There was considerable variability in the reported occurrence and timing of post-natal care (PNC) visits by HEW among the four study kebele. Respondents from all respondent groups consistently reported that HEWs in kebele A and B in Amhara visit most mothers within 3 days of giving birth. But the replacement of two longstanding HEWs by temporary workers in kebele B was reported to have led to a recent decline in visits. Visits were reported as occurring late or not at all in kebele C in SNNPR, and were said to be largely non-existent in kebele D in SNNPR. Reflecting their reportedly frequent occurrence, PNC visits in the Amhara kebeles were described as ‘ordinary’, while in kebele D respondents had ‘never heard’ of this type of visit.
Through our inductive coding three main interlinked themes related to why early PNC visit may or may not occur emerged. These were physical issues related to accessibility and transport issues; information issues related to whether the HEW knew about the delivery; and work issues related to HEW availability, HEW performance and organization. We found no pattern in relation to PNC visits and maternal education level, with nearly all of the mothers interviewed having no or primary education levels.
Physical issues
The main physical barriers to early PNC visits were related to accessibility (distance, spread of villages and topography) and to transport. In all study areas, there were households that were classed as inaccessible by all participants due to time or terrain issues. For example, in
kebele A, there were some areas that were accessible only by ladders or only in the dry season, and these were difficult for the HEWs to visit:
‘Some of the places are quite mountainous, and other places can only be accessed using a ladder to descend a ravine….There are places that we can’t access in the wet season…. Those that are nearer are not problematic. We get them within 24 hours’ [kebele A, Amhara, HEW – FGD].
Generally a flat topography and clustered settlements were seen to facilitate visits and a hilly terrain and scattered settlements were seen as a barrier. A flat terrain meant that households were generally accessible by transportation, which was facilitated by the few HEWs that had bicycles: ‘The topography of this kebele is flat like …. no ups and downs It is accessible for cars and walking’ [kebele D, SNNPR, Fathers – FGD].
Although extreme distances and terrains were limiting factors for PNC visits, moderate difficulties were not a limiting factor. Kebele A and B had the most difficult terrain overall, but these kebele are where community members reported that early PNC visits were most common. In contrast kebele D was generally flat and accessible but PNC visits were reported by community members as not occurring at all suggesting that information and work issues can be more important barriers than moderate physical difficulties.
Whether the HEWs’ knew a birth had occurred was a key theme in whether early PNC visits occurred. The main sub-themes were whether there was a functioning alert mechanism; and minor sub themes were place of delivery, migration in pregnancy and whether the pregnancy carried any stigma.
In the Amhara
kebeles (A and B), where visits were reported as being common, mothers reported that HEWs knew they had delivered because they were involved in the delivery or in calling the ambulance. Women in these
kebeles reported that they were told to inform the HEW when they went into labor, and few women had the ambulance number themselves: ‘
I directly went to their office [health post] when I felt labor pain, and it is the HEWs who called for Ambulance services’ [
kebele A, Amhara, mother-narrative]. In the difficult to access areas of these
kebeles, HEWs reported that they relied on the HDAs informing them of the delivery, which was hampered by accessibility issues as HDAs went in person or sent a messenger to inform an HEW of a delivery:
‘The problem is that we do not get the feedback through the HDAs on time. They have to go a lot of distance and they sometimes send the feedback through students…….because of that we visit them after 7 days. So that is our major problem’ [kebele A Amhara, HEW-FGD].
In the SNNP kebeles (C and D), where PNC visits were reported as occurring late or not at all, women were given the ambulance number directly, often by the HDA. The HEWs thus relied on the HDA leaders informing them that a woman had given birth, and this did not always occur. In particular, HDAs in kebele D (where PNC visits were rare) reported that they did not always tell the HEWs about a delivery ‘The problem may be with us [HDA].….for example there was a mother that had delivered; I did go and visit her but I have not come and tell the HEW about it’ [kebele D, SNNPR, HDA – FGD]. This lack of provision of information was not linked to a lack of HDA activity, which was high in these kebele. Instead, there were some reports that the HDAs were tasked by the HEWs to conduct their visits and did not see any benefit of informing them of a delivery.
Other means of identifying delivered women were using the expected date of delivery, word of mouth and being informed by the family. Using the expected date of delivery was reported as problematic as the date were not accurate, and word of mouth was only useful where HEWs were very active in the community and made regular visits. In kebele A, in Amhara, and kebele C, in SNNPR, HEWs reported that the women themselves were meant to inform the HEW of the delivery, but mothers did not know that they should inform the HEW, and this mechanism was not functioning.
At the time of the study, few women in the study Kebles reported delivering at home, with major efforts from HEWs and HDAs to ensure all women delivered in a facility. Delivering at home was reported as shameful, with threats of sanctions and a fear that the HEW and HDA would be angry. Respondents from the mother, father and HEW/HDA FGDs all reported that HEWs would not know about women who delivered at home ‘If a woman gives birth at home, the HEWs won’t hear about it. Nobody tells them that she has given birth’ [kebele A, Amhara, Mother – FGD]. In the few cases we found where the HEWs knew about a home delivery, the women felt that they were denied PNC visits as a sanction for not delivering at a facility or not attending ANC, and this was reiterated in a mothers in the FGDs: ‘If she [mother] refused and decided to stay at home, they [HEW] will never visit her and she just sit at her house alone….they won’t be at her side [kebele A, Amhara, Mother- FGD]. In general attending ANC was a proactive decision by the family, while the families’ roles in receiving PNC visits was passive, with no active care seeking decisions in relation to the home visits. We found no pattern or link between attending ANC and receiving a PNC visit.
Other minor themes related to HEWs being unaware of deliveries, that were reported in the HEW/HDA FGDs, were that some first time mothers travel to their own mother in another kebele to deliver, and that unmarried ‘teenagers’ keep their pregnancies and deliveries secret due to the stigma attached to them.
Work issues
Two main sub themes related to work issues that affected whether timely PNC visits were made were: HEW availability and HEW work ethic and organization. Mothers, HEWs and HDAs reported workload and HEW availability as barriers to making timely PNC visits. Issues included being unavailable for visits as they were escorting women for delivery, multiple women delivering in different locations at the same time, staff absences, and participation in training workshops, meetings and health campaigns: ‘There are only two HEWs. They have lots of activities, which they are expected to perform. Therefore, they cannot cover all mothers in the three days after delivery’ [kebele C, SNNPR, Mother – FGD]. Some HEWs were more organized in terms of dividing up the community and having a clear plan for visiting communities, and these plans facilitated early visits.
Differences in HEW work ethic was also identified as a reason for no or late PNC visits, and the main differences between the kebele with reported high and low levels of early PNC visits was the general level of activity of the HEWs. In kebeles with low PNC visits HEWs were reported as only coming to the community for vaccinations, being rarely at the health post, or rarely leaving the health post: ‘They [HEWs] spend the whole day here [at health post] but no one come to here…..they didn’t go inside the village’ [kebele D, SNNPR, Father - FGD]. Temporary HEWs were reported as having particular issues with poor links with the community and with the HDA. This translated into few PNC visits being made: ‘Such staff [temporary] have a feeling that they will not be there in the kebele for long and show some sort of reluctance. They will not take their job … they believe that another person will take over from them very soon’ [kebele A, Amhara, HEW – FGD]. In kebeles with low PNC coverage the HEWs sometimes relied on strong HDA teams to conduct activities, or were reported as only being interested in ensuring facility deliveries occurred.
In contrast, in those
kebeles with reported high PNC coverage, community members described a general high level of HEW activity and a sense of connectedness between the community and the HEW:
‘They themselves live with us. They are with us when the baby is delivered. They visit us every day. They do not do only visiting within three days. They call for Ambulance; they escort us to the health facility and assist us in delivery’ [kebele B, Amhara, Mother - FGD].