Women’s perspectives on the measures that need to be taken to increase the use of health-care facility delivery service among slums women, Addis Ababa, Ethiopia: a qualitative study

Background: Global strategies to target high maternal mortality ratios are focused on providing skilled attendance at delivery along with access to emergency obstetric care. Research that examines strategies to increase facility-based skilled birth attendance among slum residents in Addis Ababa, Ethiopia, is limited. Objective: The study aimed to explore women’s perspectives on the measures that need to be taken to increase the use of the facility—delivery service among slums women, Addis Ababa, Ethiopia Methods: Qualitative exploratory and descriptive research designs were used. Participants in the study were women in the reproductive age group (18–49 years of age) living in the slum areas of Addis Ababa, Ethiopia. A purposive sampling strategy was used to select study participants. Potential participants’ names were gathered from health facilities and followed to their homes for the study. Four audio-recorded focus group discussions [FGDs] were conducted with 32 participants from the three public health centers and one district hospital. The number of participants in FGDs was between 6 and 10 women. Data were analyzed simultaneously with data collection. Thematic analysis was used in data analysis, which entails three interconnected stages: data reduction, data display, and data conclusion. In addition, thematic analysis entailed evaluating the structure and content of textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes. A codebook was first devised, discussed, and adopted by the writers before they could use this technique. Using the codebook, the theme codes were then manually produced. To explain the study results, verbatim excerpts from participants were given. The researcher used Techs’ eight steps of qualitative data analysis method for analyzing the data. A multi-level life-course framework of facility-based delivery in low- and middle-income countries (LMICs) developed by Bohren et al. was used to frame the current study and link the findings of the study to the body of knowledge. Results: The FGDs included a total of 32 participants. The mean age of the overall sample was 32.6 years (± SD = 5.2). Participants’ educational characteristics indicate that the majority (24 out of 32) was found to have no formal education, and two-thirds of participants were found to have one to five children. Three-fourths of them attended the ANC twice and they all gave birth to their last child at home. Two themes emerged from the analysis of focus group data, namely provision of quality, respectful and dignified midwifery care, and lack of awareness about facility delivery. These themes were described as a rich and comprehensive account of the views and suggestions made by focused antenatal care [FANC] participants on measures required to improve the use of the facility-delivery services. The findings of the study raise concerns about the effectiveness of FANC in encouraging facility-deliveries since FANC participants had not used health facilities for their last childbirth. According to the findings of the focus groups, women who took part in this study identified measures required to increase the use of health facility-delivery services among FANC participants in Addis Ababa’s slum residents. It is to be expected that diligent counseling during antenatal care about birth plans would facilitate prompt arrival at facilities consistent with the desires of women. To address the purpose of this study, a qualitative, exploratory, and descriptive research design was used. In this study, the researcher could only understand the participants’ perceptions of facility-delivery and home delivery as well as their actions (non-utilization of health facility-delivery) from the participants’ perspective, stated in their own words and in the context in which they lived. The primary purpose of the study was not to generalize the outcome to other settings, as it was specific to its context. The current research was done at public health facilities in Addis Ababa, Ethiopia, between February and April 2018. Three health centers and one district hospital were purposively selected for the study. The public health facilities were selected because they attended to a high number of 133 women who attended FANC but attended less skilled deliveries in the past year preceding the study. The health facilities of Addis Ababa include 12 public hospitals (specialized, referral, and general), 86 public health centers, and about 720 private and non-governmental (NGO) health facilities at different levels [3]. A slum household is described in this study as a community of people living under the same roof who lack one or more of the following conditions: access to improved water, living on small business/daily labor, access to improved sanitation, adequate living space, and durability of housing. The study included Ketchne and Kolfe Keraniyo slum dwellers, who are primarily low-income residential residents [6]. The participants in the study included women in the reproductive age group (18–49 years of age) living in the slum areas of Addis Ababa, the capital of Ethiopia. The women who provide rich information that appropriately answers the research questions were purposefully chosen. The women who met the requirements for eligibility have been contacted. Potential participants’ names were gathered from healthcare facilities and followed to their homes for the study. The researcher ensured that the necessary information about the interviews was provided to all women who agreed to take part in the interviews and that they were followed into the communities where the health facilities are located. Participants had to be women who attended FANC in selected health facilities and gave birth to babies at home in the previous year of data collection, interact well in Amharic (local language), reside in Addis Ababa for at least 6 months, and in the reproductive age group (18 to 49 years) to be included in the sample. Exclusion criteria comprised women who attended FANC but had not experienced home delivery. Focus group discussions (FGDs) were conducted by the leading author with the qualified female research assistant to address the purpose of the study, namely to gain insight into the views and perceptions of FANC participants on measures needed to increase the use of health facility-based delivery services. An interview guide was used to plan the open-ended topics in English and Amharic. The interview guide used in this study was attached as Additional file 1. The women who met the eligibility criteria were contacted to discuss the purpose of the research, the study activities, and the request for participation in the study through the midwives/nurses in charge of the maternal and child health units of the selected hospitals and health centers. The investigator performed FGDs with women who attended FANC and delivered live babies at home in the previous year before the study’s data collection. The objective was to ask questions that elicited answers and produced maximum discussions and opinions within a given period among the study participants. Of the three selected health centers and one district hospital, four FGDs were conducted involving 32 participants. In FGDs, the number of participants was between 6 and 10 women. There were ten participants in the first FGD, eight participants in the 2nd and 3rd FGDs, and six participants in the 4th FGD. A central topic was included in the interview guides, as well as additional questions aimed at exploring and delving deeper into various aspects of the research phenomenon. The probing questions were focused on the responses of the participants to the issue. The researcher used probing such as “please tell me more…, what do you mean by…” for questioning. The participants were seated in a circle so that each participant had a complete and fair view of others to allow efficient contact in the FGDs. The key question for focus group discussion was: what do you think should be done to increase the use of health facility-based delivery service among FANC participants? Additional questions included: Why do women prefer home delivery to facility-based delivery service? What are your views regarding the advantages of facility-based delivery? What were the benefits of attending antenatal care for you? What information did you receive from the health care providers about health facility-based delivery? Focus group discussions were continued until data saturation was reached, and the investigator used data saturation by group, which was the point in coding where no new codes existed in the data. The interview process was clarified by a favourable, non-threatening, and comfortable atmosphere when the researcher introduced himself to the participants. In the private rooms of selected health facilities, the interviews took place. The FGDs were audio-recorded with the consent of the participants and notes were written during the interview to capture the original accounts of the responses of the participants and to validate their explanations by going back to the original answers. In a quiet and private space, free of distractions, and where they felt safe, the investigator conducted the interviews in Amharic. The FGDs sessions lasted approximately 60 min on average. Descriptive statistics have been used to summarize participants’ socio-demographic characteristics. All FGDs were transcribed from the audio recordings and notes made during the interviews and translated into English. Data were analyzed in conjunction with data collection. The data was coded by the lead investigator. The data coding procedure was carried out according to Tesch’s recommendations in Creswell [7], which included: getting a sense of the whole by reading all the transcripts carefully, select one interesting document to examine for the underlying meaning, annotate the selected document in the margin formulating topics into columns, check for any emergence of new codes and categories, combine categories that are associated to each other, shorten each category and put codes in alphabetical order, bring together the data material fitting in each category in one place and perform an initial analysis, and if necessary, recode the existing data. Using the codebook, the theme codes were then manually produced. Line-by-line coding of the various transcripts was performed. Double coding of each transcript was carried out by two of the authors. A coding comparison query was then used to compare the coding. Thematic analysis was used in data analysis, which entails three interconnected stages: data reduction, data display, and data conclusion. In addition, thematic analysis entailed evaluating the structure and content of textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes. A codebook was first devised, discussed, and adopted by the writers before they could use this technique. Using the codebook, the theme codes were then manually produced. To explain the study results, verbatim excerpts from participants were given. Some procedures were employed to ensure the report’s trustworthiness. Concurrent analysis ensured that in subsequent interviews, emerging concepts were evaluated to obtain a complete understanding of the themes. To ensure the authenticity of the transcripts, interviews held in Amharic were discussed with experts in this language. Detailed field notes were maintained that allowed the results and study processes to be checked. To ensure the study’s credibility, several measures were used, including the use of the same interview guide throughout the study. For researchers to validate the methodologies used in the study, an audit trail was kept. A detailed description of the study setting, methodology (COREQ criteria were used [8]), and background of the sample was provided to ensure the transferability of the study findings to a similar context. Data were returned to participants to cross-check and validate their responses to ensure legitimacy. The researcher also received individual input from the participants on how they reacted to the data interpretation. During focus groups, the researcher spent four weeks conversing with the participants to gain a thorough grasp of their perceptions of facility-delivery service. To ensure the study’s dependability, the researcher communicated with the two senior research supervisors via email, personal contact, and phone conversations frequently to track any changes made to the protocol and processes, such as reviewing, defining, and labelling themes uncovered. The themes produced were discussed by the research team to ensure that the data was complete. To support the results, direct verbatim quotes were used and this gave voice to the women in this research. Finally, the reporting of this study adhered to the 32 criteria recommended by the consolidated criteria for reporting qualitative research [8]. Ethical clearance was obtained from the Research Ethics Committee of the Department of Health Studies, University of South Africa. The Addis Ababa City Government Health Bureau granted permission for the study to be carried out. To perform the interviews, the authors received informed written consent from all participants. It underlined the voluntary nature of participation in this report. The Confidentiality of the identification and other personal details of all interviewees were ensured. The collected data were preserved electronically as audio recordings to be used as a backup format, and the transcripts and notes were stored as MS word files. To guarantee confidentiality, the MS word files were password secured. The current study was framed and linked to the body of knowledge using a multi-level life-course framework of facility-based delivery in low- and middle-income countries (LMICs) defined by Bohren et al. [9]. The model classifies factors that affect health services utilization into five categories: individual, family, community, health-care facility, and national. This conceptual framework demonstrates how a variety of factors interact to influence the use and non-use of healthcare facilities.