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Background: Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. Ethiopia is a major contributor to the worldwide death toll of mothers with a maternal mortality ratio of 676 per 100,000 live births. The Ethiopian Ministry of Health launched a community-based health-care system in 2003, the Health Extension Programme (HEP), to tackle maternal mortality. Despite strong efforts, universal access to services remains limited, particularly skilled delivery attendance. With the help of ‘the three delays’ framework, this study explores health-service providers’ perceptions of facilitators and barriers to the utilization of institutional delivery in Tigray, a northern region of Ethiopia. Methods: Twelve in-depth interviews were carried out with eight health extension workers (HEWs) and four midwives. Each interview lasted between 90 and 120 minutes. Data were analysed through a thematic analysis approach. Results: Three themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources. These themes represent the three steps in the path towards receiving adequate institutional delivery care at a health facility. Of the themes, ‘increased community awareness’, ‘organization of the community’ and ‘hospital with specialized staff’ were recognized as facilitators. On the other hand, ‘delivery as a natural event’, ‘cultural tradition and rituals’, ‘inaccessible transport’, ‘unmet community expectation’ and ‘shortage of skilled human resources’ were represented as barriers to institutional delivery. Conclusions: The participants in this study gave emphasis to the major barriers to institutional delivery that are closely connected with the three delays model. Despite the initiatives being implemented by the Tigray Regional Health Bureau, much is still needed to enhance the humanization approach of delivery care on a broader level of the region. A quick solution is needed to address the major issue of lack of transport accessibility. The poor capacity of the HEWs to provide delivery services, calls for reconsidering staffing patterns of remote health posts and readdressing the issue of downgraded health facilities would address unmet community needs. © 2014 Gebrehiwot et al.; licensee BioMed Central Ltd.
Tigray has an estimated population of 4.3 million of which 51% are females. Eighty per cent of the population is estimated to live in rural areas and the majority of the inhabitants are Christian [28]. The region is divided into seven zones and 47 weredas (districts), of which 35 are rural and 12 urban. There is one specialized referral hospital as well as five zonal hospitals, seven district hospitals, 208 health centres and more than 600 kebeles (health posts) in the region. Maternal health-care coverage estimations from the Tigray Health Bureau indicate 75% for antenatal care, 20% for skilled delivery (those attended by nurses, midwives, health officers and/or physicians at health centres or hospitals, 13% for clean and safe deliveries (those attended by HEWs at home or health posts) and 90% for contraceptive use [29]. The study was conducted from September 2010 to January 2011 in two rural districts of the Tigray region, Ganta-afeshum and Kilte-awlaelo. These districts are located in the eastern zone of the region, 120 and 45 kilometres respectively from the regional capital Mekelle. In 2007, the total population of the two districts was estimated to be 188,384 inhabitants. The two districts included in this study encompass 29 health posts with approximately 58 HEWs, 10 health centres and two hospitals. Five ambulances were available in the districts, two in Ganta-afeshum and three in Kilte-awlaelo. Data from the Tigray Health Bureau have estimated the antenatal care coverage in these two districts to be 53% and 80%, compared to the skilled (28% and 13% respectively) and clean/safe delivery attendance (21% and 9.5% respectively) [29]. For this interview study, both HEWs and midwives were purposively selected with the aim of including informants with different training backgrounds. All of them had at least two years’ work experience at health-care facilities. A total of 12 interviewees participated: eight HEWs and four midwives employed at health posts and health centres/hospitals respectively, with an age range from 25 to 40 years old. The participants were all women, and differed in terms of educational level: HEWs were grade 10 students with one year training on primary health care; midwives were grade 12 students who had graduated with a diploma in nursing and had been employed at public health facilities for some years, then continued midwifery education (1.5 years) based on the national curriculum. In this study, users of the services were excluded from the interview, because an article about women’s experiences of delivery care was published recently by the authors [27]. A maternal and child health expert in the district health office identified potential participants and gave out their names and work addresses to the principal investigator (TG). The researcher visited the health facilities where the potential participants were working and requested their permission to be interviewed. In order to discuss topics more openly, the places chosen for the interviews were all private and comfortable for the participants. TG conducted all the interviews. Each in-depth interview lasted between 90 and 120 minutes. At the beginning of the interview, the interviewer explained the general topic of the interview and encouraged the interviewee to express her ideas freely. The interview guide included semi-structured open-ended questions with certain key topics to be covered: reasons for women seeking/not seeking delivery care (DC), the role of elderly women, husbands and family members in decision-making processes, and encouraging and discouraging factors regarding giving birth at home or at a health facility (HF). Competency-related questions in regard to assisting births were raised based on the informants’ professional background. Relevant emerging issues were followed up in subsequent discussions during the interview. All the interviews were conducted in Tigrigna, the mother tongue of the interviewer and the participants. The recorded interviews were transcribed and translated into English by final-year medical students and thoroughly double-checked against the original interview by the interviewer (TG). Handwritten notes were reviewed to find additional useful information. Data were analysed through a thematic analysis approach [30]. During the whole process of data collection and analysis, memos were recorded to capture ideas and reflections. The translated transcriptions were imported into Open Code software in order to manage the coding process [31]. Reading the material, the authors applied ‘the three delays model’ as a framework to guide the analysis. Consequently, as a first step the parts of the text that related to each delay were identified and marked distinctly as themes. As a second step, codes were developed for each of the themes and described as barriers or facilitators. Third, several codes were further refined with the aim of finding new information emerging and this served to fine-tune the labelling of the themes, making them closer to what the informants actually said. The study received ethical approval from the University of Mekelle, Research Ethical Review Committee of the College of Health Sciences, Northern Ethiopia. Permission was obtained from the district health authorities and written informed consent from every participant. Confidentiality and privacy were guaranteed: names and other information that would enable participants’ identification were removed. Participants were also informed that they could withdraw from participation at any time, for any reason and without negative consequences.
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