Challenges of Maternal Health Services Utilization and Provision from Health Posts in Bale Zone , Oromiya Regional State , Southeast Ethiopia : Qualitative Study

Birhanu Darega1* and Nagasa Dida2 1Department of Nursing, College of Medicine and Health Science, Madawalabu University, Bale-Robe,Ethiopia. 2Department of Public Health, College of Medicine and Health Science, Madawalabu University, Bale-Robe, Ethiopia *Corresponding Author: Birhanu Darega, Department of Nursing, College of Medicine and Health Science, Madawalabu University, Bale-Robe, Ethiopia. Tel: +251-910-672-202, Fax: +251-226-652-519; E-mail: birhanudarega@yahoo.com


Background
Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period.It encompasses the health care dimensions of family planning, prenatal, delivery and postnatal care in order to reduce maternal morbidity and mortality.Complications of pregnancy and childbirth are the leading causes of disability and death among women in the reproductive age  years in developing countries [1].
Global maternal mortality statistics reflect the widening gap between the developed and developing countries.A woman who gives birth in Africa is 300 times more likely to die from complications related to pregnancy or childbirth compared to her counter-part living in a developed country [2].About 60% of maternal deaths occur during labour, delivery and immediate postpartum period [2].
More than 80% of maternal deaths can be prevented if pregnant women access essential maternity care like antenatal care, institutional delivery, postnatal care and assured of skilled attendance at childbirth as well as emergency obstetric care [3].
The Health Extension Program (HEP) is introduced during the second phase of Ethiopia's Health Sector Development Program (HSDP), since 2002/3, as a new initiative community -based health care delivery system aimed at provision of essential services to reach the people at the grassroots level [4].All HEP interventions are promotive, preventive, and basic curative care for health care services in an accessible and equitable manner to reach all segments of the population, with special attention to mothers and children.Particular emphasis has been on establishing effective and responsive health delivery system for those who live in rural areas, focusing on households at the community [4].In relation to reducing maternal mortality, Health Extension Workers (HEWs) were trained on how to provide care to pregnant mothers through pregnancy, birth, and postnatal care.It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality.
Many efforts have been made to tackle the problem of the unacceptably high maternal mortality in Ethiopia.The country has designed a number of policies and strategies to improve maternal and reproductive health.However, reliable delivery systems for life-saving and sustaining interventions are lacking [5].
In Ethiopia even though; attendance at Antenatal Care (ANC) is encouraging, worrying gaps exist in provision, and coverage [6].According to Ethiopian Demography and Health Survey (EDHS) 2011 results, countrywide 12 % of women received antenatal care services from Health extension Workers in rural areas [7].Much less is known about the utilization of postnatal care (PNC) that its importance is recently been emphasized.Therefore, the purpose of this study is of explore the challenges on maternal health services utilization like ANC, delivery and PNC services from health posts.

Study setting and period
The exploratory qualitative study was conducted in Bale zone from April 15-May 15, 2014.Bale is one of the Zone in Oromiya Regional State, that is located 430 km from the Addis Ababa, Capital of Ethiopia .The zone had 18 rural districts and 3 administrative towns .with an estimated total population of 1,708,910.In the zone, there are around 59811 mother who have less than one-year-old child.There were 316 health posts with 632 health extension workers [7].

Study Participants
Purposively five districts of the zone were selected.The districts particularly Goro, Ginnir, Dallo Manna, Madawalabu and Gasera were purposively selected depending on altitude to include location difference of districts on utilization of the maternal services.The women who have less than one year child, married men, health extensions workers, women's affairs associations, religious leaders, health extension supervisors, district and zonal health extension programs coordinators were participated in the study.
Five focus group discussions (FGD), which 1 in each selected district and 31 in-depth interviews, which six in each selected district and one as the zone were conducted.Those Focus group discussions were conducted between purposively selected women with less than one-year child and between married men.Three FGD with 32 women in 3 districts and two FGD with 24 married men in 2 districts.Specifically in Goro distict with 12 and in Madawalabu district 12 married men discussants were included.In addition, in Dallo Manna district 12, in Gasera district 11 and in Ginnir district 9 women discussants were included in FGD.
The in-depth interviews were done with purposively selected 5 health extensions workers, 5 women's affairs associations, 5 religious leaders, 5 health extension supervisors, 5-sub -district manager, 5 district and 1 Zonal health extension programs coordinators.One subdistrict was purposively selected from each district depending on their performance of maternal health extension services coverage from their report.The sub districts with lowest coverage of maternal health extension services from all sub -districts were selected in each district.One person in each categories of interviewee in each selected five subdistricts of the five districts contacted.

Instruments and Data collection methods
Semi structured guiding questionnaires, which address the objectives of the study, were adapted from pertinent literatures were used for data collection (8-15).Both investigators collected data by using tape recorder and notebooks in both focus group discussions and in-depth interviews.The questionnaires were translated from English to Afan Oromo language by language expert and retranslate to English language.Afan Oromo language was used for discussions and interviews.The discussions and interviews were tape-recorded and notes were taken.

Data Processing and analysis
Data were transcribed from Afan Oromo language to English by revising the note and replaying the tape recorder by the principal investigator.Then the group reflections were analyzed by thematic coding analysis.Ideas were merged in their thematic areas.The idea saturation was the assurance to end the in-depth interviews and focus discussions.Narrative forms were used to present the results.The results that generated by focus group discussion and in-depth interview techniques were triangulated.

Ethical Considerations
Ethical issue was approved by Madawalabu University ethical review committee.A supportive letter was obtained from University Research Directorate of the University to the Zone and all districts.Permission was obtained from district health offices to implement the study.Prior to discussion and interview, the aims and objectives of the Primary Health Care ISSN:2167-1079 PHCOA, an open access journal Volume 5 • Issue 1 • 1000189 study were clearly explained to the participants and oral informed consent was obtained.Confidentiality and anonymity were ensured throughout the execution of the study as participants were require to explain their name.Participants were informed that their participation were voluntary and can withdraw from the study at any time if they wish to do so.

Results and Discussions
In total, five focused group discussions comprising 56 discussants (32 women and 24 men) and 31 in-depth interviews were conducted in five districts of Bale Zone such as Dallo Manna, Gasera, Goro, Ginnir and Madawalabu district.

The Challenges of Maternal Health Services Utilization from Communities Side
According to their responses, maternal health services utilization from health posts were not similar throughout the districts and as well as in the Sub-districts (Sub -districts).In some Sub-districts, the community utilizes the services; antenatal care utilization was in a good manner.In addition to this, some Sub-districts gives the clean delivery and postnatal care services.In opposite to this, few Subdistricts those close to town of the district have no health post.Because, they are near to health center and they were not will to construct health post.In those Sub-districts, the community use antenatal, delivery and postnatal care from health center.Even the communities do not know as health extension worker provides those maternal health care services.From focus group discussion conducted between males, one participant said "I know as health extension worker can provide maternal health care services; even I have never seen a single mother who has utilized the services from them and we use the services from health center".Certain districts believed that once the mothers get the pregnancy, they should start getting maternal health services with antenatal care.However, the communities were not comfortable with the services provided by health extension workers.The communities have not seen HEWs as they are professional.Even the communities were not willing to take vaccination from them.They were happy if they got the service from other health professional (health center).From in-depth interview, one of Health extension worker supervisor said, "The communities want to get ANC service from health center.But we enforce them to take the service from HEWs in their Sub -district".Therefore, to change this attitude, there was pregnant mother conference every month in each Sub -district.On this conference, there were discussion on maternal health services (ANC, delivery and PNC) between the mothers and HEWs.On general Sub -district meeting, there were discussion on the ways to reduce maternal and child mortalities.Actually, in many Subdistricts that far from health center of the districts, HEWs were giving the antenatal care.From the four WHO recommended ANC visit, mothers went to health center only once for full investigations like Prevention of Mother to Child Transmission of HIV (PMTCT), Sexual Transmitted Infections (STIs), hemoglobin, etc.
In pastoralist area, the additional challenge was that the movement of community from one to another place.Even if they started taking the services from HEWs they discontinued the service while they leave their previous site.This brings difficulty to decrease maternal complication during pregnancy and home deliveries.

The Challenges of Maternal Health Services Provisions by Health Extension Workers
There was no problem of ANC services provision for pregnant mothers by HEWs.Concerning delivery services, HEWs had fear to attend it.What was expected from them was to attend clean safe delivery.But, they have never attended it.As the response of Districts HEP program coordinator during in-depth interview, he said "While HEWs are wondering from house to house for other HEP packages activities, if they get mothers who gave birth at home, they registered and report as they attended the delivery.Actually not and even they do not know when she delivered.This is because of lack of confidence (lack of self-efficacy) to attend the delivery.Except willing and taking the training on clean and safe delivery, they have not stand to conduct it".Now day in all districts, the HEWs were not allowed to attend the delivery at health post as well as at home.The government has planned for zero home delivery.For this reason and complication fear, the main duty of HEWS is identifying pregnant mother and referring to the near health center.The community phone to HEWs and HEWS calls for Ambulance services to take delivering women to health center.Since the ambulance was only one for each district, sometimes three or four calls come simultaneously that results difficulties of taking all of them to health center and they deliver at home.
Concerning the postnatal care services, it looks the delivery service.They had been reporting as they did.As that of delivery report, they report as they gave postnatal care, but there was nothing done for mothers.From in-depth interview, Districts HEP program coordinator said, "Whether HEWs report or not, we know as postnatal care has never given for the mother and it is only for reporting purpose".
Health extension workers are accountable for health center.The another challenge was also health extension workers left their working site for unknown reasons for three, five and six months.During indepth interview, as the Health Extension Worker supervisor said "When health center wrote letter to health extension workers and on their salary because of their absence from works, Districts health office interfere the procedures and HEWs returned to the work without informing health center about the situations and release the salary for them.Even health center do not know when HEWs returned to their works".This condition results big challenge on implementation of health extension program.When other HEWs hear this condition, other follows the same trend.Because of this, there was quarrel between health center and Districts health office.As health extension worker supervisor said during in-depth interview " From one health post, one health extension worker sent for up grading her career and the remaining one left the site for about four months.One day we went to the community for awareness creation on family planning.On the discussion, one mother asked us 'Why you come after we lost the services and health post closed for four months'.Their appointment for family planning was passed and even they could not use what they know.Even, there were mothers who get unwanted pregnancy because of lack of family planning services".In principle, it is impossible to change the health extension worker from one site to another site.But, in some districts changing from one site to another site was seen due shortage of HEWs.
The other challenge was also some HEWs left their work totally due their working Sub-districts were far from their family's residence, their workloads do not match with salary, they started their own business and other reasons.This result one HEW at one health post or no HEWs at health post in general.Since no trained HEWs on the Primary Health Care ISSN:2167-1079 PHCOA, an open access journal Volume 5 • Issue 1 • 1000189 market, that health post may not give the services totally.To solve these problems, one health professional from nearest health center went that health post one day per week to give those maternal services for mothers.

The Challenges on Maternal Health Services Provision from Governments Sides
Another challenge of maternal health services provision that have been seen from the direction of governments was shortage of equipments.Some health posts were equipped with all necessary materials by UNICEF sponsorship while some health posts were no necessary equipments to give those services.Even there was health post that had no examination bed.To the contrary, there was health posts equipped more than health center.But, they have not been used it.As district HEP coordinator said during in-depth interview, "The office discussed and planned to fill materials for those health posts that don't have material but still nothing has done beyond the plan".
The shortage of water supply for health post was also the big challenge that affects maternal health services provision, especially to provide delivery services.During in-depth interview HEWs said, "Even drinking water is not available.If it is available, it is not functional for one to two weeks and the community use rainwater or river for different purpose including drinking.If water is not present, attending safe and clean delivery at health post is impossible.So to attend clean delivery, even to clean different equipments and we request the persons that come with that delivering mother as they must fetch water from river".
The HEWs again raised was also a challenge.They said "Many deliveries are at night, attending the delivery is very boring and difficult due to lack of electric light".
In similar with the above finding, the study done in Tigray Region, Ethiopia shown that Health Extension Workers have brought essential maternal health care closer to the rural population in Ethiopia.Nevertheless, their success is not for all components of maternal health services.HEWs brought improvement in utilization of Family Planning (FP), ANC and HIV testing but not in assisting births.In line with our finding, their study reflects, the perception that Health Extension Workers' may be less competent in assisting births, the huge workload they already have, poorly equipped health posts and strong cultural beliefs supporting home births were the great challenges of utilizations and provisions of maternal health services at health post level [12].
Again the similar findings were reflected by another study conducted in Tigray Region, Ethiopia shown that lack of continuous training, low salary, lack of adequate supervision, workload and lack of motivations were the main barriers that hindered Health Extension Workers from providing good quality of maternal health care [16].
In consistent to this study, the study done in Goba Districts, Ethiopia shown that in rural community, most of the mothers prefer to deliver at home because of many cultural reasons and fear of cold when they deliver at health facilities [17].
Even though it is not addressed quantitatively in this study, the quantitative study done in Tanzania in 2011, a number of challenges affect the maternal health services utilization.Those challenges were; accessibility of maternal health care services is still inadequate particularly in rural and underserved areas, inadequate quality of health services provided by the health care system, the government budget allocation for health sector and inadequate numbers of skilled health workers, and still those available are unevenly distributed [3].The another study conducted in Ethiopia reflected that Sociodemographics, socio-economic, socio-cultural and personal factors are also another challenges that decrease the communities' utilizations of maternal health care services [10].
Again, the quantitative study finding conducted in Kombolcha District, Eastern Ethiopia, indicated that women with low level of education, women married to husbands with low level of education, women who are unemployed and married to farmers, women from household with no family member attending formal school, women who never experienced difficult labor, abortion/still birth, women who use foot as means of transport, and women who perceived the quality services provided to be low quality and residing in rural areas were greatly disadvantaged in utilizing maternal health care services [18].

Strengths and limitations
The data collected from different geographical variations of the region, different data collection techniques, different categories of respondents included the sample and the data were collected from the discussants by their native language that increases the validity of the study.Since the data were collected only by qualitative methods, it not addresses the information that possible only by quantitative methods.The information were transferable but not possible to generalize for other community that no addressed during data collections.Therefore, in future it is better if both qualitative and quantitative methods of data collections is considered while conduction of investigation on this title.

Conclusions& Recommendations
Antenatal care services utilization from HEWs was good.However, delivery and postnatal care services utilization were very low.In general, according to this study, the challenges of maternal health services utilizations from health posts were, the attitudes of the communities toward health extension workers, shortage of equipments, shortage of water supply, lack of electric power, HEWs left the jobs totally, HEWs left the jobs for several months, movement of communities from one place to another place and lack of coordination on supervision were the major challenges.Therefore, the Oromiya Health Bureau, Bale Zone Health Department and District Health Office should have to work cooperatively to avail necessary equipments and infrastructures for health posts, to reconsider salary of health extension workers, to train additional health extension workers for better maternal health services utilizations and provisions.