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Introduction: Ethiopia has expanded the number of health facilities that offer maternal health services during the last two decades. However, the utilization of skilled birth attendants in health facilities is still very low especially among the pastoralist regions of the country. This study explored why women in the pastoralist region of Afar, Ethiopia still prefer to give birth at home. Methods: A qualitative study approach was used to collect information from October to December 2015. A total of eighteen focus group discussions and twenty-four key informant interviews were conducted. Focus group discussions were separately conducted with mothers and male tribal or religious leaders. Key informant interviews were conducted with heads of Women’s Affairs Bureau, district health office heads and traditional birth attendants. Data were coded and categorized using open code software for qualitative data management and analyzed based on a thematic approach. Results: Women preferred to deliver at home due to lack of awareness about the benefits of maternity health facilities, their nomadic lifestyle, lack of confidence and trust in health workers and their close affinity and easy access to traditional birth attendants. Supply-side barriers included distant health facilities, lack of transportation and poor health care. Conclusion: Demand and supply related factors were identified as barriers to utilization of skilled birth attendants. Increasing awareness, bringing the service closer, arranging maternity waiting area around health facilities, and creating client-friendly service were found critical. Future research to define and improve services and approaches suitable for pastoralist population is warranted.
The study was conducted in the six districts of Afar regional state of Ethiopia where more than 86% of the population lives in rural areas and about third fourth are pastoralists. The majority of Afar (Danakil) population is Muslims. Afar has the lowest altitude in Africa and hot dry climatic conditions that force pastoralist communities move 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 at the top tier. According to Afar regional health bureau report, the region has six hospitals, 86 health centers and 379 health posts. In the study districts, three hospitals and 14 health centers with 69 satellite health posts were found functional. All hospitals and health centers provide basic obstetrical services. The health posts do not provide delivery services. Each district has an ambulance stationed at the district health office to facilitate referral cases whenever necessary and the ambulance driver has a mobile phone for communication. In the study area, the participants were selected from different population groups. The participants for the focus group discussions (FGD) were mothers who had children less than 24 months of age, grandmothers and recognized male tribal or religious leaders. All were selected purposively mainly based on either their experience of birth and birth-related traditions or being as influential persons. A total of 186 individuals participated in 18 FGDs; 60 mothers and 48 grandmothers and 54 male tribal or religious leaders. Key informant interview (KII) participants 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 (KII) 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), health workers, and the women’s association office. The main criteria for their selection was 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. The main focus was on the reasons for choosing home delivery. Six midwives 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 interviews were conducted in the Afar language and were closely supervised by the principal investigator. FGDs took up to two hours while key informant interviews took up to 60 minutes. The FGDs were conducted by two midwives; one serving as moderator and the other as note taker. Informed oral 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. The transcribed data were loaded on to the open code software developed by Umea University in Sweden for coding qualitative data and assist in analysis [12]. The transcripts were read repeatedly, coded and organized into categories. Similar categories were grouped into themes: reasons for preferential utilization of home delivery, and health facility-related factors. Findings are presented in narratives with supporting quotations. Ethical approval for the study was obtained from Mekelle University. Permission to conduct the study in the region was obtained from Afar Regional Health Bureau and from local administrative and health authorities. Verbal informed consent was obtained from each participant. Privacy and confidentiality of the participants was maintained by conducting FGDs and interviews in private places where intrusion by others was controlled. The anonymity of the data were assured by not documenting the full name of participants.
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