Barriers of ANC service utilization in Somali region
Barriers for the utilization of Antenatal care service in the region include socio-demographic, economic status, cultural believes, past experiences, level of awareness, attitude toward the service, challenges in accessing transportation and shortage of supplies (Table 1).
Demand Side Barriers of ANC Service Utilization
The ANC service utilization in low performing pastoralist and Agro-Pastoralist areas of the region were negatively affected by the socio-demographic and economic factors of the respondents. In low performing pastoralist and Agro-Pastoralist areas almost all respondents pointed out that lack of transportation and the associated poor economic status attributed for not visiting the health facilities for ANC services. Even the ANC service provided free of charge in the public health facilities, they are not able to pay for the transportation, accommodation, and other costs.
“Lack of money is one of the main reasons for mothers not to visit the health farcicality for ANC and others health care services.”KII, Health Center Head
“Those who have money can go the health facility because they have money to pay for the service, transportation and other costs.” FGD, Mother’s, Tuliguled
“Mothers must attend (visit health facility) at least four times for antenatal …, but mothers in this area do not attend at least one visit.” FGD, HCP, Kebridahar and another participant said that: “this (low ANC service utilization) can be due to lack of transportation, and far distance between community residences and health centers.” KII, Health center head Degehabour
Lack of Awareness
The stud was found out that participants were not well aware or informed about the benefits of ANC visits. Majority of the mothers living in rural areas of the region don’t have adequate information and awareness’s about ANC visits and other maternal and child health services. In addition to this, they have not considered as it is beneficial and they have no intension to use the services at all.
“Majority members the community are living in the rural areas and they are pastoralists. They have difficulties coming to the health centers and health institutions. They don’t have full information about maternal and child health (MCH) issues and services that can be rendered at facilities. Mostly, they think that it has no benefit to use those services for them and for their children. Most of them have no intention to use it. Almost all of them have no awareness about MCH program...” KII, District Health Office Head
Clients Preference of Health Care Provider’s Gender being Female
Majority of the mothers preferred to get maternal health care services from female health care providers. Mothers who get services from the female health care providers are more comfortable and satisfied with the services they obtained.
“I always prefer to get ANC and other maternal health care services from the female health care provider.” IDI, ANC user, Kabridahr and another respondent says: “…Since I am a woman I prefer to get the maternal health care services from female midwife.” IDI, ANC user, Warder
Lack of Husband support
Not understanding the need for “a healthy” pregnant women to visit a health facility and not wanting to stay at home and care for their children while her absence to visit a health facility are the two most commonly cited reasons for men do not allow their wives to visit health facilities.
“The reason for this is due to an opinion that ‘why would I go to the health facility when I am feeling well and healthy?’ And when the mothers go for follow-up the husband says, ‘why is she going to the health facility and who is going to care for the children while she goes to the health facility?’ If the husbands are willing and allow their wives to utilize the RMNCH services, women are ready to utilize the RMNCH services.” FGD, HCP, Harshin
“Definitely he (my husband) encourages me to see the health worker and I know a lot about my health and that of my child and also he gives me all the money I need and without him nothing would have been possible.”
Lack of Focused ANC Service
In general, mothers who live in region did not get a proper care during ANC visit. This is to mean that the quality of the ANC service rendered by the health facilities when they visited were not optimal enough to identify and manage anticipated obstetric complications. Also, majority of the community have low level of health care seeking behavior, which is observed in the ANC service utilization in the region.
“…most mothers in this area didn’t have ANC or optimal care during their ANC visit when they had one…” KII, Gynecologist, Jigjiga
“…members of the community are not coming to a health center in general to get treatment for their conditions or other health related services…. It is very low…. This is also seen in ANC follow up …” KII, District Health Office
The uptake of health education services provided by the facilities is also poor. The community does not give emphasis for the ANC services and related health education which are provided by the health care workers.
“We provide a health education on the ANC, delivery service but they don’t care about it.” KII, Health center head
Supply Side Barriers for ANC Service Utilization
Lack of Availability of essential Components of focused ANC services
According to the facility abstraction/observation done from the health facilities, almost half of the health posts, health centers, and hospitals which are found in the region are providing ANC services. But the availability and quality of comprehensive focused ANC visit packages vary between and within different health facilities. Out of 7 health posts included in the study, 3 of them did not provide ANC services at all and the rest provide some of the components of ANC services. Furthermore, six health centers were not providing full focused ANC services due to shortage of health care providers. There is no laboratory technician on these health centers and the service is not functional. But almost all focused ANC services were available at the 3 hospitals included in this study (Table 2).
Shortage of Supply and Equipment for ANC Service Provision at Health Facilities
Significant proportions of focused ANC components were not being provided at facilities due to shortage of supplies such as medical equipment, medications, and other instruments needed for the ANC services.
“We don’t have the essential equipment for the ANC and Delivery services.” FGD, HEW, Warder
“The problem of the supply issue is not only restricted to the pastoralist area and low performing areas. The problem was also shared among the high performing area of agro-pastoralist region and also urban areas as while they have equipment they have shortages of drugs. KII, Health center Head
A facility abstraction data indicated that about 10 (48%) of the health facilities did not provide laboratory screening services for HIV, Syphilis, Hemoglobin, and urine for protein/sugar. On the other hand, 11 (52%) of the health facilities did not provide screening services for blood pressure, diabetes, anemia, and symptoms of STI/RTIs for mothers who were attending ANC visit (Table 3).
Shortage of Health Care Providers
There is shortage of health care personnel like laboratory technician in the health facilities. Because of this, the available workers are sending back their clients without offering the health services they came seeking. This is more profound especially in the low performing pastoralist areas. Moreover, the few health professionals were moving from rural to the urban setting.
“We don’t have sufficient trained professionals in our health facilities.” FGD, HCP, Kebridahar
“Absence of a lab technician is the main problem for our health centers.” KII, Health Center Head
Lack of Defaulter Tracing Mechanism
To address mothers who discontinued their services in high performing urban areas of the region, health care providers and health extension workers may call the service user by phone, search for her at home, or use the kebele leader as a means to trace her.
“We go to the kebele and find the mothers and children who drop out from the service. If the mother comes for her 1st and 2nd ANC visit, and drops out on the third visit, we inform the kebele administrators to search for her. There is a folder prepared for each of them, then we follow them according to their tracing folder….” IDI, District health office head