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Design, sampling, and participants
a. Access and resource availability
1.1 Proximity of health facility
Long distance to heath facilities aggravated by sparsely distributed population settlements. A semi-nomadic lifestyle which increased the distance to health facilities. Some nearby PHCUs not providing ANC.
1.2 Transport means availability
Lack of commercial or private means of transportation.
1.3 Flooding and poor roads
Floods and mud during the wet season, inability to swim, parts of roads being washed away, inaccessibility of health facilities for delivery of drugs and supplies, bumpy roads which predisposed women to excessive shaking if travelling by car or motorbike.
Pregnant women being asked to pay money at some health facilities. Having been asked to pay for ANC in the past affecting current ANC service use. Transportation costs to health facilities.
b. Influence of sociocultural context and conflict
1. Domestic chores of women
Lack of time to attend ANC due to the heavy burden of domestic work. Lack of someone to leave behind with children if a woman decides to visit a heath facility. Inability to arrive at the health facility on time due to domestic chores.
2. Influence of husbands/male partners
Men unwilling to pay for costs associated with visiting a health facility, men restricting their partners from attending ANC, lack of emotional support and encouragement from men, lack of interest in maternal health by men. Men perceive ANC attendance to be unnecessary because foremothers never used to attend ANC.
Frequent attacks by neighbouring tribes/clans. Constant fear of being attacked at any time by neighbouring tribe/clans. Women cannot leave children at home alone to attend ANC because of the insecurity. Husbands cannot allow their wives to attend ANC because of insecurity. Displacement after attacks exacerbated geographic inaccessibility.
c. Perceptions of pregnancy
1. Perceived benefit
ANC perceived to be a new concept in the community, unfamiliarity with ANC and its significance, lack of prior contact with the formal heath system.
2. Perceived risk
Low-risk perception due to no prior pregnancy-related complications and trivialization of health problems during pregnancy. ANC attendance not viewed as a routine exercise but linked to pregnancy complications.
d. Perceived quality of care and efficacy of medical treatment
Dissatisfaction with ANC if medical treatment was not provided during the visit. Attendance of ANC influenced by whether the woman’s symptoms were relieved by treatment received during previous ANC visit.
Transportation/accessTransportation/access issues included long distance to health facilities, flooding and poor roads, and lack of transportation means. Long distance to health facilities was occasioned by the sparseness of the population settlements, nomadism in search for water and pasture, and the lack of enough facilities providing ANC in the county.“Another reason why women don’t attend ANC is the long distance from villages to health facilities. Some villages and payams have no health facilities and women are discouraged from visiting faraway health facilities.” (Male FGD participant, Maper centre)“Most of the ladies stay in cattle camps and are used to migrating every season to other areas. In the dry season, they have to go to a far place where there is water and during the rainy season, they move to a place where there are no mosquitoes because this place has a lot of mosquitoes if there is water.” (KII, CHD staff)Long distance and lack of means of transportation to health facilities aggravated the effect of the other barriers on ANC attendance (mentioned below). Women felt that if a health facility was near, they would attend ANC and return home quickly without having to worry about insecurity. Additionally, their husbands would be less likely to restrict them from attending ANC.“It is mainly a matter of distance. If you bring a hospital near, our problems will be solved. We will not be worried about our children, husbands, and cattle.” (Female FGD participant, Chatom village)“Most of the time, we don’t have transportation means to the hospital in Maper or Rumbek.” (Female FGD participant, Wundhiot village)Flooding during wet seasons prevented women from accessing health facilities as highlighted below:“During the wet season, the land becomes flooded and the water can reach the shoulder level. If you are pregnant, you cannot swim in such a place, because your heart will get tired and your thighs will be exhausted.” (Female FGD participant, Chatom Village)Additionally, flooding prevented delivery of drugs and supplies to health facilities rendering them functionless. Floods washed away parts of the main road connecting Maper centre and Rumbek town causing serious logistical challenges.“I did not go to the hospital because I was in the village and the land was flooded with water and there were no drugs that are usually given to pregnant women at the health facility.” (Female FGD participant, Meen village)There were also concerns about the excessive shaking that occurs when travelling by a motor vehicle on the rutted roads in the county.“I did not go to the hospital in the past month because the roads were very bad. You can neither walk on foot nor use the car because they say that pregnant women are not supposed to get in the car if there is too much shaking due to bad roads.” (Female FGD participant, Meen Village)
CostsBoth male and female FGD participants mentioned that women were discouraged from attending ANC because of being asked by health facility staff to pay money. It was unclear whether these payments were official or under-the-table payments. Participants, however, noted that this practice was not present at all health facilities, and was being encountered mainly at health facilities located in neighbouring counties.“Some health facilities ask pregnant women to pay fees. This can discourage women from attending antenatal care because they don’t have money.” (Male FGD participant, Maper centre)“I tried going to the health facility and I was told by the man I found there to bring money.” (Female FGD participant, Madhol village).The experience of having been asked to pay for ANC or for treatment during pregnancy was negatively affecting the current use of ANC services.“In the past when people were being asked to pay money, we did not use to go to the hospital because we did not have money to carry with us. We did not even have one pound to buy soap, leave alone money to pay at the hospital. If a pregnant woman is asked to pay money every day she goes to the hospital, but she is very poor and cannot afford to pay, do you think she will go again?” (Female FGD participant, Maper centre)Some women who had been asked to pay for services returned home and spread this message to their friends and relatives; discouraging more women from attending ANC.“My sister went to the hospital and when she came back she told me that I should never go there if I did not have money.” (Female FGD participant, Madhol village)
Domestic chores of womenWomen in Rumbek North bear a heavy burden of domestic chores. They were responsible for taking care of children, taking care of the house, and producing and preparing food for the family. Domestic chores increased substantially during planting, weeding and harvesting seasons when women were required to work on their farms besides attending to their families. A list of the duties of women and men in Rumbek North is presented in Additional file 1. Long distance to health facilities and insecurity worsened the problem of domestic chores. There was also the problem of lack of someone to take care of children at home if a woman wished to attend ANC.“Sometimes we are preoccupied with work at home because we are the ones who are responsible for all the work and we have no time to visit the health facility, unless if it is near. The other reason is that there is nobody to leave our children at home with.” (Female FGD participant, Achiek village)Because of domestic chores, some women could not arrive at health facilities during the regular time of service delivery and there were concerns about being turned away for arriving too late at health facilities.“Children cannot spend the whole day without eating. So you spend time cooking in the morning until the hospital visiting time is over. If you go to the hospital late, doctors will say that the time for registration is over. Therefore, women who work in the morning may not go to the hospital because they can only arrive there late every day.” (Female FGD participant, Maper centre)
Influence of male partnersPartners of pregnant women had a great influence on utilisation of ANC and other maternal health services in Rumbek North. Because men controlled the resources of the family, they were often unwilling to pay for the costs associated with health facility visits. Both male and female FGD participants mentioned that men were restricting their wives from attending ANC based on three main factors: 1) long distance to health facilities: men did not want their wives to travel to faraway health facilities leaving their homes and children unattended, 2) men did not want their wives to travel to health facilities because of insecurity, and 3) some men did not see the necessity of their wives attending ANC because their mothers never used to do so.“Our husbands do not know the benefits of the hospital. They keep us at home saying that ‘our mothers never used to go to the hospital and were giving birth to many children like me… Did I die? No, I am still alive. Why should you frequent the hospital?’” (Female FGD participant, Maper centre)"Some women do not go to the hospital because their husbands do not allow them to.” (Female FGD participant, Meen village)Moreover, women felt that they were not getting the encouragement and support they needed during pregnancy and that men lacked interest in maternal health; leaving the burden of taking care of the pregnancy to women.“Here if you are pregnant, men don’t care. They just leave the pregnancy for you alone. They leave you for the rest of the pregnancy.” (Female FGD participant, Madhol village)Some men encouraged their wives to attend ANC. However, this was primarily driven by the need to have their wives get tested for any disease that would affect the foetus or just to check the status of the foetus. There was little concern about the health of the mother.“Visiting the clinic during pregnancy is useful because it helps the pregnant woman and her husband to know the gender of the baby, the time of delivery and to determine whether she is carrying twins.” (Male FGD participant, Meen village)“Attending the hospital is for checking the foetus inside the woman’s womb; that is to find out if the foetus is free from diseases or not. If the foetus has a disease, the hospital provides treatment.” (Male FGD participant, Ror bar village)
InsecurityRumbek North is in a state of chronic insecurity and the inhabitants live in fear of being attacked at any time by the neighbouring communities. Although the county is known for frequent inter-clan feuds, the prevailing political and security situation in South Sudan had exacerbated the problem. Insecurity was widely cited as the reason behind poor ANC utilisation.“The fighting is really affecting us; for example, now we have heard that people from the neighbouring clan have attacked Madhol village. Do you think that if a pregnant woman had planned to come today she will come? She will not come because of fighting. Many people are attacking our village every day and for that reason, we cannot go to a distant hospital….” (Female FGD participant, Maper centre)
Perceived benefitANC was perceived in the county to be a new concept. The population had lived for a long time without formal health care services and some women had never visited a health facility. Consequently, some women were not familiar with ANC and its significance.“The reason why others don’t go to the hospital is that the doctors have just come recently. Our villages have been in the forest all along. For example, Maper never had a hospital in the past. So many people don’t know the goodness of the hospital and that is why they do not use it.” (Female FGD participant, Chatom village)“I have never gone to the hospital ever since I was born and so I don’t know much about the hospital.” (Female FGD participant, Madhol village)Additionally, in the case of problems during pregnancy, some women turned to traditional remedies because they did not know about the medical treatment in health facilities.“I don’t know the importance of the hospital. During my previous pregnancy, whenever I had any kind of illness, I went to the traditional healer.” (Female FGD participant, Chatom village)The health facility staff felt that efforts to raise awareness, though still limited, were resulting in an increase in the number of women attending ANC.“Last year they were not attending but this year they are. This is because previously, they were unaware of the benefits of the health facility. We have tried to create awareness in the villages and they are listening and starting to understand. A few women came, received good care and went back to inform their colleagues to come.” (KII, CHW, Maper PHCC)
Perceived riskThe risk of serious pregnancy-related complications was perceived to be low. Some women without any prior pregnancy related complication did not see the added value of ANC attendance in the context of the formidable barriers to service access. Similarly, those with a health concern did not perceive the problem to be a major threat to the pregnancy.“Some of us who did not experience any problem during the first pregnancy don’t see the need of going to the hospital. We reason that the present pregnancy will be like the first one.” (Female FGD participant, Ror bar village)On the other hand, women with prior pregnancy-related complications were more likely to attend ANC because of their higher risk perception.“For my first pregnancy, my child died because of the sickness I was having during pregnancy. From there, I said to myself that for my second pregnancy, I would not want my baby to die again. I went to the hospital for check-up and treatment, came back home and delivered safely to a life child.” (Female FGD participant, Wundhiot village)Attending ANC was often associated with medical treatment. As seen above, FGD participants seldom viewed ANC as a preventive service. On one hand this promoted ANC attendance for women with health problems but on the other hand, it was a potential reason to avoid service use for women who did not feel any discomfort.“I visited the clinic when I was pregnant because I was very sick. While there, I was injected with medicine and then I felt well.” (Female FGD participant, Maper centre)Some male participants had a positive perception toward ANC especially the medical care received at health facilities—which they felt sometimes benefited them too.“We think that it is good for a pregnant woman to visit the health facility because sometimes she may be having fever and body pain and this will require her and the husband to visit a health facility for treatment. Accompanying a woman may encourage her to attend the clinic. Both of you will be tested together. You may be suffering from a sexually transmitted disease and this will require the doctor to treat both of you.” (Male FGD participant, Maper centre)
“What we want is medicine. Even if you go to the hospital, you will not be given medicine. I have gone to the hospital twice but nothing has happened. Now I have decided to go to Marial lou hospital because this medicine of Maper hospital is not helping.” (Female FGD participant, Nhomleng cattle camp)
“Some pregnant women prefer to be injected. If you give them a tablet, they don’t accept because they think that only injectable drugs can help them.” (KII, CHW, Meen PHCU)