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Background: Armed conflict has been described as an important contributor to the social determinants of health and a driver of health inequity, including maternal health. These conflicts may severely reduce access to maternal health services and, as a consequence, lead to poor maternal health outcomes for a period extending beyond the conflict itself. As such, understanding how maternal health-seeking behaviour and utilisation of maternal health services can be improved in post-conflict societies is of crucial importance. This study aims to explore the determinants (barriers and facilitators) of women’s uptake of maternal, sexual and reproductive health services (MSRHS) in two post-conflict settings in sub-Saharan Africa; Burundi and Northern Uganda, and how uptake is affected by exposure to armed conflict. Methods: This is a qualitative study that utilised in-depth interviews and focus group discussions (FGDs) for data collection. One hundred and fifteen participants took part in the interviews and FGDs across the two study settings. Participants were women of reproductive age, local health providers and staff of non-governmental organizations. Issues explored included the factors affecting women’s utilisation of a range of MSRHS vis-à-vis conflict exposure. The framework method, making use of both inductive and deductive approaches, was used for analyzing the data. Results: A complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings. Exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services. The factors identified cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers. Conclusions: Improving women’s uptake of MSRHS in post-conflict settings requires health system strengthening initiatives that address the barriers across the individual, socio-cultural, and political and health system spheres. While addressing financial barriers to access is crucial, attention should be paid to non-financial barriers a well. The goal should be to develop an equitable and sustainable health system.
The study was undertaken in two provinces in Burundi (Bujumbura Marie and Ngozi) and a district in Northern Uganda (Gulu). In Burundi, participants were recruited from the cities of Bujumbura and Ngozi and the rural and semi-urban communes of Ruhororo in Ngozi Province and Kinama in Bujumbura Mairie province respectively. In Gulu district, the participants were recruited from the rural sub-counties of Koro, Bobi and Bungatira, and the municipality of Gulu, which comprises of four sub-counties. Maps of the study areas are found in Additional file 1. This is a qualitative study based on in-depth interviews (IDIs) and focus group discussions (FGDs). Interviews and FGDs were conducted in the local languages (Kirundi in Burundi and Luo in Northern Uganda), French or English (where applicable). All English interviews and FGDs were carried out by the principal investigator (PCC), while those in the local languages and French were conducted by trained local research assistants. The fieldwork took place from June until September 2013. Study participants were recruited from staff members of local and international NGOs and local health providers (LHPs) working in the domain of maternal, sexual, and reproductive health (MSRH). The second group of participants consists of women of reproductive age, living in rural and semi-urban areas. Since we are interested in also capturing the effect the conflict had on MSRHS, NGOs and health providers invited to participate in the study had developed, supported and/or provided MSRHS during the conflict or shortly after the conflict. Similarly, the women we invited to participate in the study had sought or attempted to seek for such services as well during such periods. The interviews and FGDs focused specifically on the general state of MSRH in Burundi and Northern Uganda, aimed at describing the general state of maternal health and understanding the factors affecting women’s utilisation of basic MSRHS, taking into consideration the possible effects of the recent conflict. The detailed guides for the interviews and FGDs for each of the participant categories can be found in Additional file 2. A sample of some of the questions posed to participants during the interviews and FGDs include: Ethics approval for the study was obtained from the Regional Committee for Medical and Health Research Ethics, South-East (Norway); le Comité National d’Ethique pour la Protection des êtres Humains Participant à la Recherche Biomédicale et Comportementale (Burundi); and Gulu University Institutional Review Committee (Uganda). We also received permission from local administrative and health authorities. All participants/informants gave their informed consent before participating in the study, and their anonymity, privacy and confidentiality was respected. Written or oral consent was acceptable and approved by the relevant ethics committees. All interviews and FGDs were audio-recorded and later transcribed and translated into English (where applicable). English transcripts were imported into the QRS Nvivo (QSR International, 2012). Considering the multidisciplinary nature of the research team and that the data were mainly made up of semi-structured interview transcripts, the framework method [28] was used to manage and analyze the data. Three team members open-coded the transcripts on Nvivo and Microsoft® Word. Microsoft® Word was used for coding and analysis by one of the co-authors who did not have access to Nvivo. The codes were descriptions or labels of specific ideas identified as the transcripts were read. Two team members reviewed the codes that were developed, and the inter-coder reliability was high. Inter-related or similar codes were then clustered into different categories, and the categories were subsequently grouped into specific themes. The themes were inductively and deductively developed. Inductive means that they were anticipated from the design of the interview and FGD guides and consciously explored in the interviews and FGDs. Deductive means that they were not anticipated during the design, but rather identified during the review of the transcripts. There was a constant interplay between data collection, analysis and theme development, with new and dominant ideas that emerged in earlier interviews and FGDs being explored deeper in subsequent and later interviews and discussions. The themes were also developed taking into consideration the main factors affecting women’s utilisation of maternal health services proposed by Wild et al.’s [29] multilayered explanatory model (i.e. individual, social, cultural, political and health system factors). A detailed description of the methods is provided in Additional file 1.
