Background
Method
Study design and setting
Study participants and data collection procedure
Data analysis
Ethical consideration
Results
Characteristics of the study population
Why rural women do not use PHC facilities for skilled pregnancy care
Broad theme & number of quotations | Sub-theme |
---|---|
Physical accessibility factors (n = 38) | Bad road |
Transportation | |
Distance to facility | |
Facility not always open | |
Quality of Care (n = 123) | Provider competence |
Unfriendly attitude of providers | |
Fear of providers and preference for Traditional Birth Attendants (TBAs) | |
Inadequate providers | |
Long waiting time | |
Inappropriate referral | |
Inadequate supply of drugs | |
PHC environment/facilities | |
Cost of Care (n = 49) | Direct cost of care |
Inability to pay | |
Informal payments | |
Other (n = 22) | Husband support |
Misinterpretation of signs of pregnancy complications |
Physical accessibility factors
Bad road
In this same group, another participant stressed the impact of bad roads “You [referring to the moderator] as you were coming you saw how bad our road is, it is too bad. In the night now around 12 midnight when a woman falls into labour, what will we do? So, this woman here [referring to a TBA in his community] she can help. It is not that we do not want to go to the health centre’ (FGD03, men <40 years old, ETE). Corroborating the views of men on bad roads, a female participant submitted: “It [bad road] can lead to miscarriage since the road is not good, it becomes risky for a pregnant woman. Assuming we have it [a facility] here, it would have been easier for us. That is, it” (FGD01, women < 31 years, ESE).Yes, there are some old women who are mature enough to assist women to give birth, if we cannot take them to the nearest health centre because sometime this our road is very rugged, it is not motorable, it is just recently that the sun is shining [dry season] that it is motorable. For the past few months due to heavy rainfall, it has been difficult to go through the roads - so we use these women who have the skill to help us to give birth (FGD03, Men <40 years old, ETE).
Transportation
Speaking on transportation as a major hindrance, a female participant said: “… we have health centres in other places but before we will get there, we may encounter danger on the way. We don’t get a motorbike in time. We have to trek before getting transportation; the health centre is very far. It is after angle 90 the health centre is located” (women < 31 years old, ESE).Like me, I have a motorbike that I can use to quickly take my wife to the health centre [PHC] during labour but for those who don't have a bike, they find it difficult to get there. Even if they have the money, to get transportation is very difficult, that is why in this situation we go to TBAs instead of staying at home to give birth to the baby. That is what we do in this community to help our women (FGD03_02, men <40 years old, ESE).
Distance to facility
Due to a far distance to a health facility, a male participant said they handle pregnancy care in their own way. When the moderator asked how the participant explained: “we have some leaves we give women in case of prolonged labour. When a pregnant woman uses the leaves, she will give birth” (FGD03, men < 40 years old, ETE). In ESE, a male respondent reiterated this view when he said: “Since there is no health centre and we have no money, what we use to take care of our wives are these herbs from the bush. Since it is God who created it, we pluck and bless it” (FGD03, men < 40 years old, ESE). Expressing the challenge of far distance to a facility made worse by scarce and poor means of transportation and bad road, a male participant stated:When my woman conceived the other time, the place I took her to was very far from here. Before we got to the hospital with the pregnancy it was by the grace of God. And after everything, we lost the baby, but my wife survived. But till date she still gives birth. If a health centre was nearby when she fainted, I would have taken her to the nearby health centre on emergency. Probably I wouldn’t have lost my baby. That’s my plea, that we should have a health centre near us (FGD05, men 55+ years old, ESE).
Expressing their predicament with the accessibility barriers, a female discussant said:Yes, it's far. We go through three different communities before we get to the health centre. Transportation is not available at night and the road is not in good condition. For these reasons, before you get to the health centre, the baby may get weak or the woman gets so tired and lose strength. That is why we request for a nearby place for a health centre (FGD05, men 55+ years old, ESE).
Yes, the reasons we don’t want to go there are many. If labour starts at midnight, the road is bad. You cannot find someone to carry you there. You are afraid not to fall from the motorcycle, you know if a pregnant woman falls from a motorcycle it is another problem. So, you will just decide to give birth at home (FGD02, women 31-45 years old, ESE).
Facility not always open
Quality of care
Not that we prefer TBAs, but when you go there [PHC centre], no help, they will leave the woman to suffer before she gives birth after she has given birth, they will come and carry the baby, bath and pour powder on the baby. Would they say they assisted the woman's childbirth? What is the need, instead of that, you stay in your house because that suffering you would suffer in the house, you will still suffer it there [PHC centre], because of that you better stay at home, you do everything, God will still help you. What’s the need now, and the money they would have collected for nothing sake, you better use that money to prepare your soup and do everything for your child (FGD02, women 31-45 years old, ETE).
Provider competence
Another woman was of the view that giving birth in a PHC facility would have led to death for her and her baby. She said: “To me I will not go to the health centre [PHC] to give birth because this my last twins, I gave birth to them at the private hospital and I know how the nurses and doctor took good care of me, if it was health centre my baby and I will not survive (FGD01, women <31 years old, ESE).Like the time I gave birth, I was in labour, by the time I was pushing for the baby to come out I did not see the nurses again. I started shouting on them to come and help that the baby is coming out and if my baby touches the ground, I will not be happy with them. When they heard that, they came and started telling me that they are sorry, with that kind of experience I don’t think I will go there next time (FGD01, women <31 years old, ESE).
Another male participant stated: “The time when that nurse [referring to a particular nurse] was here, people were using the facility very well. One woman gave birth to a triplet there when that nurse was there. Anytime we just knock the gate she opened, the nurse was staying there. It pained everybody when she was transferred to Okpella” (FGD03, men <40 years old, ETE). Expressing this same view, a man in ESE said:Yes, in those days, the health centre was the best but now you hardly see good health workers, but when you go to the private hospital, they will give you good service. Even when you take a pregnant woman to the health centre [PHC] they will be reluctant to treat. Please, you people should also talk to them to work hard and do their best (FGD03, men <40 years old, ESE).
Inability to recognise the signs of labour by the providers was another reason. A participant stated: “the reason why we do not go there [PHC centre] is that when you get there, they do not take good care of us, sometimes when you are clearly in labour, they will say you are not yet in labour and they will just leave you alone inside the labour room” (FGD01, women < 31 years old, ETE). Expressing his view, a participant alluded to provider incompetence and arrogance as a barrier to utilization of PHC for pregnancy care in the rural communities. He said:: “I don’t like the way they attend to people. They don’t treat people well. We don’t have the voice to talk to them, whatever you say, they work for the government and you cannot petition them to anybody. They do whatever they like” (FGD04, men 40–54 years old, ESE).There's a woman who was here but now transferred. When she was here, there were no complains. In short, my daughter gave birth to twins there when she was here. But today, people complain bitterly. So, the few women that still attend the health centre are just those that are new in this community. Those who understand how they operate in this health centre do not go there anymore (FGD04, men 40-54 years old, ESE).
Unfriendly attitude of providers
Another woman submitted: “To me, I can’t use the health centre because the suffering and insult is too much. I can’t allow a small nurse to insult me on my pregnancy” (FGD01, women < 31 years old, ESE).Because the health centres do not take good care and the road is too far. More so some health workers do not give good care. The nurses do not behave well; having known that a woman under labour can be angry because of the pains, instead of the nurses taking things easy with the women they will worsen everything (FGD02, women 31-45 years old, ESE).
Fear of providers and preference for home/TBAs
Two participants in a group in ETE had all their children at home because of fear of nurses. One of them said: “I did not go there because of fear” when the moderator probed further, she continued: “yes, I fear them, nurses do not hold someone in labour, they will be abusing you, that is why I did not go there”. Another woman in this group added “they will just be shouting, shouting, “did I send you? Did I impregnate you?” (FGD02, women 31–45 years old, ETE). Narrating an experience, another woman said:“Some will blame you when there is bleeding and loss of strength. They will say that's why nurses advise you to be eating vegetables. When women come to the health centre late, doctors will say that they are late. When there is a low blood level in a woman that has not visited the clinic since they will blame the woman for the low blood level. That is why we are afraid because there are some hospitals, they are just there, they don’t know how to care for people. When a woman under labour comes to them, they will say no blood; she is weak and so on” (FGD02, women 31-45 years old, ESE).
Expressing a preference for TBA, a female participant submitted that “The native medicine is as good as maternity. And it is only God who can help someone wherever you give birth. I have given birth before in the traditional health home. It was very good for me” (FGD02, women 31–45 years old, ESE). Speaking on her preference for TBAs, another woman said:There was a day I took my baby for immunisation, I saw a woman who they said has been there for the past two days and all the nurses on duty were shouting at her instead of petting her. When I saw that kind of a situation, I was afraid to go and register there because I know they will do it to me when the time comes, but when you go to a private hospital they will pet and pamper you, that is why we go to private hospitals. In the health centre their shouting can make someone lose her baby (FGD01, women <31 years old, ESE).
Like my sister who gave birth there [PHC centre] when she got there the nurse was shouting on her to push, that when she was doing it if it was not sweet and now, she is shouting. So, with that experience, I choose to always go for TBA and each time I am there and I complain the woman will attend to me fast and give me herbs to drink, also pet me, before you know it the baby has come out. So, to me, that is why I prefer TBA (FGD01, women <31 years old, ESE).
Inadequate providers
For many people, the touch of a doctor increases satisfaction with the health care received. Thus, the absence of doctors in PHC facilities makes the participants think the quality of care is low. One participant stated: “before you see the doctor, the woman would have suffered, you suffer before you see the doctor” (FGD02, women 31–45 years old, ETE). There are PHC facilities without a midwife. Speaking on this, a participant stated: “I cannot lie to you, there is no doctor, no nurse here o…. It is the woman’s [TBA] place they go for pregnancy care and childbirth. One woman gave birth in the woman’s place last week. No nurse in our health centre here” (FGD03, men < 40 years old, ETE). Speaking on providers not always available, another participant added: “What my people said is the truth, sometimes if a woman wants to give birth, she may not meet a nurse because the nurse is not always around on weekends and sometimes in the late hour. So, we need more nurses to assist and a doctor” (FGD05, men 55+ years old, ETE). Responding to the view about money as a deterrent, most participants in a group for women aged 31–45 years old responded: “no money at all (general response) it is doctors and nurses that we don’t see, that’s why we don’t want to go there” (FGD01, women 31–45 years old, ESE). Narrating her personal experience, a participant said: “Sometimes, when you get there you won’t see nurses. Like when I gave birth to my second child before the nurses came, I have already given birth at the door (entrance). We hardly see the nurses” (FGD01, women < 31 years old, ESE).The major problem I know we have is that we have only one nurse and I think it is good for us to have a specialist, then if it is difficult for them to bring a doctor, they should increase the number of the nurses. At times if the nurse is not around, this PHC centre will be completely closed down. Sometimes if women are in labour they will not meet the nurse and we have to take her to Bode, which is 12km away. They can send another nurse or increase them up to three so that this PHC will function very well (FGD05, men 55+ years old, ETE).
Long waiting time
Inappropriate referral
“We are saying health centre, can you imagine that when you get to the health centre the matron there will refer you to her own private clinic and tell you to pay a certain amount and disqualify all the baby things you bought and ask you to buy them again from her clinic. You that register in the health centre they will end up not attending to you well, that is the reasons most women go to the herbalist houses or use TBA and drink all the concussion that later affect the woman or the baby which is not supposed to be so” (FGD01, women <31 years old, ESE).
Inadequate supply of drugs
I think what he just said is very important, no drugs here because sometimes after prescription they will say we should go to other places to buy. If all these things are available here to buy them, it will be easy. Before we transport from here to Agenebode to buy those drugs, even if the drugs are expensive here, we will still buy. I think is better to have drugs here because we call here a PHC centre - a PHC centre without drugs cannot operate; provision of drugs is the first thing the government should do, thank you (FGD05, men 55+ years old, ETE).
PHC environment/facilities
What I think of these issues! like this our [PHC centre] why we don't normally go there again, the problem we have, if a woman falls into labour at night, you cannot say let me rush to the health centre we don't even have light, no generator, everywhere is bush, that is the problem we always have for that primary healthcare centre, everywhere looks dirty and no light, you can't even say you are in labour in the night and you rush there, that is the problem we always have there (FGD01, women <31 years old, ETE).
Cost of care
Direct cost of care
Affirming the high cost of care as a reason for non-use of PHC, another participant doubted that the government approved the high charges:I am a chief in this community, the reason why this PHC centre is not moving well is that the price is high [high cost of care]. They brought this PHC centre to us so that it will be easier for us but the general hospital [secondary facility] is cheaper. If they [PHC] assist a woman to give birth or give drugs they charge … this and that. Any small sickness they will charge Naira3000 (US$8.3), Naira4000 (US$11.1) but in general hospital, it is Naira 500 (US$1.4), 1000 (US$2.8). This PHC centre is now worst (in terms of costs), that is why it is not moving well, so report to them so that they will reduce the price. Because there is no documentation of it, they charge anyhow (FGD05, men 55+ years old, ETE).
In the FGDs with younger men in ETE, there were differences in opinion about direct cost care; whereas some of the participants were of the view that the charges are high, others said it is not too high. One of those who said it is high stated: “when my woman gave birth there, they charged us about Naira7,000 (US$9.4)” (FGD03, men < 40 years old, ETE). Some of those who said the cost of care is high attributed it to their inability to pay. Also, some younger women (< 31 years old) said the direct charges are not too high. In contrast, older women perceived the cost of care as high and discriminatory. One of them declared: “Yes, they charge, if you give birth there, they charge Naira8,000(US$22.2), Naira6,000(US$16.7), Naira7,000(US$9.4). That is how they do it. If you give birth to a male child, you are charged Naira8,000 (US$22.2), if you give birth to a female, you are charged Naira5,000 (US$13.8), Naira6,000 (US$16.7)”. Another participant in the same group added: “if you give birth to twins instead of them to be happy that you had twins, they will charge you more” (FGD02, women 31–45 years old, ETE). Comparing the direct cost in PHC facilities to the cost of getting birth assistance from elderly women or TBAs, one of the participants said: “anything you want, you give the person, whether it is Naira500(US$1.4) or Naira1,000(US$2.8), you give the person, that is how we do it (FGD02, women 31–45 years old, ETE).“... for example, my child gave birth to a daughter, I paid Naira50,000 (US$138.9) in the maternity [PHC]. I told you about the woman that's not serious with her job. I thank God the mother and the child are alive. But I'm not sure the government would charge women such amount for giving birth in a Maternity when there were no complications” (FGD04, men 40-54 years old, ESE).
Inability to pay
Expressing the fact of lack of money, a participant narrated what happened to a woman known to her: “there is a woman here; she was using a clinic at Okpekpe. They gave her time to come. When the time came, she had no money to go until the time for her to give birth. The woman became sick and she died with the baby in her womb” (FGD02, women 31–45 years old, ETE). In ESE, lack of money was said to be one of the reasons why they resort to using herbs for pregnancy care.You see, if you take a view of this community as a whole, we have no industry, factory or something. We are all farmers and farmers depend on annual harvest ... Now, for a farmer to have even Naira50(US$0.1) in his pocket is rare not to talk of the other children how to feed them, and you thinking of transport to a PHC centre. So, unless you go into borrowing from meeting [contributory fund] before you can get money to use a PHC centre (FGD03, men <40 years old, ETE).
Informal payments
Other
Husband support
Some women receive little or no support from their husband. As a result, they forgo skilled care because they cannot afford it due to other competing needs such as care of other children. Expressing this, a female participant said:Yes, it is true we give them money to go to the clinic. However, all men don't give their wives money anyway. We understand that poverty is the cause of such. In some homes, the men find it difficult to raise money for their wives to go for maternal care...But because of poverty, some men fail in allowing their wives to go for antenatal care. Some other times they give their wives money that won’t even be enough... (FGD04, men 40-54 years old, ESE).
The men we have in this village, we just know that we are giving births. Not that we really need the pregnancies. Because a man who really needs a baby, when the wife is pregnant, there are certain works she can do, and there are certain works you cannot do. On the day of clinic, when you tell the man today is clinic day, it will be difficult for him to bring out that money from his pocket. Baby things, he won't bring money out to buy. It is only the woman who goes to the farm, go everywhere struggling to look for all those things to buy baby things and how to take care of the baby. These are the problems we have in this village (FGD02, women 31-45 years old, ESE).