Barriers to hospital births: why do many Bolivian women give birth at home?

This study investigated the low rates of hospital/health center births recorded in Yapacaní, Bolivia, that persist despite the national maternal-infant insurance program designed to ensure equitable access to free center-based health care services for pregnant women. The purpose of this study was to identify the multilevel factors inhibiting access to and utilization of public health centers for labor and delivery. Qualitative research methods were used, including participant observation, semistructured interviews of 62 community members, and key informant interviews with eight regional experts. Data were coded and analyzed using the grounded theory approach. From the semistructured interview data, five reasons for the low rate of institutional births and their frequency were identified: (1) fear or embarrassment related to receiving care at a public health care center (37%); (2) poor quality of care available at the health care centers (22%); (3) distance from or other geographic issues preventing timely travel to health care services (21%); (4) economic constraints preventing travel to or utilization of health care services (14%); and (5) the perception that health care services are not necessary due to the experience of "easy birth" (6%). The reasons for the low rate of births in public health centers exist within the context of deficient resources, politics, and cultural differences that all influence the experience of women and their partners at the time of birth. These large scale, contextual issues must be taken into account to improve access to quality health care services for all Bolivian women at the time of birth. Resources at the national level must be carefully targeted to ensure that governmental services will successfully instill confidence in Bolivian women and facilitate their overcoming the cultural, geographic, economic, and logistical barriers to accessing "free" services.