From Decision to Delivery: A Qualitative Study of Non-Institutional Birth Pathways in Northern India

Background: Determinants of non-institutional delivery, particularly in the antenatal period, have been described previously, but less is known about the sequence of events during pregnancy and decision-making processes occurring between labour onset and birth. Aim: We explored reasons for non-institutional births and pathways leading to home and in-transit deliveries in a north Indian setting, with the aim of identifying context-specific, actionable recommendations. Methods: Participants were women from the north Indian site of the Redefining Maternal Anemia in Pregnancy and Postpartum (ReMAPP) cohort who experienced non-institutional delivery. We conducted an exploratory qualitative study using a semi-structured in-depth interview guide. An a priori conceptual framework was developed based on existing continuum-of-care literature and structured around the antenatal, intrapartum, and postnatal phases of care. The framework focused on the "decision-to-delivery pathway" and was subsequently iteratively refined and elaborated based on the thematic findings. Findings: Of the 2000 women enrolled at the north Indian site of the ReMAPP study, 75 (3.8%) experienced non-institutional delivery; among these, 50 participants were interviewed. Among those interviewed, 19 had planned, and 31 had unplanned non-institutional deliveries. Themes identified for planned non-institutional deliveries included perceived mistrust in healthcare, institutional avoidance, reliance on informal maternity care systems, and decision-making uncertainty. For unplanned non-institutional deliveries, themes included intention to institutional delivery, delay in obtaining appropriate maternity care, physical access barriers, reliance on informal birth assistance, and opportunities to avail health system services for post-delivery or newborn care. Conclusions: Our findings suggest that improving institutional delivery coverage requires more than physical access to facilities. Trust, respectful maternity care, timely responsiveness during labour, and birth preparedness appear to strongly influence whether women are able to reach and utilise institutional delivery services.