Social networking.

Most women, HEWs, WDA and religious leaders reported that they were participating in social networks such as ‘Iddir’, ‘Iqqub’ or ‘Maheber’. Women participated in mother’s forum, women’s association, pregnant women conference, group ANC, and other volunteer organizations. In the absence of men, more women could talk openly.

“I am a member of associations called ‘Iddir’, ‘Iqqub’ and ‘Maheber’. On that forum, we freely discuss it [available health services for women and children].” (a 35-year old HEW)

The other participant in the FGD highlighted that,

“I am a member in a union. It is a good opportunity to talk about women and children on association.” (FGD, a 26-year old WDA leader)

In addition, most religious leaders were participating in different groups including developmental groups, community dialogues, and peace and security counseling groups.

“We are members of the Kebele development team; we work together. In the Kebele, there is women’s structure where they can participate.” (a 36-year old religious leader)

“I have been the head of Islamic affairs for 30 years and the chairman of ‘Iqqub’ for 42 years.” (a 78-year old religious leader)

“There is a volunteer organization in our Kebele. Along with the clergy, I am the deputy district commissioner and ‘Mergeta’ [a religious leader in Orthodox Church] is the chairperson of peace council. In collaboration with it, I became involved in promoting maternal health activities.” (a-54 year old religious leader)

Some social networks had regular meeting schedules and that facilitated the group members to access health information. Then, they could transfer messages to their neighbours.

“‘Iqqub’ and ‘Iddir’ have their own establishment purpose. In our area, ‘Iqqub’ is associated with saving money; in the same way, ‘Iddir’ is valuable when a person dies. Health extension workers could use these social networks to create awareness.” (a-36 year old religious leader)

In addition, some HEWs indicated that they leveraged the available social networks to create awareness.

“They [women] have a conference once a month. It is a place where only women can discuss. The women who come here could be from any Kebele; they talk and exchange experiences.” (a 32-year old HEW)

Although HEWs recognized that the social networks and its members favor the community-based healthcare activities provided by them, few religious leaders, ‘Iddir’ and ‘Iqqub’ members had no close relationship with them.

“If we organize our work, we can easily get the job done. We often meet those who are close to us; we have little contact with ‘Iqqub’ [leaders]. The religious fathers and ‘Iddir’ [leaders] are not closer to us.” (a 32-year old HEW)

Social organizations and linkages. Social organizations and networks were helpful platforms to mobilize the community and transmit essential health messages to individuals who interrupted their children’s vaccination and traced through the social networks. There are 1 to 5 groups (i.e.one women lead a group of five women), ‘Iddir’ and ‘Iqqub’; and using these networks, variety of health information could have been provided to the community. Community health workers provided health information and regular messages in the ‘Iddir’, ‘Iqqub’ or in the church on Sunday morning time.

“Social organizations are very important; we believe that they are the solutions for ill-health and other issues. Both ‘Iqqub’ and ‘Iddir’ are good social networks.” (a 54-year old religious leader)

“In ‘Iddir’, we find large members, and an opportunity to explain about [the importance] of immunization services and sanitation. For example, I can personally go and send messages to two or three social organizations for women and children to use health services. People who did not attend that meeting will hear the information using their social networks.” (a 32-year old HEW)

In addition, HEWs explained that MCH service provisions could be improved by using social networks.

“We can further improve women’s and children’s health services using social networking. Instead of going from house to house, it is better to go to a place [‘Iddir’] where you can access many people. When we go from house to house, we find a mother or a child; we may not get the whole family. If we are creating awareness where the community is gathered; I think it [‘Iddir’s meeting] will be better.” (a 35-year old HEW)

“People know the care needed for women and babies; we need them [members in social networks] if someone has discontinued vaccination; we can resume vaccination provision by identifying them in ‘Iddir’.” (a 32-year old HEW)

Community mobilization. Health professionals, nongovernmental organizations and religious leaders mobilize the community and create awareness about the health of women and children using various platforms. However, continuous community mobilization was needed. The district and Kebele administration used a megaphone for promoting the messages.

“I have done nothing alone, however, I involve in community mobilization together with them. But, the society always needs an advertising campaign.” (a 36-year old religious leader)

“Sometimes nongovernmental organizations mobilize us; at that moment, we help each other. We also encourage our spiritual children to learn and to be vaccinated on time; sometimes people associate vaccination with something else and some people think it hurts. We try to make those people aware.” (a 42-year old religious leader)

Social participation. As most religious leaders and HEWs highlighted, women are participating in various social networks. The connection among members was a good opportunity that would help to gain financial support, health information, and to exchange ideas one another. This was attested by a religious leader:

“I participate in ‘Iqqub’, ‘Iddir’ and associations. I have also been a Moses [chairperson] of the association. I think my social interaction with my friends is good. We meet at church in Tsig`e [Sabbath] association every week, and sometimes, we meet 2–3 times a week because we live close by.” (a 36-year old religious leader)

“As a health extension worker, the connection between the family and the community will minimize my workload when I meet them together, instead of meeting them one by one. It is good to get together as it allows sharing one’s insights with one another; to provide health education, and conduct drama conversations.” (a 30-year old HEW)

Social norms.

The religious thought, belief and value of women and religious leaders as well as the social norm, traditional practices and culture of a community could influence uptake of MCH services.

This was reflected by a religious leader:

“In the absence of men, more women can talk openly. It is easier for women to tell women than men and these women’s forums are important…. It is well known that women are often marginalized in our society. But, now it is improving, especially in the city. I think there are some associations that undermine women; I think it [societal belief] will have a negative effect on maternal service utilization.” (a 36-year old religious leader)

Although social groups did not engage directly in the discussion of MCH services, the neighbours are concerned about young girls in the community who feel scared to visit facilities for pregnancy care. When HEWs visit house to house, the community itself tells information about those adolescents that hide their pregnancy and are ashamed of beginning the care.

“During my discussion, they [neighbours] informed me that there is someone pregnant in their village. It is not acceptable for someone to get pregnant out of wedlock. We meet that young woman [who reported to be pregnant] through them and get her started [pregnancy care].” (a 32-year old HEW)

The previous practice of women seeking maternal care services from the health center or hospital was low. Fear for lack of privacy of women and the perception of the community towards adolescent pregnancy were mentioned as reasons for not commencing ANC booking on timely basis. Some women also described that giving birth at health facility is not comfortable for them in which delivery coach might expose their private bodies.

“They [Women] did not go to the health center since there is a sense of shame. They are not very happy to show their bodies.” (a 32-year old HEW)

Other participants had similar viewpoints,

“If some of them were pregnant from relatives or during adolescent time, there is a fear to express their feelings. They are obsessed with it, ‘how can I reveal my secret?’” (a 36-year old religious leader)

“There is something shameful about pregnancy with young people because they suddenly become pregnant out of our culture. They have a fearful attitude, they just hide; especially those who are from rural areas. But, health extension workers teach well, and create awareness.” (a 38-year old religious leader)

In addition, most religious leaders condemned abortion and adolescent pregnancy without marriage. They explained that abortion after one month or two months of pregnancy is just considered killing a human being.

“There are young people who are giving birth and drop anywhere. They called abortion. When we teach in the church, we strongly condemn this. In theology, this is a creation of God, it is God’s building and we do not support abortion services.” (a 38-year old religious leader)

There is remarkable difference among rural and urban communities in uptake of MCH services and men’s involvement in it. Unlike women living in rural area, most urban women were educated and understand the importance of MCH services in which they gave birth in health facilities. Besides, most of the husbands in the city support their wives.

“As a city, there is no much problem as far as I can see. In fact, most of the men in the city support their wives and come together for vaccinations. Other family members and neighbours are also come along them; it’s good to see such things. In my opinion, family relationships are good.” (a 32-year old HEW)

However, traditional practices and perceptions of the community in rural settings could be barriers to women giving birth in health facilities. Women are also affected by workload and food shortages.

“There are many problems when we go to the rural area. Some traditional practices, such as giving birth out of home or in health facility may be bad for the mother and a baby. You will find communities that think that she will strike by Satan. They believe that when she gives birth, she sprays her blood.” (a 30-year old HEW)

Community support.

Social support. The community had a culture to provide support for women when there was no ambulance and get difficult to travel to the health facility. Most women get social support from neighbours and ‘Iddir’ while they were in trouble or family grief.

“If a woman is seriously ill in the evening, there is no ambulance and is difficult to travel to the health facility in the dark. If the neighbourhood relationship is good, the neighbour will make a transport bed for her. Then, she will be taken to health facility by carrying via local bed. Likewise, we take her to health facility in the evening when her labor started. This is how social life is important.” (a 42-year old religious leader)

“Any society has a responsibility to support women. For example, if I find a mother falling out of the street, I immediately call an ambulance, a Bajaj, or a person to bring her to the health facility.” (a 38-year old religious leader)

Majority of poor women received material, food and financial support from neighbours, religious groups and university students. Religious fathers coordinate wealthy people and the community to feed the poor, and dress clothes for the naked.

“…After giving birth, the neighbour said, ‘she has nothing to eat or drink.’ we support her by buying clothes. For example, in our Orthodox religion, a boy is baptized at 40 days old and a girl baptized at 80 days of old. If she is poor and has no money, we will buy clothes for her ceremony.” (a 38-year old religious leader)

Emotional support. Religious leaders along with HEWs encourage women to give childbirth in a health facility; clarify misperception of people towards vaccinations; the need to respect pregnant women, and give proper attention to children. The WDA leaders had a list of pregnant women in the Kebele and report to HEWs every two weeks.

“There is an idea support; no one supports money because everyone knows what money is (laughing). However, there is emotional support by counseling and encouragement.” (a 38-year old religious leader)

“Religious leaders are especially helpful because they are not supposed the notion of conveying bad things in the community. They are very useful to us because they are respected by the community.” (a 30-year old HEW)

"Our main role is to provide advice to women on vaccination and I provide counseling for pregnant women, at least twice a month. We recommend women to eat nutritious vegetables and fruits.” (FGD, a 33-year old WDA leader)

Financial support. A social network such as ‘Iddir’ was one of financial support mechanisms for the community. When children get sick, they [families] borrow money from ‘Iddir’ and save the life of them. Besides, if women need money to address special needs, the community could support them; the culture of mutual aid is also common.

“Usually, women have no financial income and manage their household by their husbands’ income. They participate in a union, and save money at the request of their husbands. Once upon time, I face a problem, my child was sick, and I did not have money, then I borrowed money from our ‘Iddir’ and saved my child’s life. So, I think ‘Iddir’ is a valuable asset for the community.” (a 36-year old religious leader)

“Social networks are important. We are not teaching such a wide range of health extension programs on these networks, but they are important. When there is a problem, we ask the chairman to provide financial support and they will do so on behalf of the association.” (a 35-year old HEW)

The association in Muslim religion during ‘Mewlid’ [The Prophet’s Birthday] gathers the poor and feeds them.

“Women and children are helped during our fasting time. According to our spiritual book, the believer contributes 25 birr out of a thousand birr income; that is saved for the poor, for the orphans. It is given to women who do not have a livelihood. We would distribute it to the poorest people in our ‘Mewlid’.” (a 78-year old religious leader)

Community cohesion.

Domestic cohesion. Some husbands supported their wives during prenatal care and childhood vaccinations in which they accompany their wives during health facility visits; organize transportation at the commencement of labor pain.

“I have good family and relatives; they will support my wife during [her] pregnancy or childbirth. My brother did better things for her than I would do. Clothes and shoes [for the new baby] are usually provided by the families and relatives.” (a 36-year old religious leader)

Another participant also described,

“A husband loves his wife more than he loves his mother. No one wants his wife to be abused.” (a 78-year old religious leader)

Most husbands in urban settings take care of their wives in the absence of a relative in nearby. Other family members and relatives were also responsible for the health of the mother and the baby.

“It used to be a men’s participation program to help pregnant women. As they presented their experiences, we encountered men who cooked and baked. Men are more involved in hard work, such as washing clothes and fetching water.” (a 54-year old religious leader)

On the other hand, husbands were not actively involved in community-based health services since HEWs could not find them during home visits. One HEW explained that,

“Men’s participation is low because we do not usually find them at home. If we scheduled and met them during our visits, their attitude could have well.” (a 30-year old HEW)

Neighbourhood cohesion. Religious leaders provided support to their neighbours regardless of their religious affiliations. They also participated in any community development activities. In ceremonies like marriage, neighbours shared responsibilities with the other.

“As a Muslim, it seems wrong to build a church. But, if someone asks me to build a church, I contribute money for that. For example, when saint Gebriel, Kidane-Mihiret and Michael churches built, I have contributed 800 birr for each.” (a 78-year old religious leader)

“Grandmothers, fathers safeguard the village. When the young man goes to work, they work from home to the best of their ability.” (a 38 year old religious leader)

Most children in the neighbourhood were considered as family members. This might not be possible elsewhere,

“As it is a new neighbourhood, our children leave us and eat at home together; in our area, the child in the neighbourhood is considered to be your child. If you buy bread or tea, you will give everything equally. They eat their breakfast in the some house; then they eat their lunch at your house, and they eat dinner at the other neighbor’s house. This is our social life.” (a 36-year old religious leader)

“The nearest neighbour is better; if I have a relative from a distance, but my Christian neighbour is in trouble, I should give priority to my nearest neighbour, not my relative.” (a 78-year old religious leader)

Neighbour’s relationship has both positive and negative impacts on uptake of MCH services.

“If neighbours have satisfied with the healthcare, while drinking coffee, neighbours advise pregnant women to visit a health facility. In contrast, if someone experienced wrong things in the health care, he/she communicates the bad feelings to the other neighbours.” (a 54-year old religious leader)

“Traditionally, the community is intertwined. It may be on the ‘Iddir’, coffee ceremony or other association. The community is intertwined in everything. As a health extension worker, the connection between the family and the community will reduce my fatigue when I meet them together. To provide health education, and conduct drama conversations; it is good to get together to share one’s insights with one another.” (a 30-year old HEW)

Trust. Most women in rural areas trust the community health services provided by HEWs than any other health professional. They had a positive attitude towards HEWs.

“They [women in rural areas]) accept health information provided by us because they are familiar with us. If you provide medicine to them, people are very skeptical at this time; no one will take medicine from unknown persons. The community trusts me more than you.” (a 30-year old HEW)

However, women in urban residences preferred hospitals since they were referred from health centers to hospitals in the absence of medical materials and health professionals.

“Sometimes they do not trust services given in the health center because of the lack of materials and expertise.” (a 36-year old religious leader)

“Urban people underestimate health professionals working in health center. Although a midwife is working in both a health center and a hospital, they perceive that they can find a better professional at hospital.” (a 35-year old HEW)

Few religious leaders thought that a social network particularly ‘Iqqub’ is not relevant and members in the networks do not trust each other.

“I do not think ‘Iqqub’ is useful right now because the members of ‘Iqqub’ do not trust each other. If you see, court files, most cases are ‘Iqqub’ related. That is why I quit. It is useless right now.” (a 78-year old religious leader)

Likewise, some women development groups are not functional; previously, there were training and government support to the WDA leaders. The community perceived the volunteer services provided by the WDA leaders wrongly as if they are paid workers. Therefore, it is needed to manage the wrong community’s perception towards WDA and other volunteer services.

“Previously, the leaders of women development groups were given some form of refreshment training every six months. …now that support doesn’t continue.” (a 30-year old HEW)

“I often participate in volunteer activities and attend meetings. However, the community perceived [us] in the wrong way; they say, "She is working for the purpose of her own salary." Just, we provide free service; volunteering always works with free. They came to my house in the morning and said, "Why do not you help us? You are receiving your salary.” (FGD, a 26-year old WDA leader)