Perceptional gaps among women, husbands and family members about intentions for birthplace: a cross-sectional study

ABSTRACT Objective: women are more likely to give birth at a health facility when their families agree with the birthplace. However, in rural areas of Tanzania, women are often marginalized from decision-making. This study predicted birthplace intention and identified factors to reduce perceptional gaps among pregnant women, husbands and family members. Method: explanatory cross-sectional survey was conducted in three villages in North Eastern Tanzania. Participants were 138 pregnant women and their families who answered the Birth Intention Questionnaire (BIQ), measuring knowledge, attitude, perceived behavioral control, subjective norms and intention for birthplace. Descriptive analysis, ANOVA, Chi-square, and multiple linear regression was used to analyze the data. Results: the regression model showed that knowledge, perceived behavioral control, and subjective norms predicted intention for birthplace (R2 = .28). While 81% of pregnant women thought their husbands were decision-makers for their birth, only 38% of husbands and 37% of family members agreed. Pregnant women had significantly lower scores on the item “I will prepare for childbirth with my family” compared with husbands (p < .01) and other family members (p < .001). Conclusion: providing evidence-based birth preparation and reducing the identified perceptual gaps may enhance women’s intention to deliver at health facilities.

It was also reported that husbands typically served as decision-makers about where their wives would deliver (11,14) . Therefore, even when pregnant women were aware of birth preparedness, the decision-maker of the household must have the intention for his wife to give birth at a health facility.
The other important factors identified in the previous studies were education levels and knowledge about potential dangers during birth. Using the concept of birth preparedness, a survey was conducted in Mpwapwa district, Dodoma Region, Tanzania (15) . In their analysis, women with primary education and above and those who knew more than three danger signs were more prepared for birth and complications.
Although the former studies (4,(11)(12)(13) identified that birth preparation and family agreement was important for safe childbirth, the findings did not explain how they had, or did not have, the intention to give birth at a facility, as they did not include the motivational factors in their studies. Although it is important to evaluate people's intentions and related factors on birthplace, many studies simply analyzed the relationships between non-motivation factors and their behaviors.
Ajzen's theory of planned behavior explains that intentions are assumed to capture the motivation factors including how strongly one is willing to and how much effort one makes to perform the behavior (16) . The theory also includes non-motivational factors, such as availability of requisite opportunities and resources (e.g., time, money, skills, or cooperation of others) because these factors represent people's perceived behavioral control (PBC). With empirical studies, the theory also explains two other conceptually independent determinants of intention: attitudes toward behavior and subjective norms (SN), which are the perceived attitudes and judgements of significant others.  If they agreed, a questionnaire was distributed and selfadministered. A sample size of at least 100 was needed and thus recruited to meet the assumption of a normal distribution (19) . Data were collected in August 2013.
To measure intention for birthplace and birth preparedness, the first and second authors developed the 38-item Birth Intention Questionnaire (BIQ) for pregnant women and their family members using Ajzen's theory of planned behavior (16) . Two equivalent versions of the questionnaires were developed using "I" or "she" There were 10 knowledge items that were true/ false questions about safe pregnancy and danger signs, which were derived from the Integrated

Results
Responding from the three villages was a total of 139 participants. All chose to participate in the survey; however, for reasons unknown, one participant did not complete the questionnaire and therefore was excluded. Hence, 138 participants, 42 pregnant women, 35 husbands and 44 family members (seven were mothers of the husbands and three were mothers of the women) were included in the analysis. Table 1 shows the socio demographic characteristics. Although there was statistically significance in age and household assets, they did not affect other statistical differences as covariates. of pregnant women answered they decided their birth place (Figure 2).
The family decision-making process in rural Tanzania might explain the following discrepancy; a large majority of women thought husbands decided the birthplace, whereas only a minority of husbands thought of themselves as decision-makers. A qualitative study in the coastal region of Rufiji depicted that when health workers recommended the referral, the advice was transmitted by the woman to her husband and the woman or husband consulted with mother-in-law, woman's parents, and several family members (12) . Usually the husband was the final decisionmaker and responsible to finance the transport; however, his decision was often influenced by other family members.

Another important finding is that women avoided
showing their intention for their own childbirth or being part of decision-making and preparation. The majority of women did not agree with "I will prepare Women's household assets ownership was significantly lower than husbands and other family members. Only half of pregnant women in this study agreed that they had saved money for a facility birth. This is lower than the findings of the study in central Tanzania (15) , in which 89% of women reported saving money in case of emergency.
This may reflect the marginal economic capacity of rural women in this population. It is plausible that the perceived ease or difficulty of women performing the behavior was increased by the amount of money women could use, or felt entitled to use (12) . Another study in Ethiopia showed a close relationship between women's autonomy (or position in the household) and maternal healthcare utilization (21) . The authors indicated the importance of promoting income-generating activities and education among women so that women's position in the household is enhanced.
Yet, it is important to notice that husbands and family members in this study thought that women were the decision-makers more than women themselves even though the gender literature indicates that women often encourage younger women to be submissive to their husbands (22) . A study conducted in southern Tanzania reported that the pattern of decision-making power within the household was the key determinant of birthplace, and that women who lived in male-headed households were less likely to deliver in a health facility than women in female-headed households (4) .

Conclusion
The discrepancies among pregnant women and their families regarding intention for childbirth suggest more supportive relationships are necessary for women to voice their intention. Discussion among family members should be encouraged to fill the perceptual gaps and achieve universal coverage of skilled attendants for childbirth.