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Background: Humanitarian crises can lead to the rapid change in the health needs of women and newborns, which may give rise to a complex situation that would require various interventions as solutions. This study aimed to examine the health education and promotion patterns, health-seeking behaviour of mothers, and barriers to the use of maternal health services from public health facilities in two rural areas of Yemen. Methods: We used a qualitative approach. We conducted in-depth interviews and focus group discussions with frontline health professionals and mothers respectively. Nine in-depth interviews were conducted with the health professionals, including 4 health leaders and 5 midwives, and 2 focus group discussions with mothers aged 18-45 years in Abyan and Lahj. Thematic analysis approach was used to analyze the data in Atlas.ti (version 8) Software. Results: Our data showed that health education and promotion activities on maternal health were ad hoc and coverage was poor. Maternal health services were underutilized by women. According to the data from the focus group discussions, the poor quality of services, as indicated by inadequate numbers of female doctors, lack of medical equipment and medicines, and costs of services were barriers to use maternal health services. Moreover, the use of prenatal and postnatal care services was associated with women’s’ perceived need. However, according to the health professionals, the inadequate human resource, workload, and inadequate funding from government have contributed significantly to the perceived quality of maternal health services provided by public health facilities. Despite the identified barriers, we found that a safe motherhood voucher scheme was instituted in Lahj which facilitated the use of maternal health services by disadvantaged women by removing financial barriers associated with the use of maternal health services. Conclusion: This study identified several obstacles, which worked independently or jointly to minimize the delivery and use of health services by rural women. These included, inadequate funding, inadequate human resources, poor quality of health services, and high cost of services. These barriers need to be addressed to improve the use of reproductive health services in Yemen.
Yemen is divided into 22 governorates namely Abyan, Aden, Al-Baidha, Aldhalae, Al-Hodeida, Al-Jawf, Al-Mahrah, Al-Mahwit, Amran, Dhamar, Hadramout, Hajjah, Ibb, Lahj, Mareb, Reimah, Sadah, Sana’a, Amanat Al Asimah, Shabwah, Socotra, and Taiz. Each governorate has its own local health department which reports to the central Ministry of Public Health and Population (MoPHP). According to the most recent Yemen Demographic and Health Survey (DHS), 70% of the population of Yemen lives in rural areas [26]. We purposively selected Abyan and Lahj governorates for this study. These two governorates are among few other governorates with relatively low coverages of maternal health indicators. Moreover, they were comparatively safer for the research amidst the ongoing conflict. We chose a qualitative study design for this study because it has the ability to explore participants’ perceptions and attitude, through a prepared discussion guide, which covered the areas of interest. This approach is able to explore the research question under investigation by answering questions of “what”, “how”, and “why” from participants’ perspectives [27]. We structured the issues which emerged from the respondents’ narratives into subcategories. In the first instance, two health leaders from each of the health offices in Abyan and Lahj were purposefully identified and selected for the interviews. Then, the names of midwives of maternity and childhood health service centres in Abyan and Lahj, and the general hospital in Lahj, who worked directly with pregnant and postpartum women, were requested and invited to participate. The general hospital in Lahj was included to ensure a representativeness of health facilities in our study. The selection of mothers was guided by their experiences with the use of ANC and delivery care services from public health facilities. We collaborated with health volunteers in two purposively selected reproductive health facilities, who helped with the recruitment of mothers for the FGDs. A quota of 10 participants was discretionally allocated to each maternity and childhood health centre. The volunteers were informed of the study aims and the characteristics of mothers required for the FGDs. The mothers who presented to the each maternity and childhood health centre were invited to participate in the FGDs on a later date. Of the 20 participants who were approached to participate, 15 accepted to take part in the present study. Altogether, 24 individuals participated in the present study, including 4 health leaders, 5 midwives, and 15 mothers aged 18–45 years (Table 1). Number and type of respondent by study site Two IDI guides and one FGD guide were used to collect data from the respondents (See supplementary material 1). These guides included questions and probes related to the aims of the study but also allowed for flexibility. The IDI guides for health leaders and midwives covered similar sets of topics to examine the existing health education and promotion activities and challenges faced in disseminating maternal health information in rural areas. The FGD guide explored mothers’ perceptions on maternal health and their health-seeking behaviour around pregnancy and delivery. The guide was also used to confirm information on health education and promotion given at the public health facilities. The interview guides were designed by the authors in the English language. The first and fourth authors are fluent in written and spoken Arabic. Therefore, the approved guides were translated into Arabic by the first and fourth authors. These guides were piloted among several respondents, who were similar in characteristics to the participants in the final study. Ambiguous questions were revised. The first and fourth authors conducted all the interviews and FGDs in Arabic. Written and verbal consent were obtained from the health care professionals and women, respectively before interview. The purpose of the study, including the benefits and risks were communicated to the participants. In addition, participants were informed about their right to withdraw from participating in the study. All the interviews were tape-recorded with the permission of participants. Notes were also taken during the interviews. To ensure anonymity, respondents’ names were replaced with pseudonyms. The names of the institutions where the health leaders and midwives worked were also excluded. The interviews were carried out between August 2018 and October 2018. The venues for the interviews were determined by the respondents. In total, nine IDIs were conducted with health providers and two FGDs with mothers of the reproductive age (15–49 years). All interviews were audio- recorded, transcribed verbatim in Word™ and uploaded into Atlas.ti (version 8) Qualitative Data Analysis (QDA) Software for the analysis. An inductive and deductive thematic content analysis was applied to the data. The analysis was done by first, reading the transcripts repeatedly to understand the data, identify overall themes as well as summarizing the responses to each vignette. Open coding was conducted by highlighting pieces of the text that were of interest to the study objective and the emerging themes and sub-themes were discussed within the research team. This was followed by axial coding to establish similarities between themes. We ensured that there was enough data to support each theme. As result, some themes were collapsed because they were unifying, renamed or even deleted. We paraphrased responses from respondents and applied quotations where necessary. Threats to validity and reliability of the information collected were addressed by collecting rich data. The data collectors (first and fourth authors) are experienced with the collection of qualitative data using IDIs and FGDs. The data collection tools were assessed and modified by experts in the Department of Children’s and Adolescent Health, and Maternal Health Care, Harbin Medical University. The data collection tools were pre- tested and modified before actual data collection. All the interviews were audio-recorded and transcribed verbatim. Detailed field notes were taken during the interviews and feedback was solicited from participants by sharing the detailed notes with the participants for a consensus on the interpretation of participants’ opinions. We triangulated the data sources and data collection tools to ensure the validity and credibility of the information collected from the respondents; the IDIs with health leaders and midwives provided information on the health education process and delivery of maternal health services from the provider’s perceptive; the FGDs with mothers highlighted women’s own experiences with the utilization of health care services and barriers to access, as well as the health information given around the period of ANC and delivery. This study was approved by the Research and Ethics Committee of public health college, Harbin Medical University, Harbin, China. Also, the approval letter was given by the Ministry of Health and Population of Yemen (2018/100667–8) to conduct this study. Written informed consent was obtained from the health leaders and midwives. However, the mothers gave their consent orally. Permission was obtained from respondents before recording the interviews. The confidentiality and anonymity of the participants were ensured.
