Demand–supply-side barriers affecting maternal health service utilization among rural women of West Shoa Zone, Oromia, Ethiopia: A qualitative study

Introduction Despite the efforts and strategies being applied by the government and the partner organizations to increase maternal health service utilization, maternal health service utilization is low in the general population and very low in rural communities of the West Shoa Zone specifically. Objective This study intended to identify and describe barriers contributing to low maternal health service utilization in selected rural districts of the West Shoa Zone of Oromia regional state, Ethiopia, by 2021. Methods The study was conducted from February 01 to April 30/2021 in three districts of the West Shoa Zone. The districts were selected purposively based on the report of their last year’s (2020) performance on maternal health service utilization obtained from the Zonal health office, where the ANC follow-up and Institutional delivery were the lowest among the Districts in the Zone. A community-based qualitative phenomenological approach was used to explore the demand-supply side barriers affecting the utilization of maternal health services. Six Focus Group discussions, 9 In-depth Interviews, and 12 Key Informants Interviews were conducted with women who gave birth at home in the last 12 months and with health care providers at different health offices and health institutions. Data were tape-recorded, transcribed verbatim, translated, and analyzed thematically using MAXQDA software. Results Our findings revealed that though women strongly agree on the importance and advantage of maternal health services utilization, both demand and supply side barriers such as low awareness on when to use the services, not knowing ANC schedule, misinformation about ANC and institutional delivery, not knowing their estimated date of delivery and precipitated labor, shortage of manpower at health institutions, far distance health facilities, and unavailability or un-accessibility of ambulance services during an emergency time, lack of transportation to health facilities were hindering them not to use the services. Conclusion In general, rural women are facing many challenges yet to accessing and utilizing maternal health services. To achieve the SDG targets, addressing barriers prohibiting a woman from using MCH should be critically addressed.

Enter a financial disclosure statement that  to participate were requested after briefing the objective of the study. Both verbal informed and written consent were obtained from the study participants. Confidentiality of the data to be collected was secured and will not be transferred to any other third party. To ensure the confidentiality of the participants, the participants' names were not mentioned during interviews or FGD discussion, or report writing. Instead, the term Mr., Miss was used during KII and IDI, and code numbers were used during FGDs.

I. Abstract
Introduction: Despite the efforts and strategies being applied by the government and the partner organizations to increase maternal health service utilization, maternal health service utilization is low in the general population and very low in rural communities of the West Shoa Zone specifically.
Objective: this study intended to identify and describe barriers contributing to low maternal health service utilization in selected rural districts of the West Shoa Zone of Oromia regional state, Ethiopia, by 2021.

Methods:
The study was conducted from February 01 to April 30/2021 in three districts of the West Shoa Zone. The districts were selected purposively based on the report of their last year's (2020) performance on maternal health service utilization obtained from the Zonal health office, where the ANC follow-up and Institutional delivery were the lowest among the Districts in the Zone. A community-based qualitative phenomenological approach was used to explore the demand-supply side barriers affecting the utilization of maternal health services. Six FGD, 9 IDI, and 12 KII were conducted with women who gave birth at home in the last 12 months and with health care providers at different health offices and health institutions. Data were tape-recorded, transcribed verbatim, translated, and analyzed thematically using MAXQDA software.

Results:
Our findings revealed that pregnant women strongly agree on the importance and advantage of maternal health service utilization, and they have the interest and intention to utilize ANC and delivery care at health facilities. However, barriers such as low awareness on when to use, not knowing scheduling of ANC, miss-information about ANC and institutional delivery not knowing their estimated date of delivery and short labor duration, shortage of manpower at health post and health center level, unavailability of HEWs at the needed time, far distance from the health facilities, and unavailability or un accessibility of ambulance services during an emergency time, lack of public transportation were impeding the women.

Conclusion:
In general, rural women are facing many challenges yet to accessing and utilizing maternal health services. To achieve the SDG targets, addressing barriers prohibiting a woman from using MCH care is of point to be targeted.
Key words: Maternal health, barriers, rural women

II. Introduction
Maternal health refers to the health of the women during pregnancy, childbirth, and the postpartum period. Maternal health services are services that a mother should access so that she will undergo healthy and safe pregnancy, delivery, and the postpartum period which includes but is not limited to antenatal care (ANC), delivery care postnatal care (PNC) services [1].
Each day, about 830 women died worldwide because of pregnancy and delivery-related complications. Out of this, 99% of the cases were contributed by developing countries while 88% is contributed by sub-Saharan Africa and South Asian countries. Sub-Saharan African countries contributed to nearly 66% of all worlds' maternal deaths. The majority of the causes of maternal death are preventable or treatable if detected early. This fact is indicated by the huge gap in maternal mortality ratio between developed and developing countries and even between urban and rural women of the same country and in the same region [2].
In Ethiopia, direct obstetric causes i.e. complication directly related to pregnancy or childbirth accounts for nearly 75% of all maternal death cases while the other direct causes such as anemia, ectopic pregnancy and the indirect causes i.e. preexisting medical condition, malaria, HIV, etc accounts the left percent of maternal death cases. Hemorrhage is the leading of all direct causes of maternal death.
The majority of the maternal deaths happened during the post-partum period and because of this focus should be given to this time [3](Wubegzier,2017) [5].
As Ethiopian demographic and health survey(EDHS) of 2019 data revealed, there is an increment in the number of maternal health service coverage and utilization i.e. antenatal care, delivery service, and post-natal service utilization national wide when compared to all previously conducted surveys.
About 74% of women received at least one antenatal care (ANC) and 43% of them received four and above ANC from a skilled health professional in the last five years preceding the survey. When compared with EDHS 2016, the percentage of mothers who contacted four ANC visits and above increased from 32% to 43%. However, the current ANC coverage is not equally shared among urban and rural and among different wealth quartiles. The current Ethiopian ANC coverage is below 80%, the minimum ANC coverage recommended by WHO. In the Oromia region, only 26% of the women who gave birth in the last 2 years received PNC from a health professional within 48 hours of post-partum [6].
With the concept of universal primary health service coverage, and to overcome the challenges of universal inaccessibility and low maternal health service utilization, the government of Ethiopia has gone through multi-dimensional approaches and strategies. One of them was the introduction of health extension programs in 2004 in rural areas of the country, fee exemption for maternal and child health-related services, and the recent introduction of ambulance services to rural sub-districts of the country [7][8][9] [10].
Despite these, all efforts and strategies being applied by the government, and the partner organizations, maternal health service utilization is low in the general population and very low in rural communities of the West Shoa Zone specifically [6] [11][12] [13].
Therefore, the barriers hindering rural women from utilizing the MCH service may not be identified only by quantitative study and needs detailed understanding from its base on socio-economic and cultural aspects of the community level. Therefore, this study intended to identify and describe barriers contributing to low maternal health service utilization in selected rural woredas of the west Shoa zone of Oromia regional state, Ethiopia.

III. Methods
West Shoa Zone is one of the 20 Zones in the Oromia regional state and was founded in the west direction from Addis Ababa, the capital city of Ethiopia. It has 22 rural districts. There were about 494,213(18.63%) childbearing age women in the Zone. Out of the total reproductive-age women, about 92,000 (3.47%) of the women are expected to be pregnant each year. There were 8 hospitals, 91 health centers, and 514 health posts in the Zone. In general, the west Shoa Zone health center coverage is 92.6% and the hospital coverage is 30%. Three districts of the West Shoa Zone which includes: Dano, Elfata, and Midakegni were selected purposively for this study. This study was conducted in rural kebeles of the above-mentioned three districts. These districts were selected purposively based on the report of their last year's (2020) performance on maternal health service utilization obtained from the Zonal health office, where the ANC follow-up and Institutional delivery were the lowest among the Districts in the West Shoa Zone (Zonal Health Department, 2019).
The study was conducted from February 01 to April 30/2021.

a. Study design:
A community-based qualitative phenomenological approach was used to explore the demand-supply side barriers affecting the utilization of maternal health services i.e. ANC follow-up and institutional delivery in rural communities of the three selected districts.

b. Study Population and sampling techniques
The study participants for the Key Informant Interview (KII) were leaders from selected districts i.e. head of the district health office, the catchment area health center director (PHCD), health extension workers of each selected kebeles (sub-districts), and the head of the MCH department of each selected health center. The senior HEWs were selected for KII. Accordingly, 12 KII were conducted.
Each of the key informant interviews was held at the actual working place of each participant. The study participants for KII were selected purposively based on their direct connection with the maternal health services issues.
The study participants for the focal group discussion (FGD) were women who gave birth at home in the last 12 months before the data collection period. Accordingly, Six FGDs were conducted. Each focus group discussion had 8-10 members and took 45 to 60 minutes. The FGD was held at their respective catchment area health posts. To make the discussion environment conducive, coffee and tea refreshment (which is culturally preferable among the Ethiopian population) was arranged.
To get a diversified idea, the selection of the FGD participants considered the geographical location of the kebeles. Accordingly, participants were selected from the furthest, middle, and nearest kebeles. The study participants for IDI were women who gave birth in their homes in the last 12 months. Accordingly 9 IDI were conducted. The IDIs were also conducted at the women's kebele health posts. The FGD and IDI participants were identified and included in the study through the facilitation of respective kebele HEWs. The maximum number of the FGD and IDI were determined by the point at which there was no new idea become flourished i.e. idea saturation met.

c. Operational definitions
Maternal Health Services: In this study context the term maternal health service represents only antenatal care and institutional delivery.

d. Data collection tools and methods
For both KII and IDI data collection, semi-structured, both open and close-ended questionnaires were developed in English and translated into Afan Oromo. The discussion guide was prepared for FGD in the English language and translated into Afan Oromo. The background data of each study participant was collected using a questionnaire (self-administered and interviewer-administered).
Data collection was conducted by trained data collectors who were fluent in Afan Oromo, and have an experience in qualitative data collection. KIIs, IDIs, and FGDs discussions were tape-recorded and field notes were also captured. The FGDs were facilitated by two data collectors and one supervisor. The data collector/facilitator raises the question, balance the discussion among the discussants, ask questions for further clarification, tape record the discussions and takes note.

e. Data processing and Analysis
To enable the opportunity for triangulation of ideas, first KIIs were conducted followed by FGDs and IDIs. The audio-recorded data were transcribed verbatim on daily basis, and field notes were arranged. Then, the data were translated into the English language. The translated data were transcribed to electronic format and imported to MAXQDA-22 software (Qualitative data analysis Software). Using the software, the imported data were first cleaned for their suitability for analysis and then coded (assigned category). Before coding started, a detailed re-reading of all transcription was done. After the detailed and iterative reading of the transcription, categories were developed by the start list method i.e. based on the researchers' experience, the topic of inquiry, and based on the existing literature. This method is generally the deductive approach. After the whole data (KIIs, IDIs, and FGDs) were coded and sub-coded, themes were generated. Finally, the analysis was done based on the generated themes. The data were analyzed by the members of the research themes who have an experience in qualitative data analysis using MAXQDA software.

f. Ethics approval and consent to participate
The Ethical clearance was obtained from the Institutional ethical review Board (IRB) of the College of Medicine and Health Sciences, of Ambo University. The letters of support were written to the concerned body. During fieldwork, permission and interest to participate were requested after briefing the objective of the study. Both verbal informed and written consent were obtained from the study participants. Confidentiality of the data to be collected was secured and will not be transferred 7 to any other third party. To ensure the confidentiality of the participants, the participants' names were not mentioned during interviews or FGD discussion, or report writing. Instead, the term Mr., Miss was used during KII and IDI, and code numbers were used during FGDs.

IV. Results
A total of 6 FGD among women who gave birth at home in the last 12 months of the data collection period, 12 key informant interviews with the head of the district health office, Primary Health care director, maternal and child health coordinator, and health extension workers and 9 In-depth interviews with mothers who gave birth at home in the last 12 months were conducted.
The women who have participated in the study have different experiences with ANC follow-up and institutional delivery at different pregnancies. Some of the women have a history of ANC follow-up in the previous pregnancy, and some have a history of institutional delivery in previous delivery.
With the mean of 27 years, the age of the women who participated in FGD and IDI reaches from 18 to 38 years. Of the total 57 women who participated in the FGD and IDI, 31 of them didn't attend any formal education, 17 of them attended elementary level (5-8) and 9 of them attended primary education (1-4). All of the participants were from a farmer families. With an average family size of three children, almost all of the study participants were multipara.
Following coding of the transcribed KII, IDI, and FGD data, and intensive re-reading of the transcribed documents, three themes were identified using the start list method (the deductive method). The themes are individual-level barriers (demand side), socio-economic/geographic barriers, and health facility factors (provider side barriers) Table-  All of the women who participated in the FGDs and IDI agreed and described the importance of attending ANC follow-up during pregnancy and giving birth at a health institution. However, because of the barriers, they have raised during the discussion and interview, they are unable to utilize the maternal health service specifically ANC and institutional delivery.

Individual-level barriers affecting maternal health service utilization
These are barriers related to women own personal reasons or factors related to her pregnancy. These include poor awareness related to complications that can happen during pregnancy and childbirth,

Health Facility-related barriers
These are barriers related to health facilities i.e. Health posts, health centers, and hospitals. The barriers identified as a health facility relate barriers were: a shortage of manpower, un-availability/un accessibility of ambulances services, poor out-reach services at the community level (discontinuation of pregnant women's conference), Health professionals' poor welcoming and counseling approach during ANC visits, and delivery, and inaccessibility of HEWs at health posts. Fear of infections (especially HBV).
During our discussion with KII, FGD discussants, and IDI participants' manpower shortage was raised as a critical barrier for poor/low maternal health service (especially ANC and delivery service) utilization.
One of the KII participants explained the challenges they were facing in their health center as a result of manpower shortage as follows: ''…The serious challenge hindering us from delivering MCH services is a shortage of manpower. During our discussion with the study participants, it was also raised as unavailability and/or inaccessibility of the transportation service was causing women not to utilize ANC service and institutional delivery. Ambulance, the ideally expected transportation service during emergency/labor is also discussed by the participants as it is unavailable and inaccessible. During these all days, there are many costs like food, transportation, and other opportunistic costs like leaving their children and cattle and plowing lands alone. Because of fear this all costs, the mother prefers to give birth at home.
One of the health professionals who participated in the study described this scenario as follows: "...Ambulance can't reach nearly nine kebeles of our woreda. Look, the mother will come traveling such a long road. Some of the mothers die on the road, and when they reach the health center, the case may be beyond our capacity. Then, we will be obliged to refer to Gedo Hospital. Imagine the duration and complication the mothers are facing starting from home till she reaches hospital...''

(PHCD from Midakegni District)
The other provider-side barrier hindering mothers from using MCH service is the home-to-a-home visit by HEWs is too weak. HEWs are not visiting pregnant women's homes and are not advising on the importance of ANC, risks, and complications related to home delivery. The other barriers to poor MCH utilization among pregnant women identified in this study are poor welcoming approach from health providers during ANC visits and delivery and poor cleanness of the delivery room.
"…I gave birth once at the health center. where and when to utilize it, danger signs and complications during pregnancy and childbirth, birth plan, and estimated date of delivery are the pre-conditions that the women should have to know so that she can utilize the service. This study revealed that there is a gap in the above-mentioned issues.
One of the major reasons why the women were giving birth at home was not knowing their estimated date of delivery (EDD). If the woman doesn't know her EDD, she will be less likely to prepare for birth i.e. deciding on birthplace and preparing for transportation and other matters. So, as a result of not knowing her EDD, she may face sudden labor onset and she will give birth at home.
One of the underlying reasons for not knowing EDD is not attending ANC. Once the women attend ANC, she will be more likely to be told about her EDD during ANC [15] [16].
In addition, short labor duration and not facing complications during labor were also other major reasons contributing to home delivery. These two things are miss-information we identified in this study. Rural women are considering giving birth at health institutions only if the labor is prolonged and the women faced complications. This miss information is common among women who have a history of home delivery in addition to the current birth. This finding is similar to the finding of a study conducted in Eastern Oromia, in the Amhara region, and in Sidama where the women reported not going to the health institution for ANC and childbirth unless they get sick or felt pain during pregnancy [17][18] [16].
Women's forgetting their next time appointment date is also identified as a barrier affecting utilizing ANC and institutional delivery. If the woman remembered her next appointment date after the date is passed she consider it to be already past and did not need to go to HI again. This indicates that there is a gap in women's knowledge of the ANC timing.
From supply-side barriers, a shortage of manpower, un-availability/un accessibility of ambulances services, poor out-reach services at the community level (discontinuation of pregnant women's conference), Health professionals' poor welcoming and counseling approach during ANC visits, and delivery, and inaccessibility of HEWs at health posts, Fear of infections (especially Hepatitis B Virus) were identified.
One of the building blocks of the health system is manpower. Shortage of manpower has a huge impact on the quality of the service and finally may end up with poor service. If the pregnant woman and/ or laboring woman are not accessing the quality health service they need once upon a time at a certain health facility, they will lose trust in the health system and may not utilize the service again.
One of the challenges related to the shortage of manpower is the long waiting time at health institutions, and not accessing all services they need at a single point in the health facility. As a result of this, the women may be appointed for another time or referred to another health facility because of no health professional. Rural women are coming from far distances penetrating multiple challenges such as socio-economic and/or transportation challenges. In areas where there is a shortage of manpower, let alone community-based awareness creation such as pregnant women's conferences, even health facility-based routine services will be of poor quality [19].
Even though it is expected from the HEWs to screen pregnant women and send them to nearby health centers, and facilitate the "pregnant women's conference" in their catchment kebeles (subdistricts), the HEWs were not doing such activities. This is because of two main reasons. One is there is a shortage of the number of the HEW compared to the population they were serving. Since some of the HEWs terminated their job and some of them were on long-term training.  [20]. Laboring women were not accessing Ambulance services during emergency times. This is due to many reasons. One is the number of available ambulance cars doesn't match the population being served. There were only one or two ambulance cars per district. That single ambulance will serve to bring laboring mothers from the community to the health center and from the health center to referral hospitals.
During such time, there will be a need overlap and some of the women may not access the ambulance service immediately at the needed time. Sometimes, the ambulance car faces a technical problem and may stay more than a few months to be repaired. These also contribute to home delivery too [21] [22]. In addition, a woman who gave birth at HI needs transportation to come back home. But, it is a challenge to access transportation. They were requested to pay for the ambulance fuel. Not all mothers can afford that. In fear of this, some mothers again prefer home delivery [18].
The other critical supply-side barriers hindering women not to using ANC and institutional delivery were poor respectful care during ANC, and labor and childbirth. Laboring mothers are in very severe pain. They need both medical and psychological support. Any negative reaction from health professionals will demoralize them and hinder them not to coming for maternal health services in the future. Mocking at them while they are in labor pain or when they request help, if the labor room is not clean and attractive, if the health professional doesn't approach mothers who seek ANC or delivery services with empathy and respect, they will never trust the health professional again and they will be hesitant to utilize the service another time [23][18] [20].
Infectious diseases transmitted by contact with body fluid were also contributing to home delivery.
HBV is one of such disease. In the area where the HBV prevalence is relatively high among pregnant women, health professionals become hesitant to attend the labor, since they believe it is 20 risky for them to encounter the infection. In such cases, the health professional prefers to refer the laboring woman to the hospitals where the HBV vaccine for health professionals can be accessible.
since they can't afford different costs almost all of the women who will be referred to the hospital will go back and give birth at home. This problem is challenging in the district where the HBV prevalence is high and the HBV vaccine is not available. This finding is unique to the Midekegni district of the West Shoa Zone.

VI. Conclusion
In this study, we have tried to explore barriers hindering women from using ANC and Institutional delivery in the rural area of the West Shoa Zone. Our findings revealed that pregnant women strongly agree on the importance and advantage of maternal health service utilization, and they have the interest and need to utilize ANC and delivery care at health facilities. However, many barriers such as low awareness on when to use, not knowing scheduling of ANC, miss-information about ANC and institutional delivery (perception of seeking ANC or ID only if there are complications), not knowing their EDD, shortage of manpower at health post and health center level which is leading to poor quality health service (especially poor respectful care), unavailability of HEWs at the needed time, far distance from the health facilities, and unavailability or un accessibility of ambulance services during an emergency time, lack of pubic transportation to travel to HI and fear of costs related to ID were impeding the women from utilizing ANC and ID.
In general, rural women are facing many challenges yet to accessing and utilizing maternal health services. When we frame these barriers according to Thaddeus and Maine's three delays model; all the three delays are contributing to low ANC and ID service utilization. The majority of the barriers are those already identified more than ten years ago and becoming the obstacles yet.
Ethiopia is working towards the achievement of the SDG of reducing MM to less than 140 deaths /100,000 live births, and reducing IMR to less than 12 deaths /1000 live births by 2030. To achieve these SDG targets, addressing barriers prohibiting a woman from using MCH care is of point to be targeted. Therefore, we would like to forward the barrier-specific actions to be taken as follows: 21 Action to be done to address demand-side barriers: To address the gap in awareness of ANC scheduling, misinformation about when to seek service should be addressed by resuming and strengthening the "pregnant woman conference". To overcome challenges related to the shortage of manpower, task shifting can be taken as an alternative.
Establishing a health development army, training them, and shifting some tasks of HEWs toward HDA can solve the manpower shortage at the community level.

Action to be done to address Supply-side barriers
Organizing regular outreach programs to those women from far-reaching sub-districts could alleviate the transportation shortage. In addition, organizing frequent training on Compassionate, and respectful care (CRC) for health professionals is needed.