A qualitative evaluation of the choice of traditional birth attendants for maternity care in 2008 Sierra Leone: implications for universal skilled attendance at delivery.

Maternal and newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities; and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.