Boosting Maternal and Child Health in Wollega: preliminary research

Formative Study

1b. Preliminary research on how to stimulate health

seeking behaviour

Summary of key findings

Prepared by:

Miz-Hasab Research Center

Addis Ababa, Ethiopia
Lead Researcher: Hailom Banetyerga
Project Leader: Aklilu Kidanu

and elaborated by

MANGO Consult
The Netherlands

Addis Ababa, July 12th, 2013 v2.0

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

Table of Contents

Page

Introduction & acknowledgements 4

Acronyms 5

1. Research background 6

2. Key findings and recommendations 8

A. Seeking general health care and delivery of health services

B. Seeking maternal health care and delivery of health services

C. Recommendations

(i) Make the maternity care continuum more educative and informative

(ii) Strengthen the capacity of the health service delivery system

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

Introduction & acknowledgements

As stimulation of health seeking behavior and more particular stimulation of demand for maternal and
child health services in Wollega is considered a critical success factor for the ORIO project, in the Input-
Output Plan a preliminary research was included as one of the deliverables. Following a tender issued in
February by EngerderHealth in close cooperation with MANGO Consult, the Research Center Miz-Asab
was assigned for this important task.

MANGO Consult is grateful to Miz-Hasab Research Center based in Addis Ababa, Ethiopia for the
research carried out in Wollega on deliverable:
1b. Preliminary research on how to stimulate health seeking behavior.

In particular MANGO Consult likes to thank the Lead Researcher Hailom Banetyerga and Project Leader
Aklilu Kidanu for their critical role in this research. In addition MANGO Consult is grateful to
EngenderHealth Ethiopia for their crucial support in the preparation for this research and in translating the
key findings into the Health Promotion Plan.

As MANGO Consult conducted extensive site surveys in Wollega in the period January through March
2013, information from these surveys and interviews with zonal directors, woreda directors and health
staff in the various zones is also incorporated in this summary of key findings and recommendations. The
below listed key findings and recommendations were incorporated in the Health Promotion Plan, the
Technical Medical Plan, the Human Resources Plan as well as the Institutional Plan.

The Miz-Hasab Research Center duly acknowledges the full-hearted cooperation it received from all the
participants of the study in Wollega, Oromia. These include the Oromia Regional Health Bureau,
community members, TBAs, HDAs and HEWs, skilled health workers and facility administrators. The
interest they showed in the study and their open and full-hearted cooperation enabled the researchers to
document behavior, views and pertinent events and stories that have become the central parts of this
report. The Center also gratefully acknowledges the technical and administrative support it received from
Dr Yetnayet Demisse Asfaw and Ato Jemal Kassaw of EngenderHealth Ethiopia as well as from Drs.
Wessel Eijkman and Drs. Frank van Doren of MANGO Consult, The Netherlands. The Center also pays
its gratitude to the supervisors and researchers assigned to facilitate the FGDs and in-depth interviews in
the study areas. In this regards the Center is grateful to supervisors Hailemariam Gemetchu and Solomon
Alemu as well as researchers Gizachew Haile, Tesfaye Ajema, Sirahiwot Tadesse, Hinsene Gomosa,
Dessalegne Hailu, Keteme Mulata, Taitu Wakshume and Getchew Alemu. Finally, the Center is especially
grateful to Dr Hailom Banteyerga, the principal investigator of the study, for the tireless effort he showed
from the beginning to the end of the study. His understanding and insight of the issues investigated in this
study have tremendously contributed to the validity and strength of this report.

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

Acronyms

ANC Antenatal care

BEmOC Basic Emergency maternal and neonatal Care
CEmONC Comprehensive Emergency maternal and neonatal Care
EDCA Ethiopia District Comprehensive Assessment
EDHS Ethiopia Demographic and Health Survey
EPI Expanded Programme on Immunization (World Health Organization)
HDA Health Development Army
HEW Health Extension Worker
HSDP Health Sector Development Program
ICU Intensive Care Unit
MCH ` Maternal and Child Health
MDG Millennium Development Goal
MMR Maternal Mortality Rate

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

1. Research background
As reiterated by the HSDP IV, maternal and child health are the primary health targets of Ethiopia. The
present research study looked into the barriers and facilitators in maternal and child health care seeking
behavior in Wollega, a major region in Oromia State administration. Wollega is one of the regions with low
ANC and health provider assisted births. The main aim of the study was to propose doable interventions
that boost maternal and child health in the region with a possible national implication.

The study was set-up as a formative qualitative study covering the four zones on Wollega. Qualitative
data was collected from key informant interviews, focus group discussions and a case study on maternal
waiting homes. The research participants included women in reproductive age (clean and complicated
birth), husbands, influential elderly women, community leaders, community health workers, skilled birth
attendants both traditional and health facility based providers, and health planners and leaders at kebele,
woreda and zonal levels.

The themes explored cover the events in the maternity continuum from pregnancy up to post partum care:
knowledge, attitude and practice in antenatal care, preparation for birth, selection of birth place and birth
attendants, post natal care, social networks, overall service seeking, delivery and utilization and their
relation to the so called three delays: delay one at home, delay two during transportation and delay three
at care giving facility in situations of obstetric emergencies.

The focus of the study was exploring barriers and possible facilitators in maternal and child health care in
the context of Wollega. The research gathered qualitative data through in-depth and key informant
interviews, focus group discussions and facility observations. It explored what happens in the maternity
and infant care continuum from pregnancy to post partum care. It is a formative qualitative study; it does
not include quantitative data either from facility or survey opinions of sample respondents. Hence, in
essence, it is discursive. Narrative descriptive texts are used to explain the events in the process
contributing to low ANC and facility births -the interactive behavior leading to the three delays in times of
obstetric complications and emergencies.

The study probed into the care seeking and utilization of ANC care services. It probed into knowledge,
attitude and practice of ANC of mothers in reproductive health ages, husbands, influential elderly
mothers, community leaders, community non medical health workers and their auxiliaries, health
extension workers, members of the health development army, traditional birth attendants and community
leaders, HAD and TBA’s. It also examined the availability of family health related information such as
family hygiene, nutrition, family planning, vaccination, antenatal care (care service for pregnant women at
least with 4 visits), written birth and emergency plan for each pregnant woman in preparation for safe
delivery with a system of tracking pregnancies and record births and community responses in the transfer
of women to emergency facilities when needed.

In an attempt to explain the nature of the three delays in the context of Wollega, the study examined the
availability and utilization of ANC services in relation to birth preparedness especially complication
preparedness. In this endeavor, the research activities probed into knowledge of women and their
associates on pregnancy risks and their indicators: during pregnancy (vaginal bleeding, blurred vision,
swollen hands); during labor and birth (severe bleeding, prolonged labor, retained placenta, convulsions)
and during postpartum (severe bleeding, high fever, foul smelling vaginal discharge); the decision making
process particularly in the selection of birth place, preference for birth attendant and preparation for
emergency care, cost, transport, and person to accompany. The roles of women, husbands and other
influential family and community members and cultural precepts were examined.

The study also probed into when women report for ANC and why women do not regularly attend ANC and
prepare for birth in a health facility. In this respect, the study looked into access to information and ANC
services, attitude towards health facility based care services, socio cultural barriers -if they existed at all-,
and the barriers that interactively contribute to the three delays.
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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

The study explored social capital that can be used in a program intervention to boost maternal and child
health. It probed into what people think about maternity health care from a cultural perspective and also
what they thought needed to be done if they were to make use of modern health care services. It also
looked at the possible social, community and government structures that prevail in kebeles and districts
for social mobilization towards raising awareness to seek and utilize maternal care services in health
facilities.

The study also reflected on the critical bottlenecks in the health care system that could discourage
women and their families from attending to the key care services in the maternal health continuum
especially from pregnancy to post natal care. The study also looked into what could contribute to efficient
and effective use of resources in the efforts to boost maternal and child health in the context of Wollega
with concrete implications to the way the health system is working in the country and what contextual
factor need to be considered for ramifications.

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

2. Key findings and recommendations

A. Seeking general health care and delivery of health services
The overall attitude of the community in the study area towards modern health care is positive. All
research participants irrespective of their socio demographic differences agree that,

(i) Accessing and utilizing modern health care services for prevention and treatment is critical to the
reduction of morbidity and mortality caused by illnesses.

(ii) There should be health facilities well staffed and equipped to give preventive and treatment care
services; some respondents however think that the care service delivery is still poor in quality.
Providers working at community level are perceived by some to lack skills and abilities. The
overall primary health care giving facilities (health posts and heath centers) are according to a
number of respondents ill equipped and not yet adequately staffed.

(iii) The curative services are mostly delivered at hospitals that are located far away for most care
seekers. Accessing such facilities during emergencies remains problematic due to the weak
transportation system -lack of public transport vehicles, some areas not accessible by road at all,
cost of transportation is unaffordable for many people in rural areas.

(iv) In various instances the providers working in the facilities managing emergencies are seen as
less motivated, and some rural women complained about the behaviors of health workers.

B. Seeking maternity health care and delivery of health services

This is the main target of the study. The findings noted along the maternity continuum are the following.
(i) The community is positive towards accessing and utilizing maternity health care services.
The care concept towards pregnant women is deeply rooted in the Oromo mind set as
reflected in their traditional practice and care for a pregnant woman, while giving birth and
after birth. The community is appreciative of the significant efforts done by government and
the Region to reach people and inform them on health and especially maternal health.

(ii) In general the community however does not think that it is already able to access the
services promised from the health service delivery system particularly in maternity health
care.

(iii) ANC is the main gate to the maternity health care services during pregnancy, birth and
postpartum, but it is not strong enough yet to attract pregnant women to regularly come for
pregnancy check up as medically recommended. The visits often take place towards the last
quarter of the pregnancy and in most cases are limited to one visit for most women.

(iv) Pregnancy related risks such as miscarriage and abortion happen but are mostly not
reported. The study noted that the health mobilization and communication, which health
extension workers perform, does not yet educate women adequately on the nature and risks
of pregnancy, birth and post birth and how to prevent them. As a result almost all women in
the study area decide to give birth at home, despite the severity of the risk at birth. Especially
when labor is prolonged, they seek skilled assistance either from a traditional birth attendant
or get transported to a nearby health facility experiencing the three delays.

(v) The referral system puts women in obstetric emergency in a difficult situation. The HEW’s
refer such women to a nearby health center. The assumption is that the health center would
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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

refer the patient to a hospital with comprehensive emergency obstetric care services in case
needed. In most instances the health center does not transport the woman using ambulance
emergency services; only some woredas have an ambulance services and these are
therefore mostly not available as needed. It rather advises the family by giving a referral slip
to take the patient to the referral hospital. The patient experiences all dangers and risks of
additional delays including death. This discourages women to seek health care services. In
some cases families transport such a woman to a hospital without asking for referral. In many
situations women die at home from obstetric complication that otherwise would be
preventable.

(vi) In areas where the care service is better organized and delivered such that the health post
manages vaginal delivery and ambulance service is available on call from the health post,
the care seeking behavior is higher and more women attend ANC, get prepared for facility
birth including complication preparedness. However, the post partum care even in such
places can be further improved as too many women who gave birth and should stay in a
health facility especially in case of Caesarian Section are asked to leave the facility of birth
within five days in most cases. This is because of lack of recovery spaces. Pregnant women
who come to a health center are often told to return to their home and await the start of labor
as adequate waiting areas are lacking.

(vii) The case study on maternity waiting homes shows that it is an appropriate option towards
dealing with the second delay in Wollega. The experiences in the maternity waiting homes at
hospitals and the thinking of the community support the idea of building a facility where
women under risk condition can stay while being monitored by care providers until birth.
Maternity waiting homes close to where comprehensive obstetric emergency is managed
have saved the lives of many women and their babies; Ayra and Gimbi hospital being a case
in point.

C. Recommendations
The study has made the following recommendations.

(i) Make the maternity care continuum more educative and informative

This should be inclusive: pregnant women and other women in reproductive age (not married), husbands,
community influential members both men and women, community health workers such as members of
the health development army, health providers and managers/leaders. In this process it is recommended
that the education and communication activities be,

 Interpersonal and interactive communication: make people reflect on their health problems
and actions they can do.

 Enhance community and household efficacy, confidence and openness to deal with
pregnancy related complications; rural people are sensitive and can be opinionated.
Education/ communication should guide people to report on the risks and problems they
encountered and what could be done to prevent such dangers and risks.

 Target health provider, facility management staff and health leaders; there are some issues
of inappropriate behavior towards clients and governance.

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult
 Boosting Maternal and Child Health in Wollega: preliminary research

 Use social capital for social mobilization in maternal health as basis for behavioral change in
care seeking: the community’s positive attitude and the social and government structures
could be utilized more effectively in social mobilization.

 Mobilize communities to be part of risk and emergency mitigation -communities have to be

part of the solution in dealing with delay one and two, -communities can think of having an
emergency unit for transporting patients like women in obstetric emergencies to care giving
facilities without long delay as well as in the realization of maternity waiting homes near
health facilities with CEmONC services

(ii) Strengthen the capacity of the health service delivery system

The health system in Wollega needs further strengthening. The following doable actions are
recommended to be considered.

 Train primary health workers such as nurses, HEWs in the management of maternal risks
and clinical care.

 Strengthen the primary health structure in terms of space and equipment to be able to deliver
maternal health care services. This includes both the health post (clean and safe delivery)
and health center (BEmONC).

 Make available CEmONC services at accessible distance. In districts where hospitals are not
available, it is possible to select the best located health center and upgrade it to a level where
it can deliver CEmONC service without any interruption—consider power, water, and staff.

 Build additional rooms for waiting and recovery in facilities that attract more clients, especially
hospitals and CEmONC upgraded health centers that manage emergencies.

 Build maternity waiting home in collaboration with concerned authorities, partners and
communities in health facilities that are located in bigger catchment areas.

The study -cognizant of its limitations- concludes that if the health care service delivery is further
improved and the awareness of maternal complications is stimulated, that the care seeking behavior of
the communities will increase. The availability of maternal and child health care provided by skilled health
workers at a close distance to the clients, such as the health post and health centres, is crucial to ANC
attendance as well as institutional SBA birth important steps towards reaching the MDGs, the ORIO
project targets.

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Research carried out by Miz Hasab Research Center, Executive summary elaborated by MANGO Consult