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Background: Access to adequate antenatal care (ANC) is critical in ensuring a good maternal health and in preventing maternal and neonatal morbidity and mortality. South Sudan has one of the world’s poorest health indicators due to a fragile health system and a combination of socio-cultural, economic, and political factors. This study was conducted to identify barriers to utilisation of ANC services in Rumbek North County. Methods: Using a qualitative design, data were collected through 14 focus group discussions with 169 women and 45 men and 12 key informant interviews with community leaders, staff working in health facilities, and the staff of the County Health Department. Data were analysed using inductive content analysis. Results: The perceived barriers to ANC utilisation were categorised as follows: 1) Issues related to access to health facilities and lack of resources. These included long distance to health facilities, lack of means of transportation to the health facilities, floods and poor roads, and demand for payment for health care at some health facilities; 2) The influence of the socio-cultural context and conflict including heavy burden of domestic chores, the negative influence of husbands who were reluctant to allow their wives to attend ANC, and insecurity; 3) Perceptions about pregnancy including misperceptions about the benefits of ANC and low perceived risk of pregnancy-related complications; and 4) Perceptions about the quality of care and the efficacy of medical treatment. Conclusions: This study identified a myriad of factors deeply entrenched in the society, which prevent women from utilising ANC services. It also elicits broad aspects of interconnectedness among the barriers. To ensure effectiveness, strategies to improve utilisation of ANC in the study area and in similar contexts need to take into account the barriers identified by this study.
This study is reported per the consolidated criteria for reporting qualitative research (COREQ) [11]. The detailed methodology (including the COREQ checklist) has been described elsewhere [10]; below is a summary. This study was conducted in Rumbek North County, which in 2015 had a population of 59,740 inhabitants [12], and was divided into six payams (sub-county units): Alor, Malueth, Mayen, Madol, Maper and Wunrieng. The county’s population is semi-nomadic and pastoralism is the main economic activity. In 2015, the county had one Primary Health Care Centre (PHCC) located in Maper, and seven Primary Health Care Units (PHCUs). Each one of the PHCUs was run by one community health worker (CHW), one traditional birth attendant (TBA), and one drug dispenser. The PHCC had three expatriate professional health workers: a nurse, a midwife, and a clinical officer. In South Sudan, PHCUs and PHCCs are, respectively, the lowest- and second lowest-level health facilities of the health system. These health facilities are mandated to provide ANC services [7]. Each PHCU is supposed to be staffed by two CHWs and a community midwife while a PHCC is supposed to have one clinical officer, three professional nurses, two midwives, three CHWs, and lower cadre staff [7]. At the time of this study, a complete package of ANC services, apart from laboratory tests, was being provided daily at the PHCC and at four PHCUs and through scheduled outreaches at the rest of the PHCUs. In South Sudan, the ANC package at PHCUs and PHCCs includes identification of pregnant women and rising awareness on early initiation and compliance with ANC, provision of services for prevention of mother to child transmission of HIV, prevention and treatment of sexually transmitted infections, nutrition counselling and micronutrient supplementation, malaria prevention interventions, identification and referral of women at high risk, and monthly outreach clinics [7]. This qualitative study collected data through focus group discussions (FGDs) in eight randomly selected villages and through key informant interviews (KIIs). Villages in the county were stratified by payam and randomly selected as follows: two villages from each of Malueth and Mayen payams (the most populous) and one from each of Madol, Alor, Maper and Wunrieng. In each village, one FGD was conducted with women aged 18 years and above who had delivered in the preceding 12 months and were usual residents in the county. Additionally, in a random sub-sample of half of the villages, husbands of women who delivered in the preceding 12 months were recruited to participate in men’s FGDs. Two extra FGDs with women were conducted in one cattle camp. In each selected village, CHWs invited 12 eligible participants to take part in the FGDs and all those who turned up were included. KIIs were conducted with a purposive sample of CHWs in the PHCC and PHCUs, community leaders, and staff of the County Health Department (CHD). The choice of the number and type of participants to be enrolled in this study depended on the extent to which they could contribute to providing relevant information in response to the research questions [13]. FGDs and KIIs were conducted in March 2015 utilising open-ended pretested question guides. Each FGD was conducted by two Dinka-speaking facilitators who were previously unknown to participants. The facilitators were of the same gender as participants, had at least high school-level education, and were conversant with the local language and culture. One data collector facilitated the sessions while the other one managed audio recordings and took field notes. The data collectors were trained for 1 day and were supervised by one of the co-authors (CW) who is experienced in qualitative research. The FGDs were held in local church structures and under tree shades. KIIs took place at venues that were convenient to participants. A total of 14 FGDs with 45 men (4 FGDs), 127 women in the villages (8 FGDs), and 42 women in cattle camps (2 FGDs) were conducted. The characteristics of FGD participants have been described previously [10]. In brief, the women FGD participants had a median age of 25 years. A majority had no education (96.7%); were married (92.6%); and had attended at least one ANC visit during their most recent pregnancy (67.5%). The median age of male FGD participants was 35 years and 71% of them had no formal education. Twelve KIIs were conducted with the following individuals: 3 community leaders, 3 PHCU staff, 4 PHCC staff, and 2 CHD staff. Women’s FGDs had a median of 16 participants while men’s FGDs had a median of 9 participants. There were no drop-outs during FGDs. All KIIs were conducted by one of the co-authors (CW) either directly in English (for CHWs and CHD staff) or through a translator (for community leaders). Both KIIs and FGDs were audio recorded. Each FGD session lasted for about one hour whilst each KII lasted for about 20 min. No repeat interviews were conducted. Audio recordings in Dinka language were transcribed and translated into English by bilingual (Dinka and English) speakers while audio recordings of KIIs conducted in English were transcribed by CW. The transcripts were not returned to participants for review because of logistical constraints. The transcripts were then analysed using the inductive content analysis approach [14]. The analytic framework was adapted from a large systematic review [15]. Although the original framework is about barriers to childbirth service use, the themes were modified to apply to ANC use. Coding was done using NVivo 10 (QSR International, Melbourne, Australia). Information from KIIs was used to triangulate findings from FGDs. The data for each theme and sub-theme were then pieced together to provide an overview of the content relating to that specific theme (charting). The four broad themes were: 1) access and resource availability, 2) influence of the sociocultural context and insecurity, 3) Perceptions of pregnancy, and 4) perceptions of the quality of care. Quotes were selected to represent a typical response or to illustrate a deviant opinion.
