Characteristics of the in-depth interviewees and focus group participants
The age of the interviewed women ranged from 22 to 40 years. A majority had primary (grades 1-8) education. Most focus group participants were between 25 and 34 years, six were less than 25 years, and another six 35 years or older. More than half of the focus group participants (16 out of 27) had attended primary education, while three had no formal education. All respondents were married, farmers, and orthodox Christian followers. The healthcare providers were two health extension workers and four health workers from health centers and woreda health offices. Four women’s development group leaders also participated in the study (Table 1). Interviews, as well as focus group discussions, had a duration of 45 minutes to two hours.
Table 1: Characteristics of study participants
Characteristics
|
Women (n=39)
|
Women Development Group leaders (n=4)
|
Health workers
(n=6)
|
Age
<25
25-34
>=35
|
8
23
8
|
0
2
2
|
5
1
|
Education
No education
Primary
Secondary and above
|
8
23
8
|
1
3
0
|
6
|
Occupation
Farmer
Employee
|
39
|
4
0
|
0
6
|
Marital status
Married
Single
|
39
|
4
0
|
5
1
|
Religion
Christian Orthodox
Muslim
|
39
|
4
0
|
6
0
|
The concept of equity was difficult for women respondents. They used to define it in terms of timely service provision and utilization. However, during the pretesting of field guides, we explained inequity in terms of unfair differences in the utilization of maternal and child health services. We used an equivalent local term fithawnet in service utilization. We asked the respondents if the differences in the utilization were fithawi (fair)? All respondents understood the local term for ‘fairness’.
We identified the following major themes and sub-themes emerging from the data (Table 1). Below follows a presentation of the results complemented with direct quotes from the respondents.
Table 1: List of themes and sub-themes that emerged from the data
Major themes
|
Sub-themes
|
Perceived inequity in maternal, newborn, and child health services utilization
|
1. Equitable services
|
|
2. Inequitable services
|
Perceived causes of inequity in maternal, newborn, and child health services utilization
|
|
Structural causes
|
1. Economic/financial barriers
|
|
2. Lack of physical accessibility
|
Social and cultural causes
|
1. Lack of husband’s support
|
|
2. Women’s heavy housework
|
|
3. Women’s cultural taboos
|
Perceived quality of service
|
1. Healthcare providers’ bad behavior
2. Poor availability of drugs
|
Individual-level causes
|
1. Maternal age
2. Maternal education
|
Insufficient implementation of equity-oriented interventions
|
|
Suggestions
|
|
Perceived inequity in maternal, neonatal, and child health services utilization
Equitable services
Immunization was perceived as a fairly distributed service. All interviewed mothers reported that their children had been vaccinated. They attributed this completion to the immunization services provided by the health extension workers at outreach centers. An interviewed woman explained this:
In our village, you don’t find a child left unvaccinated. They (the health extension workers and women’s development group leaders) mobilize us for vaccination. There is no single woman who remains at home during a vaccination day. Vaccination is the most satisfactory service for all women in our village. They (the health extension workers) come to our village every month on the day of St. Mary, our leisure day, and vaccinate our children (IDI woman, age 35).
A focus group participant explained:
In vaccination, there is no difference. Because we are told to vaccinate our children 45 days after delivery, we, all women, vaccinate our children without any difference (FGD woman, age 27).
Inequitable services
All respondents reported that the utilization of maternal, newborn, and child health services was increasing at health facilities. More women attended antenatal care and gave birth at a nearby health facility. They stated that giving birth at a health facility could save both their lives and the newborns if complications arose. However, some women did not fully use the antenatal services. The respondents underlined that antenatal care and facility-based delivery were still inequitably distributed. Women’s development group
leaders considered antenatal care to be most problematic since pregnant women got tired and lacked money for transportation to the health center’s services. Also, they didn’t have access to ambulance services to reach a health facility during labor. The health workers underlined that poor women from remote places were less likely to attend antenatal care and deliver at health facilities.
The participating women reported that they did not attend postnatal care at health facilities after giving birth. Once a woman had delivered safely, she didn’t see the importance of going back to the health facility for health check-ups. According to their understanding, a woman should go back to the health facility if she or her newborn baby experienced any illness symptoms or had developed any complications, such as postpartum bleeding. An interviewed woman explained:
I did not visit the health facility after birth because my baby was fragile; how can I take her to the health center at this age. Here, we don’t have the practice of going to the health facilities before baptizing our children. Now, my baby is one month and two weeks old; I will take her for vaccination tomorrow (IDI woman, age 30).
Another interviewed woman explained:
After birth, I was healthy; hence I did not see the importance of going to the health center for a checkup. We (mothers) do not go to the health center if we and our babies are healthy. But we go there if the mother or baby is not feeling well (IDI woman, age 35).
The health workers corroborated with the mothers’ perceptions of postnatal care utilization. A young health extension worker said that mothers came to the health posts after delivery to vaccinate their babies, but not for a health check-up. Another healthcare provider also noted that mothers who gave birth at the health facility could attend the first postnatal care within 24 hours at the facility. But the subsequent postnatal visits at days 7 and 42 were missed.
Perceived causes of inequity in the maternal and child health services utilization
The themes identified were structural, social, cultural barriers, perceived quality of services, individual-level causes, and insufficient implementation of equity-oriented interventions.
Structural causes of inequity
Two sub-themes emerged under this structural cause of inequity in maternal, newborn, and child health services utilization: economy and distance.
Economy or lack of financial resources
The participants linked the inequity in the utilization of maternal, newborn, and child health services to the lack of money that prevented poor women from visiting the health facilities. Money was needed for transport, including the costs of their escorts, food, and buying drugs for their children. This problem was worsened when healthcare providers told them to buy medicines from private pharmacies that were very expensive. The inability to cover these costs discouraged women from using the health facilities. A woman explained:
The women who have money are taking public transport to go to health centers for delivery. However, the poor are giving birth at home, despite that services are free to all women. So, lack of money for transportation causes inequality between the poor and rich women (IDI woman, age 22).
The health workers and health extension workers also acknowledged the economy’s influence on services utilization, especially lack of money for transportation and drugs. One health extension worker said:
…those women from the wealthiest households were hiring minibusses for ETB 300 (USD 8.1) to go to the health facility for antenatal care and delivery. However, women from poor households don’t have this opportunity (IDI health extension worker, age 28).
Another woman also explained that the unfair child health-seeking behavior was linked to lack of money.
The poor woman doesn’t go to a health facility when her child gets sick because she can’t buy drugs. So, what can a poor woman do if she doesn’t have money at hand? Nothing at all. Days pass, thinking of taking the child to a health facility, but she fail to seek medical care timely because of a lack of money (IDI woman, age 35).
Lack of physical accessibility
All respondents in the in-depth interviews and focus group discussions unanimously mentioned that traveling distance was the primary cause of inequity in maternal, newborn, and child health services utilization. Traveling distance included distance from residence to the nearby health facility, poor road conditions, and the villages’ topography combined with limited availability of transportation for the community. Many women from remote villages did not utilize the health facilities for sick children.
… it (health center) is too far from our home. Those residing near the health facilities or living in urban areas use the health facilities more than us. In our village, let alone a pregnant woman, it is even more challenging for non-pregnant to go to the health facility and seek medication. For example, it took me about three hours to reach the health facility for antenatal care follow-up, or six hours, including the trip back. It would be impossible to attend all antenatal care (FGD woman, age 40).
The respondents said that women previously used traditional stretchers to reach the health facilities for delivery. However, the women’s development group leaders highlighted that young men are seasonally migrating to urban areas searching for jobs and are therefore absent when traditional transportation is needed. They stated that an ambulance is available, but the ambulance drivers’ unfriendly behavior deters women from utilizing these services to reach health facilities. They reported that the drivers do not respond to phone calls or put their cell phones off. As a result, women are compelled to deliver at home or on the road to the health facilities.
The different health workers were also in agreement with the women respondents’ opinions. They perceived that pregnant women from remote tabias attended the first antenatal clinic but could not participate in subsequent follow-ups. A maternal, neonatal, and child health expert at the district health office stated that the district had failed in achieving the planned coverage of antenatal care, i.e., four or more times, because women from remote areas were unable to comply with the recommended schedules. Inaccessibility by road was a major deterring factor. A women’s development group leader highlighted the importance of constructing roads to each village so that ambulances could reach.
One health care provider underlined that causes of inequity in the utilization of the services were combined and not a single cause. He explained his view as follows:
Women have multifaceted problems that distance them from the health facilities. First, household-related problems, second, limited access to transportation, third, lack of awareness and understanding of the benefits of utilizing the health facilities. When these problems co-exist, they widen the distance between home and health facility. Even the distance alone causes a considerable disparity in maternal health services utilization, disregarding the other co-existing problems. If you are far away from the health facility, you are also distant from the information. Thus, lack of access to roads, no transportation, and lack of information combined with distance multiply the distance from the health facilities (Health worker, age 26).
Social and cultural norms
Under this heading, lack of husbands' support, women’s cultural taboos, and women's heavy housework emerged as deterring factors from seeking maternal health services.
Husbands’ support
Participants in the in-depth interviews and focus group discussions said that the husbands needed to be at home for women to attend antenatal care and seek care for their sick children. One reason was that husbands could cover their wives’ responsibilities at home. Further, husbands arranged transport, including traditional stretchers, for pregnant women to go to the health facilities for delivery. Most respondents also noted that a lack of support from husbands prevented women from accessing health facilities. Husbands migrate to urban areas these days searching for jobs, leaving women without their support, thereby reducing the chance of giving birth at a health facility.
A woman explained:
I had delivered at home because I was alone. My husband was not present at home. Had he been present, he would have taken me to the health center (IDI woman, age 35).
Other respondents reported that some husbands were helpful. They supported their wives by either accompanying them to the health facility for delivery or staying at home caring for their children when the women went to the health center. Focus group participants and healthcare providers stressed that a husband should not move away during his wife’s pregnancy. A focus group woman said:
Those who are utilizing the health center are those whose husbands are present at home. Husbands encourage their wives to go there. If the woman shows the appointment card to her husband, he allows her to visit the health center. For example, my husband says, you need to go to the health center; I will take care of my children and animals (FGD woman, age 27).
Women’s heavy housework
The respondents mentioned that women were overburdened with household chores. Because of this, they only traveled to the health facilities for delivery. The women’s development group leaders also noted that husbands perceived themselves as breadwinners, negatively affecting women's health-seeking behavior. Husbands believed that their primary role was to make money for their families while women were busy with housework, like caring for children, cooking, and cleaning houses. Pregnant women worked the whole day to fulfill their household needs. This heavy housework prevented women from utilizing maternal, newborn, and child health services. A women’s development group respondent described this:
Pregnant women here do not have any break time during their pregnancy. They work until the end of their pregnancy, cooking, caring for their husbands and children, and cleaning the house. They are very busy with the housework (IDI Women’s Development Group leader, age 30).
Women’s cultural taboos
Women encountered cultural limitations in seeking care after delivery. They were restricted from moving outside of their home post-delivery. This limitation made women not attend postnatal care before baptizing their babies. Also, the fear of exposing babies to the evil eye and witchcraft discouraged them from participating in postnatal care. An interviewed woman described the attendance to postnatal services:
It is uncommon to attend the services after delivery. In our village, no single mother attends postnatal care in the nearby health center. Because the culture doesn’t allow us to go out after birth before baptizing our babies (IDI woman, age 35).
Women’s development group leaders and health extension workers had also noted these restrictions.
Perceived quality of services
Bad behavior of healthcare providers
The participants had different experiences of the health workers’ behavior at the health center. Some had been welcomed and treated with respect, while others had been mistreated. Some of the respondents reported that health workers became unreasonably angry when women arrived late, gave birth en route to the health facilities, or gave birth at home due to the delay of ambulances. They mentioned that the health workers did not even listen and understand that the situation had been out of the woman’s control. The health workers’ bad behavior discouraged some women from utilizing the health facilities and getting a facility-based delivery.
I have seen a health care provider snapping a laboring woman. They had to refer her to Mekelle, the regional referral hospital, and then she cried. They (health workers) then said you didn’t feel ashamed when you got pregnant, but you lost the shame and cried while giving birth. They were just joking with her. Also, another female hakim (health worker) came and snapped at the woman for crying. It has never happened to me, but I have seen the health workers mistreating laboring women. Some women are not coming to the health facilities because of fear of mistreatment (FGD woman, age 30).
Many focus group participants stressed that women who were uncomfortable with the health workers’ attitudes were negatively affected in their care-seeking behavior. They highlighted that negative experiences would also negatively influence other women in the utilization of health facilities. A focus group participant explained:
I don’t think a woman mistreated by the health workers will go to the health facility again. A woman who was beaten by the health workers in her first visit will not come to the health facility again (FGD woman, age 40)
On the contrary, an interviewed woman who gave birth at a health center stated that the health care workers who assisted her during delivery were very respectful and caring. She explained her experience as follows:
The health workers assisted me during my delivery with much respect and care. Even your mother can’t do what the health workers do for you. They (health workers) today are taking the role of our parents in caring for us. They are much worried and highly concerned about our health. For example, I had experienced bleeding while giving birth, but they immediately injected me with a drug and stopped the bleeding. I thank them all for saving my life (IDI woman, age 26).
A women’s development group leader explained the health care providers’ fair and non-discriminating treatment of woman based on her own lived experience:
The health workers are caring, especially for the poor women. I am poor and was referred to Mekelle regional referral hospital. The health care providers there were very caring. Some patients were dressed neatly and had their bedsheets and blankets. But I was served equally to those wealthy patients. I slept at the hospital for about three weeks, and I am satisfied with the services they provided me (IDI WDA, age 39).
Poor availability of drugs
All focus group participants and most in-depth interviewees noted that the unavailability of drugs was a significant concern in the government health facilities. The health workers in these facilities wrote a prescription and told the patients to buy medicines from private pharmacies. This problem made them skeptical about the availability of drugs at these facilities. They highlighted that this was deterring the poor people from using the health facilities.
The healthcare providers wrote a prescription and told us to buy drugs from private pharmacies. We are skeptical about the availability of medicines at government facilities. We do not trust facilities that run out of stock. How could the private pharmacies have a better supply of drugs than the government facilities? (FGD woman, age 40).
Individual-level barriers
Maternal age
Younger women used maternal, newborn, and child health services more than older women. This phenomenon was associated with modernity and education. Since younger women are more educated, they know the benefits of using maternal, newborn, and child health services. All in-depth interview respondents and focus group participants unanimously agreed on this issue.
Today’s younger women are by far better than the older women in many aspects. They are educated and relatively modern so that they develop over time. These women more frequently attend antenatal care than older ones. They also have a good practice of giving birth at health facilities. Most women delivering at home are the older ones. You barely find younger women giving birth at home. Both wives and husbands of this generation are educated. This is why younger women more utilize health facilities (FGD woman, age 25).
An experienced and older women’s development group leader described this as follows:
…most young women today are educated. There are even some women who completed grade 10. These educated women have a better understanding of the benefits of health services. Hence, the utilization of maternal and child health services is higher among these younger ones (IDI WDA, age 58).
Maternal education
Many respondents mentioned that lack of education reduces the utilization of maternal, newborn, and child health services. Home delivery was more common among uneducated women. These women were also more likely to drop-out of antenatal care. They associated this with limited knowledge and understanding of the benefits of utilizing maternal, newborn, and child health services. One interviewed woman explained her view as follows:
…yes, we, the non-educated women, are not delivering at the health facilities. For example, the health extension workers provided me with the cell phone number of ambulance drivers. But I didn’t call the drivers because I don’t know how to make a phone call. This is happening for all of the non-educated women in our village. In labor, I will be compelled to give birth at home, hoping St. Mary visits me with Her spirit. If I am educated, I will call the ambulance and give birth at the health facility. But, we (non-educated women) cannot make calls to ambulance drivers. So, our literacy level makes us give birth at home (IDI woman, age 30).
Insufficient implementation of equity-oriented interventions
Some equity-oriented policies, such as community-based health insurance, maternal waiting homes, and ambulance services were reported to be insufficiently implemented, resulting in inequities in services utilization. Health insurance was believed to potentially solve the financial barriers of poor women. However, the participants reported that they were not benefiting from this intervention. The focus group participants suggested that this scheme had become a reason for the drug unavailability because they were told to buy drugs from private pharmacies.
We pay 240 Ethiopian birr for health insurance every year (equivalent to USD 6.5). We go to the health center to get free services, but the health workers tell us that there are no drugs. So, health insurance is becoming worthless (FGD woman, age 27).
Another focus group participant said:
I had a seven-month-old infant who was sick, and I brought him to the health facility. They (the health workers) examined him and wrote prescriptions. They told me to buy the drugs from a private pharmacy. I showed my insurance card, but they didn’t respond. I went back home without any drugs because I didn’t have any money. Health insurance is not contributing to saving our children (IDI woman, age 25).
The respondents were aware of the maternal waiting homes, but women did not accept these services because of a lack of water, food, and electricity. Some women also mentioned that there was nobody at home who cared for their other children and animals if waiting to deliver at the health facility. Therefore, they preferred not to stay at those maternity waiting homes.
The women’s development group leaders also mentioned that their role in promoting the use of health facilities was weakening because of insufficient contact and supervision from the health extension workers. They believed their contribution could be significant in creating demand for health facility utilization by increasing awareness and mobilizing the women within their network. They noted that they used to support women disregarding social groups. Some women were also pleased with the support from women's development group leaders, especially during pregnancy and at delivery. The participating women also said that the women's development group leaders helped them mobilizing young men to carry a laboring woman on the traditional stretcher to the health facility.
Our (women’s development group leaders) work is deteriorating now. We had a monthly meeting to monitor the activities of the women's development group. In this meeting, we reported who are delivering at home and who are not attending antenatal care. However, today our role is becoming passive due to weak coordination from the health extension workers. We have reduced the role we used to play in educating and making women go to the health facilities to use the maternal and child health services (IDI women’s development group leader, age 39).
Suggestions to improve equity in the utilization of health services
The respondents emphasized the importance of improving access to maternal, newborn, and child health services by pushing the services closer to the community. They noted that the disparity created because of poor access to health facilities was unfair. One woman, aged 22, highlighted the construction of a health facility in each tabia to enhance equitable health services utilization. Some also suggested upgrading the health posts to health centers by equipping those with the required health workers, drugs, and other supplies. They also suggested constructing roads and increasing the number of ambulances, educate and take measures against bad behavior by health workers and ambulance drivers. It was also proposed to support the poor to improve inequity in the utilization of services. An interviewed woman suggested establishing a green bank to solve the poor households’ money problem to cover medical and non-medical expenses. The woman explained her idea as follows:
I would suggest contributing cereals, especially during the harvesting season, and store in one place to support the poor. It is during this season that the farmers can easily get grains. If we contribute at least two shember (equivalent to 3 kilos) a year, it would be adequate to support the poor. The banked cereals could even cover the poor mothers’ medical and non-medical expenses (IDI 6-woman, age 22).