Factors influencing decision-making for facility-based childbirth in rural Nepal: a qualitative study.

Introduction: Maternal mortality remains a major global health challenge, with most preventable deaths occurring in low-income and lower-middle-income countries. Despite progress in reducing maternal mortality, Nepal continues to face challenges in achieving universal facility-based childbirth. Understanding how decisions about place of childbirth are made, particularly in rural settings, is critical to reducing delays in accessing obstetric care. Methods: This qualitative study was conducted in two rural districts of Nepal. Using purposive sampling, thirty-four semistructured interviews were conducted with women who had given birth within the previous twelve months, along with their husbands and mothers-in-law. In addition, nine key informant interviews were held with healthcare providers and local authorities, and eight focus group discussions were conducted with women, men, health workers and community stakeholders. Data were audio-recorded, transcribed, translated and analysed using a thematic approach combining bottom-up coding and topic guide-based categories. Results: Decision-making regarding place of childbirth was found to be dynamic and shaped by multiple factors across pregnancy and labour. While women were increasingly involved in decision-making during pregnancy, authority frequently shifted to husbands and mothers-in-law once labour began. Fear of complications, prior obstetric experiences, perceived competence of healthcare providers and community influence strongly affected care-seeking decisions. Despite reported birth preparedness, many women were unable to reach health facilities in a timely manner due to delayed recognition of labour, hesitancy to seek care at night, family influence and structural barriers. Conclusions: Decision-making around facility-based childbirth in rural Nepal is strongly influenced by family and community dynamics, particularly during labour. Interventions should prioritise family-centred antenatal counselling, engagement of husbands and key family members, and strengthening trust in health services. Improving service quality and addressing structural barriers are essential to promote timely utilisation of facility-based childbirth services.