Understanding women's decision-making process for birth location in Tanzania based on individual women's reproductive pathways: a life-course perspective

Background Determinants for women's care seeking for birth in low-income setting are multifactorial and remain poorly understood. A life course approach can assist to structure the interplay of the different factors that lead to women seeking care or not. Objective In this study we aimed to explore individual women's reproductive pathways, and increase understanding of how important life events including previous pregnancy and birth experiences can help us to understand individual choices made for care seeking during childbirth. Methods The study took place in Tanzania between 2015 and 2017. 14 women were followed throughout their pregnancy, birth and postpartum period through participant observation and in-depth interviews. In total 94 in-depth interviews were held (between 5-7 interviews per woman). Analysis occurred continuous throughout the data collection period resulting in detailed narratives of crucial events across women's life course, with specific attention to their current pregnancy. Results Of the 14 women, seven had a facility birth, six a home birth and one woman gave birth at the home of a local birth attendant. Four different story plots were identified: expected home birth, expected facility birth, unexpected facility birth and unexpected home birth. Birth narratives of four women representative of the different story plots are presented. Narratives illustrate women's individual reproductive pathways including the various factors influencing women's expectations and justifications for their actions during their pregnancy and birth. Conclusion Women's agency, including women's perception of self, the self in relation to the social environment and reflection on risks associated with the range of options, influences the final decision made for birth. Women's narratives suggest that quality of care can function as a primary pull factor for facility birth. As long as home birth is by some perceived to be a better alternative, achieving skilled care for all will be difficult to achieve.