Background
Globally, women continue to face inequities in health care with regards to their sexual and reproductive health. About 830 women worldwide died every day from complications related to pregnancy and childbirth in 2015 [
1] and over 90% of these deaths occurred in low-income countries. About 225 million women worldwide are estimated to have unmet family planning needs, 12.7 million of which are adolescent girls who are married or in union [
2]
. An estimated 100.000 deaths a year could have been prevented had timely access to effective contraception been available.
Access to care as the cornerstone idea of the Universal Health Coverage is often associated with determinants such as availability, accessibility, affordability and acceptability [
3‐
5]
. The gender determinant, namely being a woman, brings in additional social and cultural dimensions of access
to and utilization
of health care services. On the one hand, domestic and intimate partner violence, system discrimination and cultural harmful practices, such as female genital mutilation or female infanticide, pose gender-specific risks to women’s health and well-being. On the other hand, limited access to education, job market or adequate resources often prevents women from obtaining necessary healthcare services.
Tajikistan is a landlocked country in Central Asia with a population of 9 million, a 0.99/1 male/female ratio, 25% of female population in reproductive-age (15–49 years old), a total fertility rate of 3.8 and a 99% total literacy rate (2018). Within the first two decades after gaining independence from the Soviet Union in 1991, Tajikistan underwent significant demographic and health changes. The maternal mortality rate doubled in the first three years reaching an unprecedented level of 120 deaths per 100.000 live births in 1995, and later decreased to 44 by 2013 [
6]
. Girls’ net attendance rate to mandatory secondary school had decreased from 100% in 1990 to 70% in 2012, and back to 90% in 2017, reported adolescent marriage rate for girls (married before 18) reached 13%, with 85% of married adolescent girls justifying wife-beating [
7]. The 2012 Tajikistan Demographic and Health Survey [
8] showed that, in the context of access to necessary care during pregnancy, 45% of women stated that obtaining money from family members to cover healthcare costs was a major barrier; for 26–29% of women distance and unwillingness to travel alone was a serious obstacle, while 17% said that obtaining permission to see a healthcare provider was difficult.
The recent, 2017 Tajikistan Demographic and Health Survey [
9] revealed that 92% of pregnant women sought professional care at least once during pregnancy, while 64% had 4 antenatal visits; 95% of women delivered with skilled birth attendance, 88% of which in a health facility.
Labour migrants’ wives
A continuously declining economy and growing poverty have driven the majority of the country’s men to long-term labour migration to the Russian Federation, making Tajik households primarily dependent on remittances [
10‐
14]. The 2009 Tajikistan Living Standards Measurement Survey showed that 9% of the country’s population was abroad because of labour migration, and 28% of households reported at least one family member had migrated [
15]. The long-lasting migration of men has, in its turn, changed the lives and conditions of their wives left behind; women traditionally residing with their in-laws have limited or no control over family budget. Similarly, they often have limited autonomy to take decisions about their health and well-being [
13].
Despite the persistent socio-economic and cultural developments aggravating women’s opportunities and living conditions, very limited research on women’s health and well-being has been conducted in Tajikistan.
With this qualitative study, we aimed to explore factors affecting women’s health seeking behaviour in rural Tajikistan; a special focus was made on access to antenatal and obstetric services. Our preliminary hypothesis was “wives of labour migrants have limited opportunities to take decisions about access to health care which often leads to delays in obtaining necessary services”. We deliberately selected labour migrants’ wives because their responses could serve a double purpose: (a) to describe common trends and barriers to access health care in disadvantaged groups of women; (b) to explore general health beliefs and practices among women in rural Tajikistan.
Methods
Study setting
This study was conducted in Isfara district of Sughd region, Tajikistan, which has an estimated 90% male labour migration rate. According to local authorities, these men are occupied in different seasonal jobs in the Russian Federation for at least 7 months every year; a big proportion of labour migrants stay abroad for two and more consecutive years. The long absence of men has gradually affected the living conditions and opportunities of their wives, who in most cases are unemployed or have no alternative sources of income. Traditional patterns of family relations and household management in rural Tajikistan oblige married women to reside with their in-laws, especially in the absence of their husbands [
16‐
18]
. The 2009 study on the abandoned wives of Tajik labour migrants [
13] reported that women residing with their extended families often become economically and socially vulnerable. The latter creates an additional limitation for women to access necessary care: with 63$ per capita public spending on health (2015) and no health insurance system, informal out-of-pocket payments by service users are estimated to constitute over 70% of the total healthcare expenditures in Tajikistan [
19]
.
Study design
In order to understand how decisions to seek health care are made and why, we opted for a qualitative research method with a descriptive and interpretive approach. To include cultural factors affecting women’s health choices and practices, we have introduced behavioural components in the data collection tools.
To ensure the validity and credibility of the collected data, we based our methodology on the triangulation of data sources and data collection tools: (a) in-depth interviews (IDI) with women provided primary information on women’s own experience accessing health care and the barriers to access; (b) semi-structured interviews (SSI) with healthcare professionals added more specific information on assumed barriers and actual practices; (c) focus-group discussions (FGD) with household leads highlighted common health beliefs and practices in the community.
Conceptual framework
We have adapted the “Three delays” model by Thaddeus and Maine [
20] originally designed to identify factors contributing to maternal death in the case of an obstetric complication from the moment of its onset to its eventual outcome. The authors suggest that a delay in access to necessary care may occur at any of the three stages: (1)
decision to seek care; (2)
reaching a healthcare facility and (3)
receiving necessary care. They presume that the
decision to seek health care can depend on factors such as costs, health beliefs, women’s power and autonomy to take decisions and can cause the first delay in accessing necessary obstetric services. Assuming a timely taken decision, physically
reaching a healthcare facility can act as another delay, mainly due to the distance to health providers, transportation costs or road conditions. Finally, after reaching a healthcare provider,
receiving necessary care in a timely and adequate manner can be delayed as the result of long waiting times and poor organization at a healthcare facility, a lack of necessary competences and supplies, or corruption, resulting in an adverse outcome of the complication.
The initial “Three delays” model has in the last two decades been widely expanded and adapted in different areas of health research and practice [
21‐
24]
. For the purposes of our study, we have adjusted the original model to investigate factors affecting access to health care services in general and built our questions on participants’ last episode of sickness. The adapted model was also used to explore the actual experience of women in accessing and obtaining maternity services in cases where a pregnancy occurred in the last three years.
Sample selection
We purposely selected three study groups: (1) women from Isfara district whose husbands were in a labour migration for a period of over 6 months; (2) extended family members with household lead roles (mothers-in-law); (3) healthcare professionals in Isfara district providing antenatal, obstetric and postnatal services in primary, secondary and tertiary level facilities. Altogether, we conducted 29 in-depth interviews with migrants’ wives, 16 semi-structured interviews with healthcare providers and 2 focus group discussions with 16 mothers-in-law. We ensured that participants for in-depth interviews and focus group discussions were not related and did not belong to the same family or household.
We selected three villages (Navgilem, Surh, Kulkand) with different (a) socio-economic status; (b) levels of cultural and religious conservatism and (c) distance to the administrative centre where secondary and tertiary healthcare facilities are located. Unlike specialized secondary care, primary healthcare facilities exist in every village of Isfara district regardless of their size and distance from the administrative centre. Antenatal services as part of the primary health care are jointly provided by family doctors (for normal pregnancies) and gynaecologists (for pregnancies with complications). Obstetric care is available in the administrative centre, which for different villages of Isfara district is located up to 45 km away. For the three selected villages this distance ranges from 4 km (Navgilem) to 9 km (Kulkand) and to 15 km (Surh). Based on a Soviet example of a socialized, state-funded system, health care in Tajikistan is formally free for the population; in reality, due to extremely scarce state allocations for the healthcare system and the poor remuneration of medical professionals, most healthcare services, especially laboratory tests and medications, are covered by patients’ out-of-pocket, unofficial payments [
8]
.
Two interview guides and one FGD guide were applied to collect data. The in-depth interview guide for migrants’ wives and the FGD guide for mothers-in-law covered similar sets of topics to investigate a process of taking a decision to seek and access healthcare services for different household members. A semi-structured interview guide for healthcare professionals used antenatal and obstetric complications as a key theme to explore factors affecting women’s health-seeking practices in Isfara district.
The data collection tools were designed by both authors in the English language; approved tools together with consent forms were translated into Tajik and Russian languages. The first author conducted interviews and focus group discussions in either colloquial Tajik or Russian, depending on participants’ preferences. Written consent was obtained from interview participants (migrants’ wives and healthcare professionals); focus group discussion participants were asked for verbal consent that was tape-recorded before the start of the group discussions. All interviews and focus group discussions were tape-recorded with the permission of participants.
Data management and analysis
The first author transcribed the data in the language it was originally collected in – Tajik or Russian. Given clear study objectives, the main themes and sub-themes in the data collection tools were used as preliminary codes complemented by new themes that emerged during analysis. The transcripts were analysed using a qualitative data analysis software: NVivo Qualitative Data Analysis Software; QSR International Pty Ltd. Version 10, 2012.
The collected data were first analysed against the study groups they were collected in. Further, codes that evolved across two or three groups were categorized as main themes. Simultaneously, new themes were put into separate categories based on their significance and relevance. While reducing categories, we were guided by the study objectives. Finally, we have compared the major findings in all three groups to identify links in similar categories across the groups. We based our interpretation of data on the preliminary hypothesis and the authors’ knowledge of the study context.
Discussion
With this qualitative study we aimed to explore factors that influence rural women in northern Tajikistan to access and use healthcare services. Special emphasis on access
to and utilization
of maternity care was instrumental in investigating whether decision-making processes in families may cause antenatal and obstetric complications due to delayed access. The adaptation of the “Three delays” model [
20] as the conceptual framework not only served the objectives of our study, but also enabled its potential replication and allowed for comparison of our findings with results from similar studies.
Our study demonstrated that rural women in northern Tajikistan have no or extremely limited autonomy to make independent decisions about their health and well-being. Traditional patterns of family organization and culturally assigned gender roles within family structures oblige married women to reside with their in-laws and/or sometimes other extended family members of their husbands. Decisions to seek and utilize healthcare services by married women are strongly influenced by their mothers-in-law, who were found to act as household leads and ultimate decision-makers when matters of their sons’ families were involved. The revealed pattern of the decision-making process involved several steps and actors: (a) the need to seek health care should be first recognized by household leads; (b) permission to seek and utilize healthcare services should be obtained from at least two family members. In most cases, these were found to be a mother-in-law and a husband, and this hierarchy pertains regardless of whether the husbands are in country or in the long-time labour migration abroad.
These findings resonate with the vast body of evidence from different settings with similar gendered family roles [
18,
25‐
28]
. Dube [
25] in her book analysing gender performance within family structures in Muslim, Buddhist and Christian populations of Bangladesh, Pakistan, India, Nepal, Malaysia, Sumatra, Thailand and Philippines, concludes that a woman in those cultures is seen in the shadow of an imaginary mother-in-law. Other studies on the influence of mothers-in-law on family planning decisions in rural India [
28] and Pakistan [
29] highlight the dominating role of mothers-in-law in the fertility issues of their children’s families.
We found that mothers-in-law base their decisions primarily on their own experiences of illness and utilization of care, especially where pregnancy and childbirth are concerned. If a healthcare service or intervention is not perceived as necessary or adequate by mothers-in-law, they tend to use their power to prevent their family members from using it. It particularly applies to antenatal care, which is widely seen as unimportant and, in some instances, as harmful to a foetus. This finding is supported by the results of the qualitative research on the role of mothers-in-law in the uptake of antenatal care in Nepal [
30] and the quantitative study on the relationship between women’s autonomy and maternal care utilization in India [
26], showing that decisions on the use of antenatal care influenced by mothers-in-law do not always reflect the actual needs of pregnant women.
In addition, a number of myths and misconceptions about routine pregnancy-related interventions, such as ultrasound and gynaecological examination common among the elderly generation in Isfara district, were found to prevent pregnant women from using antenatal services. This is consistent with the existing evidence on how knowledge and beliefs around pregnancy and childbirth influence actual health seeking practices. Goodburn and colleagues [
31], in their research on the effect of beliefs and practices on maternal morbidity and mortality in Bangladesh, found the neglect of health services as a factor associated with maternal morbidity and mortality. Khadduri and colleagues [
32] revealed that, even knowing the benefits of maternity care, women in Haripur (Pakistan) opt for traditional practices harmful for women and new-borns.
Our results show that reaching a healthcare facility and receiving necessary care do not pose notable obstacles to obtaining health services. Primary healthcare facilities, including antenatal and obstetric care, exist in all villages; secondary and tertiary care can be obtained in Isfara town, which is located 15 to 50 min away by car. While all respondents reported being satisfied with the primary health care services they received in their villages, referral to secondary, tertiary or specialized services (laboratory tests, advanced diagnostics) in Isfara town was associated with reportedly insignificant issues of traveling time and cost of services.
Whether a husband was in the country or absent did not influence a woman’s autonomy or position to take decisions on seeking health; the primary role of a mother-in-law as a household lead and decision-maker was preserved regardless of a husband’s whereabouts. However, in the periods when their husbands were in the country, women reported having better access to financial resources and support.
The study has some important policy implications. First, given a relatively high rate of pregnancy and childbirth related complications due to delayed access to care in a setting with well-established antenatal and obstetric care structures, clinical standards and medical personnel, non-structural determinants of ill-health such as cultural beliefs and practices should be recognized by the decision-makers in the health sector. In doing so, it will be important to (a) support research on non-structural determinants of women’s access to and utilization of health care; (b) develop response measures, including effective awareness raising and behaviour change communication strategies on the community level; (c) introduce necessary changes to maternal health policies in order to ensure effective and sustainable implementation of the selected response measures.
Second, deteriorating socio-economic conditions and education opportunities of girls and women over the last two decades [
7]
, coupled with growing radical Islamic tendencies in Tajikistan may have a drastic effect on women’s position in society. Comprehensive, intersectoral actions to empower women and increase their autonomy and possibilities to attain the highest level of well-being and health should be urgently prioritized.
The antenatal care reform and introduction of the family medicine as the primary entry point to maternity services were seen by the interviewed healthcare professionals as a negative development. In addition to the increased risks of antenatal and obstetric complications, the reform is believed to exacerbate the inefficiency of the antenatal care system in the region. While family doctors paid by the system for provision of antenatal services fail to cover pregnant women with antenatal care, gynaecologists who are no longer responsible for physiological pregnancies often have additional workload due to the reluctance of pregnant women to be seen by a male family doctor. In addition, maternity hospitals report that women admitted for childbirth (whose antenatal care was covered by family doctors) often have incomplete or inadequately managed antenatal records, with crucial pregnancy-related data missing.
Building on the findings of this study that women’s access to health care services in Tajikistan is strongly associated with a number of non-structural determinants, more research looking at factors influencing the access and utilization of care of both, other groups of women and other regions of the country would provide a basis for large-scale interventions to improve the health and well-being of women in Tajikistan.
Our study has certain limitations. This was a small-scale study in one district of Sughd Region, hence not all results can be generalized to similar groups of women in other regions of Tajikistan. Data were collected in Tajik or Russian and analysed in English, which may have led to a certain distortion of content as a result of translation. Finally, keeping in mind the cultural inappropriateness of publicly disclosing family or personal issues, which could possibly have led respondents to provide socially acceptable answers rather than sharing actual experiences, we applied a certain level of reservation when analysing and triangulating our data.