Abstract
BackgroundEvidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. Ethiopia is a major contributor to the worldwide death toll of mothers with a maternal mortality ratio of 676 per 100,000 live births. The Ethiopian Ministry of Health launched a community-based health-care system in 2003, the Health Extension Programme (HEP), to tackle maternal mortality. Despite strong efforts, universal access to services remains limited, particularly skilled delivery attendance. With the help of ‘the three delays’ framework, this study explores health-service providers’ perceptions of facilitators and barriers to the utilization of institutional delivery in Tigray, a northern region of Ethiopia.MethodsTwelve in-depth interviews were carried out with eight health extension workers (HEWs) and four midwives. Each interview lasted between 90 and 120 minutes. Data were analysed through a thematic analysis approach.ResultsThree themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources. These themes represent the three steps in the path towards receiving adequate institutional delivery care at a health facility. Of the themes, ‘increased community awareness’, ‘organization of the community’ and ‘hospital with specialized staff’ were recognized as facilitators. On the other hand, ‘delivery as a natural event’, ‘cultural tradition and rituals’, ‘inaccessible transport’, ‘unmet community expectation’ and ‘shortage of skilled human resources’ were represented as barriers to institutional delivery.ConclusionsThe participants in this study gave emphasis to the major barriers to institutional delivery that are closely connected with the three delays model. Despite the initiatives being implemented by the Tigray Regional Health Bureau, much is still needed to enhance the humanization approach of delivery care on a broader level of the region. A quick solution is needed to address the major issue of lack of transport accessibility. The poor capacity of the HEWs to provide delivery services, calls for reconsidering staffing patterns of remote health posts and readdressing the issue of downgraded health facilities would address unmet community needs.
Highlights
Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries
The deadline is approaching and the progress to reduce maternal mortality has been slow. This is worrying in sub-Saharan Africa where more than 162,000 women die each year during pregnancy and childbirth, most of them because they lack access to maternal health care, mainly skilled delivery attendance, comprehensive and basic emergency obstetric and neonatal care [1,2,3,4,5]
Three themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources
Summary
Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. The deadline is approaching and the progress to reduce maternal mortality has been slow This is worrying in sub-Saharan Africa where more than 162,000 women die each year during pregnancy and childbirth, most of them because they lack access to maternal health care, mainly skilled delivery attendance, comprehensive and basic emergency obstetric and neonatal care [1,2,3,4,5]. In 1994, Thaddeus and Maine proposed a model to explain the social causes of maternal deaths, beyond the already known medical causes (e.g. haemorrhage, obstructed labour, sepsis) They described how maternal deaths occurred primarily due to three types of delays in accessing health-care services that are able to deal with obstetric complications: 1) delay when deciding to seek appropriate medical care, 2) delay when reaching an appropriate obstetric facility, and 3) delay when receiving adequate care once the facility is reached [7]. ‘The three delays model’ aimed to classify in which of these steps maternal complications and deaths took place, and to explore ways to prevent deaths by minimizing such delays
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