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Background The majority of women suffering from maternal morbidities live in resource-constrained settings with diverse barriers preventing access to quality biomedical health care services. This study aims to highlight the dynamics between the public health system and alternative healing through an exploration of the experiences of health care seeking among women living with severe symptomatic pelvic organ prolapse in an impoverished setting. Methods The data were collected through ethnographic fieldwork at the hospital and community levels in the Amhara region of Ethiopia. The fieldwork included participant observation, 42 semi-structured interviews and two focus group discussions over a period of one year. A group of 24 women with severe symptomatic pelvic organ prolapse served as the study’s main informants. Other central groups of informants included health care providers, local healers and actors from the health authorities and non-governmental organisations. Results Three case stories were chosen to illustrate the key findings related to health care seeking among the informants. The women strove to find remedies for their aggravating ailment, and many navigated between and combined various available healing options both within and beyond the health care sector. Their choices were strongly influenced by poverty, by lack of knowledge about the condition, by their religious and spiritual beliefs and by the shame and embarrassment related to the condition. An ongoing health campaign in the study area providing free surgical treatment for pelvic organ prolapse enabled a study of the experiences related to the introduction of free health services targeting maternal morbidity. Conclusions This study highlights how structural barriers prevent women living in a resource-constrained setting from receiving health care for a highly prevalent and readily treatable maternal morbidity such as pelvic organ prolapse. Our results illustrate that the provision of free quality services may dramatically alter both health-and illness-related perceptions and conduct in an extremely vulnerable population.
A qualitative exploratory approach was employed in the current study. The data were collected through ethnographic fieldwork and implied participant observation, semi-structured qualitative interviews and focus group discussions. The study took place at the University of Gondar Hospital (hereafter ‘the hospital’), a 500-bed comprehensive and specialised hospital located in the city of Gondar, and in semi-urban and rural communities within Dabat and Debark districts. All the study settings were located within the Amhara region in North-West Ethiopia. Ethiopia has exceeded 100 million inhabitants and currently holds a total life expectancy of 65 years [23]. The nation’s fertility rate is 4.6 children per woman, and the percentage of institutional deliveries is 26% [11]. The maternal-mortality ratio remains high, with 412 deaths per 100,000 live births [11]. Despite documented improvements, the huge disparity between urban and rural residents remains evident. An indication is the fertility rate, estimated at 2.3 children per urban woman versus 5.2 children per rural woman, and that 80% of births to urban mothers are assisted by a skilled provider compared to 21% of births to rural mothers [11]. In the Amhara region people primarily practice Orthodox Christianity and speak Amharic as their first language [24]. The large majority of the rural population practice agriculture [11]. Around 54% of women and 42% of men have never attended school. The median female age upon first marriage in the region is 16 years, the lowest in the country [11]. The 24 women who were enrolled at different stages of the newly initiated campaign and thus received free surgical treatment for their severe stages of prolapse served as the main informants in the present study (hereafter ‘the women’). Eight of the 24 women were followed up for a second interview in their homes some six to nine months following their surgery. The large majority of the women recruited to the study resided in the two study districts. The recruitment of the main informants stopped when no major new topics emerged, and thus followed the principles of data saturation. Other groups of supporting informants who had experience with the recruiting, referring or treating of women with prolapse were included in the study and added important contextual information (Table 1). The study was conducted over a period of 12 months in 2015–16 with repeated visits to the field. A total of eight months was spent in the study area by the first author (female), who is a Registered Nurse of background. Participant observation lasting for about three and a half months was carried out by the first author at the hospital and involved participating in nursing rounds, including assisting in the pre- and post-op care of patients, informal and systematic observation, communicating with health staff and stakeholders on the ward, interacting with the patients as well as identifying patients for interviews, and finally writing daily field notes. Follow-up interviews with some of the women who had undergone surgery involved numerous visits to the two study districts where the women lived, which increased the knowledge about the women’s home- and village-context through observations. Healing through ‘tsebel’ (holy water) was frequently brought up by the women even from the initial stages of the fieldwork. It was thus decided to include visits to holy water sites to learn more about what this common healing option implied. This visits to the locations of holy water involved participation in the morning prayer and/or the baptism in ‘tsebel’ and interaction with women at the sites followed by the detailed writing of field notes. The use of local healers also emerged as important arenas for health care seeking among the women, and interviews with local healers were included in the study. The interviews were carried out both at the hospital and in the communities by the first author in close collaboration with and the assistance of a local research assistant who was well acquainted with the culture, customs and language in the fieldwork area. The interviews normally lasted for one to two hours, and semi-structured interview guides with open-ended questions were employed with the aim to let the informant speak freely and with as few interruptions as possible. The interviews took place in a private room at the hospital or at the informant’s home or work place. The majority of the women had stayed days or weeks at the hospital at the time of the interview and had shared experiences among themselves as well as built up a certain level of trust in the researcher who interacted with them on a daily basis at the ward. During the interviews the majority of the women appeared somewhat shy but nonetheless willingly shared their experiences. Towards the end of the fieldwork two focus group discussions were conducted at the hospital. These included a total of 12 women who were admitted to the hospital for free surgical treatment of prolapse through a later round of the campaign. Research assistants moderated the focus group discussions in Amharic and took notes. The participants were encouraged to speak freely and to each other within the overarching topic of health care seeking, and lasted for approximately one hour. An important aim of this method was to confirm seeming patterns and ambiguities in the already emergent findings of the study. The analysis took place throughout the data-collection process through discussions of emerging findings with the research assistant and more extensively between the field visits. After the completion of the fieldwork a more rigorous analytical phase guided by the writing of Miles and Huberman [25] was carried out. All interviews were audio-recorded, transcribed verbatim in Amharic and translated to English. The complete data material was carefully reviewed to identify core themes. The full dataset was imported into NVivo 11, a qualitative data-analysis software tool that was employed to organise the material and ease the analysis and data retrieval process. The main themes identified were organised into sub-categories followed by the coding of the material line by line. Each sub-category was scrutinised for central patterns, for ‘case-stories’ and for potential nuances, ambivalence and contradictions. Ethical approval was obtained from the Regional Committee for Medical and Health Research Ethics in Western-Norway on 25. August 2014 (2014/589) and from the Institutional Ethical Review Board of the University of Gondar, Ethiopia on 2. February 2015 (R/C/S/V/P/05/315/2015). The aim and purpose of the study as well as the contents of the consent form, including the assurance of anonymity, was read aloud to all informants prior to the interviews or focus group discussions. Written or oral consent to participate was obtained depending on literacy status. Oral consent was explicitly approved by the ethical committees for use among illiterate informants. Participants’ oral consent to participate in the study was recorded in writing for each study participant by the research assistant. Utmost care was taken to secure privacy and confidentiality during the interviews and throughout the entire research process. Approval was provided by the hospital to conduct participant observation and data collection at the relevant hospital ward. All patients on the ward were moreover provided with information about the study, the ongoing participant observation and their rights not to participate or to be observed. No patients declined to be observed; however, two women declined to be interviewed. In the two rural study districts, the heads of the district health administrations were informed about the purpose of the research project and were provided with an ethical approval letter. In the following presentation of the data, all names used are pseudonyms.
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