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Background: Health extension workers (HEWs) have substantial inputs to reduce maternal and newborn morbidity and mortality in Ethiopia. However, their perceptions and experiences were not well understood. Therefore, this study aimed to explore their perceptions and experiences on facilitators and barriers to maternal and newborn health services in Ethiopia. Methods: A descriptive qualitative study was conducted from 8–28 April 2021 in Oromia, Amhara and Southern Na-tion, Nationality, and People’s Regional State of Ethiopia. Focused group discussions were made with purposively selected 60 HEWs. The data were transcribed verbatim and translated into Eng-lish. An inductive thematic analysis was carried out using Atlas ti.7.1. The findings were presented in major themes, categories, and sub-categories with supporting quote(s). Results: The findings were categorized into two major themes (i.e., facilitators and barriers) and seven sub-themes. Commu-nity-related facilitators encompass awareness and behavior at the individual, family, and commu-nity. Significant others such as traditional birth attendants, religious leaders, women developmental armies, and kebele chairman substantially contributed to service utilization. Availability/access to infrastructures such as telephone, transportation services, and solar energy systems facilitated the service utilization. Furthermore, health facility-related facilitators include the availability of HEWs; free services; supervision and monitoring; maternity waiting rooms; and access to ambulance ser-vices. Maternal and newborn health services were affected by community-related barriers (i.e., dis-tance, topography, religious and socio-cultural beliefs/practices, unpleasant rumors, etc.,), health facility-related barriers (i.e., health worker’s behaviors; lack of logistics; lack of adequate ambulance service, and placement and quality of health post), and infrastructure (i.e., lack or poor quality of road and lack of water). Conclusions: The HEWs perceived and experienced a wide range of facilita-tors and barriers that affected maternal and newborn health services. The study findings warrant that there was a disparity in behavioral factors (awareness, beliefs, and behaviors) among community members, including pregnant women. This underscores the need to design health education programs and conduct social and behavioral change communication interventions to address indi-viduals, families, and the broader community to enhance maternal and newborn health service uti-lization. On the other hand, the health sector should put into practice the available strategies, and health workers provide services with empathy, compassion, and respect.
The study was conducted in selected districts of Oromia, Amhara, and Southern Nation and Nationality People’s regional state regions of Ethiopia. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia, these regions had an estimated total population of 26,993,933, 17,221,976, and 14,929,548, respectively. Regarding religion, the populations were Muslim (48%), Orthodox Christians (30%), and Protestant Christians (18%). The populations of Southern Nation and Nationality people’s regional state were Protestant (55.5%), Orthodox Christianity (52.86%), and Muslim (14.12%). The predominant religion of the Amhara for centuries has been Christianity, with the Ethiopian Orthodox Tewahedo Church (82.5%) playing a central role in the culture of the country followed by Muslims (17.2%) [17]. Data were collected on April 2021 from the three zones of these regions. The districts were selected from those settings where the Optimizing Health Extension Program was implemented [8,9]. Currently, Ethiopia follows a three-tier health care system: primary, secondary, and tertiary levels of care. At the grass-root level, there is a primary level of care (PHC) which includes primary hospitals (each serving 60,000–100,000 population), health centers (each serving 15,000–25,000 Population), and health posts (each serving 3000–5000 population). A primary hospital provides emergency, inpatient, and ambulatory services, and referral sites for health centers. It provides health care services for an average population of 100,000. In addition, it acts as a practical training center for nurses and other health care providers. Under the primary health care level, there is a primary health care unit (PHCU) that comprises one referral health center and five satellite health posts. Health posts are the lowest-level facilities in the healthcare system, and the point where PHC is administered and primary services are facilitated. Therefore, the HEP is a program designed to provide primary health care services in the nearby community. However, in an urban setting, the health care system is organized with a health center as the primary entry point (each serving about 40,000 people). The secondary health care system includes a general hospital (each serving 1–1.5 million people) that acts as a referral center for primary hospitals and also a training center for health officers, nurses, and emergency surgeons. A tertiary health care system includes a specialized hospital, a referral center for general hospitals (each serving 3.5–5 million people) [1,4,11,18,19]. A descriptive qualitative study was conducted to explore the perceptions and experiences of HEWs on the facilitators and barriers to maternal and newborn health service utilization at health posts. This approach was chosen because it is an important and appropriate design for research questions focusing on discovering who, what, and where of events or experiences that happened and gaining insights from informants regarding a poorly understood phenomenon [20]. It is also preferred because of its low time and resource consumption. A purposive sampling technique was used to recruit study participants. Data collection involved primary sources through semi-structured in-depth interviews and focus group discussions. The data analysis involved inductive thematic analyses. A purposive sampling technique was used to recruit 60 HEWs from the three zones (Table 1). The HEWs were recruited based on certain criteria or considerations (i.e., inherently criterion/judgmental sampling technique) such as the number of the population they serve, level of education, work experience, diversity in distance from health centers, and performance. Distribution of health extension workers (HEWs) who participated in the study to explore barriers and facilitators to maternal and newborn health service utilization, Ethiopia, 2020. Data were collected through focus-group discussions. A semi-structured discussion guide containing 10 questions was developed to collect data. The data collection tool was initially developed in English and then translated into Afan Oromo, and Amharic languages. Finally, the English language expert back-translated it to English. The guiding questions were prepared primarily to address the following issues: Three individuals who had experience in qualitative research moderated the discussions; each in a different district town. In addition, three research assistants were involved in taking field notes and audio recordings. Twelve focus group discussions were conducted each comprising five participants. The group discussion lasted for a time ranging from 42 min to 67 min. Inductive thematic analysis, through which codes, sub-categories, categories, and themes were developed from the data, was employed to analyze the data. The analysis started by listening to the audio. Verbatim transcription was performed and field notes were simultaneously incorporated into the transcription. Then, the transcriptions were checked for completeness and consistency. After ensuring completeness and consistency, the transcriptions were translated from Amharic and Afan Oromo to English by another individual. Reading and re-reading of the data were done to extract an important statement from the description and then coded line by line. First, the principal investigator and another assistant conducted line-by-line coding using ATLAS.Ti.7. Then, the given codes were checked for inter-coder consistency and a codebook manual was developed. The principal investigator then coded the data using the codebook manual to ensure code consistency and credibility. Potential major themes and sub-themes were developed by clustering sub-themes and codes, respectively to answer the research questions. The principal investigator repeated the coding system by refining the codebook manual, sub-themes, and themes. The trustworthiness of this study was ensured through credibility, dependability, transferability, and conformability principles [17,19,20,21,22,23,24]. The credibility of the study was ensured through peer debriefing, triangulation, and member checking. Research assistants, who had experience in a qualitative study, were involved in the data collection and analysis. Orientation was also provided to research assistants regarding the general purpose of the research and methodological procedures. The participants were also asked to summarize the major thematic findings of the discussion. Similarly, the modulator summarized the major points raised during the discussion, and the discussion was made on some unclear ideas at the end. Data were also obtained from health extension workers in different study settings. To ensure transferability, thick descriptions were provided for the methodological procedures, interpretation of results, and contributions of research assistants. Therefore, the findings of this study can be applied to settings that have a health system and contexts similar to Ethiopia. Similarly, the dependability of the study is ensured through a thick description and audit trial. Moreover, the detailed chronology of methodological procures emerging themes; sub-themes or quotations were audited by qualitative research experts. The principal investigator was also not familiar with the study settings or participants. The findings of this study were presented in a way that the reader(s) can confirm through methodological procedures and findings. Furthermore, the findings are reported with supportive quotation(s) which opened a door for the reader to evaluate and build trust in the interpretations. In addition, the findings were audited and verified by qualitative research experts. Ethical approval was obtained from the Jimma University Institute of Health Institutional Review Board with the ethical code IHRPGD742/20. The principal investigator also took supports letters from the Ethiopian Public Health Institute and Regional health bureaus of the Oromia, Amhara, and Southern Nation and Nationality Peoples Region regions. The support letter helped the principal investigator to get acceptance of the respective zones and study participants. Written informed consent was obtained and participants were informed of the audio-recording and consent was obtained. Study participants were informed adequately about the purpose of the study, and the right to participate or withdraw at any time. To ensure their privacy and autonomy, codes were used instead of participant’s names during data collection and were informed that the study used the code in place of their name in connection with the study findings or their answers on discussions. Moreover, all COVID-19 preventive measures have been applied to prevent the infection.
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