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Background: In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women’s experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.Methods: We used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.Results: One core category emerged, ‘making pragmatic choices’, which connected the categories ‘aiming for safer deliveries’, ’embedded in tradition’, and ‘medical knowledge under constrained circumstances’. In this setting, women – aiming for safer deliveries – made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category ’embedded in tradition’, was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category ‘medical knowledge under constrained circumstances’, and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.Conclusions: Although women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained. © 2012 Gebrehiwot et al.; licensee BioMed Central Ltd.
The study was conducted from September 2010 to January 2011 in two rural districts of Tigray province, Ganta-afeshum and Kilte-awlaelo. These districts are located in the northern region of Ethiopia, more than 800 km away from the capital Addis Ababa. The total population of the two districts in 2007 was estimated to be 188,384 [21]. The two districts included in this study encompass 29 health posts, 10 health centres and two hospitals; around 58 HEWs work in the area. Data from the Tigray Health Bureau have estimated the antenatal care coverage in these two districts to be 52.8% and 80% respectively, whereas skilled delivery attendance drops to 21 and 20% [22]. For this study, women who had given birth in the last three years (regardless of their current pregnancy status) were invited to take part in focus group discussions (FGDs). The three year period was chosen in order to have enough eligible participants without too long of a recall period. We included both women who had delivered at home and women who had delivered at health facilities, since we expected their experiences and attitudes to be different. Fifty-one women participated in the FGDs; 27 had delivered at home and 24 at a health institution and their age ranged from 15 to 40 years. The participants differed in terms of parity and educational level, all of them were married and the majority were engaged in farming activities. Women who had been working as community health volunteers were not included in the FGDs, since they were expected to be more aware of the subject in focus (from training and workshops about maternal health). In order to gather different experiences, FGDs were held both with women who lived in kebeles that were close to town and with those located in remote areas. The HEWs identified potential participants and invited them to come to the health post for the FGD. Once the women arrived, they were requested to choose the place for discussion. The majority of FGDs were conducted outside the health posts. In order to ensure that the women discussed topics more openly, the HEWs and the district health office workers were not allowed to take part in the FGDs. The first author (TG) moderated all the FGD, and a note-taker was always present as well. Six FGDs were conducted and each lasted between 90 and 120 minutes. Oral informed consent to participation in the recorded FGDs was obtained from every woman. Confidentiality and privacy were guaranteed, names and other information that would enable participants’ identification being removed. At the beginning, the moderator explained the general topic of the FGD and encouraged the participants to express their ideas freely. The FGD guide included semi-structured open-ended questions with certain key topics to be covered: reasons for women seeking and not seeking antenatal care (ANC) and delivery care (DC), the role of men and relatives in decision-making processes, and encouraging and discouraging reasons to give birth at home and at a health facility (HF). Relevant issues that emerged were followed up in subsequent discussions. All the FGDs were conducted in Tigrigna, which was the mother tongue of the moderator, the note-taker and the participants. The FGDs were recorded and transcribed verbatim. Handwritten notes were reviewed to add information while we listened to the recordings. The transcriptions were translated into English and thoroughly double-checked against the original by the first author. During the whole process of data collection and analysis, memos were recorded to capture ideas and reflections. The translated transcriptions were imported to software for managing qualitative data (Open Code). The data was analyzed informed by a grounded theory approach with the constant comparison method [23]. First, open coding was conducted and codes were negotiated between the authors. Through selective coding the categories and subcategories were refined and the core category was identified. The study received ethical approval from the University of Mekelle, Ethiopia. Permission was obtained from the district health authorities, besides oral informed consent from participants.
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