Barriers to the uptake of reproductive, maternal and neonatal health services among women from the pastoralist communities of Afar, Ethiopia: A qualitative exploration

Background: Women from the pastoralist communities of Ethiopia have lower levels of utilizing reproductive, maternal and neonatal health services compared to women living in agrarian communities of the country. Despite this disparity, the barriers to utilizing reproductive, maternal and neonatal health services in the pastoralist setting are not well understood. Objective: This study aimed to explore the barriers to the uptake of reproductive, maternal and neonatal health services among women of reproductive age from the pastoralist communities of Afar, Ethiopia. Methods: The qualitative study was carried out in five districts of Afar region in January 2016. Ten focus group discussions and 45 key informant interviews were conducted. The focus group discussants were married men and women. Key informant interview participants were clan, kebele and religious leaders; traditional birth attendants; health extension workers; health experts working in maternal and child health units and family planning units at health institutions, and at woreda and regional level; heads of women's affairs and health sectors (kebele, woreda and region); and representatives of non-governmental organizations in the region. Participants were selected based on their potential wealth of information. Semi-structured guides were used to facilitate the discussions and key informant interviews. Data were inductively coded and analyzed using Alas. ti software version 7.5. Data were coded, similar codes were organized into categories, and non-repetitive themes were developed. Peer debriefing and triangulation of data from focus group discussants and key informants were undertaken to enhance the reliability of the data. Results: Low awareness regarding fertility regulation, skilled birth attendance and postnatal care, accompanied by low access to services, domestic work burdens and health facility-related factors, prevent women in the Afar communities from up taking reproductive, maternal and neonatal health services. The sub-themes of low awareness that emerged included religious disapproval of family planning; fertility and childbirth-related norms; husbands' disapproval; and limited discussions with partners regarding fertility. Moreover, difficulties getting transportation to give birth at a health facility, mobility, service-related costs and closed health facilities were components of low access to the uptake of these services. Health facility-related barriers were also explained by the absence of a conducive environment to give birth at a facility, including water availability, and women's preference for a female birth attendant at the facility and a traditional birth attendant during delivery. Conclusions: The current study revealed poor awareness about, and low access to, reproductive, maternal and neonatal health services. Women in the Afar community still opt to use traditional birth attendants and female attendants for care during and following the delivery of a child. Strong, tailored and contextualized information, education and communication interventions aimed at women, husbands and religious and cultural leaders, may help to raise awareness and improve the uptake of these services. Empowering community health workers may also contribute to addressing low awareness these services. Moreover, concerted efforts to ensure actual and perceived access to the services are also recommended.