Characteristics of the participants
The study participant mean age was 39.8 year. Out of 34 focused group discussion participants, 8 female participants were illiterate and 15 participants were can read and write (Table-1).
Out of 16 individual depth interview participants; 10 participants were health care providers and 6 informal participants who came at Health facility for scheduled child immunization and family planning. More than three quarter of in-depth interviewees were found on mean age of 29 (Table- 2).
Institutional delivery Practices and Barriers
The study revealed various reasons that favour home delivery to be first in the selected district. The three main themes: the individual, community and facility factors were come out to show how the pregnant women is affected to use skilled birth attendants and quality of health care. Theme-1፡ Individual factors
Category-1: Information gap
Illiteracy and information gap to identify risks and benefit of home delivery were among reasons of low skilled birth attendance. Majority of the participants were no one had interest to attend their delivery in health facilities unless complication faced.
“Institutional delivery is the last option for us…we can manage everything without any challenges using our traditional birth attendants.” (FGD_3 Participant)
Category-2: Low risk perception to pregnancy and delivery
“…in my life I know one woman who gave birth in her home more than 12 times without any health risks or complications. So, why you forced us to go and give birth in health facility. As you observed; there is no road, transport and is very difficult to reach to nearby health facility due to flooding, filled river and mud.” (FGD_3 Participant)
Theme-2: Community reasons of home delivery
Category-1: Women’s poor position to decision
Majority of health care providers said that husbands are considered influential in deciding the whole process at home and dependency on husbands’ financial support is one of the reason for poor provision of skilled care during pregnancy and delivery.
“... Only we husband have power in deciding where wives should give birth. This is due to fear of payment and not to miss the deceased women in the referral hospital since majority of people believed many hospitals use the deceased body for teaching learning process...” (FGD_1 Participant)
Category-2: Beliefs and cultural practises at home delivery
Religious acts conducted during childbirth were among reasons to retain labouring women in home.
“During home delivery, prayers of priests come and conduct religious practices, reading religious books entitled with ‘Metsehafe Rufaele' and ‘Abune Zeraberuk'e. With by nodding his head and souk up his lip we highly believed on these religious books to be read during labouring time because of immediate solutions.” (FGD_1 Participant)
All FGD participants believed that spiritual books have power to ease and facilitate labor.
“For me, if these books are available in my home during my labor, no need of going to health facility.” (FGD_3 Participant)
“If labor is prolonged, we will conduct various traditional practises such as females roast coffee; if the women do not yet deliver, men would then substitute the women and roast coffee to consider their luck.” (FGD_1 Participant)
“In my life, I confronted one woman whose labour endured three days. However, when I started roasting coffee, she delivered immediately. Hence, many individuals want me to roast coffee when their wives started have labour by considering me as the luckiest person and all Laughed.” (FGD_1 participant)
“If the first trial were failed, other options will be attempted. For instance, Fenugreek in local language, “Abash” will take the place of coffee to be roasted. “Fenugreek roasting” believed to be a tool to acquire St. Mary come and to be blessed the labor process. They all understood that, labor would facilitate and smooth with the help of St. Mary.” (FGD_3 Participant)
“...There is a habit of putting husband's trousers under the pillow and sleep on it to facilitate delivery.” (FGD_3 Participant)
“Besides, extra amazing traditions were conducted if labor is welcomed. Both men and women were forced to untie their belts; all closed household containers were open. If possible a selected sheep could be bought from anywhere and rounded three times on the head of the laboring mother, then the sheep will stand or slaughtering in front of the laboring mother to make excite and give birth immediately.” (FGD_3 Participant)
All participants mentioned that when women faced lost her consciousness after delivery/in local language ‘Sereka’, they immerse in a river to make her conscious. Besides, poorly had a habit of putting Maria Teresa in between the victim upper and lower teeth to prevent clinch and sometimes people made postnatal mothers to catch mirror in front of her face to prevent eye closure.
All participants said that in addition if the postnatal mother loses her consciousness, we start knocking tin, whipping whip, installing spear parallel to the pillar of the house to prevent entrance of ‘Sereka' and firing gun near her ear to make her wake up so far nowadays there is improvement. All religious leaders believed that they had traditional medicine to remove retained placenta.
“...When retained placenta is faced, the woman sits on hyena's leather and on dry cow dug by the tip of her legs...then the placenta could be removed soon...” (FGD_3 Participant and FGD_ 2 participant)
They also claimed that local language ‘Adefe/yhuala leje' or retained placenta could be remove if a script from ‘Melke Rufaele' or religious book is read. If such acts could not remove the retained placenta, the traditional healers can prepare local medicines from different herbs. Most of the participants said that, ‘the placenta is buried inside home because the community is considered it as second child.
All FGD participants said that If it is throwaway home, the women might be suffering from severe abdominal pain called as local name “Marate”. So, the placenta should be buried inside home by the husband's left hand using spear. Most respondents knew that laboring women do not allow go out of home before the baby is baptized with holy water which is supposed to protect them from evil or devil spirit and because of fear of crossing the river brings heavy snow and rain to inhabitants.
Theme-3: Health Facility Related Barriers
Category-1: Lack of availability
“...in our health Centre, there is no water and light. You can imagine without water how could we manage laboring women and with no light most investigations can’t be done and sterilization is difficult for delivery sets.” (KI-1 participant)
In addition to this all healthcare providers worry about patients or client health due to shortage of basic needs of the health facility.
‘‘...to your surprise in our health facility, by nodding his head, there is no delivery coach and other important delivery equipment. We simply help our mothers on antenatal coach, which is broken. Government declared that no woman could die while she gives life but this motto doesn’t work for those marginalized women.” (KI-1 participant)
Category-2: Issues related with access
Most HCP and HEWs explained, the long and difficult journey to reach the nearest health centre with no adequate infrastructure to use institutional delivery.
“...Maternal death will be continuing in rural Ethiopia unless problems linked to health facilities are not averted.” (KI-1 participant)
“The problem was worsening during winter since most deliveries could happen at night that makes difficult to carry labouring mother reaches health facilities”. (KI-2 participant)
“...Due to infrastructure, topography and other barriers, they are still doing nothing to save lives. Due to this, most of laboring women said that our home had better care than health facilities”. (KI-1 participant)
Category-3: Lack of privacy
The health extension workers indicated that, lack of privacy at health facility during delivery is one of the reasons for home delivery.
“Most of the time we prefer to deliver in home than health institution. This is because of not exposing our bodies to an outsider including students that touches repeatedly for learning- teaching process. But, in our home no one can touch us except female family members.” (FGD_3 Participant)
Category-4: Misconducts of health providers’
Most participants revealed that, health providers are generally criticized, distrusted and not accepted by their approaches. They usually serve by focusing on urban dwellers and relatives.
‘‘.... When we visit health facility in some occasion, health providers do not say welcome and give attention to us. We see them simply quarrel, disrespect for us and they considered themselves as ‘God.” (FGD_1 Participant)
Category-5: High risk perception to health facility delivery
Most participants perceived that risks towards institutional delivery. During institutional delivery, we worry about further referrals, our uterus not to be tied, not to be exchanged their new-borns, exposure of babies’ eyes to excessive light. Most participants also complained about risks of pelvic examination.
“Ohm ... I hate medical students as they are the beginner for everything I worry about the health of my uterus and foetus, the eyes of my new-born baby and I worry not be contaminated with infectious disease during vaginal examination.” (FGD_3 Participant)
“There were many health risks occurred in the new-born baby during pelvic examination and delivery in her lives. Of these in her life, she saw one baby injured by fingers of health care provider during inserting her hand in her vagina, as his eye was red for a long period of time”. (KI-3 participant)
Category-6: Community’s misconception towards health facility
Majority of participants had misconceptions towards health facility delivery. If the baby nose is broad and short and the forehead is protruded, the communities think that the existence of such body structure is due to healthcare provider mistakes.
“...in home delivery we can assist manually the structure of newly born babies nose straight by pinching and pulling up and prevent the forehead from frontal bossing through squeezing around the head soon or before the bone gets hard”. (FGD_3 Participant)