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Maternity should be a time of hope and joy. However, for women in pastoralist communities in Ethiopia, the reality of motherhood is often grim. This problem is creating striking disparities of skilled birth uptake among the agrarian and pastoral communities in Ethiopia. So far, the depth and effects of the problem are not well understood. This study is intended to fill this research gap by exploring mothers’ lived experiences and perceptions during skilled birthing care in hardto-reach communities of Ethiopia. An Interpretive Phenomenological approach was employed to analyse the exploratory data. Four key informant interviews, six in-depth interviews, six focus group discussions, and twelve focused observations were held. WHO responsiveness domains formed the basis for coding and analysis: dignity, autonomy, choice of provider, prompt attention, communication, social support, confidentiality, and quality of basic amenities. The skilled birthing experience of nomadic mothers is permeated by a deep-rooted and hidden perceived neglect, which constitutes serious challenges to the health system. Mothers’ experiences reflect not only the poor skilled delivery uptake, but also how health system practitioners are ignorant of Afar women’s way of life, their living contexts, and their values and beliefs regarding giving birth. Three major themes emerged from data analysis: bad staff attitude, lack of culturally acceptable care, and absence of social support. Nomadic mothers require health systems that are responsive and adaptable to their needs, beliefs, and values. The abuse and disrespect they experience from providers deter nomadic women from seeking skilled birthing care. Women’s right to dignified, respectful, skilled delivery care requires the promotion of woman-centred care in a culturally appropriate manner. Skilled birthing care providers should be cognizant of the WHO responsiveness domains to ensure the provision of culturally sensitive birthing care.
The study was carried out in Afar Region, which is located in the north-eastern part of Ethiopia. This region is one of the eleven regional states of Ethiopia. Afaraf is the local language, widely spoken by rural communities. The region has an estimated total population of 1,816,304, of which 799,174 (44%) are females [25]. Pastoralism is the dominant production system in the Afar Region (90%), while agro-pastoralism constitutes the rest (10%) [26]. The region is characterized by an arid and semi-arid climate, with low rainfall. The region is one of the hottest inhabited places in the world, with temperatures exceeding 40 °C and less than 200 mm rainfall per annum. Afar is increasingly drought-prone. A high percentage of the total population is food-insecure and illiteracy rates are high. Health information is rarely available in the Afaraf language. There is low health service coverage, low access to paved roads, and low access to potable water. Maternal health services are poorly equipped and are inaccessible in terms of geographic location, security issues, linguistic barriers, and poor documentation of vital events [27,28,29]. The study was carried out in three districts (Mille, Afambo, and Kori). Women with recent SBAs were selected purposely. The rationale for the sample size in this study focused on obtaining data saturation, where an iterative interview process continued until no new themes emerged and no new insights could be gained with additional data collection. This brought a varied sample, having sufficient textual data to make an iterative categorization of qualitative data possible. This research is framed by a larger research project, named Reproductive, Maternal, and Newborn Health Innovation Fund, which is aimed at improving reproductive, maternal, and child health services uptake in pastoralist communities [30]. Qualitative methods are appropriate to capture the voices of specific populations for measurable as well as unmeasurable outcomes. Thus, the phenomena of observed and unobserved experiences, actions, internal meaning, and external consequences can be recorded. It is the best method for describing the perceptions of different populations and their local understandings [31,32]. An Interpretive Phenomenological approach was employed to analyse and interpret the interview texts for the exploratory data [33]. Key informant interviews, in-depth interviews, and focus group discussions were held with purposively selected study populations. A list of registered post-natal women with recent uptake of skilled birth attendance within the past six months was collected from registry report books of the nearby health facilities. A local community coordinator was carefully chosen in consultation with the local health bureau, with the intention that she be capable of convincing women to participate in the study. This coordinator was well known and led the locally established health development army. She was a respected, long-standing member of the community and well aware of the local language and culture. This local coordinator contacted eligible post-natal women to invite them to participate in the study. Under her guidance, a transect drive was conducted at each site to approach mothers with recent experience with skilled delivery service uptake to volunteer to take part in the study. A total of 36 participants volunteered for the study. Data collection was done through four key informant interviews, six in-depth interviews, six focus group discussions, and twelve focused observations. The key informants were health experts who were chosen because of direct involvement in the health facility, either as health service providers or as facility administration. The in-depth interviews were done with pastoral women, who were chosen for their knowledge and experience of maternal health services and their dynamics. The focus groups also consisted of pastoral women who were targeted on the basis of a recent experience with skilled delivery service uptake in the nearby health centre. The focused observations were done to observe health providers’ approach to care for labouring women, room hygiene, and cleanliness of basic amenities. This was possible with a structured observation checklist. Each observation took 25 to 40 min, on average. All participants were informed about the study purpose and all of them provided oral consent to participate in the study. Trained research assistants, who were health professionals, had proven experience in qualitative data collection, and were well aware of the local language and culture, were chosen to moderate the data collection under the strict supervision of the principal investigator and supervisors. All interviews and FGDs were audio-recorded, transcribed in the Amharic language by the research assistants, and translated into English by the principal investigator. We used a semi-structured interview guide to ensure that important discussion topics were not missed. The WHO health system responsiveness framework, [16,17,19,21,34,35] was used as a source to develop the interview guide. The knowledge gained from the analysis of each interview was used to modify the consecutive interview guide. Interviews were performed continually until data saturation was achieved to the point that no new code could be extracted. A minimal compensation for travel expenses was paid in cash to study participants. Snacks and soft drink refreshments were provided to keep the participation active. Key findings were mapped against the framework of the wider health system responsiveness domains that are used to promote health service uptake. This WHO framework consists of eight themes for health system responsiveness: dignity, autonomy, choice of provider, prompt attention, communication, social support, confidentiality, and quality of basic amenities [16,34]. Health responsiveness–related factors that stop pastoralist women’s from SBA were explored. Data analysis was conducted according to the principles of interpretive phenomenological analysis (IPA), where the researcher attempts to understand the interview and observations from the participants’ (or interviewees’) perspective [33]. The domains of the health responsiveness framework [16] were used to establish coding with emerging and re-emerging themes, with the help of Atlas.ti version 7.0 (Atlas.ti Scientific Software Development, GmbH Berlin, Germany) to organize the data. The codes were able to capture perceived experiences and perceptions towards utilization of SBA services. Key statements of the participants were explored to find recurring patterns, thoughts, feelings, or ideas. The final set of themes was summarized as a codebook; recurring and unique quotes were described. In the first stage, we read the translation files several times to capture the women’s experiences, feelings, and perceptions. The total focus for analysis was based on empathy, where the researcher’s previous readings, judgments, and understandings were put to the back of his or her mind (naivety) [33]. Women’s perspectives became the key to understand the depth of the subject (bracketing). In the second stage, we identified important key phrases in the text document. Then, in the third step, we extracted the concepts, and in the fourth, we categorized concepts into groups based on similarity. In the fifth stage, we combined the categories to form concepts that explain the development of classes that are more general in terms of categories. In the sixth stage, we presented a comprehensive description of the structure of the phenomena under study. In the final stage, we validated our interpretive phenomena by comparing them to the standard HSR domains of the WHO. The research team, consisting of research assistants (data collectors), local coordinators, and supervisors, was extensively trained in qualitative data collection techniques. Supervisors, together with the principal investigator, conducted regular feedback and follow-up sessions. The quality of this study was assured through prolonged engagement of the principal investigator in the fieldwork. We did member checking, where feedback from study participants was taken in the final sessions of each interview before concluding the main points. Two researchers read the files several times and performed coding, clusters, and themes independently. We also included peer debriefing among the research team. We allotted time to the specifics of the interviews and the review of conflicting cases to improve credibility. Qualified peer researchers were invited to review and assess transcripts, emerging and final categories from those transcripts, and the final findings of a given interview. Data triangulation was done via the application and combination of several research methods (interview, observation, and literature review). Various disciplines in the research team and previous experience allowed a high level of reflexivity, which challenged us to examine and address assumptions and biases. We examined the similarity of the extracted themes and theme clusters to those extracted by HSR categories. There was almost 80% agreement in coding and theme formulation with those extracted from HSR domains. In the case of a discrepancy, the research team reviewed the file and re-analysed the disagreement. The study was conducted according to the guidelines of the Declaration of Helsinki; ethical permission and support letters were obtained from Mekelle University School of Public Health (with reference letter CHS/498/SPH/11). Permission was also secured from the Afar regional health bureau and respective district health offices. The purpose and aims of the study and researchers’ expectations of participants were explained to study participants by the research team. The information sheet was read to participants in the local language so they could understand their rights. The issue of confidentiality was addressed by using unique identification numbers. Verbal informed consent was sought from the study participants. The interviews were conducted individually and in private. The FGDs were held in three district health centre meeting rooms. All information collected, including the audio files, was kept confidential in password-protected files with personal computer access; participant identities were coded to keep all data anonymous.
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