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Skilled attendance at birth is widely regarded as an effective intervention to reduce maternal and early neonatal morbidity and mortality. However, many women in Ethiopia still deliver without skilled assistance. This study was carried out to identify factors that influenced or motivated women to give birth in a health facility in their previous, current, and future pregnancies. This descriptive explorative qualitative study was conducted in two districts of West Gojjam zone in North West Ethiopia. Fourteen focus group discussions were conducted with pregnant women and women who gave birth within one year. An inductive thematic analysis approach was employed to analyze the qualitative data. In this study, two major themes and a number of subthemes emerged from the focus group discussions with the study participants. The factors that influenced or motivated women to give birth in health facility in their previous, current, and future pregnancies include access to ambulance transport service, prevention of mother to child HIV transmission service, referral service, women friendly service, and emergency obstetric services, good interpersonal care from health workers, and fear and experience of obstetric danger signs and complications. In addition, reception of information and advice on importance of skilled delivery care and obstetric danger signs and complications from health workers, use of antenatal care, previous use of skilled delivery care, ensuring wellbeing of parturient women and newborns, and use of emergency obstetric care were also identified as influencers and motivators for health facility childbirth in previous, current, and future deliveries. Increased understanding of the factors that influenced or motivated women to deliver in facilities could contribute to developing strategies to improve the uptake of facility-based maternity services and corresponding declines in maternal morbidity and mortality.
This study was an integral part of a PHD project with the ultimate aim of developing strategies to improve the uptake of skilled birth attendance services in North West Ethiopia [22]. This research was conducted in two districts of Amhara regional state administration. This region was chosen on account of the low coverage of skilled attendance at birth (27.1%) [2]. The two districts, Womberema and Burie zuria, are located in West Gojjam zone and purposively selected based on their performances with respect to skilled attendance at birth. Besides, Burie zuria district health office comprises of four primary health care units (PHCU) under its supervision, namely, Tiatia, Kuche, Alefa, and Dereqwua primary health care units and all of them were included in this study. Womberema district health office also consists of four primary health care units and, of these, three of them (Shendi, Koki, and Wogedade primary health care units) were included in this study. Furthermore, one kebele and one health centre were purposively selected from each of the primary health care units. A kebele is the smallest administrative unit of Ethiopia, similar to a ward that consists of at least 3000–5000 people. As a result, a total of seven kebeles and seven health centers were included in this study. The kebeles included in this study were Kuche, Zalema, Tiatia, Ambaye, Shambela, Markuma, and Kentefen. The selected health centers were also Tiatia, Kuche, Alefa, Dereqwua, Shendi, Koki and Wogedade health centers. A qualitative descriptive explorative study design was employed to identify and describe factors that influenced or motivated women to give birth in a health facility in their previous, current, and future pregnancies. Purposive sampling technique was used to select the study participants in this study. The study participants were pregnant women and women who gave birth within one year. Those women who had previously given birth at least once were purposively selected because they had the experience of giving birth in a health facility. Hence, this enabled the researchers to explore and comprehensively understand the factors that influenced or motivated women to utilise skilled attendance at birth. Having oriented the aim of the study and inclusion criteria to the health extension workers (HEWs), who were working in the selected kebeles, the health extension workers identified and recruited the study participants. Furthermore, the researchers corroborated whether they fulfilled the inclusion criteria or not. Data collection took place between January and February 2016. The data collection team was composed of the researcher and two female research assistants. They were graduates in the fields of health science and sociology, with previous experience of qualitative data collection. The researchers were working in the government health office at the time of the data collection. The researcher organised refresher training on interview skills, data transcription, and management prior to the actual data collection. The researchers introduced themselves to the participants, explained the purpose of the research, and obtained a written informed consent from each participant before commencement of the actual data collection. A semistructured focus group guide was used to collect data in the current study. The researcher developed a written focus group discussion guide in advance and the guide was very specific to the research questions with carefully worded open-ended questions. The topics of the focus group guide were derived from the literature review, theoretical orientation of the study, and the main research questions of the current study. The focus group guide was composed of open-ended questions that enabled the researcher to know the participant’s orientation on the research topic. The open-ended questions in the guide were sequenced flexibly in a pattern of the main question, follow-up questions, and probing questions. The researcher posed the main question to the participants to clarify the idea of the topic or guide the direction the researcher wanted the question to take. The main question posed to the focus group discussion participants in the current study was “describe your perception and experiences with regard to the utilisation of skilled delivery service.” Follow-up questions were asked to take the discussion to a deeper level by asking for more details and these were accompanied by further probing questions to move the discussions to still a deeper territory with or without being specific to the topic of discussion. The focus group guide was prepared in English, translated to Amharic, which is the national working language in Ethiopia, and spoken well in the Amhara region. The focus group discussions were audiotaped and supplemented with notes taken during the discussion. The note taker expanded the notes after each focus group discussion session and shared them among the research team members. This enabled the researcher to devote his full attention to listening to the discussion and probing in-depth information. The audiotape recording provided an accurate, verbatim record of the discussion and captured the language used by the participants in more detail. The researcher sought the informed consent of the participants prior to using the audiotape recording by providing a clear, logical explanation about its use, reassurance about its confidentiality and explained what would happen to the tapes and transcripts. The researchers utilised two audiotape recorders; one was used as a backup in case the other audio tape recorder failed. The researcher tested the scope of the focus group discussion guide, carried out initial tests of the fieldwork, and piloted the focus group discussion guide, as it was a critical part of the research. The pilot testing was conducted a few days ahead of the actual data collection commencement in one district health office, one health centre, and two health posts that were not among the selected study sites for the actual research. The researcher conducted two focus group discussions with pregnant women, and two with women who recently gave birth, and an individual interview with district health office technical officer to pilot test the scope of the guide, fieldwork strategies, and the focus group discussion guide. This enabled the researcher to refine the fieldwork strategies and fine-tune the topic guide by arranging the questions in a logical order, adding or removing minor follow-up questions and estimating the duration of focus group discussions to check for appropriateness of data collection procedures and to familiarize the researcher with the data recording materials such as the audiotape recorder. The focus group discussions were conducted in the health posts that were easily accessible to the study participants and this helped the researchers to avoid any physical and noise nuisance from nonparticipants. The focus group discussions lasted at least sixty to ninety minutes. Focus group discussions with pregnant women and with women who gave birth within one year were conducted separately to make the most out of their shared experiences. A total of 14 focus group discussions were conducted, with pregnant women (7 groups) and women who gave birth within one year (7 groups). Each focus group consisted of 7 to 12 members. The researcher recognised that no new idea or insight emerged after conducting five focus group discussions with pregnant women and five with women who gave birth within one year, which revealed data saturation. An additional two focus group discussions with pregnant women and two with women who gave birth within one year were conducted in order to ensure that data saturation was reached and further data collection stopped at this point. The analysis of the data was initiated on the field before the completion of data collection. The researcher listened to the audio files and read the expanded field notes and transcripts after the end of each focus group discussion session and the transcripts were ready to use. This helped the researchers to make the necessary revisions and refinements in the subsequent focus group discussion sessions. The audiotape records of the focus group discussions were transcribed and the research assistants to prepare the interview transcripts for analysis expanded the field notes. The researchers translated the Amharic transcripts directly into English. The researchers’ colleague who fluently speaks both English and Amharic checked the consistency between the Amharic transcripts and their English version. The engagement of the researchers in the translation and partly in the transcription of the interviews familiarized and acquainted with the concepts as the researchers read the Amharic transcripts and their English version iteratively in the process. An inductive thematic analysis approach was employed to analyze the qualitative data. The translated data were exported onto Atlas ti version 7 qualitative data analysis software to efficiently store, organise, manage, and reconfigure the data to enable human analytic reflection. The current study adhered to the following qualitative data analysis steps embracing reading, coding, displaying, reducing, and interpreting. Ethical clearance was obtained from the University of South Africa (UNISA) Department of Health Studies Higher Degrees Committee and Amhara Regional Health Bureau Research and Laboratory Department to conduct the current study. Letters of support were obtained from all levels of the health system and granted access to the study sites. Written informed consent was taken from participants who could read and write, whereas fingerprints were used to obtain signed informed consent from participants who were unable to read and write. Confidentiality was ensured by removing all names and addresses of participants from the data collecting tools. The information that the participants provided was kept confidential and used only for the purpose of the research. Only codes were used to identify participants, along with audiotape recorders. Anonymity was ensured through the use of codes, thus making it difficult to attribute responses to particular participants. Data collected were kept in the strictest confidence; they were not made public to other people. Audiocassette tapes were also erased after the completion of the study. Only aggregated demographic information was reported to maintain anonymity.
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