Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia

Background: In 2015 the maternal mortality ratio for Ethiopia was 353 per 100,000 live births. Large numbers of women do not use maternal health services. This study aimed to identify factors influencing the use of maternal health services at the primary health care unit (PHCU) level in rural communities in Sidama zone, south Ethiopia in order to design quality improvement interventions. Methods: We conducted a qualitative study in six woredas in 2013: 14 focus group discussions (FGDs) and 44 in-depth interviews with purposefully selected community members (women, male, traditional birth attendants, local kebele administrators), health professionals and health extension workers (HEWs) at PHCUs. We digitally recorded, transcribed and thematically analysed the interviews and FGDs using Nvivo. The ‘three delay model’ informed the analytical process and discussion of barriers to the use of maternal health services. Results: Lack of knowledge on danger signs and benefits of maternal health services; cultural and traditional beliefs; trust in TBAs; lack of decision making power of women, previous negative experiences with health facilities; fear of going to an unfamiliar setting; lack of privacy and perceived costs of maternal health services were the main factors causing the first delay in deciding to seek care. Transport problems in inaccessible areas were the main contributing factor for the second delay on reaching care facilities. Lack of logistic supplies and equipment, insufficient knowledge and skills and unprofessional behaviour of health workers were key factors for the third delay in accessing quality care. Conclusions: Use of maternal health services at the PHCU level in Sidama zone is influenced by complex factors within the community and health system. PHCUs should continue to implement awareness creation activities to improve knowledge of the community on complications of pregnancy and benefits of maternal health services. The health system has to be responsive to community’s cultural norms and practices. The mangers of the woreda health office and health centres should take into account the available budgets; work on ensuring the necessary logistics and supplies to be in place at PHCU. The study was conducted in Sidama zone of the South Nation Nationalities and Peoples Region of Ethiopia in 2013. The capital of the zone is Hawassa. The zone comprises 19 rural woredas with a total population of 3.4 million. In Sidama, 12% of pregnant women gave birth assisted by a skilled birth attendant, 88% made one ANC visit, 48% made four ANC visits and 58% received PNC in 2013. Around 14% of births were assisted by HEWs [29]. This explorative qualitative study involved focus group discussion (FGDs) and in-depth interviews (IDIs). FGDs were held to understand the views and norms of different groups regarding factors influencing use of maternal health services. Interviews were carried out with community members and health professionals who were expected to be knowledgeable, have experience or were directly involved in services delivery at the primary health care unit. A total of 14 FGDs were conducted: 6 FGDs with HEWs (one in each woreda), 6 FGDs with women (one in each woreda) and two FGDs with male (in two purposively selected woreda amongst the six). We conducted a total of 44 IDIs: 12 IDIs with pregnant women or women who delivered recently (two in each woreda), 12 IDIs with HEWs (two in each woreda), 6 IDIs with TBAs (one in each woreda), 3 IDIs with Kebele administrators (in three purposively selected woredas), 6 IDIs with persons in charge of the health centre or leaders of the labour room workers (one in each woreda), 3 IDIs with woreda health extension program coordinators (in three purposively selected woredas), 1 IDI with the zonal health department health extension program (HEP) coordinator and 1 IDI with the regional health bureau HEP coordinator (Table ​(Table11). An overview of participants in IDIs and FGDs We focused on the first two levels (health post and health centres) of the PHCU, as they are the first point of contact for the rural community to access maternal health services. Participants were purposefully selected eligible women comprised of those who had given birth in the previous 2 years or were pregnant at the time of data collection. Male participants for the FGDs were selected on the basis of having an influential position in the community: husbands (of women with babies), influential elders, religious leaders and other influential male in the community were included. HEWs and health professionals were those who served for three or more years so they had sufficient experience to share. The study took place in six purposively selected woredas, taking into account the rate of skilled delivery in 2012 and the distance from the zonal capital. We took 12% skilled delivery, which was the average coverage of the zone in the year, as a cut off point to categorize the woredas’ performance. The woredas achieving 12% or more were classified as “relatively well performing” and those below 12% were considered “poor performing”. We included three woredas which were performing relatively well and three woredas which were performing poorly, and ensured that half were close to the regional capital Hawassa, and half further away to explore differences in level settings. To identify and recruit participants for the study at woreda level, the research team approached the woreda health office, discussed the objectives of the study, the sampling approach and strategies to be used for identification of participants. Woreda health office, HEWs and kebele administration supported the identification and recruitment of women for the study. Health centre and woreda health office staff assisted in the identification of HEWs and health professionals for inclusion in the study, and HEWs were involved in the recruitment of TBAs and community representatives. Data were collected by four Ethiopian researchers who had experience in conducting qualitative studies and were trained for 1 week. Semi-structured interview guides were developed in English, translated to Sidamigna and Amharic (Additional file 1), and back translated and checked for consistency by an independent person from Ethiopia, who was able to speak both languages. The interview guides contained questions eliciting factors that facilitate or hinder the use of maternal health services at different levels. During the interview and FGDs, participants were asked about their knowledge on maternal health services, health seeking behaviour, the factors influencing decision-making process, experience with pregnancy, use of services, possible barriers to use of the services and perceptions of service quality. Background information of participants such as age, education level, roles and responsibilities, services years (for health workers) were gathered and queries were run to see their effect on responses of respondents. The interview guides were piloted in one woreda, were not included in the analysis and the questions were modified where needed. Debriefing sessions were held daily to discuss key findings, identify saturation of themes, refine questions and support the quality of the research process. The interviews were carried out in the usual work settings of participants: health posts, health centres, offices and homes (TBAs only). The FGDs were conducted at schools and kebele administration offices. The duration of the IDIs was 60–90 min and for the FGDs 90–130 min. The FGDs were conducted by two facilitators: one recorder and one discussion facilitator, whereas the IDIs were conducted by one interviewer. All interviews and FGDs were digitally recorded, transcribed and translated into English. A sample of transcripts was randomly checked against the recordings to support quality assurance. Key themes were identified and a coding frame was developed after reading the transcripts in two pairs of two researchers. The coding frame and analytical process was informed by the three delays model to enable demarcation of experiences and challenges at different levels [2]. Transcripts were coded using Nvivo (v.10) software. The coded transcripts were further analyzed and summarized in narratives for each theme and sub-theme. The three delays model was used to frame our findings, as the model supports critical and integrated analyses exploring how individual, community and health system related factors hinder the use of maternal health services. Study findings were presented, discussed and validated in stakeholders meetings at the woreda and zonal level.