3.1.1. Gender and productive roles.

Routine task sharing: household chores and livelihood. The majority of the study participants mentioned that the community predominately assigned tasks, such as grain grinding, collecting firewood, preparing food for the family, fetching water, cleaning household utensils, dismantling small huts, and animal husbandry activities by gender. In all regions, men were excluded from childcare and household activities, although they often engaged in income generation. In contrast, women were overburdened with household chores and had limited roles in generating revenue.

“…. while men often engage in income generation, farming lands, and trades, women often work in house cooking foods and caring children…” (FGD, women from Somali)

Women autonomy and power relations. This study revealed that women were less powerful in easily going out of home to seek health care, participated in income-generating activities and social-cultural occasions, and had limited power over resources. For instance, women demand their husbands’ approval of to visit health facilities for FP use. Women need to present acceptable reasons other than FP to convince their husbands and endorse their visit.

“…in those households in which the man is dominant, then he can sell the animals and have the money for himself.” (KII, religious leader, Bambasi District)

“…. The men don’t allow the women to go far out of home and engage on trades and generate income… and they even want to endorse their visit to health facilities” (FGD, women from Somali)

3.1.2. Gender and reproductive roles.

These roles consider the behavior of caring for and maintaining the health of families and children, as well as the uptake of family planning, pregnancies, and childbirth services.

Taking care of children. The majority of the study participants pointed out that taking care of their children was their mother’s duty and responsibility.

“Women are responsible for taking care of their children. It is solely the responsibility of the woman. Man’s role is minimal regarding taking care of children.” (KII, LSA, Dangur District)

Seeking RMNCH services and providers. First, men dominantly decide on the agenda of FP services, whereas women can decide on ANC and child immunization services.

“Regarding decision making on the use of RMNCH services: women alone can decide, but in case of family planning, she must discuss with her husband for approval.” (KII, WCA, Lare District)

“…..Other than this, it is the woman who in the majority of the time, takes children for vaccination or follows her antenatal or postnatal follow-up alone. But during delivery or labor, it is culturally mandatory for the husband to attend to her ….It is not out of rudeness for the men not to be helpful on the other RMNCH/FP services, it is however originating from their cultural practices.….” (WCY Affairs Office, Gulina District)

Surprisingly, although men had reservations about FP, they would compromise and permit FP use on certain occasions:1) Women’s past delivery was through cesarean section. In this case, FP was perceived as helpful in delaying pregnancy, potentially leading to illness, and 2) the wives had health complications arising from previous childbirth or medical issues. Unmarried young people were not allowed to use FP services.

“…Generally, FP is considered as ‘haram’ unless it’s indicated after surgical and medical problems that warn the women not to get pregnant. Unless and otherwise, they do have a positive attitude towards other reproductive services…” [Female FGD, Afar region]

“…young and unmarried people are never permitted to use FP service. They are condemned and outcaste by religious and clan leaders if they are found while using FP and other service such as abortion care as getting pregnant is unthinkable among young ladies. “[Females, young FGD,Somali region]

Seeking RMNCH information. Associated with the responsibility that women have to maintain the health of children and families and ensure that the sick are treated, they are supposed to seek even more accessible RMNCH information than men do. Women are targeted by RMNCH/FP education, such as health talks with HEWs and discussions with women/health development armies (HDA).

“…Females have better access to education than males because females have a better chance to meet the HEWs as they are more responsible for families and children’s health and to be targeted by the school clubs for RH awareness-raising initiatives in the school.” (KII, health center head, Lare District in Afar)

Nonetheless, young females are often excluded from RMNCH/FP education, given that such matters are not openly discussed at a young age or among unmarried ones.

“We do not have access to any community based education about sexual matters and the related services as discussing such matters between parent, health workers, and young adolescent like us is considered taboo. We only access information related to sexual health and FP through school or mass media…” (Female, young FGD, Afar region]

3.3.1. Intersectionality of structural conditions, gender and RMNCH.

Structural contexts/conditions (policies/laws, empowerment opportunities, participation in leadership, and control-over economy and resources) intersected with gender in influencing access to and use of RMNCH in DRS, as discussed below.

Laws and policies, gender, and RMNCH. Although legal frameworks addressing gender norm challenges and inequalities in RMNCH are in place, knowledge and implementation of the laws among respondents, including health workers, are limited. Community and religious leaders adopted laws on the harmful traditional practices of HTPs for use in local sociocultural contexts.

“If a husband beats his wife, the punishment is 180 Birr, but if he causes head injury, he will provide her with broth made from goats through ‘Erro’ and pay the 180 Birr. In the case of rape, the punishment will be 12 cows, and he will be free.” (WCY Affairs Office, Gulina District)

Existing policies suggest that RMNCH service delivery be modeled in a gender-sensitive manner that addresses programmatic-gender intersectional barriers to RMNCH uptake. For example, addressing the issue of female birth attendants preferred by the sociocultural context of DRS is one example of a poorly implemented gender policy in the health system. Health systems/facilities have attempted to recruit adequate female health workers/midwives and persuade the community to accept male health workers. Accordingly, the intersectionality of laws with gender, culture, and programs influenced the uptake of RMNCH services in the DRS.

“…Afari men do not want their wives to be seen by male health professionals during pregnancy or childbirth. As a result of which they prefer to be assisted by their mothers, family members or TBAs.” (Clan leader, Afar region)

Some regions resolved the issues of female birth attendants through joint efforts of health professionals, communities, and religious leaders.

“….now, there is not much challenge regarding preference for female birth attendants although it still existed. And, providing services entirely according to clients’ preference would be difficult because we have a shortage of female health professionals (midwifery).” (KII, Health worker, Berhale District)

“…We are working with religious leaders….Whatever activity we do, the community would not accept us unless it is endorsed by the religious and community leaders (KII, Health worker, Somali)

Control-over resources and decision making, gender, and RMNCH. The power to control resources intersects with gender norms in influencing access to RMNCH. Most of the time, men were empowered to control resources, such as selling livestock and occasionally jointly deciding.

“Either the man or the woman can sell the animals. The husband and the wife jointly make the decision. But in those households where the man is dominant, he can sell the animals and have the money for himself.” (KII, religious leader, Bambasi District)

Across the DRS, while men do not usually interfere with or exert much influence on other RMNCH services (immunization, antenatal care, and postnatal services), family planning is less favored by men.

“Regarding decision making on the use of RMNCH services: women alone can decide, but in case of family planning, she must discuss with her husband for approval.” (KII, WCA, Lare District in Gambela)

Access, use, follow-up, and discontinuation of RMNCH/FP services relied on men’s approval of the services and financial support according to their sociocultural and religious privileges.

“I have experienced lots of Muslim women hiding from their husbands to use FP service because they hadn’t got an agreement from their partner. Sometimes they discontinue follow-up schedules because of financial problems. Other than FP services, women can decide to seek services; this is actually with an intention that males don’t oppose the rest of the services like ANC, PNC, child vaccination.” (KII, District Health office, Dangur District)

Participation in leadership and RMNCH. Across the DRS, participants mentioned that men held important leadership positions, such as administering customary and religious institutions, kebeles, meetings, and events. Hence, men’s leadership checks matter against religious dogmas or customs, irrespective of the women’s knowledge and demand for RMNCH/FP services. Women have fewer positions in such positions but largely participate in rituals such as births and genital cuttings. This revealed the intersectionality of the leadership structure and gender norms, as described in.

“In Muslim community (like Berta community), women are not allowed to hold the important position because of ‘sharia’….” (KII, community leader, Assosa District)

“Men hold the position of a religious leader, clan leader, kebele administrator…women also take leadership in birth rituals and FGM practices.” (KII, religious leader, Hamero in Somali)

Nonetheless, there has recently been a shift in such trends in which girls/women hold important positions (e.g., women’s network/HDA leadership) in a government structure.

“Previously, women do not hold any leadership positions. But this is showing improvement, and they are assuming positions in different leadership positions. They are now more observed in government positions and associations organized by non-governmental organizations.” (Clan leader, Telalak District)

Empowerment and education opportunities, gender disparity, and RMNCH. Gender disparity was observed when accessing information on RMNCH/FP services. Women have access to RMNCH/FP information and educational opportunities. Most of the time, the health extension program (HEP) uses different educational strategies such as home visits, HDA schemes, trained TBAs, and traditional means of exchanging information (the ‘Dhagu System’ in the case of Afar region) to empower and access the women with RMNCH information. By contrast, although men have better access to general information than women, their access to RMNCH information is minimal because they are excluded from RMNCH/FP educational strategies. Moreover, mobility in pastoralist communities has predominantly prevented men from educational opportunities that interact with their restrictions on women’s FP uptake.

“…Married women and those who have children have better knowledge of RMNCH/FP issues. This is because of the focus on strategies involving women in the programs like the HEP, and there are some audio-visual education sessions in waiting areas of HCs. Besides, women get information on RMNCH through the HDA, and community representatives, including a mother whose child is treated and cured, will participate as part of the mobilization team to teach the community and promote health…” (NGO representative in Beneshangul-Gumuz)

“…RMNCH/FP services and education provided in the nearby health facility do not reach fathers and husbands or encourage their participation in RMNCH/FP care. Because the current HEP targets mothers and children while fathers and husbands seem to be less focused for RMNCH/FP services…unless they get such information from other sources.” (Women FGD, Hamero in Somali)

“… Pastoralists, who move from place to place in search of livestock feed and water, have less knowledge i.e., about service availability or its benefit…. As a result, I believe, their awareness is less to support RMNCH/FP utilization…” (KII, LSA, Awubere district)

3.3.2. Programmatic factors intersecting gender on RMNCH uptake.

The facilities and systems by which RMNCH services are delivered determine access use. The unavailability or punctuality of health professionals, respectfulness, perceived lack of skills and capacity, distance at which facilities are located, transport and ambulance services, lack of essential supplies and equipment, friendly services, and gender sensitivity of the services are some of the factors affecting RMNCH access use.

“…as a result of women experiencing that Implanon removal service is provided by appointment and not by their immediate request because of lack of provider. It inhibits their long-acting FP service seeking. As a result, they prefer depo as it is a one spot service with no requirement for removal…” (HEW, Afar)

“…If a woman comes bleeding or delivered at a health center and there is no water facility for washing, food to eat…she would think she is inviting death to herself and may not come again. The problem with water shortage in the HC is serious, and it affects us not to come to the HC.” (women, FGD, Gambella)

The availability of health workers, perceived competencies, and user-friendliness of the RMNCH service intersected with gender norms. Sociocultural beliefs and religious dogmas interacted and determined how the RMNCH/FP program and services needed to be arranged. For example, 1) the absence of female health professionals (even in the presence of males) determines RMNCH uptake as females socioculturally prefer to attend births, and 2) youth-friendly RMNCH services seem unthinkable in Muslim dominated settings across the DRS due to the religious dogmas.

“In our culture, a man is not allowed to see a woman’s body. Most men in our community believe that male health professionals should not assist their wives’ delivery at a health facility. This is the main reason why women in the community do not have institutional delivery…sometimes, when it deems necessary to deliver at health facility traditional birth attendants will accompany the women” (Clan leader, Afar)

“…We have a shortage of health care staff. There is a high turnover of staffs as they leave to other regions. During the last political turmoil, it could be said that most health facilities were almost closed. More than 450 staffs left, especially those who initially came from highland regions [non-Somalis]…” (KII, Somali)

“…There is no adolescent’s reproductive health officer down at district or kebele level. This situation has hampered utilization of RMNCH / FP services by young people… we are trying to make adolescent and youth RH services accessible for all…but the key challenge would be that it is socio-religiously forbidden to address unmarried youths on RMNCH/FP” (KII, Benishanzul)

“…We as young people do not have access to FP services. One thing it is a taboo to engage in sex before marriage. It also is not expected from young ladies to be sexually active and get pregnant before marriage. So, access to FP at health facilities is generally poor,even if youngs want to you [Male, FGD, Afar region]

“…young people may access FP or other services such as abortion from private facilities by hiding themselves from the public.[Female, FGD, Gambella]

3.3.3. Intersectionality of sociocultural factors and gender and RMNCH.

In this study, the sociocultural factors intersecting gender in influencing RMNCH embrace sociocultural practices and socio-demographic/economic, and socio-psychological dimensions. Different drivers contributing to intersectional gender and sociocultural influences in RMNCH service uptakes were illustrated by drawing on the lived experiences of the study participants.

Sociocultural practices and gender. Their husbands felt responsible for caring for their wives during their pregnancy and delivery. Men arrange transport and other expenses as women seek RMNCH services. Cultural beliefs that supposed parents to care for and support their children influenced the men to cover costs as the women visited health facilities for child vaccination, treatment, and postnatal follow-up services. Nonetheless, sociocultural beliefs did not encourage men to develop a custom of accompanying women on their way to seek RMNCH services other than delivery, although the norm is shifting.

“The husband has a cultural responsibility to take care of his wife during her pregnancy regarding covering costs and expenses related to delivery and labor. The office has been educating men on the issue. Other than this, it is the woman who, in the majority of the time, takes children for vaccination or follows her antenatal or postnatal follow-up alone. But during delivery or labor, it is culturally mandatory for the husband to attend to her. It is not out of rudeness for the men not to be helpful on the other RMNCH/FP services; however, it originates from their cultural practices.” (WCY Affairs Office, Gulina District)

“…Currently, education being given to the community to promote male involvement and support in helping a woman financially, psychologically, and physically. The community only accepts if the man is supporting his wife or accompanying her to a health facility during labor and for delivery services, but support for other services is not common…” {KII, Benishangul Gumuz)

Some husbands refrain from accompanying their wives during ANC visits because of the fear of HIV testing.

“…Men do not participate and support women because they have many partners, and they do not allow their wives to undertake HIV testing. They don’t also want to accompany their wives because of fearing to undertake HIV testing…” (HEW, Gog Woreda)

As a result of their experiences attending deliveries at home, some TBAs scare women with the potential absence of female health professionals from health facilities (hence, males see their private body) and cesarean section as a dangerous delivery mode. They discouraged the utilization of health facilities for delivery services. TBAs engaged in women’s education and empowerment opportunities determine the type of information they disseminate and that influence women’s uptake of RMNCH/FP services. This demonstrates how sociocultural practices interact with empowerment structures and intersect gender norms to influence RMNCH/FP and FP uptake.

Socio-demographic and economic disparities, gender and RMNCH. The interaction and intersection between gender norms and socio-demographic factors, such as education and rural-urban residence, determined how women and men responded to RMNCH issues and uptake. For example, an unfair gender division of labor increases the burden on women. This limits their potential and time to look for self-development opportunities and education, address other intellectual needs, and attend to their own and their children’s health. Similarly, women who were relatively educated or informed of RMNCH and lived in urban settings had a better capacity to manage their productive and reproductive roles and RMNCH uptake. Access to social support from close relatives, siblings, or even productive offspring facilitates women’s access to health facilities.

“…We do not have time as we are more burdened with our household activities than men. There is a challenge to go to the health center anytime we want due to the burden we have with our household chores; it is difficult to use the services as needed. However, some women in our community get support from their educated and economically productive children, who may visit health centers anytime they want. They are very advantageous; they have given birth early, and now they are getting this support. Women who get health facility in their vicinity are more advantageous” (FGD female, Telalak District Afar)

Women in rural areas who have lower formal educational attendance and are overburdened with roles, and men in the pastoralist regions of Afar and Somali, where mobile health services are available, reportedly have lower access to information and knowledge about RMNCH than their counterparts.

“… Pastoralists, who move from place to place in search of livestock feed and water, have less knowledge i.e. about service availability or its benefit. They give more value to sustaining their livestock than their health. As a result, I believe, their awareness is less…” (KII, LSA, Awubere district)

“…Men are not usually present when we provide health education targeting women and children. They usually go away for income-generating activities and some to care for their livestock. During such times, they do not participate and miss the health education sessions…” (KII, Afar region)

Intersectionality of religion, gender and access-uptake of RMNCH. Religious leaders have informal power to influence women’s uptake of RMNCH/FP services. In Muslim-dominated settings, men are responsible for safeguarding the religious doctrine, whereas women don’t defend their husbands’ sayings. Religious leaders/husbands recited verses from the Quran to defend their position when the women presented with FP demand, resulting in unmet FP needs in the DRS.

“…At one time in the past, several women refused to seek RMNCH/ FP services. Then religious leaders held a strong debates in the presence of the women for and against the use of FP service. Eventually, those who produced supportive evidence from the Quran have triumphed. (KII, Bambasi District in Benishangul-Gumuz)

Religious and clan leaders in most settings of the DRS discourage FP service use, especially the insertion of foreign materials like IUD and Implanon into the body: they condemned the act as “sin.” The debate among religious leaders regarding the appropriateness of FP across the DRS has not yet been resolved. Some religious leaders wanted to leave their decisions to their partners instead of imposing sanctions.

“…The community is largely in favor of RMNCH service that does not include FP. Religion is motioned as a pretext for not using RMNCH services. Those against family planning services assert that only Allah can feed its creatures. They claim that no one should get worried about the size of their family.

In contrast, there are also other Muslims in favor of FP services and child spacing. Hence, the people who belong to the same religion have divergent opinions on FP services.” (KII, Bambasi District in Benishangul-Gumuz)

The engagement of religious and community leaders determines gender norms and the use of RMNCH, as evidenced by the successful introduction of the Human Papilloma vaccine in the Somali region.

“…We are trying to work with religious leaders to introduce new vaccines or campaigns. The community would not accept us in whatever activity we do unless the religious and community leaders endorse it. For example, last time we introduced a vaccine called HPV [Human Papilloma Virus: which prevents cervical cancer] ….We finally used community and religious leaders to convince the communities…I can say that almost 100 percent of the Mosques in Somali region have been transmitting positive messages about the vaccine during Friday prayers…” (KII, Somali)

Intersectionality of socio-psychological factors and gender. This section describes the perceptions of the DRS intersecting gender pertaining to RMNCH. Perceptions in the community regarding existing RMNCH/FP inhibited the use of these services. Participants often negatively evaluated FP services due to misperceived side effects (e.g., FP causes infertility), religious sanctions attached to it (especially among Muslim-dominated regions of Afar and Somali), and values for children and fertility were deep-embedded in the cultures and religions. Men, particularly those in rural settings, often prefer large families. This shaped men to inhibit their wives from using FP.

“… Using injectable family planning causes swelling of the body on some women and excessive bleeding during menstruation on other women. I tried it one or two times, but it didn’t cause me anything…” (TBD)

“…Women fear FP services’ side effects; they often think FP may bring infertility. On the other hand, there is a misunderstanding that TT vaccination may make labor difficult while giving birth…” (HEW, Gog District)

A belief that says “it is improper to show women’s private body to a man other than a husband” refrained women from delivering at health facilities, mainly where they are by male health professionals. Men also do not want male healthcare professionals to provide antenatal care. Antenatal and delivery services provided by male health professionals are undermined and not seen as services.

“We also recommend recruiting female midwifery to assist our women during the birth. Our women would not volunteer to be assisted by a male midwife unless they experience severe labor pain. Even in our Islam religion, “even for a dead female, the process of postmortem care would be done by women only” ((KII, a religious leader in Telalak District in Afar)

“…Afari men do not want their wives to be seen by male health professionals during pregnancy or childbirth. As a result of which they prefer to be assisted by their mothers, family members or TBAs.” (Clan leader, Afar region).