Menu
Menu
Menu
Menu
Background Gender remains a critical social factor in reproductive, maternal, and child health and family planning (RMNCH/FP) care. However, its intersectionality with other social determinants of the RMNCH remains poorly documented. This study aimed to explore the influence of gender intersectionality on the access uptake of RMNCH/FP in Developing Regional States (DRS) in Ethiopia. Methods We conducted a qualitative study to explore the intersectionality of gender with other social and structural factors and its influence on RMNCH/FP use in 20 selected districts in four DRS of Ethiopia. We conducted 20 Focus Group Discussions (FGDs) and 32 in-depth and key informant interviews (IDIs/KIIs) among men and women of reproductive age who were purposively selected from communities and organizations in different settings. Audio-recorded data were transcribed verbatim and analyzed thematically. Findings Women in the DRS were responsible for the children and families’ health care and information, and household chores, whereas men mainly engaged in income generation, decision making, and resource control. Women who were overburdened with household chores were not involved in decision-making, and resource control was less likely to incur transport expenses and use RMNCH/FP services. FP was less utilized than antenatal, child, and delivery services in the DRS,as it was mainly affected by the sociocultural, structural, and programmatic intersectionality of gender. The women-focused RMNCH/FP education initiatives that followed the deployment of female frontline health extension workers (HEWs) created a high demand for FP among women. Nonetheless, the unmet need for FP worsened as a result of the RMNCH/FP initiatives that strategically marginalized men, who often have resource control and decision-making virtues that emanate from the sociocultural, religious, and structural positions they assumed. Conclusions Structural, sociocultural, religious, and programmatic intersectionality of gender shaped access to and use of RMNCH/FP services. Men’s dominance in resource control and decision-making in sociocultural-religious affairs intersected with their poor engagement in health empowerment initiatives that mainly engaged women set the key barrier to RMNCH/FP uptake. Improved access to and uptake of RMNCH would best result from gender-responsive strategies established through a systemic understanding of intersectional gender inequalities and through increased participation of men in RMNCH programs in the DRS of Ethiopia.
There is differential heterogeneity in overall health development within and between Ethiopia’s regions. To narrow this gap, the government of Ethiopia, in collaboration with development partners, has been implementing various interventions in Afar, Benishangul-Gumuz, Gambella, and Somali the least developing region of Ethiopia under the Transform Health in Developing Regions (HDR) project. The DRSs are predominantly pastoral (characterized by limited access to information, weak health systems, limited availability of health facilities and health staff, and seasonal mobility), accounting for 52% of the country’s landmass, and have relatively low RMNCH service utilization compared to the agrarian regions and national averages. For instance, according to the 2016 Ethiopian Demographic Health Survey (EDHS), the contraceptive prevalence rate (CPR) in the Afar and Somali regions was 12% and 1%, with the highest total fertility rates of 5.5 and 7.2 children per woman, respectively. Institutional delivery assisted by skilled attendants was comparatively low: 16.4% for Afar, 20% for Somali, 28.6% for Benishangul-Gumuz, and 46.9% for the Gambella regional states. These regions also have the highest under-five mortality rate, far from the national average of 67 deaths per 1000 live births: 125 in Afar, 94 in Somali, 98 in Benishangul-Gumuz, and 88 in Gambella [43]. Ethiopia ranked 97th of 157 countries globally in the gender gap index estimated at 0.69 in 2021[44]. The USAID Transform HDR project aims to attain 50% of the health sector transformation plan’s RMNCH-related indicators by 2022 by improving existing government efforts and strengthening health systems by increasing access to integrated, quality, and high-impact RMNCH/FP services, improving health-seeking behaviors by reducing gender inequalities, and improving evidence-based decision-making and program learning. The study was conducted from March 3 to 26, 2019, in 40 kebeles (the lowest government administrative unit) selected from 20 districts nested under 20 zones of four developing regional states (DRS). We conducted an exploratory qualitative study to assess the gender intersectionality of sociocultural, structural, and programmatic barriers and facilitators of RMNCH/FP service access and use. The focus was on an in-depth understanding and interpretation of the settings and people’s feelings, experiences, perceptions, choices, and preferences regarding gender and other social factors of RMNCH/FP. The gender analysis framework for health systems was used to elicit concepts regarding how gender norms interact with the structural, sociocultural, and programmatic contexts associated with RMNCH/FP services. First, we selected 20 zones from the four regions and chose one district from each zone and two kebeles/villages from each district, for a total of 40 kebeles. Purposive sampling was used to select study settings and participants. Districts and kebeles selection was guided by RMNCH/FP service performance and coverage rates in consultation with DRS health offices, whereas participants were selected by referring to RMNCH/FP use/non-use status, sex, and age groups from the community and health facilities. The study participants included men and women (including boys and girls) of reproductive age (15–49 years of age), representatives of regional, zonal, district, and kebele-level government offices (health, women and children affairs, labor and social affairs, and health facilities), and religious and community leaders. We conducted key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs) using S1 File. The sample size included 20 FGDs and 32 IDIs/KIIs, resulting in 52 interviews. KIIs were collected from regional offices, NGO partner staff, HEWs, Health Center staff, district health offices, district women and children affairs offices, district labor and social affairs offices, and religious and clan leaders. IDIs were performed with RMNCH service users and nonusers. Age, sex, and RMNCH user status were considered in the FGDs (Table 1). On average, there–8–12 individuals participated in the FGDs. Diversity of data was ensured as IDIs and FGDs were with men and women, with two age groups (young:15–24, and adult:25–49), RMNCH service use status (ANC, FP, and child health users/nonusers), and regional/zonal/district/kebele representations. Fifteen interviewers (one female and 14 males) with a master’s degree and experience in qualitative data collection conducted the KIIs, IDIs, and FGDs. They received two-day training on the study objective, tools, ethical issues, and sampling criteria. Participants’ selection and arrangements for the interviews and discussions were assisted by local guiders: Health Extension Workers (HEWs) and women’s development army (WDA) leaders. All interviews were audio recorded. Notes were taken while in the field. Data collection was supervised by daily debriefings and discussions on idea saturation, field experience, general impressions, and challenges. Data collection and analysis were performed iteratively. First, we transcribed the record verbatim, translated it into English, and uploaded it to NVivo software for coding S2 File. A thematic analysis using open coding was applied. Field notes were used to support the coding and interpretation. Before open coding, three experienced data coders independently read and re-read each transcribed document to identify the rich text data obtained from the FGDs, IDIs, and KIIs to generate the initial codebook. Accordingly, we identified ten text-rich data to initiate the independent coding process, then discussed the initial codes and reached a consensus on the code definitions, after which we added the newly emerged codes to develop a refined code. We read, re-read, and clustered the codes to develop the categories, subthemes, and main themes. We provided thick descriptions of the contexts and triangulated the data to substantiate the interpretations of sub-themes and categories. Finally, we presented the results in themes, sub-themes, and categories, with quotations supporting the underlying concepts. The credibility of our findings was confirmed in this study. The data were collected and managed by experienced qualitative researchers with PhD and master’s degrees and knowledge of the health system, gender, and RMNCH. Nonetheless, they bracketed themselves from intentionally providing expertise and reflexive meanings with minimal interpretation bias. Supervisors closely monitored the quality of transcriptions against actual audio recordings. Tick descriptions of the data and themes were presented with supportive quotations that added value to credibility. Subjective neutrality, peer debriefing, daily interactions with the research team, and audit trials were considered to ensure the credibility and dependability of the findings. The diversity and triangulation of data (FGDs, KII, and IDIs) by region, district, kebele, age, gender, and RMNCH use status can enhance the transferability of the findings to DRS and similar contexts. Additionally, the saturation of ideas in the data, richness, and credibility of the findings are confirmed through empirical and theoretical evidence on gender and its sociocultural intersectional influences on the health system, RMNCH, and socio-ecological perspectives. Ethical clearance was obtained from the Ethiopian Public Health Institute (EPHI-IRB-143-2018). Verbal informed consent was obtained from participants after providing information on the objectives of the assessment and the benefits/risks associated with their participation. The participants understood the purpose of the study and the topics they discussed during the interviews. In addition, the collected information was anonymized, as personal identification information was not reported. The interviews were kept confidential and private, as they were conducted in private rooms and spaces in the community. The audio records and transcriptions were stored on a private computer. In addition to informing the purpose of the study and how the findings inform RMNCH/FFP services, the interviewers maintained prolonged engagement with all participants to facilitate interviewees’ free and objective responses in a non-judgmental manner.
