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Background: Sexual and reproductive health (SRH) care services are essential to improving the lives of women and achieving the Sustainable Development Goals. In Cameroon, the Catholic Church is one the largest non-governmental suppliers of health care, but its role in providing SRH care is restricted by religious norms. Methods: This study explored doctors’ experiences and perceptions of providing SRH care at Catholic hospitals in a conflict-affected area in Cameroon by using 10 in-depth interviews with doctors from three Catholic hospitals in the North-West region. Qualitative coding was done with NVivo, and data were analysed using thematic analysis. Results: Three themes and seven categories were identified. The respondents described strict rules and a broad range of challenges to providing comprehensive sexual and reproductive health care services. Nonetheless, there is evidence of doctors overcoming obstacles to providing SRH care despite the religious and political climate. However, whilst attempting to overcome challenges, participants described numerous examples of poor SRH care and health outcomes. Conclusion: The study highlights the importance of understanding the intersect between religion and women’s health, particularly in improving access to SRH for vulnerable populations in conflict-affected areas. It further provides insight into doctors’ motivations in practicing medicine and how doctors cope and make efforts to provide care and minimize harm.
The conceptual framework that guided this study is situated at the interface between gender and religion, particularly Catholicism, and health care provision in fragile health systems. The research explores and builds on research on tensions between Catholicism and sexual and reproductive health and posits these in a context where the health system is fragile due to conflict [11]. Civil conflict has been shown to directly affect the health outcome of a population, leading to poor health outcomes, particularly in women. In regions with already fragile health care structures, conflict further exposes these weaknesses and leaves the population stranded. A study on post-war effects of conflict showed that long-term death and disability due to direct and indirect causes of civil war disproportionately affect women and children [26]. It draws on literature and builds on the idea that faith-based health care providers can reach communities in the context of conflict because they appear more flexible and manage to withstand the stress of the crisis [26–29]. This conceptual framework guided the following aim: to explore the experiences of doctors providing sexual and reproductive health care at Catholic hospitals in a conflict-affected region. This is a qualitative study using in-depth interviews to explore doctors’ experiences in delivering sexual and reproductive health care at Catholic hospitals. The study was reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) [30]. Cameroon is a lower-middle-income country located in Central Africa and has a population of about 26,545,863 inhabitants [31]. This bilingual (English-French) country comprises 10 administrative regions divided into 189 health districts [32]. The English-speaking part constitutes two of the 10 regions and makes up about 20% of the country’s population [33]. The population of Cameroon is 38.4% Catholic, 26.4% protestant, 20.9% Muslim and about 14% other beliefs [33]. The main health financing sources are the government, public enterprises, foreign aid donors, private enterprises, households, religious missions and non-governmental organisations (NGOs) [34]. This study was conducted in the North-West region of Cameroon, one of two anglophone regions. The anglophone regions have been undergoing what is controversially known as the “Anglophone Crisis”, characterised by civil protest, strikes, the evolution of armed groups and militarization of the region to date [24]. Human Rights Watch reports indicate that hundreds of thousands of civilians have been displaced and/or killed, including the deaths of many armed separatists and military personnel since the beginning of the crisis [35]. The crisis has caused the destruction of many health care structures in an already fragile health care system, leaving the population in the North-West region of about 2 million inhabitants [36] vulnerable to disease and death [25]. There are about 20 Catholic health providers in the North-West Region of Cameroon, of which only a few have remained functional since the onset of the crisis. These services have primary, secondary and tertiary health structures in the region. Three Catholic hospitals, which were still functional, were purposefully selected for this study based on their offering general consultation services, including sexual and reproductive health care services such as maternal and childcare services to the population. The hospital names are purposively omitted to protect the anonymity of the research participants. Cameroon was selected as a case study because it was accessible to the research team even though it is a conflict-affected area. Purposive sampling was used to select 10 medical doctors working at three Catholic health care facilities. Selection criteria were general practitioners who have worked at a Catholic hospital for at least one year. General practitioners were selected because they have first-hand exposure to all patients who present at the hospital, including women seeking sexual and reproductive health care services. Specialists were excluded because the range of patients they see is specific and would not fit the scope of this paper. The participants included three female and seven male doctors available for the study; their working experience in Catholic hospitals ranged from two to seven years. We reached the maximum number of participants at these hospitals. Selecting additional sites was not possible due to security reasons. All interviews were conducted in English by AAF, who used an interview guide (Annex 1) within a 6-week period. Some interviews were conducted over Zoom, whilst others were done at the doctors’ offices. Interviews lasted approximately 40 min and were recorded using a mobile phone and computer. The interviews were transcribed. Information was stored in the researcher’s laptop and safely kept using a password known only by the principal investigator to ensure the confidentiality of sensitive information. Data were analysed using the principles of thematic analysis by Braun and Clark [37]. The analysis began by transcribing the recorded data within four weeks of the in-depth interviews. The recorded data was listened to twice to ensure information was not lost and underlying meaning was represented in the transcription. The data was re-read, making notes of explanations. Double open coding was done by AAF and SHvW with the assistance of NVivo version 12.0 [38]. Initial coding involved analysing the meaning of the text, including all data that were potentially relevant to the research aim, into different or similar codes. The next stage of coding included recoding and rechecking original codes. After this, similar codes were grouped into subcategories, categories and themes. Every subcategory consists of at least five quotes to illustrate the subcategory. In other words, a subcategory was only created if we found repetition in the data. Later, the researchers re-examined and re-evaluated the themes and categories to ensure there was no overlapping of ideas and the interpretation within and between the themes were coherent. The review of themes and categories by the team led to some changes by looking for the latent meaning of the data and resulted in merging, deleting and renaming some subcategories and themes. After repeating this process a few times and ensuring that each theme had a distinct focus, was not repetitive and answered the research question, a final version of three themes was developed. Ethical approval (2021/292H/uba/IRB) was sought from the ethical review board of the University of Bamenda, Cameroon, to conduct this study (Annex 1). Permission was also sought from each hospital to allow the researcher to conduct interviews with their staff. All participants were informed of their right to participate or not in the research project and their right to withdraw at any time during the duration of the project. All interviewees signed a written consent form and agreed to audio-recording. During the research process, researchers must be aware of their role in conducting the research and analysis and how this might influence the outcome of the study. AAF has previously worked as a doctor at a Catholic hospital; consequently, the participants felt at ease and were open to discussing sensitive issues with her. AAF also tried to ensure that the information collected accurately represented the participants’ ideas by asking many follow-up questions for clarity. Additionally, AAF made a conscious effort not to express her opinion during the interview and analysis process. Avoidance of personal bias was possible through regular reflections in a research diary and continuous discussion of progress and findings with the research team.
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