Research Design
To address the purpose of this study, a qualitative, exploratory, and descriptive research design was used. The design was contextual. In this study, the researcher could only understand the participants’ perceptions of facility-based and home delivery as well as their actions (non-utilization of health facility-based delivery) from the participants' perspective, stated in their own words and in the context in which they lived. The primary purpose of the study was not to generalize the outcome to other settings, as it was specific to its context.
Study setting
The current research was done at public health facilities in Addis Ababa, Ethiopia, between February and April 2018. Three health centers and one district hospital were purposively selected for the study. The public health facilities were selected because they attended to a high number of women who attended FANC but attended to less skilled deliveries in the past year preceding the study. The health facilities of Addis Ababa include 12 public hospitals (specialized, referral, and general), 86 public health centers, and about 720 private and non-governmental (NGO) health facilities at different levels [3].
A slum household is described in this study as a community of people living under the same roof who lack one or more of the following conditions: access to improved water, living on small business/daily labor, access to improved sanitation, adequate living space, and durability of housing. The study included Ketchne and Kolfe Keraniyo slum dwellers, who are primarily low-income residential residents [6].
Participants and sampling method
The participants in the study included women in the reproductive age group (18-49 years of age) living in the slum areas of Addis Ababa, the capital of Ethiopia. The purposive sampling strategy was used to select women who, because of their FANC experience and home delivery, we're able to provide rich information that adequately answered the research questions. The women who met the requirements for eligibility have been contacted.
The researcher ensured that the necessary information about the interviews was provided to all women who agreed to take part in the interviews and that they were followed into the communities where the health facilities are located.
Participants had to be women who attended FANC in selected health facilities and gave birth to babies at home in the previous year of data collection, interact well in Amharic (local language), reside in Addis Ababa for at least 6 months, and in the reproductive age group (18 to 49 years) to be included in the sample. Exclusion criteria comprised women who attended FANC but had not experienced home delivery.
Data Collection
Focus group discussions (FGDs) were conducted by the leading author with the qualified female research assistant to address the purpose of the study, namely to gain insight into the views and perceptions of FANC participants on measures needed to increase the use of health facility-based delivery services. An interview guide was used to plan the open-ended topics in English and Amharic. The interview guide used in this study was attached as 'Annex 1'.
The women who met the eligibility criteria were contacted to discuss the purpose of the research, the study activities, and the request for participation in the study through the midwives/nurses in charge of the maternal and child health units of the selected hospitals and health centers.
The investigator performed FGDs with women who attended FANC and delivered live babies at home in the previous year before the study's data collection. The objective was to ask questions that elicited answers and produced maximum discussions and opinions within a given period among the study participants. Of the three selected health centers and one district hospital, four FGDs were conducted involving 32 participants. In FGDs, the number of participants was between 6 and 10 women. There were ten participants in the first FGD, eight participants in the 2nd and 3rd FGDs, and six participants in the 4th FGD.
A central topic was included in the interview guides, as well as additional questions aimed at exploring and delving deeper into various aspects of the research phenomenon. The probing questions were focused on the responses of the participants to the issue. The researcher used questions such as "please tell me more..., what do you mean by..." for questioning.
The participants were seated in a circle so that each participant had a complete and fair view of others to allow efficient contact in the FGDs. The key question for focus group discussion was:' what do you think should be done to increase the use of health facility-based delivery service among FANC participants?
Additional questions included: Why do women prefer home delivery to facility-based delivery service? What are your views regarding the advantages of facility-based delivery? What were the benefits of attending antenatal care for you? What information did you receive from the health care providers about health facility-based delivery? Focus group discussions were continued until data saturation was reached, and the investigator used data saturation by group, which was the point in coding where no new codes existed in the data.
During the interviews, the interview process was clarified by a favorable, non-threatening, and comfortable atmosphere when the researcher introduced himself to the participants. In the private rooms of selected health facilities, the interviews took place. The FGDs were audio-recorded with the consent of the participants and notes were written during the interview to capture the original accounts of the responses of the participants and to validate their explanations by going back to the original answers. In a quiet and private space, free of distractions, and where they felt safe, the investigator conducted the interviews in Amharic. The FGDs sessions lasted approximately 60 minutes on average.
Data Analysis
Descriptive statistics have been used to summarize participants' socio-demographic characteristics. All FGDs were transcribed from the audio-recordings and notes made during the interviews and translated into English. Data were analyzed in conjunction with data collection. All transcribed information was read and classified into meaningful units, which were subsequently manually coded by the principal investigator. Both a priori codes (from the query guide) and emerging inductive codes were used in the study. Thematic analysis was done for the study. In three phases, qualitative data were analyzed: exploring and creating initial codes; searching for themes by collecting coded data addressing particular themes, and identifying and naming themes found. To explain the study results, verbatim excerpts from participants were given. The researcher used Techs' eight steps of qualitative data analysis method for analysing the data.
Trustworthiness of the study
To ensure the trustworthiness of this report, a variety of processes were used. Concurrent analysis ensured that in subsequent interviews, emerging concepts were evaluated to obtain a complete understanding of the themes. For all the study participants, the same interview guide was used. In order to ensure the authenticity of the transcripts, interviews held in Amharic were discussed with experts in this language. The themes produced were discussed by the research team and ensured that no part of the data was left out. Detailed field notes were held that allowed the results and study processes to be checked. To support the results, direct verbatim quotes were used and this gave voice to the women in this research.
Ethics approval and consent to participate
Ethical clearance was obtained from the Research Ethics Committee of the Department of Health Studies, University of South Africa. The Addis Ababa City Government Health Bureau granted permission for the study to be carried out.
To perform the interviews, the authors received informed written consent from all participants. It underlined the voluntary nature of participation in this report. The Confidentiality of the identification and other personal details of all interviewees were ensured. The collected data were preserved electronically as audio recordings to be used as a backup format, and the transcripts and notes were stored as MS word files. To guarantee confidentiality, the MS word files were password secured.
Research Findings
The results of FGDs were presented below, the aim of which was to explain the views of women on measures required to increase the use of delivery services based on health facilities.
Characteristics of participants in the study
The Focus Group Discussions included a total of 32 participants. The mean age of the overall sample was 32.6 years (±SD = 5.2). Participants' educational characteristics indicate that the majority (24 out of 32) were found to have no formal education, and two-thirds of participants were found to have one to five children. Three-fourths of them attended the ANC twice and they all gave birth to their last child at home.
Themes
Two themes emerged from the study of interview data from FGDs. These themes were described as a rich and comprehensive account of the measures necessary to increase the use of facility-based delivery from the perspectives of the participants by FANC participants.
Theme I: Provision of Quality, Respectful and Dignified Midwifery Care
The first theme that emerged from data analysis was the provision of quality, respectful and dignified midwifery care. Within the theme, 4 (four) sub-themes, namely perceived incompetence of staff, negative attitudes of health professionals, effective referral systems, and provision of adequate resources emerged. Sources of data from FGDs were as shown in table 1.
Table 1 Theme I: Provision of quality, respectful and dignified midwifery care
Theme
|
Sub-themes
|
Data Source: FGDs
|
Provision of quality, respectful and dignified midwifery care
|
I. Perceived incompetence of staff
|
FGDs 1,2,4
|
II. Negative attitudes of health professionals
|
|
III. Effective referral systems
|
FGDs 1, 2,3,4
|
IV. Provision of adequate resources
|
FGDs 1, 2,3
|
Perceived incompetence of staff
The results of FGDs uncovered health care providers' perceived incompetence, lack of experience, expertise, and acceptable attitudes to care for pregnant women during pregnancy and childbirth as reasons why women do not go for delivery based on health facilities. To this effect, the participants suggested that competent staff (capable of providing quality care, characterized by respect and preservation of patients’ dignity) should be made available at the health facilities. The focus group participants suggested skills development programs which may include training, retraining, in-service education, and refresher courses to enable nurses/midwives to manage not only childbirth but also to provide respectful care to patients.
Sample responses included:
“Further education and in-service training opportunities will help the staff to update their skills and knowledge to manage childbirth and provide respectful care to the women (FGD2, woman 1, 29 years)”.
“Exploring how best midwives/nurses can be educated, developed and supported to provide high-quality midwifery care in the facilities is needed and ensuring that in-service training for staff on obstetric care is also helpful (FGD2, woman 3, 27 years)”.
“Some of the providers indeed lack midwifery experience and skills. It seems that they weren’t trained well in school and not exposed to the clinical setting….so, the authorities should do something to improve their skills” (FGD3, woman 6, 28 years)”.
"Besides, deploying an adequate number of supportive staff in non-clinical roles suggested freeing nurses/midwives to provide more midwifery care to minimize their work burden" (FGD3, woman 1, 26 years)”.
Negative attitudes of health professionals
The study results showed that women did not prefer facility-based delivery due to the negative views of health care practitioners. According to the participants, they [providers] subject patients to mistreatment, such as verbal abuse, neglect, or denial of services. Sample responses included:
“They (providers) have to respect their clients because human beings naturally need respect and dignity in childbirth” (FGD 1, Woman 7, 30 years).
“Indeed, staff should behave positively towards their clients and that they have to be trained ethically (FGD4, woman 3, 26 years)”.
"There are several negligent workers. To get their support, we go there, but they talk and talk about their private problems. So, going there is not advisable or they must behave morally (FGD 1, Woman 2, 34 years)
"The providers will beat you, and they will shout on you without any mistakes. So, they should first stop such abusive behaviors if they want us to go there for childbirth. I mean they need to have sound professional ethics and behavioral change" (FGD2, woman 4, 33 years)”.
Effective referral systems
Patient referral is a medical judgment dependent on many variables, including the prescribing team's expertise, testing resources, the health institution's availability of specialist facilities, the level of service at the referral institution, the cost of treatment, distance, transportation, contact, patient travel, and consumer travel viability. Delays in access to referral facilities have been seen in this study as a significant contributing factor to feto-maternal deaths Sample responses include:
"Due to shortages of supplies or diagnostic facilities, some women are referred from one facility to another". The comparison should be based on the woman's condition (FGD2, woman 8, 40 years).
"You are referred here and there when you go there (HF), and finally end up with a dead baby. The authorities should work hard to improve this problem" (FGD2, woman 3, 24 years).
"It is essential to provide ambulance services with an effective referral system to district hospitals to boost facility-based delivery services because poor women cannot pay for tertiary-level hospitals" (FGD3, woman 5, 29 years).
Provision of adequate resources
The study results showed that the Ethiopian government encourages all women to deliver at the health facility. Therefore, it follows that medications and medical services such as ultrasound tests should be made available because some poor women cannot afford to pay for them when they are referred to other places for examination. Sample responses include:
“At present, the government encourages all women to deliver at the health facility. So, drugs, and diagnostic facilities such as ultrasound examination should be made accessible because some poor women can't afford to pay for it when they are referred for examination to other places (FGD1, woman 1, 26 years).
"There are no or limited basic medical supplies, delivery beds and diagnostic facilities such as ultrasound exams, drugs, etc. if you visit public health facilities" (FGD1, woman 5, 32 years).
"There are no bedsheets, soaps, and other things and it should be worked on by the government" (FGD3, woman 7, 36 years).
"Due to shortages of supplies or diagnostic facilities, some women are referred from one facility to another" (FGD 3, woman 2, 38 years).
Theme II: Increase Awareness
The second theme to emerge from data analysis was increase awareness. Within the theme, two subthemes information sharing (between providers and women receiving care) and family support emerged. Sources of data from FGDs were as shown in table 2.
Table 2 Theme II: Increase awareness
Theme
|
Sub-themes
|
Data Source: FGDs
|
Increase awareness
|
I. Information sharing (between providers and women receiving care)
|
FGDs 1,2,3, 4
|
II. Family support
|
FGDs 1, 2,3,4
|
Information sharing (between providers and women receiving care)
The results of the FGDs showed a lack of understanding among some of the women who participated in the study of the significance of facility-based births, hence the proposal to raise awareness through effective information sharing (between providers and women receiving care] and health education. According to the WHO criteria for improving maternal and new-born treatment in health facilities [1], information about their care and relationships with staff should be accessed by both women and their families. Simple and precise exchange of information should occur. Sample responses include:
'I did not receive any information about a facility's delivery. She (the midwife) just tested me and told me to come to the next appointment; I believe I have the right to that information (FGD 3, woman 4, 31 years).
"They (providers) have often not communicated about the progress of labor and childbirth with the client or her family" (FGD 1, woman 9, 35 years).
I was really upset then and cried a lot, but to whom are you disclosing such a case? I think there should be a strong mechanism to report any annoying events and physical violence; otherwise, they [staff] need close monitoring (FGD 2, woman 5, 37 years).
According to the results of the study, some women claimed that unnecessary procedures, such as caesarean section and episiotomy, were conducted at health facilities. This finding was focused on the absence of women and their families with knowledge, hence the misconceptions. Sample responses include:
"Particularly in private facilities, Caesarean section delivery is quite common.... I think they just do it without sufficient medical reasons" (FGD 3, woman 2, 39 years).
“Several women are cut and stitched for the reasons I don’t know. (FGD 2, woman 4, 40 years).
"Fear of the delivery by the Caesarean section discourages us [women] from coming for delivery based on health facilities" (FGD 1, woman 2, 42 years).
Family supportduring childbirth
Most FGDs women were worried about health facility policies that prohibit family members (including their husbands) from providing them with the requisite physical and emotional support during labor and delivery. Many of them proposed that their family members [and husbands] be permitted to support them in labor wards. This finding was evident in the sample responses:
My sister lives in Europe and she tells me that her husband plays a big role in helping her through labor and childbirth. But our husbands are not permitted to see their wives in the labor unit......this needs to be changed because they [husbands] should be able to be with their wives (FGD 4, woman 2, 33 years).
[...] If my husband were allowed to accompany me to the delivery room, I would be happier because he had to share my pain and misery as well. I, therefore, hope that the facility will one day recognize this problem and permit my husband to join the labor wards (FGD 2, woman 6, 34 years).
The WHO guidelines for enhancing maternal and newborn care in health facilities [1] support this finding, noting that women can choose to have a partner of their choice present for labor and childbirth and, that they must obtain support to improve capacity during delivery.
Measures for enhancing facility-based delivery, as suggested by women
Below are the measures proposed by women to increase the use of facility-based delivery:
1. Provision of quality, respectful and dignified midwifery care
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Increase the availability of qualified staff: In this study, women, therefore, proposed steps such as examining how best midwives/nurses can be trained, developed, and assisted to provide high-quality midwifery treatment in the facilities and ensuring that frequent updates are carried out for in-service training for obstetric care staff. Furthermore, the deployment of ample numbers of supportive staff in non-clinical positions indicated free nurses/midwives to provide more midwifery care to reduce their workload.
-
Development of expertise: Through in-service training, refresher courses, and continued education, the skills of service providers employed in public health facilities must be strengthened. The abilities described included communication, positive attitude, interpersonal skills, and empathy in particular.
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Effective referral system: Render prompt referrals for emergency treatment, ensure arrangement for ambulance service and care during travel to a higher-level health facility. Reduce women's referral to health facilities in the district of equal status (prevent delay in seeking care).
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Adequate resources:The results indicate that participants in the study considered that some of the health facility buildings were mainly small with minimal delivery beds (couches) and waiting rooms for women in labor. The women, therefore, propose that there should be more delivery beds (couches), medications, and medical services such as ultrasound testing.
2. Increase awareness
- Information sharing (between providers and women receiving care)
Both women and their families should receive and communicate with staff with details about their treatment plan. Simple and precise exchange of information should occur. Improve the understanding of health professionals about pregnant women's access to information and adequate health care.
Personal reflections as regards focus group discussions
Through using bracketing, the researcher ensured that his beliefs, viewpoints, and experiences about the phenomena under investigation did not influence data collection and data analysis. The gender of the researcher (male nurse- midwife) and context did not influence the data collection process and data analysis for the current study in any way.
During the second focus group interviews, the researcher had to deal with a threat from dominant participants by asking questions directly to the silent members. After the interview had finished, one study participant arrived late. When the participant calmed down and resumed the interview, the researcher postponed the session. Otherwise, during the entire interview process, the study participants were cooperative and conformed to the ground rules.