Socio-cultural factors favoring home delivery in Afar pastoral community, northeast Ethiopia: A Qualitative Study

  • Reproductive Health, Volume 16, No. 1, Year 2019

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Study Justification:
– The study aims to explore the socio-cultural factors influencing health facility delivery in the pastoralist region of Afar, Ethiopia.
– Despite the expansion of health facilities, Ethiopia still has high home delivery service utilization, and understanding the factors behind this can help improve maternal health outcomes.
– Health care service utilization varies between regions within Ethiopia, and studying the specific factors in Afar can provide insights for targeted interventions in this region.
Study Highlights:
– The study found that social factors such as workload, lack of independence and decision-making power of women, and lack of substitute for childcare and household chores during pregnancy and childbirth influence the choice of delivery place.
– Cultural and spiritual factors, including the belief that delivery is a natural process that should happen at home, trust in traditional birth attendants, and traditional practices during and after delivery, also contribute to home delivery preference.
– Health facilities’ denial of traditional and spiritual practices, such as prayers and traditional food preparations, further discourages women from utilizing health facilities for childbirth.
– The study highlights that socio-cultural factors are significant barriers to the utilization of health facilities for childbirth, and suggests the provision of a maternity waiting home around health facilities as a potential solution.
Study Recommendations:
– The study recommends the establishment of maternity waiting homes near health facilities to address the socio-cultural barriers to health facility delivery.
– These waiting homes can provide a safe and supportive environment for pregnant women, addressing the concerns related to workload, childcare, and household chores.
– Health facilities should also be more accommodating of traditional and spiritual practices, allowing women to maintain their cultural beliefs while receiving necessary medical care.
Key Role Players:
– Women’s Affairs Bureau: Responsible for advocating and implementing policies related to women’s health and well-being.
– District Health Office: Responsible for overseeing health services delivery at the district level, including maternal health services.
– Traditional Birth Attendants: Provide delivery services in the community and play a significant role in the cultural and spiritual aspects of childbirth.
– Health Extension Workers: Local health workers who can collaborate with traditional birth attendants and provide guidance on integrating traditional practices with modern medical care.
Cost Items for Planning Recommendations:
– Construction and maintenance of maternity waiting homes near health facilities.
– Training and capacity-building for health workers, including midwives, on cultural sensitivity and accommodating traditional practices.
– Awareness campaigns and community engagement activities to promote the utilization of health facilities for childbirth.
– Communication tools and equipment, such as mobile phones and ambulances, to facilitate referral cases and emergency transportation.
Please note that the provided cost items are general suggestions and may vary depending on the specific context and needs of the Afar region in Ethiopia.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on an exploratory qualitative study conducted in a specific region of Ethiopia. The study used focus group discussions and key informant interviews to gather data. The data were analyzed using open code software and a thematic approach. The study provides insights into the socio-cultural factors influencing health facility delivery in a pastoralist community. However, the abstract does not provide information on the sample size or the representativeness of the participants. To improve the evidence, future studies could consider increasing the sample size and ensuring a more diverse representation of participants. Additionally, providing more details on the data collection process and the analysis methods would enhance the transparency and rigor of the study.

Background: Despite expanding the number of health facilities, Ethiopia has still the highest home delivery services utilization. Health care service utilization varies between regions within the country. This study explored the socio-cultural factors influencing health facility delivery in a pastoralist region of Afar, Ethiopia. Methods: An explorative qualitative study was conducted in October-December 2015. A total of 18 focus group discussions were conducted separately with mothers, male tribal leaders and religious leaders. In addition, 24 key informant interviews were conducted with Women’s Affairs Bureau and district health office experts and traditional birth attendants and all were selected purposively. Data were coded and categorized using open code software and analyzed based on a thematic approach. Results: The social factors that affect the choice of delivery place include workload, lack of independence and decision-making power of women, and lack of substitute for childcare and household chores during pregnancy and childbirth. The cultural and spiritual factors include assuming delivery as natural process ought to happen at home, trust in traditional birth attendants, traditional practices during and after delivery and faithful to religion practice, besides, denial by health facilities to benign traditional and spiritual practices such as prayers and traditional food preparations to be performed over there. Conclusion: Socio-cultural factors are far more than access to health centers as barriers to the utilization of health facilities for child birth. The provision of a maternity waiting home around the health facilities can alleviate some of these socio-cultural barriers.

The study was conducted in six districts of Afar regional state of Ethiopia where more than 75% population is living a pastoralist lifestyle. The majority of Afar (Danakil) population is Muslim. Afar region has the lowest altitude in Africa and hot dry climatic conditions that force pastoralist communities to move around constantly in search of grazing land and water. Ethiopia has a three-tier health system consisting of primary health care units which include health centers with satellite health posts at the base, district hospitals in the middle, and specialized hospitals on the top tier. According to Afar regional health bureau report, the region has a total of six hospitals, 86 health centers and 379 health posts. In the study districts, three hospitals, 14 health centers and 69 health posts were functional at the time of the study. All hospitals and health centers provide basic obstetrical services. The health posts do not provide delivery services but refer women in labor to the nearest health center. Each district has an ambulance stationed at the district health office to facilitate referral cases whenever necessary. The ambulance driver has a mobile phone for communication. An explorative qualitative study conducted to identify socio-cultural barriers to the utilization of maternal health services. All participants were purposively selected mainly based either on their experience of birth and birth-related traditions or being as important persons. The participants for the focus group discussions (FGD) were the mothers who had children less than 24 months of age, grandmothers and recognized male tribal or religious leaders. A total of 162 individuals participated in 18 FGDs; 60 mothers and 48 grandmothers and 54 male tribal or religious leaders. Key informant interview (KII) participants were consisted of heads of district health office, women’s affairs office and traditional birth attendants who were providing delivery services in the community. Key informant interviews were carried out with a total of 24 participants; six district health office heads, six women’s affairs office heads, and 12 traditional birth attendants (TBAs). TBAs were selected in consultation with health extension workers (HEW), the local health workers, and the women’s association office. The main criteria for their selection were being an active service provider and knowledgeable about the local culture. Data were collected from October to December 2015. Semi-structured and open-ended FGD and interview guides were developed to guide the data collection. Separate guidelines were prepared and pre-tested conducted with different participants out of study districts in the region. The main focus was on the factors for choosing home delivery. Six midwives a fluent in the local language (Afar) conducted the FGD sessions and key informant interviews after receiving a thorough training. The training provided by the principal investigator was focused on facilitation and interviewing techniques. FGDs and KIIS interviews were conducted in the language and were intimately supervised by the principal investigator. FGDs were conducted in a place agreed by participant and took up to 2 hours while key informant interviews took up to 60 min. The FGDs were conducted by two midwives; one serving as moderator and the other as note taker. Written informed consent was obtained from all participants. All FGDs and KI interviews were recorded using a digital recorder. Audio records were transcribed verbatim and field notes were later integrated into the transcript. Audio records were transcribed verbatim and field notes were later integrated into the transcript. The transcribed data were loaded on to the open code software developed by Umea University in Sweden for assisting coding qualitative data [25] and analyzed using Attride-stirling’s framework for thematic network analysis [26]. The transcripts were read repeatedly, coded and organized into categories. Analysis was done using a thematic approach, similar codes were grouped into themes. The result of the thematic analysis is presented in narratives with supporting quotations.

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Based on the information provided, here are some potential innovations that could improve access to maternal health in the Afar pastoral community of northeast Ethiopia:

1. Maternity Waiting Homes: The study suggests that providing a maternity waiting home around health facilities could alleviate some of the socio-cultural barriers to accessing maternal health services. These homes would provide a safe and comfortable place for pregnant women to stay close to the health facility as they approach their due date, ensuring timely access to skilled care during childbirth.

2. Mobile Health Clinics: Given the nomadic lifestyle of the pastoralist community, mobile health clinics could be utilized to bring maternal health services closer to the community. These clinics could travel to different locations, providing antenatal care, delivery services, and postnatal care to pregnant women in remote areas.

3. Community Health Workers: Training and deploying community health workers, particularly those from the local community, could help bridge the gap between the health facilities and the community. These workers could provide education, counseling, and support to pregnant women, encouraging them to seek skilled care during childbirth.

4. Culturally Sensitive Health Education: Developing culturally sensitive health education materials and programs that address the socio-cultural beliefs and practices of the community could help dispel myths and misconceptions surrounding childbirth and encourage women to seek care at health facilities.

5. Strengthening Traditional Birth Attendants: Traditional birth attendants (TBAs) play a significant role in the community’s childbirth practices. Collaborating with TBAs, providing them with training on safe delivery practices, and integrating them into the formal health system could help ensure that women receive appropriate care during childbirth.

6. Telemedicine and Teleconsultation: Utilizing telemedicine and teleconsultation services could enable pregnant women in remote areas to access medical advice and consultations from healthcare professionals, reducing the need for physical travel to health facilities.

7. Improved Transportation and Communication: Enhancing transportation infrastructure and communication networks in the region could facilitate timely referrals and emergency transportation for pregnant women in need of specialized care.

It is important to note that the implementation of these innovations should be done in consultation with the local community and stakeholders, taking into account their specific needs, preferences, and cultural context.
AI Innovations Description
Based on the study conducted in Afar, Ethiopia, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Provision of Maternity Waiting Homes: The study suggests that the provision of a maternity waiting home around health facilities can alleviate some of the socio-cultural barriers to utilizing health facilities for childbirth. Maternity waiting homes are residential facilities where pregnant women can stay close to a health facility as they approach their due date. This allows them to access timely and skilled care during labor and delivery.

Implementing this recommendation would involve establishing and maintaining maternity waiting homes near health centers and hospitals in the Afar region. These homes would provide a safe and comfortable environment for pregnant women to stay in the weeks leading up to their expected delivery date. They would have access to skilled healthcare providers and necessary medical interventions if needed.

The maternity waiting homes could also offer education and support services to pregnant women, such as antenatal care, childbirth preparation classes, and breastfeeding support. This would help address some of the socio-cultural factors identified in the study, such as lack of independence and decision-making power of women, by empowering them with knowledge and resources.

Overall, the implementation of maternity waiting homes would improve access to maternal health services by providing a supportive environment for pregnant women and addressing the socio-cultural barriers that prevent them from utilizing health facilities for childbirth.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health in the Afar pastoral community in northeast Ethiopia:

1. Establish Maternity Waiting Homes: The study suggests that providing a maternity waiting home around health facilities can alleviate some of the socio-cultural barriers to utilizing health facilities for childbirth. Maternity waiting homes can provide a safe and comfortable place for pregnant women to stay near health facilities as they approach their due dates, ensuring timely access to skilled birth attendants.

2. Strengthen Community Engagement: Engaging the community, including tribal and religious leaders, is crucial for promoting the utilization of health facilities for childbirth. Community leaders can play a vital role in raising awareness, addressing misconceptions, and encouraging women to seek skilled care during pregnancy and childbirth.

3. Improve Transportation and Referral Systems: Enhancing the availability and functionality of ambulances, as well as improving communication systems, can facilitate the timely referral of pregnant women to health facilities. This can help overcome the challenges posed by the nomadic lifestyle of the pastoralist community and ensure access to emergency obstetric care when needed.

4. Address Socio-cultural Factors: Efforts should be made to address the socio-cultural factors that influence the choice of home delivery. This may involve sensitizing the community about the potential risks associated with home deliveries and promoting the benefits of skilled care. Additionally, incorporating traditional practices and beliefs into the healthcare system can help bridge the gap between modern healthcare and cultural traditions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline Data Collection: Collect data on the current utilization of health facilities for childbirth, including the percentage of home deliveries and the reasons behind the choice of home delivery. This can be done through surveys, interviews, or existing health facility records.

2. Define Indicators: Identify specific indicators that will be used to measure the impact of the recommendations. For example, the percentage of women utilizing maternity waiting homes, the number of referrals made through improved transportation systems, or changes in community attitudes towards facility-based deliveries.

3. Implement Interventions: Implement the recommended interventions, such as establishing maternity waiting homes, strengthening community engagement, improving transportation and referral systems, and addressing socio-cultural factors.

4. Monitor and Evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through surveys, interviews, or health facility records. Evaluate the data periodically to assess the progress and impact of the interventions.

5. Analyze and Interpret Data: Analyze the collected data to determine the extent to which the interventions have improved access to maternal health. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Draw Conclusions and Make Recommendations: Based on the analysis of the data, draw conclusions about the impact of the interventions on improving access to maternal health. Identify any challenges or barriers that may have hindered the desired outcomes. Make recommendations for further improvements or modifications to the interventions.

7. Disseminate Findings: Share the findings of the simulation study with relevant stakeholders, including policymakers, healthcare providers, and community leaders. Use the findings to advocate for the implementation of effective strategies to improve access to maternal health in the Afar pastoral community and similar settings.

Note: The methodology described above is a general framework and can be adapted and customized based on the specific context and resources available for conducting the simulation study.


Statistics:
Citations: 12
Identifiers:
DOI: 10.1186/s12978-019-0833-3
Research Areas:
Cancer, Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Ethiopia
Study Design:
Cross Sectional Study, Grounded Theory
Study Approach:
Qualitative
Participants Gender:
Male & Female
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