Characteristics of study participants
The mean age of the women was 26.9 years (SD ±6.9). There was a statistically significant difference between the two woredas by wealth status (p < 0.001), maternal education (p < 0.001), parental education (p < 0.001), food insecurity status (p < 0.001), head of the household (p < 0.0001), total family size (p < 0.001) and religion (p < 0.001). However, no difference was observed in terms of maternal age (p = 0.51), mean age at first marriage (p = 0.054) and decision-making power (p = 0.41). The average number of pregnancies a woman had in her lifetime was 4.6 (3.1), and about 10.1% of women were pregnant at the time of the survey (Table 1).
Maternal health care service utilizations and associated factors
Five hundred fifty (44.6%) of women had four or more ANC visits during their latest pregnancy and 429 (34.8%) had their first ANC visits during their first trimester. Regarding delivery care (DC) use, 576 (38.4%) of women used DC services. On the other hand, only 20.5% of the mothers had used modern contraceptive methods (Table 2).
Factors associated with modern contraceptive method use
Women whose age at first marriage was delayed (> 17) were 1.64 more likely to use a modern contraceptive method than their counterparts (AOR = 1.64, 95% CI 1.22, 2.20), and women whose partner attended secondary education were two times more likely to use contraceptive methods (AOR = 2.00, 95% CI 1.33, 3.01) (Table 3). Women living in middle-income (AOR = 1.73, 95% CI 1.16, 2.59) and highest income HHs (AOR = 2.02, 95% CI 1.31, 3.11) and had a history of ANC (AOR = 2.21, 95% CI 1.45, 3.36), previous experience of delivery (AOR = 1.40, 95% CI 1.02, 1.91) and knowledge about family planning (FP) (AOR = 1.45, 95% CI 1.30, 1.61) were more likely to use contraceptives than their counterparts (Table 3).
Factors associated with ANC use
The majority of women asserted that it is not customary to use ANC services (40.5%) and others stated it is not necessary to use ANC (14.6%). Other factors such as distance (12.0%), absence of traditional cultural practices at health facilities (5.2%) and facility-related factors (5.2%) were also mentioned by women (Fig. 1). Table 3 describes the determinants of ANC utilization. Primary education (AOR = 1.60, 95% CI 1.03, 2.49), secondary education (AOR = 1.62, 95% CI 0.89, 2.97), women autonomy (AOR = 1.16, 95% CI 1.07, 1.25), highest income (AOR = 1.62, 95% CI 1.09, 2.42) and knowledge about FP (AOR = 2.35, 95% CI 1.56, 3.54) were positively associated with ANC utilization. In contrast, older women (AOR = 0.64, 95% CI = 0.46, 0.90) and women living in food-insecure HH (AOR = 0.97, 95% CI 0.95, 0.99) were less likely to use ANC (Table 3).
Factor associated with delivery care
The most commonly cited reason (27.9%) for not using delivery care services was that facility-based delivery was not their custom, followed by distance was too far (15.4%) (Fig. 1). Factors positively associated with delivery care utilization include secondary education (AOR = 3.40, 95% CI 2.16, 5.34), highest income (AOR = 2.18, 95% CI 1.55, 3.07), previous use of ANC services (AOR = 4.23, 95% CI 2.82, 6.34), women’s autonomy (AOR = 1.08, 95% CI 1.01, 1.15) and good knowledge of DC (AOR = 1.78, 95% CI 1.21, 2.60) (Table 2). In contrast, older women (AOR = 0.45, 95% CI 0.32, 0.63) and more gravidae (> 3) (AOR = 0.48, 95% CI 0.36, 0.63) were less likely to use delivery care services (Table 3).
Barriers for family planning/modern contraceptive use
Lack of awareness, misconceptions and perceptions
In this study, we found that pastoralist women had little awareness about family planning (FP) and there are also misconceptions related to the modern contraceptive method use. As one of the informants said: “Generally, awareness about contraceptives methods is low among women in our communities. A few women knew different types of contraceptives methods mainly injectable, pills and implants” [in-depth interview, Gorodola]. Such awareness was also influenced by poor perceptions, myths and misconceptions about contraceptives. For instance, one of the respondents mentioned that: “They perceived that contraceptive are not suitable for ‘busy women’ like them” [in-depth interview, Dhas]. Some also associate the nature of pastoralist lifestyles and diet quality as one of the reasons for not using contraceptive methods. In one of the FGDs, a woman said that “Women need to eat good and enough food and should not do heavy loaded activities like fetching water from long distances if she uses contraceptives. Contraceptive is not suitable for us[women in pastoralists] since our life style is demanding” [FGD with mothers, Gorodola].
Looking for respect and love
Most of our discussants believed that having a large number of children cherished them respect and love from their partners. “Most women in the community aren’t ready to limit the number of children. They want to have as many children as they can because they think that the more children they have, the better their husbands love them and more stable their marriage will be” [KII, Dhas].
Spouses disapprove of using such services and using. Some women hide the use of contraceptives from their husband. One of the reasons is fear of husband betrayal or divorce,
“The women are not confident to use FP due to the fear of confidentiality. If their husband learned that his wife uses any modern contraceptive, he may betray and proposes to divorce”. [in-depth interview, Gorodola].
“Everything is in the hands of ‘waaqa’/God”
According to the respondents, fertility is a blessing and sterility is a curse. If a married woman did not have a child, her neighbours and relatives may label her as “Hasidaa” (meaning barren or infertile cursed women. Therefore, she needs reconciliation with God through practising some rituals).
“Everything is in the hands of Rabi/God”, one of the FGD participants explained [FGD with women, Dhas]. “He (God) who creates human being has everything to feed and grow. We perceive those human beings are born not only with mouth to eat, but also with hands to work” [FGD with their husband, Gorodola]. They repeatedly mentioned: Waaqni keenyas hori, faca’i, balladhu jetti which literally means “Our God says may you reproduce, expand and fill the land”. One of the mothers also said Yoo mammaakan Afaan sooraaf uume waan keessa kaa’u Rabbitu beeka [He (God) who created the mouth, knows what to put in.] [FGD with mothers, Gorodola].
Large family as a “survival strategy” and means of economic security
According to the respondents, having more children is not an end by itself but a means for household economy and family security. Children contribute to the economic activities of the family/households: “If one keeps cattle, the others keep camel, goats and sheep and others also help on household activities like fetching water”. [FGD with women, Gorodola].
Large family as a protection from enemies
A large family is also perceived as a means to secure protections from enemies. One of our respondents said that “Children are valued as sources of social security, peace keeper and fighters for their communities in times of difficulties such as conflicts” [in-depth interview, Dhas].
Therefore, a large family size is perceived to provide the needed security in a community which is prone to conflicts. One of the participants said: “Having many children was considered as the source of social respect. Enemies cannot easily attack those large families” [FGD with their husbands, Gorodola].
One of the barriers to the use of modern contraceptive methods is the rumours which hover around the communities by previous users. They sometimes associated menstrual irregularities to contraceptive use. “There were women who suffered from continuous bleeding and menstrual irregularities. They fear that the same fate may happen to them” [KII, Gorodola].
Health system factors
Although contraceptive methods are available in health facilities and provided for free, most women do not use contraceptive methods due to a lack of professionalism and ethics among health care workers. It discourages the mothers to use contraceptive methods. “Whenever women reported perceived pain or discomfort associated with the use (e.g., Implanon) and came here to remove it, the health professionals were not willing to do so. Instead, they belittle, insult and sometimes beat them”. [KII, Gorodola].
Reasons for not using ANC services
Lack of knowledge and awareness
Some pastoralist women do not use ANC follow-up because they lack awareness about the service and its importance.
Most of the women do not have awareness about ANC [in-depth interview, Gorodola].
Household division of labour/chores
Women mainly give priority to look after their children and family members at the cost of their health. One discussant said:
Most women are busy with household activities such as cooking, feeding, cleaning and caring for family members. Hence, they have no time to attend the awareness creation meetings organized by the health extension workers. [FGD with women, Gorodola].
Husband disapproval and disinterest
In this study, husband’s lack of interest and willingness to support attending ANC was repeatedly mentioned by women during their discussion:
Some husbands consider that there is no need for their wives to visit health care providers under normal circumstance or without health complications. [FGD with women, Gorodola].
Community beliefs and perceptions
In this study, there is a widely accepted social belief among the communities that “pregnancy is not a sickness” and hence there is no need for a woman to visit health institutions under normal circumstance. For example, one of the discussants uttered “only sick people visit health facilities”. [FGD with women, Gorodola].
Beliefs that “God has determined destiny”
It is believed that God, who creates the womb, protects it from any damage and thus it is better to pray to him. One of the discussants said that “They (the health professionals) are not God. They cannot create or save our lives as that is already determined by God. So, why do we long for their support? Above all, it is better to surrender oneself to the Almighty than bothering too much”. [FGD with women, Gorodola].
Women’s decision-making power
Women’s autonomy to use health care services is also one of the major determinants. Culturally, a woman has limited power to decide on aspects of family life. Without her husband’s approval, she cannot go anywhere, even to buy necessary materials for birth preparedness.
Lack of supplies such as drugs and equipment
One of the most frequently mentioned issues that limit women’s ANC follow-up is the absence of drugs in health facilities. Most women complained that they “only get prescriptions” from the health facilities. Hence, they think visiting the health institution for ANC is “just wastage of time”. “If we do not get what we want, why do we go there (health centers) … we prefer to go to the private clinics than simply wasting time at health centers”. [FGD, with women, Gorodola].
Health professionals’ lack of ethics and cultural competency skills
The other issue repeatedly mentioned as barriers to pregnant women is that some health professionals were not welcoming. “The language” they use was offensive and they were not respectful and compassionate. Hence, most women said that it is “better to stay at their homes instead of being humiliated and mistreated by the health professionals”. [FGD with women, Dhas].
Providers do not give women a chance to ask questions and get clarifications. Rather, they simply told the women what to do.
The health professionals in health centers often belittle and shout at clients especially women from the rural areas. [KII, Dhas].
Most of the women claimed their inability to afford transportation cost: Even if some women are interested to go for ANC, the centres are too far. It is very difficult for them to travel such a long distance on foot.
Reasons for not using health facility delivery
Lack of awareness and misconceptions
Women do not use delivery services for various reasons. One of the reasons that emerged in this study was the lack of information. One of the KIIs said that “they have not got adequate information on the benefits of delivery care”. Even if they have got awareness, “some women also fear that they may get injured if they deliver at a health center”. Delivery at health centres is a last resort only after they tried at home by traditional birth attendants.
In this study, we found that negative experience of a child’s or woman’s death results in poor utilization of the services. “The health professional cut and removed the child’s umbilical cord inappropriately resulting in death of the baby”. Such rumours were widely circulated in the community and they develop fear to go to a health centre for delivery.
Taboo of “Don’t show private parts” to male
A woman feels ashamed of showing her private parts to male health care providers during delivery. Culturally, it is not allowed to expose their bodies including reproductive parts to someone (health care providers) they did not know before and who is younger than their age. They are comfortable only with significant others such as their mother, close friends, relatives and the husband.
Less involvement of significant others
Even though women preferred their partners/relatives to stay with them during delivery, health professionals do not allow their significant others to stay in the delivery room. Furthermore, assisting the birth in a group is strange for them and shameful, according to their culture: “On the contrary, they (the health professionals) came in group and attend the birth process and see woman’s private part which is very shameful”. [FGD with women, Dhas].
Most women were not comfortable with horizontal delivery positions. They preferred kneeling, squatting and sitting on bed during labour than lithotomy position. One of the discussants raised this issue as “Women dislike such kind of delivery positions which expose their private body part to strangers (“the health care professionals”) particularly, males and those they do not know before” [FGD with women, Gorodola].
Health care professionals’ gender preference
Women repeatedly mentioned that they prefer to be assisted by a female than a male health care worker. It is a shame for them to be seen “naked” by male health care providers.
They repeatedly told us they would prefer to be assisted by female health care workers. [KII, interview, Dhas]
Husband involvement — past experience as a frame of “reference”
“…Nothing is new with my wife, why should I take her?”, asked one of the discussants during the group discussion. Most of the participants argued that their mothers and grandmothers never had attended antenatal care or delivery care. Thus, most husbands prefer home in the same way their grandmothers and their mothers used to. “They perceive that may expose the mother and the infant to various health risks”.
Misconception of health risks
The community perceives that delivery at health center expose the mother as well as the newly born infant to risks. According to their norms, a newly delivered woman should stay at home for at least three months with her child. In contrast, the health centers discharged the mothers within short period of time. [in-depth interview, Dhas].
Belief on labour: Concepts and its process (norms)
According to the norms, even her husband should not hear the voice of his wife while she is in labour. For instance, there is a traditional saying, Manni moggaa si hindhaga’in which means “May your neighbor never hear your voice during your labour”. Siree ati irra ciiftu illee sihin dhaga’in which means “May even your bed never hear your voice”, i.e. the woman should hold the pain while she is in labour. They said Ciiniinsuun hin lallabamtu, which literary means “We don’t shout louder on labour”. They also said, “There is no pain more than this in any of one’s life. If she fails to hold it, it means she is not courageous”. During the discussion, in some contexts, the birth process is a “sign of bravery or endurance” if a woman kept silent while giving birth. Shouting or crying was described as “Weakness”.
Failures of the modern health care institutions to be responsive to their cultural needs were repeatedly mentioned as the main reasons why they do not use the services. Most of these practices were not practised or accommodated at the health facility level, hence discouraging women from using delivery care services. The cultural practices include:
Okolee uuluu and ittittuu obaasuu to increase inter-abdominal pressure, to ease delivery process and to expel the placenta.
Gubbifachuu was practised right after the birth of the baby. Her husband should tie pieces (called samaxee) of sheets of clothes on his head to notify the locals that his wife gave birth. It is a sign of respect that must be practised within the first 3 days of delivery. However, if a woman delivered at a health facility, they would miss this practice and the child is said to miss respect from the community when he/she grew up.
Arguugaa eelmachuu (literally mean milking a cow): This cultural practice lets the father to milk a cow for three consecutive days. It is a sign of blessing and wishes for the new baby to have more wealth when he/she grows up.
Eerbee Fannisuu (waving animal skin): Following the delivery of a baby boy, there is a culture of flagging/waving the animal “skin/hide” in front of their door. It is a sign that showed the birth to a “baby boy”. In so doing, it guides neighbours, families and relatives to choose the special saying/songs they should sing while congratulating the mother and the family.
Ayyaana dabarsuu (transversion of the spirit): According to Borana’s culture, the community take into account the day, time and condition at which the baby was born and define the baby’s Ayyaana (the spirit) as Ayyaana bitaafi Mirgaa (the spirit of right and the spirit of left). If the baby’s spirit (Ayyaana) is categorized under Ayyaana bitaa (the spirit of left), the family is expected to go to Ayyaana Hedduu/Lakkooftuu (fortune tellers) to transverse into Ayyaana Mirgaa (the spirits of rights). Otherwise, it is believed that the child’s fate and destiny will be complicated.
Hidhaa buufachuu (easing ties): When labour starts, her husband should unfasten his tie and belts and wear a towel (fooxaa marxifachuu qaba) as well as loosen any other tied materials in the house (Waantoota qadaaddii ykn kiddoo qaban/waantoota hidhamanii mana keessa jiran mara bubuqqisuu ykn hiikuu, i.e. when the labour starts, all tied/closed things/materials in the household must be opened). They associate this with helping women get relief from their labour pain and being made comfortable, and shorten the labour duration
Dhadhaa dibuu (“Butter on abdomen”). When contractions reach its peak, her husband is expected to put butter on her abdomen. This is believed to relieve her pain and shorten the contractions.
Obbaatii Marsachuu: The community perceives that the placenta is the main part of the foetus. Without it, the baby never exists so it should be respected and buried under Sunsuma and not to be burned and/or given to dogs. This is reflected by the communities’ saying Kun sareef mucaa darbachuu jecchuu dha, which means “throwing the placenta is like giving our baby to dogs”. They perceive that the child may abandon his family if the placenta is not buried according to their cultural practices.
Lack of transportation
One of the main reasons FGD participants repeatedly raised for low delivery care uptake by respondents was the lack of transportation or ambulance services.
“There was only one ambulance for the 22 kebeles. These kebeles are very far away from each other and even far from the health centers up to 60 kms”. One ambulance is not enough given the size of our woredas, within a 100-km radius. Second, the way in which ambulances are giving the service was difficult. Moreover, the absence of transportation services between their living place and health centres
“…. they were afraid of both the cost and lack of transportation after delivery. These women come to health centers by ambulance but were forced to take a motorbike or “Bajaj”, a three-wheel drive at high price (200-300 birr) which was not affordable” [in-depth interview, Gorodola).
Lack of ethics and professionalism among health workers
Some health care workers insult and even slap women while on labour. “They humiliate and treat us like animal. We need delivery at health centers only as the last resort. We prefer our home where our relatives and friends encourage and help us with humble heart, where we deliver with respect”. More importantly, some of them were culturally incompetent, use languages that are sensitive and women found intolerable or unacceptable.
Inaccessibility of service and infrastructures
According to key informants, a myriad of factors such as lack of blood transfusion and neonatal unit, limited delivery couches in health facilities, the lack of linen for the couches, the absence of light and space for attendants and medication were influencing delivery-seeking behaviours of women. Most of the community members did not have a mobile phone to call for services; those who have mobile even do not have access to power to charge their battery. The absence of medications in the health centres was another factor affecting the use of delivery services. Most of the time, women were referred to private clinics to buy medicine outside.
Role of community health workers
Community health extension workers were supposed to stay in contact with communities for more than 75% of their working time. However, pastoralist women reported that they had less contact with HEWs: “The health extension workers and other health professionals have not done adequate effort to raise the awareness of women on these issues” [KII, Gorodola].
System dynamic analysis
Unlike the traditional epidemiologic approaches that have focused on isolating the causal health effect of a single factor, we assumed pastoralism and health care system by their own are complex systems. Thus, the focus of our understanding about why poor maternal health care service use should take the function of both systems as a whole. The main aim of the system dynamic analysis was to offer a practical way to understand the inter-related parts and the cause-effect linkages for the low utilization of RMNH services and explain the mechanisms within complex systems which include the relationships, dynamics and delays associated with the variables that generate them. That is, the effect of a single factor may depend on the state of other factors in the system and be affected by feedback loops and dependencies. Understanding fundamental relationships is also essential for identifying appropriate intervention points to address these factors and for anticipating the potential impact a new programme will have when introduced into a pastoralist community. Accordingly, we have identified three balancing loops: (B1) health care delivery approaches, (B2) the role of past experiences and (B3) population factors. For instance, lack of health care workers’ skills and cultural competencies could influence the perceived quality of care in a health care institution resulting in low RMNH service use. Past experiences of the mothers influence their attitude towards male health care providers resulting in poor satisfaction and promote low RMNH service use. Regarding the reinforcing loops, we have, for instance, shown how religion influence positively their social norms and the social norms also influence individual perceived norm/attitudes resulting in poor RMNH service utilization (R1). The effect of distal factors in contributing to low RMNH service use is also shown (R2). Most of the distal determinants could take some time. For instance, the more educated the mother is, the higher she uses the RMNH services. However, educating a mother through formal education may take more than a decade. An increase in awareness of these mothers about RMNH could improve the service use, but the motives to know something are highly influenced by their perceived social norms (see Fig. 2).
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