Characteristics of the in-depth interviewees and focus group participants
The age of the interviewed women varied between 22 and 40 years. A majority had primary (grades 1-8) level of education. Most focus group participants were between 25 and 34 years old. More than half of the focus group participants (16 out of 27) had attended primary education while three had no formal education. 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. Interviews, as well as focus group discussions, had a duration of 45 minutes to two hours.
During the pretesting of field guides, the concept of equity was difficult for mothers to understand. They used to define it in terms of timely service provision and utilization. In the actual data collection, 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’.
Two major themes emerged from the data: perceptions of inequity in provision and utilization of maternal and child healthcare and perceived causes of healthcare inequity. Below follows a presentation of the results complemented with direct quotes from the respondents.
Perceived inequity in the utilization of maternal, neonatal, and child health services
Mothers perceived child immunization to be a fairly distributed service. All interviewed mothers reported that their children had been vaccinated. They attributed this completion to the outreach immunization services provided by the health extension workers on vaccination days. 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 mothers 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 (In-depth interview, woman, age 35).
Also, a focus group participant told:
In vaccination, there is no difference. Because we are told to vaccinate our children 45 days after delivery and we, all mothers, vaccinate our children without any difference (Focus group discussion, woman, age 27).
Most mothers reported that they used the primary healthcare services, although some mothers commented that they did not fully attend the antenatal clinics. They 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 mothers got tired as the pregnancy advanced and lacked money for transportation to the health centers’ services. Further, they could not get ambulance transport to a health facility during labor. The health workers also stated that poor mothers from remote places were less likely to attend antenatal care and deliver at health facilities.
The participating mothers reported that they did not receive postnatal care at health facilities after giving birth. Once a woman had delivered safely, there was no reason going back to the health facility for control. A woman should visit the health facility if she or her newborn baby experienced any illness or complications, such as postpartum bleeding.
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 health facilities before baptizing our children. Now, my baby is one month and two weeks old. I will take her for vaccination tomorrow (In-depth interview, woman, age 30).
Another woman added:
After birth, I was healthy. Hence, I did not see any reason to visit the health center for a checkup. We (mothers) do not go to the health center if our babies and we are healthy. But we go there if mother and baby are not feeling well (In-depth interview, woman, age 35).
The health workers confirmed that mothers who gave birth did not receive regular postnatal care. A young health extension worker said that mothers came to health posts after delivery to vaccinate their babies only, but not for a health check-up. Another health care provider also noted that mothers who gave birth at the health facility could receive a first postnatal care within 24 hours at the facility. But the subsequent postnatal visits at days 7 and 42 did not happen.
Perceived causes of inequity in the maternal and child health services utilization
The sub-themes identified were socioeconomic context, lack of access, poor quality health services, and insufficient implementation of equity-oriented interventions.
Socioeconomic Context
Two major codes emerged under the socioeconomic context as reasons to inequity in maternal, newborn, and child health services utilization: the households’ economic resources and parents’ education.
Most of the participants linked inequity in the utilization of maternal, newborn, and child health services to lack of economic resources. This prevented poor mothers from visiting the health facilities. Money was needed for transport, including transportation cost of their escorts, food, and buying drugs for their children. Poor mothers could not buy expensive medicines from private pharmacies. The inability to cover these costs discouraged poor mothers from using the health facilities.
The mothers who have money are taking public transport to go to health centers for delivery. However, we (the poor) are forced to give birth at home, though we know that the services are free. It is the lack of money for transportation that is deterring us (the poor mothers) to deliver at the health facilities (In-depth interview, woman, age 22).
The health workers at health centers and health extension workers at health posts also acknowledged the influence of economy on service utilization.
Those mothers from the wealthiest households were hiring minibuses with 300 Ethiopian birr (USD 8.1) to go to the health facility for antenatal care and delivery. However, mothers from poor households don’t have this opportunity (In-depth interview, health extension worker, age 28).
Also, the poor woman doesn’t want to seek care at the health facility when her child gets sick because she can’t buy drugs. So, what would a poor woman do if she doesn’t have money at hand? She can do nothing at all. Days pass and she is thinking of taking the child to a health facility, but fail to seek timely medical care because of lack of money (In-depth interview, woman, age 35).
The respondents considered home delivery to be more common among non-educated women. Women with no education were more likely to drop-out of antenatal care. They associated this with less knowledge and understanding of the benefits of utilizing maternal, newborn, and child health services.
…yes, we, the non-educated mothers, 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 mothers in our village. In labor, I will be compelled to give birth at home, hoping that 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 to give birth at home (In-depth interview, woman, age 30).
The interviewed women stated that younger mothers used maternal, newborn, and child health services more than older ones. They associated this difference with modernity and younger women having more education.
…most young mothers today are educated. There are even some mothers who completed grade 10. These educated mothers 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 (In-depth interview, Women’s development group leader, age 58).
Lack Of Access
All respondents agreed that distance to health facilities and topography caused inequity in maternal, newborn, and child health services utilization. These problem worsened when road conditions were poor, if the area had a mountainous topography, and availability of transport was limited. Many mothers from remote villages did not utilize health facilities for their 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, six hours, including the back trip. It would be impossible to attend all antenatal care (Focus group discussion, woman, age 40).
Previously, mothers used traditional stretchers to reach the health facilities for delivery. But today, such service is absent. The women’s development group leaders associated this with the seasonal migration of young men to urban areas in search of jobs. Therefore, they were absent when such traditional transportation was needed. If an ambulance was available, the ambulance drivers’ unfriendly behavior deterred mothers from utilizing these services to reach health facilities. They stated that drivers did not respond to phone calls or put their cell phones off. As a result, mothers were compelled to deliver at home or on the road to the health facilities.
The interviewed health workers reiterated mothers’ opinions on distance as a cause of inequity in healthcare utilization. The health workers had observed that mothers from remote areas attended the first antenatal clinic but failed to return to subsequent follow-ups. A women’s development group leader suggested connecting villages to health facilities with roads to reduce the disparity in health services utilization.
Within the sub-theme social and cultural norms we identified lack of husbands' support, mothers’ cultural taboos, and mothers' heavy housework that deterred poor mothers from seeking maternal and child health services.
Some participants reported that husbands were not able to support their wives during pregnancy. These days, they migrated to urban areas in search for jobs, leaving their wives without support. This was claimed to be a reason for home delivery.
I had delivered at home because I was alone. My husband was not present at home. He moved to ketema (urban area) in search for a job to bring food to our family (In-depth interview, 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 in their absence. Focus groups participants suggested that a husband should not move away until the pregnant woman gives birth.
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 (Focus group discussion, woman, age 27).
The respondents suggested that husbands need to be at home for mothers to receive antenatal care and seek care for their sick children. Husbands should cover their wives’ responsibilities at home in their absence, arrange transport, including traditional stretchers, for pregnant women to bring them to health facilities for delivery. Lacking husbands’ support reduced their wives’ utilization of health services.
The respondents reported that women were always busy with household chores, which could reduce their ability to attend antenatal care. The women’s development group leaders described the husbands’ primary responsibility to make money for their families, sometimes far away from home. This absence from home could affect their wives’ health-seeking behavior.
Pregnant mothers here do not have any spare 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 their housework. No time to go to the health center (In-depth interview, women’s development group leader, age 30).
Women reported cultural limitations if seeking care after delivery. In the local tradition, they were restricted from moving outside of their home after delivery. This limitation made mothers not to attend postnatal care before baptism. They also reported fear of exposing their babies to the evil eye and witchcraft if participating in postnatal care.
It is uncommon to attend the services after delivery. In our village, no single mother attends postnatal care in the nearby health center. The culture doesn’t allow us to go out after birth before baptizing our babies (In-depth interview, woman, age 35).
Women’s development group leaders and health extension workers had also noted these restrictions.
One health care provider underlined that there was not a single cause of inequity in the utilization of health services; multiple causes were intertwined.
Mothers 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. If you are far away from the health facility, you are also distant from the information. Thus, lack of access to roads and lack of information are intertwined with lack of economic resources and inflate the distance to the health facilities (Health worker, age 26).
Quality Of Services
The participants had a range of experiences of 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 a mother arrived late, gave birth on the way to the health facilities, or gave birth at home due to the delay of ambulances. They mentioned that the health workers did not listen and understand that the situation had been out of the woman’s control. Health workers’ bad behavior discouraged some mothers 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 did not 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. Thus, it is fear of mistreatment that is affecting the healthcare seeking behavior (Focus group discussion, woman, age 30).
Many focus group participants stressed that health workers’ attitudes negatively affected women’s care-seeking behavior. Negative experiences could also negatively influence other women’s utilization of services.
In contrast, a woman who gave birth at a health center described the health workers who assisted her delivery as very respectful and caring.
The health workers that assisted me at delivery were respectful and caring. Even your mother can’t do what the health workers did for you. Today, they (health workers) take the role of our parents in caring for us. They are much worried and highly concerned about your 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 (In-depth interview, woman, age 26).
Similarly, a women’s development group leader expressed health workers’ fairness and non-discriminating treatment of women based on her own lived experiences:
The health workers are caring, especially for those poor mothers. 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 (In-depth interview, women’s development group leader, age 39).
All focus group participants and most in-depth interviewees noted that the unavailability of pharmaceutical drugs was a significant concern at government health facilities. The respondents had been told to buy their medicines at private pharmacies when these were lacking at public facilities. This had deterred poor people from using the health facilities.
The healthcare providers wrote a prescription and told us to buy drugs from private pharmacies. We feel distrust when medicines are lacking at government health facilities. How can private pharmacies have a better supply of drugs than the government facilities? (Focus group discussion, woman, age 40).
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 could potentially address the financial barriers for poor mothers. 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.
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 having any drugs because I didn’t have any money. Health insurance is worthless (In-depth interview, woman, age 25).
The respondents were aware of the maternal waiting homes, but did not accept these services because of lack of water, food, and electricity. Some mothers also mentioned that there was nobody at home who could care 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 mentioned that their role in promoting the use of health facilities had weakened because of inadequate contact and supervision from the health extension workers. They believed their contributions potentially to be significant in creating demand for health facility utilization by increasing awareness and mobilizing women within their network. They used to support mothers from all social groups. Mothers appreciated their support, especially during pregnancy and at delivery.
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 those 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 mobilizing mothers to use the maternal and child health services (In-depth interview, 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 moving the services closer to the community. They noted that the social disparity created because of poor access to health facilities was unfair. One woman, aged 22, suggested that there should be a health facility in each tabia to enhance equitable access to health services. Some suggested upgrading of health posts to health centers by equipping those with the required health workers, pharmaceutical drugs, and other supplies. They also suggested new roads and increased number of ambulances. The respondents wanted the health services to 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. A participating woman suggested a green bank to solve the poor households’ money problem to cover medical and non-medical expenses.
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 kg) a year, it would be adequate to support the poor. The banked cereals could even cover the poor mothers’ medical and non-medical expenses (In-depth interview, women’s development group leader, age 22).