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Background: Homeless women are a highly vulnerable group for risks of pregnancy and childbirth-related complications. They may also face multiple challenges to access and utilize maternity healthcare services. This study was aimed to explore the experience of homeless women on maternity healthcare service utilization and associated challenges in Aksum Town, Northern Ethiopia. Methods: An exploratory qualitative study was employed using in-depth interviews among 22 study participants from February to March 2016. Purposive sampling was used to recruit 12 homeless mothers who gave birth when being homeless in the last 12 months and 10 healthcare providers as key informants. Data were captured using audio recorders and field notes and transcribed, translated verbatim and thematic analysis approach was facilitated using ATLAS.ti7 software. Results: The finding reveals that homeless women did not use any of the basic maternity health care services, namely antenatal care, skilled birth attendance, and postnatal care. Lack of permanent place and awareness, and fear of stigma and discrimination were some reasons hindering homeless women from using the services. Conclusions: Even though maternity health service utilization is the most crucial intervention to reduce maternal and newborn deaths, this finding shows that maternity health service utilization among homeless women was limited. Socio-cultural, socioeconomic and healthcare-related factors contributed to the non-use of these services. Efforts should be made to address the challenges faced by homeless women to utilize maternity health services.
Aksum town is one of the ancient towns in Ethiopia, found in Central Zone of Tigray Regional state and located 1024 km North of Addis Ababa with an altitude of 2189.91 m above sea level. The town has an annual average temperature of 18.3 °C, annual rainfall of 652 mm and an area of 3247squere kilometer. According to the town’s administrative office report of 2016, Aksum town has about 63, 435 populations, of which 32,698 are female. Because Aksum is a historical place many local and foreign tourists visit the town every time. To use this advantage, there are many homeless peoples in the town coming from different parts of the country; engaged in begging around the historical places including the churches. In the town, there are two public health centers, one general hospital, one referral hospital, and four private clinics potentially fit to provide maternity healthcare services. Considering the season for the high number of homeless women in the surrounding the study was conducted from February 1, 2016, to March 4, 2016. An exploratory qualitative study was conducted inductively. All homeless women living in Aksum town in the last 12 months and who gave birth when being homeless in the last 12 months; thus, homeless women were purposely selected and interviewed to understand their experience as per the study objectives. In addition, key informants (health care providers) were purposely selected to gather the information that complements women’s data. Women’s and key informants who were unable to communicate due to physical or mental illness were excluded from the study. Twelve homeless women and ten health care providers (key informants) were interviewed; further sampling process was stopped based on the saturation of coming ideas. Six of the key informants (2 medical doctors, 2 midwives, and 2 nurses) were from the governmental public hospitals and four of them (2 health officer, and 2 midwives) were from the public health centers. We used local guidance to locate and identify potential sampling sites where homeless women actually live and concentrate such as churches, main roads and around other public institutions. Criteria based purposively sampling was used to select participants. Participant recruitment was through a direct approach. Mothers who fulfill the inclusion criteria participated in the study. Key informants (healthcare providers) were also enrolled in the study based on their experiences and involvement in the provision of maternity healthcare services providing and their willingness to participate in the study with the help of a respective head nurse. Semi-structured interview guides for homeless women and healthcare providers were developed by investigators. The guide was first developed in English, translated into Tigrigna (the local language) then back-translated and rechecked by a third person, to ensure its consistency and correctness. The interview guide contained open-ended questions with four key items; socio-demographic characteristics of the participants, experience of maternity health service, reasons for not seeking maternity health service (ANC, SBA, and early PNC), and what constraints they faced during pregnancy, childbirth and postnatal care. Key informants were asked about where homeless women accessed maternity health service, what challenges encountered during pregnancy, childbirth and postnatal care services and suggestions for improving the provision of maternity health service to homeless women. Probing questions were also asked, as needed to get a more in-depth understanding of the participants’ feelings and their experience with the situation. Once the respondent was identified, a suitable and a private place was arranged based on their interest to conduct the interview with each respondent. All interviews were prescheduled and took place in rooms and healthcare facility offices that guarantee optimum privacy. The interviews were conducted in the local language, Tigrigna supporting interview guide, recorders and also wrote field notes. The interviews ranged from 45 to 60 min per participant. All participants agreed to be audio-taped. After each interview, notes including memos of participant behavior and contextual aspects were taken to assure triangulation of the data with the record. We analyzed the data simultaneously with data collection. All interviews which were audio-taped and field notes of the interview were fully transcribed verbatim to Tigrigna (the local language) then translated into English after careful reading, listening to the audio and field notes independently. The individual transcribed documents were imported into ATLAS.ti7 computer software program as a separate primary document in a new hermeneutical unit for coding and analysis. After reading and re-reading the transcribed document line by line, the raw data were systematically coded and categorized to themes and sub-themes. Then, we created non-repetitive central themes that were constructed based on the natural meaning of categories. Finally, we cross-cheeked the themes that emerged after analysis; likewise, in the overall process of this data analysis, an inductive approach was implemented to identify themes and sub-themes. We considered a different set of criteria focusing on the credibility, dependability, transferability, and conformability of the study using different techniques. Per-test was conducted in a similar setting and participants but out of the study area, edited and modified to our setting by an expert in the maternity health field. We invited some healthcare providers who were participated in the actual interview to review the findings and ideas which they think if they correctly represent their point of views were taken for the study. The collected data from homeless women and healthcare providers were triangulated during analysis to increase the credibility of the findings. Respondent bias and the risk of reactivity whereby holding back researchers preconceived ideas about the issue under study. Moreover, public health experts from different experiences were used to check the consistency between the analyzed data and the final textual findings.
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