An exploratory qualitative study was conducted, following the principles of Grounded Theory, which is an inductive approach, whereby no theoretical framework was used to guide the research. ¹⁵ Primary data were collected from March 2023 to May 2023, through semi-structured, in-depth expert interviews, conducted remotely, and self-completed interviews through online questionnaires with healthcare providers to explore their perspectives on barriers and facilitators to obstetric services during childbirth in rural Sudan. Prior to data collection, a literature review was conducted to gather existing knowledge relevant to the study objective and geographic area.

In the region of Nuba Mountains, located within South Kordofan state, a prolonged armed conflict has unfolded between Sudanese government forces and the non-state armed group Sudan People’s Liberation Movement-North (SPLM-N) over several decades. ¹² South Kordofan, bordering South Sudan, is partially inaccessible due to the conflict, posing significant health risks for its nearly 2 million residents. ^{13, 14} The SPLM-N insists on the delivery of humanitarian aid across the border with South Sudan, while the Government promotes aid from within Sudan. As a result, humanitarian access to these areas remains inconsistent, and there is virtually no information about the current humanitarian and health situation. The area is difficult to access and is therefore not included in regular data collection activities coordinated by the United Nations or the Government of Sudan. ^{12, 14, 28} This dynamic has led to variations in humanitarian access and a deficiency in essential services such as healthcare and education. ^{12– 14} The humanitarian challenges triggered by years of governmental neglect in Sudan include displacement, critical food insecurity, and infrastructural damage. For the communities in the affected regions, access to essential social services is either severely limited or entirely absent. ²⁶ In South Kordofan, entrenched gender roles and traditional social norms play a significant role in perpetuating harmful practices, including child marriage, type-III female genital mutilation (FGM), and Adal circumcision—the re-stitching of genital tissue after childbirth. ²⁷ Within this context, women encounter challenges accessing contraception, antenatal care, and obstetric services, ¹² with a significant number giving birth at home without assistance. ¹⁴ Women facing complications during childbirth are often forced to undertake perilous, days-long journeys—sometimes even crossing active conflict zones—in order to reach emergency obstetric care. ¹² According to a needs assessment in Nuba, 91% of the women gave birth at home and 30% of them unassisted. ²³ In the study from Kassala, in Sudan however, 56.8% of women had skilled birth attendants and 66.3% gave birth at home. ⁶

Currently, the SPLM-N controls various areas in South Kordofan, with the Nuba Mountains predominantly situated within these monitored regions. Presently, the region remains in a transitional phase without a peace agreement with the government, making the health situation in the Nuba Mountains (Nuba) distinct from the rest of the state, necessitating separate consideration. ¹⁴

Since April 2023, the renewed conflict in Sudan has had substantial consequences for civilians, affecting nearly half of the population. Numerous individuals have lost their lives, requiring humanitarian aid or facing displacement. ¹⁶ During preparation and execution of this study, the extent of this conflict and its impact on the humanitarian situation was not fully evident, and thus, not considered.

The participants were experts working in maternal and reproductive health in Nuba and included local hospital staff, such as midwives, physicians, and nurses. In addition, physicians and nurses of non-governmental organizations (NGOs) working in the area, who have insights into the topic, were included. The identification of respondents and the recruitment process were non-probabilistic and were based on a combination of reasoned choice (purposive selection) and convenience sampling. Snowball sampling was used as a complementary strategy. The invited participants, who were willing to participate and provided informed consent, were included in the study. The sample size was determined by the saturation point, whereby all themes were exhaustively explored, and no new themes emerged in subsequent interviews.

The data were collected through in-depth interviews and online questionnaires. A semi-structured interview guide was developed by the research team specifically for this study based on existing literature and expert knowledge in the field of maternal and reproductive health in rural Sudan. The questionnaire included both open-ended and close-ended questions designed to gain insight into participants’ perspectives on women’s practices related to obstetric care and childbirth in Nuba.

In-depth interviews were conducted over the phone in German with employees of a German-speaking aid organization active in the region and in English with participants from Sudan or other countries. Interviewees were asked to choose a private setting for confidentiality. Interviews, lasting between 35-55 minutes, were digitally recorded, and notes were taken.

Additionally, an adapted online questionnaire was employed, specifically designed for participants with difficult access to electronic devices or stable internet connections. It mirrored the interview guide, featuring similar open-ended questions for written responses, alongside some close-ended questions for selection. Overall, this approach ensured that the quality and depth of responses did not substantially differ between the interviews and the online questionnaires. An online form developed using Google Forms was sent via email or other online platforms. Participants’ responses were automatically collected in a Google spreadsheet.

The collected data were digitized, and the audio files were transcribed verbatim, if in English, or translated into English. The transcriptions and translations were subjected to quality control and compared with the audio files to verify accuracy.

The interview transcripts, field notes, and digitized data from the online questionnaires were manually coded using Microsoft Excel. Data were analyzed using a thematic analysis approach, which consisted of identifying emerging themes relevant to the study aim. A general outline of themes and codes was developed, which was updated as themes emerged. Data analysis followed a cyclical process of data collection and preliminary analysis and culminated in the final analysis after completing data collection. This study adheres to the reporting standards outlined in the SRQR guidelines for reporting qualitative studies ¹⁹ (Additional File 1).

The study was conducted in accordance with the Good Clinical Practice Guidelines, the provisions of the Declaration of Helsinki, and local rules and regulations.

Ethical approval for the study was granted by the Ethics Review Committee of the Hospital Clínic de Barcelona, Spain (CEIC) [Reg. HCB/2023/0107] on the 02/03/2023.

As the study was conducted entirely online with participants from multiple countries and without involvement of local institutions, additional ethical approvals were not required. ²⁹

Participants provided written or oral consent for the interviews and audio recordings. Given that the interviews were conducted remotely, verbal consent was recorded before the interview began. ¹⁸ All names in the transcripts were deleted to guarantee anonymity.

Eleven health experts were interviewed (seven in-depth interviews and four online questionnaires) between March and May 2023. Sociodemographic characteristics of the participants are presented in the following Table 1.

While offering nuanced insights into healthcare and maternal health-seeking practices based on their own views and experiences, the interviewees also provided a rich and detailed description of the context.

War history and political situation

The participants portray Nuba as an unstable region. Many years of war, conflict, and displacement have left the people in the region isolated. As there is still no peace, the region remains cut off and abandoned by the Government of Sudan. Humanitarian aid must therefore be provided across South Sudan’s border. However, the crossing is fraught with security issues and enormous delays often occur. Some participants described the political situation as hopeless and assumed that the health situation of the population would only improve with a peace agreement.

Positive trends in regional development

Many participants mentioned a general positive trend in the development of the region. In recent years, there has been some change for the better, for example, enhanced health education through increased NGO presence and a general rise in formal education driven by more children attending school.

Healthcare system and practices

According to the participants, there were 200-220 health facilities at different levels in Nuba, of which an estimated 70% were supported by NGOs. Nevertheless, most health facilities are poorly equipped, especially in the less centrally located areas. Participants explained that healthcare is still very rudimentary; in some areas even non-existent.

There are two major referral hospitals where surgical procedures can be performed. The two hospitals are based in the centrally located county of Heiban and are an hour’s drive from each other. These hospitals are the only ones in the entire region, with an estimated population of 2 million, where caesarean section and other surgeries can be performed.

According to hospital staff interviewed, there are an estimated 28 trained midwives, but it is unclear if or where they are practicing.

As stated by the participants, women were hardly relieved of their domestic duties during pregnancy. During this time, they must perform hard physical labor. As a result, some interviewees described repeated miscarriages or premature labor resulting from hard physical labor during pregnancy.

Based on participants’ responses, some women give birth alone or birth is performed by an untrained person, such as an older woman of the family, a village elder woman, or a traditional birth attendant (TBA). Often, even a TBA is called in only when complications during childbirth arise, often when it is already too late and irreversible complications have occurred. For home births, families and TBAs are often not equipped with sterile materials or emergency medication.

Another special characteristic in Nuba is the so-called co-patients. This locally used term refers to family members, friends, or neighbors who accompany patients to the hospital or health facility and take over the entire care of the patients. Bringing a co-patient during a hospital stay is essential.

Four overarching themes and 17 factors were identified in the interviews. These four themes are shown in the Figure 1 below.

① Sociocultural

Gender roles

Participants universally highlighted a critical issue: the lack of women’s empowerment and gender-based imbalances. This issue was underscored by the lack of assertiveness among women who often refrained from contradicting their husbands or family elders. As mentioned by the participants women’s opinions were consistently undervalued and they faced unequal participation in decision-making, notably in health matters such as family planning and professional obstetric care choices. Furthermore, the broader neglect of women’s roles in the healthcare system, encompassing inadequate funding, financial investment in health, and political decisions, has emerged as a notable concern.

As indicated by the participants, some maternal health-related issues, such as abortion or family planning, were highly stigmatized in the community and are often considered taboo. This stigma could discourage women from engaging with health facilities, as fear of condemnation or rejection can lead to avoidance of institutional care, including childbirth.

Lack of formal education & low health awareness

All participants mentioned a low level of school education as well as low knowledge about health. This refers to pregnant women and the people surrounding them in their daily lives, as well as the people who make medical decisions for pregnant women, such as older women in the family, husbands, or TBAs.

As stated by the participants, illiteracy or a low education level is also associated with low health awareness, which refers to a lack of knowledge, understanding, or concern about one’s own physical or mental condition, as well as that of the unborn child. Through poor health literacy, pregnant women and those surrounding them are not aware of the benefits of giving birth with professional healthcare providers or visiting regular preventive health measures, such as antenatal care. Furthermore, it leads to the fact that danger signs during childbirth are not recognized and that professional medical help is not used or is used too late.

Perceptions around death

According to interviews, how the death of a child or a woman during childbirth is viewed and accepted also influences whether professional services during childbirth are used.

Many participants explained that death is something ubiquitous and normal in Nuba and is often accepted as God’s will. Many families have already experienced child loss, which diminishes the surprise and contributes to a high level of acceptance when the mother or child dies in childbirth.

Tradition and cultural norms

In accordance with the interviewees, one of the main reasons why women do not use obstetric care is the widely accepted social norm that birth is something common and therefore no professional help is needed. Phrases such as “because that’s the way it has always been” (Interview 1, female) came up frequently in the interviews.

② Perceptions of health and healthcare

Low risk perception of childbirth

As per the interviewees, the benefits of institutional childbirth were mostly unknown. Birth is usually perceived as a natural and uncomplicated event in Nuba. The potential for risks and the possible need for medical care during childbirth are usually underestimated.

Previous contact with the healthcare system

Participants mentioned that prior contact with the healthcare system during pregnancy could positively influence seeking obstetric care during birth. This contact may occur through antenatal care, in which women are encouraged to give birth at healthcare facilities. Satisfaction with professional care in previous pregnancies may encourage women to seek similar care in their next pregnancy.

Lack of priorities

As stated by the participants, it is a question of prioritizing whether healthcare is used or not. Many women have obligations at home, for example, to take care of other children or to work in the field. This work would otherwise be neglected, and there is usually no one who could continue this work.

Perceived quality of care

The listed facilitators included the construction of new spaces for maternity units and the distribution of non-food items as an incentive to visit a health facility. Another factor mentioned was the increased likelihood of women seeking hospital care for childbirth when there was awareness of the presence of international professionals in the locality, such as obstetricians from international NGOs.

The participants also identified expectations of “poor quality of care” as a barrier, including concerns about uncomfortable or substandard facilities, anticipation of inadequately qualified staff, and expectations of poorly equipped facilities with medication shortages. Fear and skepticism about hospital visits stemmed from the belief that people are more likely to die in hospitals, often due to delayed arrivals. Anxiety regarding surgical interventions, particularly caesarean section, and privacy concerns during the birthing process were also barriers mentioned. Additionally, there was a lack of trust in modern medicine, and discomfort with potentially inexperienced or male staff members.

③ Actors

Influence of family and peers on decision-making

It became clear during the interviews that the decision on whether to give birth in a hospital was very rarely made by the pregnant woman herself. Usually, this decision is made by the head of the family, usually either the husband or an older woman in the family. Participants described family influence as a major barrier to skilled obstetric care.

Alternative traditional health providers

Inadequately trained traditional health providers, such as TBAs and traditional healers, also have a great influence on the decision-making process. According to the interviewees, although some of them are experienced in obstetrics, TBAs in Nuba usually have little or no professional training and often do not recognize signs that a birth does not progress well until severe complications appear.

④ Structural factors

Costs and economic situation of pregnant women and their families

High costs (direct and indirect) coupled with the low economic status of the population were cited as barriers by the participants.

Based on the interviews, in most hospitals and health facilities, women did not have to pay money or only a nominal fee for obstetric care. Participants indicated that the nominal fees are not a barrier to obstetric care because they are usually affordable. It would only be considered a barrier due to the misconception that giving birth in a hospital is expensive, and therefore, women might prefer home birth.

Indirect costs include food and laundry during the stay in the health facility and neglected responsibilities at home, such as fieldwork and caring for children. The same applies to the co-patient. Neglected domestic duties or professional activities for the patient and her companion have financial disadvantages that are described as barriers. Another barrier is the high transport costs.

Geographical and infrastructural conditions

Nuba is a very rural and remote area, which is why the distances are often long and many smaller villages are isolated.

Participants indicated that the travel time to reach the nearest health facility was very long, usually more than two hours, sometimes even several days. Poorly constructed roads have also been described as significant problems.

As maintained by the interviews, it was difficult to access care due to the weather and environmental conditions. In particular, the rainy season poses major difficulties, for example, impassable roads and, as a result, being cut off.

Another problem described by all participants was the lack of transportation to health facilities. All participants stated that most women had to walk to get there, even if they were already in labor. Participants describe the possibility of getting to the hospital by a means other than walking as a “ matter of luck” (Interviews 1, 2), for example, if a passing car offers them a ride.

Another major problem that leads to delayed or non-utilization of qualified obstetric care is the absence of a functioning referral system. Families have hardly any possibility of reaching the hospital quickly in the case of obstetric complications. There are no standby ambulances or other public systems to assist with referrals. Furthermore, there are hardly any network or communication possibilities, for example, to exchange patient information, announce a transfer or referral, or ask for help.

A general shortage of health facilities and hospitals has also been frequently described. Centralized care in terms of geographical accessibility and distribution of care services presents a significant healthcare challenge in Nuba. With both referral hospitals located in the itself rural central region, the concentration of essential services in one area leads to the neglect of distant communities, depriving them of access to critical medical procedures.

Quality of healthcare services

All participants described a deficient infrastructure of the health system, including a lack of medical equipment, devices, and medicines. Almost all health facilities rely on external aid and are supported by NGOs operating in the region. Due to the political situation, humanitarian goods must be delivered via countries other than Sudan. Frequent floods interrupt the supply chain and cause delays.

One barrier to the use of obstetric care for childbirth is poorly trained healthcare workers. Many employees working in the region do not have professional training. Typically, they are trained by existing staff in the hospital or undergo short, general training, often for only a few months. Consequently, complications during the birthing process are often detected too late.

A summary of the themes, factors, and individual barriers and facilitators is listed below ( Table 2).