age and 36.6% were between 26-30 years of age. All were
literate and 54.4% women belonged to middle and 23.9% to lower middle socioeconomic class
according to the Uday Pareekh scale. About 60.0% were previously pregnant (twice or more
number of times), 66.7% of which had normal vaginal delivery during their previous child births.
About a quarter of women had availed the secondary health care facility for previous childbirths
and none had visited a primary health centre (PHC).
The narrative responses giving reasons for attending a tertiary care center or not availing primary
care services for a normal delivery with the factors responsible and their interpretations have
been presented in Table 1. The factors according to which these responses are categorized are
those used in the epidemiological triad in Figure 1. These responses are further interpreted as a
facilitator towards delivering at tertiary center or barrier to access primary care services.
The lack of women physicians at PHCs and higher absenteeism rate of doctors and specialists in
position are the major barriers. The above resources are all present at a tertiary center, hence
acting as a facilitator for them. These factors fall in the broad category of human resources in the
health system. Logistics and facility shortage are also a part of the health system and their
deficiency acts as a barrier. The responses like ‘Absence of delivery services/ labour room at a
nearby PHC/CHC’ (“nazdeeki prathmik swasthya kendra ya samudayik Kendra par delivery
nahi hoti”) or ‘Lack of neonatal resuscitation services and complication managing services at
CHC/PHC/DH’(hamein waha se refer kar diya kyuki unke pas bachche ko kuch hone par use
waha theek karne ke liye kuch saman nahi hai”) by around 29% of women acted as a barrier
towards seeking services of the nearby PHC/CHC. Responses grouped as acting as facilitator to
tertiary centers in 30% of cases were as follows; ‘A bigger hospital is near to home where
emergencies can be handled and operations are done ’(“yahi ek badaa aspatal ghar ke pas hain
jahan operation hojata,ya koi emergency dekh li jaati toh yehi aagae”) and ‘DRPGMC, Tanda is
big center with continuous availability of doctor here’ (“tanda hospital badaa hai aur doctor
hamesha mil jaate hain isliye yahi aajate hain”).

The geographical factors of accessibility and availability of health facilities to pregnant women
also act as a barrier to PHC/CHC and facilitator to tertiary care center. About 37% of responders
gave reasons for coming to tertiary center as ‘Referral from a PHC where a doctor was posted, to
a higher center, and this was the nearest higher center with all facilities’ (wahan se refer hi kar
dete hain, ilaaz nahi karte aur tanda me sab kuch hojata hai” ) or ‘Came here for previous
pregnancy also’(“ pichli baari bhi yehi delivery hui toh yhi aagae fir hi”). Regular referral from
PHC/CHC/CH and they being regarded as small centers with not much facilities were the
reasons for not visiting them for the services which are their primary functions.

Host factor of risk perception, that any emergency and complication related to childbirth can be
dealt with at a tertiary center but not a PHC/CHC/DH act as a facilitator towards tertiary care

The Alma-Ata conference urged countries to provide accessible and affordable primary health
care services at a cost which the community and the country can afford.4 Maternal and Child
health (MCH) remained a top priority to ensure “Health for All” as reflected in Millennium
Development Goal (MDG).5 Committed to this cause, the Government of India (GOI) evolved a
National health policy based on primary health care approach and reoriented its strategy as a
mission in the year 2005 which was referred to as National Rural Health Mission (NRHM) now
known as National Health Mission (NHM).6,7 A significant investment since 2005 expects
improvement in MCH services. Efforts are on to ensure institutional deliveries to prevent
hemorrhage related maternal death and improve the newborn health. Under NHM, investment
was made at the PHC and CHC levels to provide round the clock Essential and Emergency
Obstetric care, and newborn care.8 Over 10 years, with investment in the form of health care
professionals and logistics at the PHC and CHC levels, a positive change in behavior and
practice towards MCH primary health care is expected.

The present study observed that the women who delivered at a tertiary care hospital blamed the
ill-equipped services at their nearby CHC/PHC, either due to non availability of a doctor or the
logistics for providing intranatal care. The patient’s right for choice of facility for health services
acted as a driver for accessing basic MCH services. This phenomena was also observed by
Hoffman et al in his study in Austria where the secondary and tertiary levels of care directly
observed high load of patients.9,10 The free and unregulated patient access to all levels of medical
care is linked to several unwanted developments for the health care system as a whole and in
particular for essential primary care functions.11

The study observed that lack of women physicians at PHCs and higher absenteeism rate of
doctors and specialists in position were also major barriers for seeking health care services at
PHC’s/CHC’s. Despite the long waiting hours at out-patient departments and overcrowding in
labor wards, women preferred to give birth to their child at tertiary care hospital. The evidence
from many developing countries shows that the sheer absence of staff and facilities is observed
as a substantial barrier for health facilities. 12

The perceived risk to the health of the mother and the child, served as a facilitator to choose
tertiary health care facility as requirement of an expert intervention was always considered a
possibility.13 Since the risk may not be medically evident or clarified, therefore women sought
referral to high order facilities themselves, even without the obstetric complications. 14

Satisfaction with antenatal care services motivates pregnant women to seek and continue
antenatal care whereas its dissatisfaction results in decreased utilization of services.15 Current
evidence observed dissatisfaction in the primary health care services in addition to other factors
which frames the decision making process. Evidence observed that high percentages of women
receive poor quality of care at primary or secondary level further leading to overburdened
tertiary care centers.16 Several studies in the country have summed up the causes of low
utilization of primary outpatient care in public facilities as long distances, inconvenient opening
hours, lengthy waiting, staff absenteeism, poor availability of medicines, and poor quality of
care.17-20 In Ghana, as few as 17% of births in health facilities at the primary level met criteria of
good clinical practice,21 and technical quality scores were low in health centres in Nigeria and
Côte d’Ivoire.22

The decision about mode or place of delivery is often taken during the course of pregnancy and
influenced by events in the previous delivery as well as the current pregnancy.23 Further research
is needed on a larger population for each of the factors discussed in the current study. The major
limitation of the current study is information bias due to inclusion of the perception and

experiences of women who delivered at a tertiary hospital, not those delivering at primary and
secondary care.

In the light of evidences and observations it can be concluded that despite the investment in the
primary health care, NHM is still awaiting the confidence of the people for quality of care. The
relative availability and accessibility of good quality of services drives the people for choosing
health facility for care.


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Tables and Figures:

Table 1: Response assessment of women for decision making process to gave birth of baby at
tertiary care facility.

Reasons given by postnatal Number Factors Interpretation Facilitator/barrier

women for delivering at (%)
tertiary center

Absence of 21(30) Lack of Human Health system Barrier

doctor/specialist/obstetrician/lady resources (PHC/CHC)
doctor at PHC/CHC

Absence of delivery services/ 8(11.4) Lack of facility Health system Barrier

labour room at PHC/CHC/DH (PHC/CHC)

Lack of neonatal resuscitation 12(17.1) Lack of Health system Barrier

services and complication logistics/facility (PHC/CHC)
managing services at

DRPGMC, Tanda is big center 21(30) Human Health system Facilitator

with continuous availability of resources (Tertiary care)
doctor here available

A bigger hospital is near to home 21(30) All facilities Health system Facilitator
where emergencies can be available (Tertiary care)
handled and operations are done

PHC/CHC is a small center with 6(8.6) Ineffective Health system Barrier

not very good services available services (PHC/CHC)

Referred from PHC to a higher 12(17.1) Accessible and Environment Facilitator

center with doctor and this was available
the nearest higher center with all
Always refer without treating at 9(12.9) Ineffective Environment Barrier
PHC/CHC/DH so I come here services
Came here for last pregnancy 14(20) Experience Host Facilitator
Since it is our first child so we 25(35.7) Risk perception Host Facilitator
wanted to come to a higher
Previous pregnancy either 9(12.9) Risk perception Host Facilitator
resulted in stillbirth or abortion
or death of a neonate hence came
to higher center this time

Figure 1: Conceptual framework of pregnant women’s decision making to deliver at tertiary care

Agent Pregnant women’s decision Environment

Health System making to deliver at tertiary Accessibility and
(Primary, Secondary care center Availability of
and Tertiary) health facility
Facilitator or Barrier

Risk Perception

How to cite this article: Singh M, Sharma S, Kumar D, Bhardwaj AK. Studying the decision making
process for giving birth at tertiary health facility of Sub Himalayan region. International Journal of
Epidemiology and Public Health 2016 ;1(1):15-24

Address for correspondence: Dr Mitasha Singh, Department of Community Medicine, DRPGMC

Tanda. Email:

Date Received: 18th December 2015 Date Accepted: 15th June 2016