Socio-demographic characteristics of participants
Twelve in-depth interviews were conducted. Two-third of the participants were females and midwives constituted half of the participants. Nearly 58% of participants had received diploma and above. The below table provides the socio-demographic characteristics of participants.
Table 1
Socio-demographic characteristics of participants, rural Amhara, Ethiopia
Sociodemographic characteristics | n = 12, N (%) |
Age | |
20–25 | 2 (16.7) |
26–30 | 10 (83.3) |
Sex | |
Male | 4 (33.3) |
Female | 8 (66.7) |
Zone | |
South Gondar | 7 (58.3) |
West Gojjam | 5 (41.7) |
Profession | |
Midwife | 6 (50) |
BSc Nurse | 1 (8.3) |
Health extension worker | 5 (41.7) |
Level of education | |
Level 4 | 5 (41.7) |
Diploma | 3 (25) |
First Degree | 4 (33.3) |
Experience (in years) | |
1–5 | 6 (50) |
6–10 | 3 (25) |
>11 | 3 (25) |
Total | 12 (100) |
Thematic Categories
Healthcare providers’ perceptions towards healthcare seeking behavior of pregnant women were clustered around the following six thematic categories. Interaction of pregnant women with healthcare providers, care and perception of mothers for their small babies, group antenatal care preferences/acceptability and scheduling, dietary practices, infection management practices and women’s ANC & PNC attendance and institutional delivery.
a. Interaction of pregnant women with healthcare providers (HEWs, nurses, midwives)
Healthcare services such as antenatal care (ANC), birth and postnatal care (PNC) were provided at health center and hospital levels. In health centers, midwives primarily provided these services to women. However, in health centers where there were few/no midwives, nurses took over the responsibility of providing the services. On the other hand, in health posts, where health extension workers were the only providers of healthcare services, services were only limited to vaccination, health education and monthly conferences. Monthly conference is a special type of meeting where pregnant women and healthcare providers meet once per month to discuss about issues around pregnancy.
Midwives, nurses and health extension workers explained the kind of relationship pregnant women had with them in slightly different ways. However, one thing they shared in common was that they have a good relationship with women.
I have been working as a midwife for the last 5 years and it has been three years since I joined this health center. I would say I have built a good relationship with pregnant women and other mothers who come to this health center to receive various healthcare services. The trust they have on us and the respect they have for us is simply amazing. Their willingness to do whatever order comes out of healthcare professionals can partly explain what I said before. They always consider us as reliable source for their information needs. We usually meet pregnant women when they come to health centers seeking services like antenatal, birth and postnatal services. In addition, they also come in between appointments whenever they have any issue including illness. In all of these contacts, we always strive to provide services in the best possible way. [Midwife, South Gondar zone]
Healthcare providers usually met with women either in healthcare facilities or at women’s homes. Health extension workers mostly spent much of their time in villages where they provided services home-to-home. This interaction of HEWs with women was believed to strengthen their relationship.
Unlike other healthcare providers, our (health extension workers) contact with women is not only limited around health facilities. We usually go out of health posts and provide services home-to-home. Monthly conferences, one-to-five meetings and vaccinations are other platforms that bring us together. Due to this reason, it has now become very common to consider us as members of their families. During our daily home-to-home visits, they invite us for lunch and to have some coffee with them. Our relationship extends further and we get invited when during weddings and other bigger festivals. I think this shows the kind of intimacy we have with women. [Health extension worker, West Gojjam zone]
It was not very common for nurses and midwives to provide services outside healthcare institutions. However, in some occasions such holidays, they went out to villages and educate the community on various topics either in a smaller group around their homes or in big gatherings around churches. In terms of strengthening their relationship with women, out-of-facility meetings were found to be more productive. One of the nurses explained the reason as follows.
If not very often, we also go to different kebeles where we provide health education to the community including pregnant women. This mainly happens during saint days like St. Michael, St. Mary, St. Gabriel etc. In this community, Orthodox Tewahdo Christians have a special kind of respect to these Saints. One way of showing this respect is by calling their close relatives to their homes so that they can have some drinks and food together. Considered as one of their relatives, I have been invited to their homes many times. In my opinion, this frequent contact coupled with our friendly approach have shaped our relationship to look more like a family than a service provider & service recipient. [Nurse, West Gojjam Zone]
b. Care and perception of mothers for their small babies
According to healthcare providers (HCPs), although some pregnant women were aware of the causes of giving birth to small babies (e.g. dietary deficiency during pregnancy, workload, poor personal hygiene etc.) and the possible preventive measures to do during pregnancy (e.g. taking balanced diet, decreasing workload, ANC follow-up etc.), others still remained highly attached to local beliefs.
During our home-to-home visits, what we have observed is that mothers of small babies are not willing to bring their children to health facilities for services like immunization on time and when we asked them the reason, they responded like ‘Why would I bring a very small weight baby who is going to die sooner or later to a health facility? They will not grow anyway and are rather burden to the community and to his/her parents in particular.’ What is more worrisome is that they do not even want to show us their babies while we are at their homes. I clearly see a knowledge gap here. Although we are working day and night to teach the community about such perceptions, I do not think we are even closer to our target. [Health extension worker, South Gondar zone]
Women did not bring their small babies to healthcare facilities did not mean they will just keep fingers-crossed. When they encountered such unusual incidents, they would relate the case with something, either to a supernatural power or cultural belief. If they linked it with a super natural power, they would try “tsebel”. On the other hand, if they attach it with culture, they would try traditional healers. They would only seek care from healthcare providers if none of these worked out.
Women usually relate giving birth to small babies and preterm births to religious and cultural beliefs. For instance, punishment/curse from God, visiting people who are mourning, touching a dead body while pregnant, ‘shotellay ' etc. As a result of this, they do not want anybody know about this and they are not willing to share this with anyone including healthcare providers. But this does not mean that they will keep just quiet. Depending on their religion, they still might look around for solutions. For instance, Orthodox Tewahdo Christians, might go to ‘tsebel’. Others might prefer traditional practitioners. Only if the traditional medicines or whatever they tried do not work, families access care from healthcare providers. [Nurse, South Gondar zone]
According to a midwife who has been working for many years in that area, there were few conditions when women would consider seeking care from healthcare providers as the only way out for their current problem. For example, if the situation with their babies seemed very serious, they would go straight to nearby healthcare facilities.
Working for the last 10 years in different health facilities, I have learned that women do not usually seek care for their small babies and they do not have the courage to bring their children to health facilities unless their babies get seriously sick as it can be exhibited by various symptoms like stopping breastfeeding. The health education programs seem to have brought some changes in this regard but we still need to work aggressively to bring the required behavioural changes to the expected level. [Midwife, West Gojjam zone]
c. Group Antenatal Care (gANC)
Group antenatal care is a kind of healthcare service provided to pregnant women of similar gestational ages who are placed in cohorts of 8–12 women to receive scheduled care. gANC has some resemblance with monthly conferences. It is a new concept and has never been practiced in any of the health facilities where this study was conducted. Therefore, the assumption here was that women’s perception towards monthly conferences could give some clue about the feasibility/acceptability of gANC. According to healthcare providers, women did not show interest in monthly conferences nor gANC for reasons outlined below.
In rural areas, people usually went to health facilities expecting drugs mainly in the form of injection. In addition, they felt that they got appropriate therapy only when they were requested to provide sample and got tested. Therefore, women’s expectation was mentioned as one major reason for showing no/little interest to monthly conferences and gANC.
Pregnant women consider monthly conference as an ordinary meeting where women just gather, listen and go home when it is done. Some of them also consider this conference as irrelevant and participating in such programs is simply wasting their precious time because there is no laboratory testing, TT immunization and abdominal examination. Unfortunately, none of them are done during the conference except health education. Due to this reason a woman who has participated in one conference usually do not show up in the next conference. gANC is no exception here. [Midwife, South Gondar zone]
Schedule and topic preference were also raised as potential reasons for women to lose interest in monthly conferences. A rural woman is relatively free during holidays as there are no outdoor activities. As a result, holidays are more preferred by women to go to health facilities. Topics were also determining factors for women to participate in conferences. During conferences, there was little room for women to ask whatever complain she had. Topics were prespecified.
From what we have learned so far, unless gANC is made to fall on a holiday, number of attending mothers would be significantly low. Women also prefer to discuss more on their priority issues than topics pre-specified by healthcare providers. [Nurse, West Gojjam zone]
Privacy was another issue that made women less comfortable with conferences. They did not want to talk in public about their issues related to pregnancy.
Pregnant women did not want others know about their pregnancy issues. Women from rural areas are shy and this problem gets even worse when it comes to a group where there are more attending women. [Health extension worker, South Gondar zone]
Long waiting time was also mentioned as another reason that made women show less interest in conferences and gANC. They always wanted to get services so quickly and get back to home.
Women travel 3–4 hours to get into this health center. They want to get the service as quickly as possible so that they can get back to home before it is too late so that they can cook food for their family and take care of their children. However, for the gANC, I think she needs to wait for other women to join the group before they start getting the service. From my experience, they do not like this at all. [Midwife, West Gojjam zone]
d. Dietary practices
Nutritional counseling took place mainly during antenatal visits, monthly conferences and home-to-home visits. Each counseling sessions touched upon various points.
Nutritional counseling is one major topic during monthly conferences and ANC visits. During nutritional counseling, we advise women mainly on how taking appropriate nutrition during pregnancy is key to the wellbeing of both the mother and child, how to get and prepare balanced diet from locally available cereals and food sources, when to start breast feeding and how long to breast feed, when to start complementary feeding after birth and preparation of baby food after 6 months. [midwife & health extension worker, West Gojjam zone]
Every healthcare services demanded the face-to-face communication of both groups: healthcare providers and pregnant women. Nutritional counseling was no exception. The more women were courageous to visit healthcare facilities, the better they would be acquainted with dietary practices.
The frequency of nutritional counseling depends on the frequency of our contact with women. In other words, if she visits health facility four times throughout her pregnancy period, then she will get counseled 4 times. Every time a woman comes to health center for ANC, her weight will be regularly measured. As a woman is expected to gain weight during pregnancy, our counseling is based on her previous records. [Midwife, South Gondar zone]
Health extension workers also shared us their view about one component of nutritional counseling which had been implemented in that area: food preparation demonstration.
Although it is no longer happening now, food preparation demonstration has been conducted by two organizations which were operating in this area: ENGINE and World Vision. I can witness how productive it was to combine nutritional counseling with food preparation demonstration. It has changed the dietary practices of many women. I wish if I could keep demonstrating how they can prepare different types of food from what is available locally but we do not have the essential materials such as utensils. [Health extension workers, West Gojjam zone]
Despite the repeated counseling sessions, women poorly practiced the health education messages at home. Much of participants’ opinion for the poor dietary practices by pregnant women went around religion.
During nutritional counseling, we advise pregnant women to eat additional food stuffs on top of their regular diet, to include animal products in their diet and to increase the frequency of eating compared to what they used to do before they got pregnant. However, majority of them are Orthodox Christians and they do not eat meat, egg and dairy products during fasting seasons [Midwife, West Gojjam zone]
Women’s poor dietary practice was only limited to food types prepared at home. They were also very hesitant to take iron folate, a supplement freely provided to pregnant women by health centers.
Pregnant women get iron supplementation either from health center or health post. They take it daily at night until delivery. Despite its access for free in health facilities, women do not take it as expected mainly for two reasons. It frequently stocks out. On the other hand, some women do not adhere well to iron because of fear of fetal weight gain and side effects like GI irritation. [Midwife, South Gondar zone]
e. Infection management practices: UTIs/STIs
When women came to health centers, providing specimen and getting tested for any complaint they might have was their top priority. However, provision of this service was dependent on a number of factors such as presence of a laboratory professional and availability of test kits among others.
Once women arrived at health centers, they always wanted to start with laboratory testing (UTIs, STIs), otherwise they would not be satisfied. But the reality was that all treatments were not preceded by laboratory testing. [Nurse, South Gondar zone]
The types of services provided at health center and health post level were different. Health extension workers who were the sole service providers in health posts did not have the skill and training to do any kind of laboratory testing. Hence, tests for UTI and STI were done in health centers and hospitals. However, STI test using vaginal swab has never been done in any healthcare facility.
Urine and STIs tests (like syphilis and HIV) take place during ANC visits in health centers. Unlike very common specimens such as urine, blood and stool, taking one's own vaginal swab is a completely new procedure which pregnant women have never been requested before and it has never been practiced in any of the health facilities in this region as far as my knowledge goes. We do not have also prior experience. However, if women are ordered by HCPs to collect vaginal swab by their own, they would be willing to provide the sample. Women are always very enthusiastic to provide any kind of specimen. [Midwife, West Gojjam zone)
f. Women’s ANC & PNC attendance and institutional delivery
Mostly in rural communities, if a woman is in her early days of pregnancy, she did not want people know that she is pregnant. One of the participants explained the reasons as follows.
In this area women do not want to disclose pregnancy especially if she is in her early days. They believe that if they do, abortion will follow. Due to this and other reasons, they usually come to health centers very late. Others will just give birth at home. [Midwife, South Gondar zone]
There were different traditional ways to suspect pregnancy among women in the community. WDAL and district/kebele chairman were more used to these identifying mechanisms than healthcare providers.
A woman is suspected to be pregnant if she stops fetching water or her husband refrains from carrying dead body or if she does not show-up to places like religious institutions and public markets as she used to do before she got pregnant. [Midwife, West Gojjam zone]
In the health centers where this study was conducted, there was a structure in place to track and link pregnant women in villages who are not yet linked to health facilities. They also used this structure to track home deliveries. Included in this structure were HEWs, WDALs, district chairman and study nurses.
Tracking pregnant women and home deliveries is usually done by Health Extension Workers (HEWs) in concert with Women Development Army Leaders (WDAL) and district chairman. There is a 1 to 5 women structure in the community that helps WDAL identify pregnant woman and home deliveries easily. If a woman is identified to be pregnant, then she will be linked with health centers to start getting her ANC services. On the other hand, if home delivery is identified, mother will be advised to visit health facilities for any complication or to get her child vaccinated. [Health extension workers and Midwife, South Gondar zone]
Pregnant women were also tracked and linked to health facilities based on their estimated date of delivery (EDD). This worked only for those women who showed up to the health center at least once during their gestational period.
There is also a system in place where HEWs are tasked to keep an eye on those pregnant women who are in their last gestational week based on their estimated date of delivery. Those who are willing will be sent to health centers and made to stay there until they give birth. [Midwife, South Gondar zone]
There were possibilities for a woman to switch health centers. That means a woman might have her prior ANC at one health center and continue the rest of her visits at another health center. In this case, tracking this woman is very important so that she will not start her ANC from scratch.
Although not common, if we found out a pregnant woman/mother attending her ANC at a different health center, she will be tracked using her address (like kebele, got etc.) that was originally recorded in our register. In addition, pregnant women/mothers with prior ANC visits at different facilities will be linked with our facility if they bring their files/documents. However, there is very little (if not none) communication with other health centers to crosscheck whether the newly arriving woman in our health center has attended her prior ANC visit in that health center or not. [Nurse, South Gondar zone]