Journal of Women's Health Care
Open Access

Factors Enabling Women to Attend Health Facility Delivery in Gullele Sub City, Addis Ababa, Ethiopia, Qualitative Study

Mikias Negash^1* and Bizuwork Haile^{2 *}Correspondence: Mikias Negash, Department of Medical Laboratory Science, College of Health Science, Addis Ababa University, Ethiopia, Email:

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Introduction

Background

Maternal health was launched in September 2000 when 147 heads of state and 189 nations in total signed the Millennium Declaration, in which the proportion of births assisted by skilled birth attendants (SBA) became an important indicator to measure the progress of improving maternal health and achieve universal access to reproductive health by 2015 [1].

Maternal mortality rate (MMR) was shown to have a significant discrepancy between developed and developing countries. It is very high in developing countries, in 2017 it was 462 per 100 000 live births compared to 11 per 100 000 live births in high income countries. In line with this, 295,000 maternal deaths occurred during and following pregnancy and childbirth in the same report of which close to 94% occurred in low resource setting. From this Sub-Saharan Africa accounted 196 000 of maternal deaths which is almost two third of the burden [2].

In Ethiopia, maternal and infant mortality/morbidity levels are among the highest in the world. The infant mortality rate was 48 deaths per 1,000 live births and the maternal mortality ratio was 412 per 100,000 live births in the year 2016. The maternal death which was 676 in the 2011 survey has evidently decreased in 2016 but still remain to be profound [3].

Different factors; like income of house hold, education, cost and quality of care in hospital, family size, knowledge about modern facility, social taboo and traditional belief, access for media, and family planning program play important role in choosing modern delivery care system [4].

Despite significant reduction in the number of maternal deaths since 1990, it is still less than half what is required to reach the Millennium Development Goal (MDG). Substantial numbers of women are losing their lives because of lack of proper antenatal care (ANC) follow up and SBA. The ANC follow up was 51% and the SBA 64% globally in the fifth MDG report for the period between 2007 and 2014 far less than expected [5].

According to the 2016 Ethiopian demographic health Survey report, 62%, of mothers received antenatal care (ANC) from health professionals, and yet only 26% of births took place in health facilities [3]. In Addis Ababa the ANC coverage and the skilled attendant delivery was 97% and 95% respectively [3, 6]. The ANC coverage of slum areas of Addis Ababa were masked by the city average and it was reported that four or more ANC visits in the slum areas was 81% and only 20% received adequate ANC with the full package [7]. Considering majority of Gullele sub-city and the health centers we chose for this study are also considered one of the poorest areas in the city, the ANC visit and SBA would be far less than what is reported. Therefore, this study was conducted to assess utilization of health facility for delivery services and identify factors influencing use of this service among women in the study area.

Methods

Study setting

The study was conducted at Gullele sub-city which is among the 10 sub cities in Addis Ababa city administration between December 2016 and September 2017. The sub city has a total population of 284,865, where women account for 51.6% according to the sub city report. The sub city has three hospitals, 10 governmental and one none governmental health center together with 37 private different level clinics [8].

Study design and sampling

A qualitative study design was used in three randomly selected health centers in the sub city. Mothers who gave birth in the health facilities and came for post natal services in the health centers were enrolled to the study. Purposive sampling of criterion method was used to select from those mothers who came for post natal services and a total of 19 women who volunteered to participate were interviewed. Verbal consent was obtained by nurses who counsel the mothers and they were linked with the researchers for the interview. The researchers had no affiliation with the health facilities which minimized an interviewer bias.

Data collection method

An in-depth interview was used to collect the data. The interview guide was first prepared in English then translated to the local language “Amharic”. The interview lasted on average for 20-30 min and has continued until no further new information was generated from interviews. Finally a total of 19 interviews were conducted and considered for analysis.

Data analysis

The tape recorded audio files were transcribed to “Amharic”, then translated to English and coded based on predefined themes. Both-investigators performed the coding and the analysis that had experience of conducting such kind of qualitative study. Analysis was done by using N-Vivo Version 10 (QSR International, Cambridge, MA). Concepts and unique ideas generated were summarized in memos and linked with respective themes and descriptive narratives generated for the themes accordingly.

Data management

The entire tape recorded document and the transcribed file was handled and protected from anyone who was not part of the study. The coding between the two investigators was cross checked and edited to maintain consistency.

Result

Socio-economic and demographic background

A total of 19 women had participated in the study, of which more than half of them were in the age range of 20-35 years and during their recent delivery all of them were married. Most of them completed primary level education and few were with college diploma and above. Most of the mothers were unemployed /house wives/ who depends on their husband’s monthly income. The average monthly income of their husband’s was in the range of 50-100 US Dollar.

Reason for attending health facility for delivery

Among the participants, most of them mentioned the following reason for preferring health facility for delivery; the descriptions are narrated based on these themes; perceived benefit of professional care and adequate facility, provider/professional approach, perceived susceptibility to complication of pregnancy, decision making and the role of partners, source of information, cost of delivery and accessibility, and perceived fear of delivery in health facility.

Perceived benefit of professional care and facilities

Perceived health benefit of women and their unborn babies from trained professionals, like advises on how to push, checkups to the baby, proper hygiene keeping, getting further service like cesarean section if complications occur were reasons given by most of the participants to choose institutional delivery. Few of them also chose it because of impartiality and safety measures provided by health professionals.

“This place is safe and they are here to help us, if I couldn’t give birth normally, the professionals can perform cesarean section and give necessary services….”(Participant #1, #8 & #12).

Most of the mothers affirmed that availability of medication and better equipment were additional factors to prefer institutional delivery. They also indicated that the health institution services has improved in recent times and they were no longer being referred elsewhere to buy medication and for laboratory tests.

“……at home you don’t have accesses to trained professional, medical supplies, blood transfusion and treatment, but at facility level they provide what is needed for me and my child, they also checked my health status before I was discharged” (participant #4).

“In the health facility even if they couldn’t save the baby, they could save my life. They gave me glucose, medication and food which I couldn’t get if I deliver at home…..”(Participant #16).

Providers approach

Respectful and non-negligent approaches during follow up at health institution influenced some of the participants to attend skilled delivery.

“The professionals were so good, they gave me proper care, the facility was so clean, and they were always with me, created conducive environment that I felt like I was at home….”(Participant #5).

Perceived susceptibility to complication of pregnancy

Perceived susceptibility to pregnancy complication could be seen in two ways; susceptibility to obstetrics complication and susceptibility to exposure of disease. Most of the participants stated that fear of obstetrics complications such as; prolonged labor with bleeding, retained placenta, arrival of the child in the wrong direction, and breathing problem. Few of them mentioned hypertension and non-opening of uterus.

“I prefer this health institution for delivery, for the sake of my health and the safety of my child. The baby may come in wrong direction, by his feet, which is too dangerous to the child and me. So, in order to avoid this problem I chose this health facility and to get cesarean section by professionals in case it is needed” (Participant #2 & #17).

“……….the placenta may be retained and not completely removed, the child may face breathing problem, I may also have severe bleeding. Therefore, I have to choose such kind of facilities to avoid such dangers…..”(Participant #15).

Most of the participants especially those who had previously gave birth assisted by traditional birth attendants (TBA) stated that the current TBAs are incapable of managing delivery complication than the previous ones. Some said they have doubt on the knowledge and skill of TBAs to assist delivery and they did not properly clean blood from their body and uterus which could cause problem in the future.

“I have decided not to visit traditional birth attendants because the current TBAs lacks skill compared to previous ones. Before this delivery I have attended TBA for my second child, she told me simply to push and push, she didn’t do anything for me, no medications given but health professionals gave me delivery medication” (Participant #14).

Some of the mothers also mentioned their own and their relative’s previous bad experience in choosing health facilities for delivery.

“…..I attended a TBA for my second child, she massaged my belly and kept telling me to push, finally when things got complicated, she told me it was beyond her capability and I had to go to health facility to safe my life. Even though I managed to arrive at the health center, they couldn’t save my baby. After that horrific experience of long lasting labor and bleeding, I decided to come here for my third delivery” (Participant #6).

”I know some mothers who lost their life while giving birth at home, I didn’t want to face this situation, so I decided long ago that I have to come to health facilities to get assistance during delivery” (Participant #1 & #9).

“……..the major influencing factor for me is my mother painful experience, she had gone through severe pain for five days, when she tried to give birth at home by TBA……”(Participant #8).

Furthermore, many mothers mentioned they prefer skilled delivery due to contamination risks with infectious disease.

“……..home delivery is not safe and the materials may not be clean, so I may be exposed to infectious diseases like HIV/AIDS and could eventually endanger myself and my child” (Participant #15 & #18).

Decision making and the role of partners

Almost all of the mothers stated their husband’s involvement had significant impact for deciding a place of delivery through saving money and partner engagement for ANC follow up. Few mothers whose husbands were reluctant or lack awareness about institutional delivery decided by themselves.

“My husband and I decided together to have the ANC follow up at the health center. When I came to the health facility for follow up or any case, he accompanied me, he saved money in case cesarean section is needed, which may require more money…..”(Participant #2).

“You don’t know what could go wrong during delivery, to avoid this unexpected risk I decided to give birth at the health facility. My husband also insisted we had to have the follow up at the health facility….”(Participant #5 & #18).

“….my husband was not willing to come to the health facility with me during ANC follow up, so I decided to come here by myself….” (Participant #16).

Source of information

Information from the media and health professionals (counseling given during ANC follow up) were mentioned by most mothers as their source. Information from their neighbors, friends and their family were also stated by few participants. But the contribution of health extension workers was minimal as stated by the participants.

“I get information from media especially ‘your health at your house’ [a televised program which focuses on health issues], and also from my friends and family….” (Participant #3, #4, #12, & #19).

“When I was in rural area, health extension workers told me that all mothers should give birth at health institutions in order to avoid risk related to TBAs assisted delivery but here in Addis Ababa the health professionals do not come to our house most often….” (Participant #4).

Cost for delivery and accessibility

Cost was one of the reasons mothers pointed as a challenge. Many of them were not able to afford to pay for contract taxi or for extra expenses such as a visit to private health facilities. Most of the mothers mentioned private health facilities are way expensive and they had to come to governmental health facilities because they give free ANC visit, medication and delivery services. They also indicated shortage of delivery services and beds in government health facilities. Accessing ambulance services in a time of sudden onset of labor were also mentioned as another challenge. In this situation they had to take a contract taxi which would incur additional expenses.

“If the government health facilities run out of beds to admit mothers for delivery, we pay extra cost for contract taxi or private facility delivery. My husband always told me, I should have to go early to health center because he couldn’t cover any extra expenses….” (Participant #10).

“…….my home is near to the health center that I didn’t need any transportation to come here and I saw the capability of the health center when I came for other purpose. I think they give good services except that it is somehow crowded” (Participant #7).

Perceived fear of delivery in health facility

Even though most of them explained the enabling factors which influenced them to attend skilled delivery, some of them mentioned barriers which may hinder mothers not to attend skilled delivery, like disrespect and insulting by health professionals, negligence of professionals (there are some fear they might leave scissors and gauzes inside their body after surgery), fear of disclosing body to unfamiliar person, and lack of trust on students who practice at health facilities.

‘’I saw the nurse shouting loudly on one mother when I was there for my follow up. The nurse was not polite and she didn’t have any respect for mothers, after seeing that I hesitated to come back….” (Participant #16).

“We don’t trust students practicing in the health facilities, they don’t know what to do if complications occur, and most of the time the senior and experienced professionals are not available to help us in this situation” (Participant #11 & #19).

Discussion

The current study showed that women in the study area strongly preferred health facility attributes, trained health care providers, safe and clean environment, reliable supply of medicines, and better equipment for choosing place of delivery. Provider/professional attitude and approach were also important. Convenient access (i.e. being near to home and cost) were stated as additional factors.

A study in Cambodia indicated women choice of health facility is influenced by their perception of safety and staff attitude where some women preferred private health facilities because they considered them safe and receive better care [9]. Moreover, respectful approach of workers, continuous and non-negligent follow up, good communication and spending time with mothers and creating home like environment were reported to be key factors to attend health facilities in this and other similar studies [10-14]. Therefore, provision of training and education to health professionals to address attitude issues and behavior is indicated to be a successful approach in attracting mothers for institutional delivery [15]. However, there should be a balance not to frustrate health professionals where they are overburdened with work load and underpaid in lower income countries.

Perceived risk of home delivery assisted by traditional birth attendants was another reason stated for avoiding home delivery in the current study. Studies by Blum LS, et al. [10] and Ekirapa- Kiracho, et al. [11] emphasized factors to prefer institutional delivery over home delivery; inadequate equipment and supplies and inappropriate environment during home delivery. Moreover, previous experiences of life threatening obstetric complications either to themselves or to their neighbors and friends influenced the utilization of institutional delivery in the current study, this was also reported in other researches from Indonesia [16] and Ethiopia [17].

Partner support in terms of saving money, accompanying during ANC follow up and awareness about skilled delivery had great role in choosing institutional delivery over home delivery as observed in the current and other similar studies [14,18,19]. The participants mentioned, they benefit from free ambulance, fast referral system and cheap cost or no cost at all when they visit governmental health facilitates. One study in rural Gambia in particular indicated women are not privileged during pregnancy period, did not have the resources or the means to access prenatal care and the decision to receive skilled delivery is often beyond their control, further making birth related complications a challenge [20]. A demographic and health survey from 48 developing countries also reported 68% of women said it was designated “not necessary” to attend a skilled delivery by the house hold decision makers who most often are males [21]. Hence, empowering women, persuading and teaching their partners to provide support and care are vital under such circumstances. A study in rural Tanzania also emphasized the importance of teaching husbands and family members where despite 90% antenatal care, only half of them used skilled delivery services [22].

The current study also found mothers gather information about institutional delivery from different sources which influenced their preference to choose place of delivery. The contribution of Medias, relatives and health professionals were the primary sources. Counseling during ANC follow up and closeness of their home to health facility had substantial contribution to choose facility delivery in the current study. Other similar studies reported that mothers who had at least 3 ANC visit and who lives near the health facilities are more likely to deliver at the facility [4, 23].

Some mothers also mentioned factors which may hinder them from attending health institutions for delivery such as; fear of exposing body to unfamiliar persons, previous normal delivery at home, societal traditional norms and fear of students who practice at the health institutions.

A study in Bangladesh reported the challenge of family pressure to adhere to traditional birth norms which further undermines skilled delivery practice [24]. In line with this, a study in Iran revealed factors which caused delay in referring women with obstetric complication to emergency obstetric care facilities; socio cultural and familial reasons, disrespect and insulting by physicians, and lack of health insurance [25]. Moreover, a study in India in a resource poor setting indicated; trust in TBA, belief of a child should be born only in natural event and health facility may be needed only if there is complication as major impeding factors to attend institutional delivery [26].

The notion of fear of practicing students is not good because it is today’s students that become tomorrow’s professionals. The trust and the confidence should be reestablished and this can only happen when both students and the mothers know that senior and experienced professionals are close by in case any complication may occur.

Conclusion

The current study showed that provision of respectful and supportive care, awareness about skilled delivery and partner support on decision making have considerable impact in preferring health facility for delivery. Health care providers should have to use every opportunity to properly counsel and teach women along with their partners about the importance of skilled delivery and they should have to develop good communication and interactive approach, be friendly to mothers who come for ANC follow up.

Awareness creation by health extension workers was low as compared to media contribution. Hence, teaching and linking mothers to health facilities by going to the mother’s households should be improved by health extension workers. The education would be more fruitful if accompanied by influential local peoples and mothers who experienced the suffering of home delivery. Finally, we recommend that it’s better to do further qualitative study in different sub cities by enrolling study participants from governmental and private health institutions using random sampling to get more representative and comprehensive data.

List of Abbreviations

ANC- Ante Natal Care

BEOC- Basic Essential Obstetric

BSC- Bachelor of Science

CEOC- Comprehensive Essential Obstetric Care

CSA- Central Statistical Agency

EDHS- Ethiopia Demographic and Health Survey

EOC- Essential Obstetric Rare

G8- Group of Eight

HD- Home delivery

HF- Health facility

HS- Health Services

HEW- Health Extension Worker

ID- Institutional Delivery

MMR- Maternal Mortality Ratio

MNCH- Maternal Neonatal, and Child Health

MTP- Medically Trained Persons

MDG- Millennium Development Goal

NGO- Non-Governmental Organization

PNC- Post Natal Service

PMR- Prenatal Mortality Rate

SDA- Skilled Delivery Attendant

SSA- Sub-Saharan Africa

UNICEF- United Nations International Children’s Fund

WHO- World Health Organization

Ethics Approval and Consent to Participate

Ethical approval was obtained from the ethical review board of Addis Continental Institute of Public Health prior to the actual data collection procedure (Protocol no. ER/ACIPH/0039/16). The respondents were informed about the purpose of the study and asked to cooperate for an interview through verbal consent. This method of consent was acceptable for this type of study by the ethics committee. Recorded and transcribed materials including personal data were coded and accessible only to investigators.

Availability of Data and Materials

The necessary data are analyzed and provided in the current study.

Acknowledgement

Our deepest acknowledgement goes to study participants who volunteered to be part of this study and to the health facilities and the nurses who helped us in facilitating the research.

Competing Interests

The authors declare no competing interest with financial or nonfinancial interests.

Authors Contributions

BH contributed to conception, design, acquisition, analysis of data and write up of the manuscript. MN contributed in the design of the research, its analysis and interpretation, and in writing the manuscript. All authors read and approved the final manuscript.

Funding Statement

No financial funding was obtained for this research project.

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