Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting and Period
2.2. Study Approach
2.3. Study Participants and Sampling
2.4. Data Collection Procedures
- (A)
- Perceptions and experiences of HEWs toward community-related barriers affecting maternal and newborn health service utilization;
- (B)
- Perceptions and experiences of HEWs toward community-related facilitators of maternal and newborn health service utilization;
- (C)
- Perceptions and experiences of HEWs toward health facility-related barriers affecting maternal and newborn health services utilization;
- (D)
- Perceptions and experiences of HEWs toward health facility-related facilitators to maternal and newborn health service utilization.
- (E)
- Perceptions and experiences of HEWs toward infrastructure-related facilitators and barriers to maternal and newborn health service utilization.
2.5. Data Analysis
2.6. Trustworthiness
2.7. Ethical Considerations
3. Results
3.1. Socio-Demographic Characteristics of Study Participants
3.2. Facilitators and Barriers for Maternal and Newborn Health Service Utilization
3.2.1. Theme 1: Facilitators to Maternal and Newborn Health Care Service Utilization
Sub-Theme 1: Community-Related Facilitators for Maternal and Newborn Health Care Service Utilization
“Having demand and awareness for the service provided is one of the facilitators. For example, a mother who knows the importance of immunization is utilizing more.”(27 years old, HEW)
“Yes. There are several saving options. For example, in our kebele, the health developmental armies collect money and save in the form of Ekub, and they give priority to the pregnant woman while raising it. She would also save money through Ekub with other members or Omo microfinance.”(21 years old, HEW)
“These days, pregnant women go to the health center and stay at the maternity waiting room near term. All services are provided for free.”(20 years old, HEW)
“Even if it is not an exaggerated case, she [pregnant woman] would seek care from or deliver at the health facility if her newborn died previously after home delivery. Again, for the newborn, she might seek care if she had experience or know other women’s newborn died from not taking the vaccine.”(22 years old, HEW)
“For example, a pregnant woman who knows a woman who died from bleeding after home delivery might incline the supplementary fluid given at the health facility and demands to deliver there.”(37 years old, HEW)
“Previous obstetrics history is one of the reasons for a pregnant woman not to get delivery service from the health facility. They would not go to the health facility, for example, if her newborn was asphyxiated and died during her previous delivery.”
“In addition, mothers’ inability to deliver at a health facility is a lack of health problems encountered during the previous deliveries that happened at home. They perceive that since there was no problem encountered during the previous deliveries, no problem would encounter us during the current delivery.”
“The satisfaction obtained from the service provided for newborn and maternal health problems is one facilitator. For example, if the health facility provides appropriate or quality health services for mothers with the retained placenta or sick newborns and the clients are satisfied, the community develops a good attitude toward the services provided at the health facility.”
“The husbands also play role in reducing their workload [of pregnant women], physical support, support to have different investigations, and supported in improving their dietary practice. The families also supported her in avoiding workload, improving her dietary practice by taking additional meals and enforcing to follow her health status.”(19 years old, HEW)
“Facilitators are resources mobilized at the community level, coffee ceremony, health workers approach, availability and services provided in the maternity waiting room.”
“The other was that there was nothing that a pregnant woman took from home while she stayed in the maternity waiting room. This is because all necessary resources were mobilized from the farmers, and the health center prepared their [pregnant women] meals by employing servants. Therefore, they feel comfortable with the service and develop a positive attitude to give birth at a health facility.”(27 years old, HEW)
“The family, as well as the community, support in taking her to the health facility, serving children at home and sharing the workload.”(21years old, HEW)
“There are different facilitators among the community that makes mothers seek care for their own or newborn from the health facility…The community also motivates pregnant woman and tells her to analyze the benefits and risks of not going to the health facility during pregnancy, delivery, and post-delivery. Community members also go with her to the health facility during delivery. This is important to reassure and make her comfortable.”(26 years old, HEW)
Sub-Theme 2: Significant Others Related Facilitators for Maternal and Newborn Health Care Service Utilization
“Previously, the traditional birth attendants said to the pregnant woman we provide you delivery service better than the health center. However, at the current time, we have involved them during pregnant women conferences and other discussions, and the problem is improved.”(19 years old, HEW)
“Currently, religious leaders have improved their status and enforce pregnant women to give birth at health facilities. Some religious leaders said that what was the problem if a woman delivered at home? They also said that there is no need to go to a health center for a pregnant woman to get a delivery service. The major issue is awareness.”(28 years old, HEW)
“Our major role players and supporters are kebele leaders and health developmental armies. They facilitate resource mobilization, preparation of traditional ambulances and ambulance services.”(37 years old, HEW)
“The women development armies supported us [HEWs] in supporting a pregnant woman goes to the health facility. They played a great role and called us [HEW] during labor. They also played a great role in preparing and supporting pregnant women for birth and delivery at the hospital.”
Sub-Theme 3: Infrastructure Related Facilitators for Maternal and Newborn Health Care Service Utilization
“Previously, mothers give birth at home and die. However, currently, the community meets together, calls for an ambulance, and takes the pregnant woman to the health center during labor. This is the role of the community.”(20 years old, HEW)
“Here, in the context of our community, since there is no transportation access at village areas, they use traditional ambulance, bed. They also use public buses like other people, which is not comfortable for her. The other, when she is around the asphalt area, she might get an ambulance service.”
“In the context of our Kebele or cluster health center, what I want to acknowledge is the district health office and different partners who supplied us solar energy system and television.”(32 years old, HEW)
Sub-Theme 4: Health Facility Related Facilitators of Maternal and Newborn Health Care Service Utilization
“In our Kebele, since the health extension program was started, there is no newborn death. For example, when newborns become sick, they can treat in the health post with Gentamycin and easily dispersible amoxicillin. Concerning mothers, similarly, it is good and if they become sick, they would be referred to the health center.”
“First, we tell the mother to come to the health center after she tells us about her pregnancy status or we identify the pregnancy through a home-to-home visit.”(29 years old, HEW)
“After she has the first visit there [health center or hospital], I provide the second and third follow up, and again for the fourth follow up, we advise her to go to the health center or hospital to get the delivery service…We also teach her about danger signs that happen during pregnancy.”
“Level IV HEWs can attend the delivery if the labor starts suddenly and the head of the newborn is significantly visible, and if there is a glove and other materials, but, an ambulance has not arrived early.”
“After delivery, the health extension workers can do four postnatal visits. Then, hand over to the cell leader for the next follow-up under close consultation with the health extension worker. On the first visit, the health extension workers teach her and can check the status of vaginal bleeding, about her hygiene, breastfeeding, umbilicus, and others. After the fourth visit, she gives to the cell leader for further follow-up.”(26 years old, HEW)
“During the postnatal period profuse vaginal discharge, high-grade fever, and lower leg and body swelling might happen. Therefore, during this time she should go to the hospital and set the service.”(30 years old, HEW)
“We send her to the health center for the first and the fourth antenatal care visit and come to us for the second and third antenatal care. She receives services such as the provision of iron, vaccine, etc. both from the health post and health center.”(19 years old, HEW)
“…Immediately after delivery, it would be facilitated for the newborn to get the BCG vaccine and Polio 0 at the health facility…We also provide advice to start immunizing the newborn on the 45th day…”
“During the postnatal period, we also provide the service that was provided during the antenatal period. For example, we provide nutritional counseling and add one more meal than the ordinary. We advise the importance of exclusive breastfeeding. Second, if we recognize any maternal and newborn danger signs, we advise her to go to a nearby health facility immediately and receive appropriate services. The other is that we advise the mother to expose the newborn to sunlight.”(26 years old, HEW)
“We advise her to expose the newborn to the sunlight and to breastfeed 10–12 times. Also, we advise her to completely breastfeed one breast before switching to the other. Other, we advise her not to start complementary feeding and feed only breast milk until six months.”
“We conduct a pregnant women conference and make them share information and experience about their pregnancy, delivery and postnatal period to each other.”(20 years old, HEW)
“There are many facilitators than the previous one…At all the health posts, ICCM (integrated community case management) service is provided free of cost for the newborn and children.”(31 years old, HEW)
“The services provided for free are preparing porridge and coffee ceremony to make the mothers feel at home and comfortable. The health facility also prepares foods preferred by pregnant women such as chicken, which motivates them to deliver at the health facility. The families would come to the maternal waiting room and different foods would be prepared for them, and through this they enjoy. This motivates them to deliver at the health facility.”(37 years old, HEW)
“The health center asks the pregnant woman to pay for the card during antenatal care visit. I have seen this issue and made health workers return birr. This stresses mothers.”(24 years old, HEW)
“Even in the case when the delivered mother has an economical problem, baby kits would be provided for them. This motivates them to deliver at the health facility.”(32 years old, HEW)
“One of the facilitators access the ambulance service for free of cost and free service for drugs or service provided.”(28 years old, HEW)
“There are a lot of facilitators. Availability of health posts at the Kebele level, availability of and the service provided by the health extension workers, health center and health post linkage… are all the facilitators.”(31 years old, HEW)
“Previously, many mothers died from home delivery, prolonged labor, bleeding, and lack of access to transport. But, currently, the availability of ambulance services and maternity waiting room with blankets, televisions and other necessary materials facilitated mothers to seek care from health facility”.(25 years old, HEW)
3.2.2. Theme 2: Barriers to Maternal and Newborn Health Care Services Utilization
Sub-Theme 1: Community-Related Barriers to Maternal and Newborn Health Services Utilization
“After deliver, if the newborn develops a fever or becomes irritable, there is distance or difficulty of carrying it to seek care from the health facility.”(28 years old, HEW)
“…Also, there is a topographical difficulty and distance from a health facility. It is very difficult even for us [normal people or non-pregnant women], not only for a pregnant woman. It is difficult even to use traditional ambulance because of its sloppy and hill.”(37 years old, HEW)
“The husband might not support her in conducting different activities. Some women are overloaded with different activities at home or outdoors. Therefore, we conduct discussions with the husbands, families [mother and father], mother-in-law, religious leaders, and influential persons, and identify the barriers. We also create awareness about maternal and newborn health services.”
“In the context of my kebele, there are also those who know their date of delivery but do not have anything at home to prepare for birth. Also, the husband goes to the neighbor during labor to find something important during delivery.”(31 years old, HEW)
“There are mothers-in-law who complain that they gave birth of 10 or 13 children at home and resist the pregnant woman to deliver at home.”(28 years old, HEW)
“According to our community, it is forbidden to see a female’s bare body other than her husband or brother. Therefore, they prefer to deliver at home.”(32 years old, HEW)
“There are factors related to this issue that affects maternal and newborn services delivery. For example, there was a pregnant woman who challenged us to give birth at a health facility and delivered at home. On the next day after delivery, when I went to give postnatal care, they bruited slain hen under her bed. This is a traditional practice conducted within the community for women delivered at home. Therefore, we should continue to provide the service and change the practice through the process. I know that there was a woman who wanted to slay hen at the health center after giving birth. During this time, if we do not allow her to do this, they would not come to the health center.”
“In the context of our Kebele, the Muslim community does not allow pregnant women to stay in the maternity waiting room or deliver at health facilities. They complained that there is a porridge ceremony on the 7th and 9th month and do not go to a health facility. Due to this, they perceive that the pregnant woman would die if she goes and delivered at a health facility.”
“There are community’s traditional practices that affected intuitional delivery. For example, if a newborn is born at a health facility, it is not bathed within 24 h unlike that of newborns born at home. So, the community perceives that it comes home with the dirty body.”(22 years old, HEW)
“The community also perceives as an evil spirit contracted the women if she faces bleeding (APH) during pregnancy and takes to the religious leaders. Therefore, since the religious leaders and other community leaders are accepted by the community, it affected service utilization.”(19 years old, HEW)
“There are mothers not allowed to eat foods like sugar cane, spice, cabbage, etc. For example, there is a belief that if women eat sugarcane during pregnancy, she [the pregnant women] would face prolonged labor; if she[the pregnant women] drinks hot drinks, the newborns become bald; if she [the pregnant women] eats pimento, it would burn, if she [the pregnant women] eats porridge, it would be stickled on the newborn’s body. Therefore, we have to remove this belief from her mind and make her eat all these foods.”(19 years old, HEW)
“Rumors might be disseminated within the community. For example, if a woman died at a health center or hospital, others might perceive that she died due to going to a health facility or from poor health workers handling. Due to this, they might not go to the health facilities.”(21 years old, HEW)
Sub-Theme 2: Health Facility-Related Barriers to Maternal and Newborn Care Service Utilization
“Even if it is not all, there are some health workers that disrespect the pregnant women. They also tell her to return after she comes from far. Again, they tell her as the health worker goes site, and this is an obstacle for a pregnant woman to seek care. Due to this, she might become angry or negligent.”)
“They would say you do not bathe your body or hair or smell foul. Why you do not come changing your cloth or shoes? Due to this reason, they fear coming to the health facility. There is anger among the health workers.”(29 years old, HEW)
“The barrier from the health center or hospital side is that the health workers do not provide the service equitably. This means that they provide service judging based on the wearing style of a pregnant woman…They provide drugs or other services for those who wear clean clothes but order others to buy from outside. Is that the drug or other services are given for free are only for those who wear well? Not for those who come from the village [rural]? What our community has are mouth and hand, and if they buy drugs, even they might have nothing used for transport to return to home. This needs special attention and these are all the barriers.”(29 years old, HEW)
“Again, they tell her [pregnant woman] that the health worker goes outreach, and this is an obstacle for a pregnant woman to seek care. Due to this, she might become angry or negligent to utilize the service.”(27 years old, HEW)
“At the health post, there is lack of quality or clean equipment. Pregnant woman should have to deliver by clean materials.”(26 years old, HEW)
“While we implement ICCM (integrated community case management), there is a shortage of drugs…For the children above 6th month, for example, Plump nut and other drugs are provided. But, the supplies or drugs might not be available.”(28 years old, HEW)
“The health post is not constructed in the middle of the community. The second barrier is that there is no difference between constructed health posts with the house of the community except the materials available within it. It has nothing that we put the materials. This is because there are rats, which destroys the materials available at the health post.”(19 years old, HEW)
Sub-Theme 3: Infrastructure Related Barriers to Maternal and Newborn Health Care Service Utilization
“The barriers to seeking care are a distance from the health facility, inability to cross a river during summery from flooding…Due to this, there is maternal death or stillbirth.”
“The other barrier is lack of water at the health post.”(28 years old, HEW)
“The available ambulance if not enough or it is a big challenge. Sometimes, they say that there is no benzene, tire or the ambulance goes for referral purpose.”(29 years old, HEW)
4. Discussions
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Region | Zones | Districts | Number of HEWs Recruited | Number of Kebeles |
---|---|---|---|---|
Oromia | West Hararge | Chiro | 20 | 20 |
Amhara | North Shoa | Tasma Ber | 20 | 20 |
SNNPR | Dawro | Loma | 20 | 20 |
Total | 3 | 3 | 60 | 20 |
Characteristics | Category | Number (n) | Percent (%) |
---|---|---|---|
Age | ≤20 years | 5 | 8.3 |
21–30 years | 25 | 41.7 | |
31–40 years | 30 | 50 | |
Level of training | Diploma (level III) | 28 | 46.7 |
Level IV | 32 | 53.3 | |
Work experience | <5 years | 13 | 21.7 |
5–10 years | 22 | 36.7 | |
11–15 years | 25 | 41.7 |
Major Themes | Sub-Themes | Concepts |
---|---|---|
Facilitators to maternal and newborn health services | Community-related facilitators for maternal and newborn health care service utilization | |
Individual (pregnant women) related facilitators | Awareness | |
Behavior (Utilize the services, prepare for birth and birth-related complications, and stay at maternity waiting room) | ||
Experience | ||
Satisfaction | ||
Husband or family behavior | Resource mobilization | |
Social support | ||
Motivational support | ||
General community behavior | Resource mobilization | |
Social support | ||
Motivational support | ||
Significant others related facilitators for maternal and newborn health care services utilization | ||
Traditional birth attendant behavior | ||
Kebele chairman’s commitment | ||
Religious leaders involvement/behavior | ||
Women developmental army behavior | ||
Infrastructure related facilitators for maternal and newborn health services utilization | ||
Telephone service | ||
Transportation service | ||
Power energy system | Solar energy system | |
Health facility related facilitators to maternal and newborn health care services utilization | ||
Availability of health extension program | ||
Access to and health extension workers behavior to provide maternal and newborn service | Antenatal care | |
Delivery service | ||
Postnatal care | ||
Referral service | ||
Immunization service | ||
Information | ||
Pregnancy identification | ||
Pregnant women conference | ||
Sick newborn treatment | ||
Facilitators to maternal and newborn health services | Access maternal and newborn health services for free | |
Incentives | ||
Access to ambulance service | ||
Supervision and monitoring | ||
Access to maternity waiting room and service | ||
Barriers to maternal and newborn health care service utilization | Community-related barriers to maternal and newborn health care services utilization | |
Distance | ||
Topographic nature | ||
Workload | ||
Economic constraint | ||
Woman’s power in decision making | ||
Religious and socio-cultural beliefs and experience | ||
Unpleasant rumor | ||
Health facility-related barriers to maternal and newborn health care services utilization | ||
Health workers behavior | Empathy | |
Compassion | ||
Respect | ||
Postponement | ||
Fairness and equality | ||
Absenteeism | ||
Lack of adequate medical supply and equipment | ||
Lack of adequate ambulance service | ||
Placement and quality of health post | ||
Payment request | ||
Infrastructure related barriers to maternal and newborn health care services utilization | ||
Lack or poor quality of road | ||
Lack of water supply at the health post | ||
Inadequate ambulance |
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Higi, A.H.; Debelew, G.T.; Dadi, L.S. Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study. Int. J. Environ. Res. Public Health 2021, 18, 10467. https://doi.org/10.3390/ijerph181910467
Higi AH, Debelew GT, Dadi LS. Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study. International Journal of Environmental Research and Public Health. 2021; 18(19):10467. https://doi.org/10.3390/ijerph181910467
Chicago/Turabian StyleHigi, Alemayehu Hunduma, Gurmesa Tura Debelew, and Lelisa Sena Dadi. 2021. "Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study" International Journal of Environmental Research and Public Health 18, no. 19: 10467. https://doi.org/10.3390/ijerph181910467