Journal of Addiction Research & Therapy
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According to the 2003 WHO report countries with better prenatal care service utilization experiences have better chance of minimizing maternal deaths and improving maternal health conditions? On the contrary, those countries with low or poor prenatal care service utilization level can have poor maternal health condition and high pregnancy related deaths. In developed countries, the pregnancy related mortality rate is around 5 to 10 per 1000, and the rate in poorer countries is greater than this figure which implies the need for great attention for antenatal care service utilization of such countries [1].

Some of the reasons associated with low utilization of prenatal care services in most developing countries are inadequate health infrastructures, limited information access about the services and socio cultural related factors. In author point out that socio cultural conditions in which the pregnant women exist can have a serious impact on women’s prenatal care service utilization behavior. Socio-cultural factors associated with prenatal care service utilization may encompass traditional ways of life which disfavor pregnant women; isolation of pregnant women right from their labor till delivery, traditional beliefs about modern health care services, societal perception about pregnant women [2].

The 2006 WHO report revealed that there are different international conventions and human right laws clearly put the need for a better attention for maternal health care. This report further points out that especially CEDAW under article (12) clearly stated that there should not be any sort of discrimination based on gender in accessing health facilities. This article further recommends special rights for pregnant women to be treated in the right ways and in areas of good health facilities during the time of prenatal, post natal and time of delivery [3]. The report concludes that despite these international conventions and laws, the problem is not mitigated especially in the least developed countries. Here, the report asserted that socio-cultural factors such as societal beliefs towards prenatal care services, traditional medication practices and religious influences are the main contributors for the problem to be perpetuated [4].

According to the 2003 WHO report, pregnancy related death rate is over 728 per 100,000 live births in the country. The reasons behind this figure are lack of information about the services, misconceptions about the services, inequitable distribution of health care infrastructures and the socio-cultural factors play significant role in shaping and influencing the societal attitude and beliefs towards prenatal care Services. Moreover, through the courses of individuals’ lives; families, social institutions and the society as a whole contribute their share in shaping their behaviour. Therefore, people in the same society tend to have common behaviour patterns and ways of thinking [5]. Specially, women’s prenatal care service utilization behaviour can be affected significantly by these factors either at individual or communal level and the corresponding consequences could have a great magnitude. Again, most African societies are tradition bound societies and practitioners of most socio-cultural practices [6].

A study conducted in one of the districts of Kenya on prenatal care service utilization and associated factors found out that knowledge of pregnant women about the service, negative attitude towards health providers, economic and socio-cultural factors were identified as important factors that affect the utilization of prenatal care services in the district. Among these, economic and socio-cultural factors were the most influencing factors of prenatal care service utilization in that particular area [7].

In addition to those socio-cultural factors, the prenatal care service utilization of women can be affected by other related factors. One of the factors is women’s lack of participation in decision making process to use the service. The major factors contributing for the poor prenatal care service utilization in most African countries are low educational level and limited knowledge about prenatal care services. The report also stated that a woman that is not educated has a great probability to have limited or no knowledge about the benefit of using prenatal care services [8].

A study by author in Harari region indicated that the main reason for non-utilization of prenatal care services in the area was lack of knowledge about the purposes of prenatal care services. The findings showed that out of the total number of non-user respondents, about 35.9% of them gave reason for non-utilization as having no knowhow about the service. Another research undertaken in EphratanaGidim district of Northern Showa of the Amhara regional state indicated that knowledge of the respondents about prenatal care service utilization was identified to be one of the main reasons for non- utilization [9]. Decision making power to use prenatal care service is another factor to influence prenatal care service utilization of women. Whenever women lack to control over their own life or health condition, other family members most often husbands, mother-in law or other family members make decisions whether to use prenatal care services or not. In Pakistan, for example, a study found that two-thirds of women not used prenatal care services because the husbands forbid scientific prenatal care service utilization in their country [10].

A research undertaken by author [11] found out that any woman in Assaita and Dubti towns needs a husband’s permission to visit a health service centers, or must be accompanied, particularly when the husbands are away from home. This tradition can severely limit women’s ability to use prenatal care services even in the nearby prenatal care service centers. Findings of another research conducted in Yirgalem town of the Southern Nations and Nationalities Peoples Region indicated that the decision making power of women in issues related to health and family planning in the area is over imposed by their husbands. Moreover, this research revealed that in the majority of household cases especially in decision to use prenatal care services, male partners or husbands have a vital role to play than women [12].

Attitude of women towards prenatal care services can also affect them in using the prenatal care services in their respective localities. A study undertaken in Wolayita Zone showed that the risk of nonattendance was high for those pregnant women whose attitude towards prenatal care services was negative [13].

However, most of these studies gave a due emphasis on demographic variables and they overlooked other factors which might have a direct or indirect influence on prenatal care service utilization of women. Again, none of these researches explored and looked in detail socio-cultural factors affecting the prenatal care services utilization of women in distinct communities like Gumuz. Hence, exploring in detail those context specific factors affecting women’s prenatal care service utilization as well as making statistical tests on measurable variables which are identified in the first phase of this study to generalize about the population is the main focus of this study [14].

Statement of the problem

Various factors can affect women’s prenatal care service utilization. However, those factors related to access to information and sociocultural factors are among the most dominant factors to affect the prenatal care service utilization of women especially in those countries which are weak both in economy as well as technology. This is because these countries have limited capacity to inform or create awareness about the issue and most African countries are under this problem including Ethiopia. Most Ethiopian women have limited or no experiences of utilizing prenatal care services, and their utilization level is much lower than most African countries. As a result, most women in Ethiopia especially rural women are exposed to pregnancy related deaths [1].

Although few existing empirical studies conducted at national level indicated that factors such as knowledge, attitude, women’s decision making power and socio-cultural factors are among the main hindering factors for antenatal care service utilization, there are no studies that intended to investigate the influence of such factors on Gumuz women. Studies which tried to explore factors affecting women’s prenatal care service utilization are scanty especially in those communities that are remotely located in the country including Gumuz .On top of these, most of the communities in such remote areas of the country have their own distinct socio-cultural manifestations which have not been well studied yet and ultimately need attention and detailed research on such issues [15].

The researcher from his previous experience in the area observed that Gumuz community consists of socio-cultural practices which are against the modern prenatal care services available in the area. Therefore, this study was intended to explore in-depth such factors that hinder Gumuz women in utilizing the prenatal care services and investigate in detail how these factors affect Gumuz women. This research was also intended to make statistical measures on some variables which are identified in the first phase of this research (through the qualitative approach) to make inferences about the population.

Objectives of the study

The general objective of this Research was to study factors affecting Gumuz women in using prenatal care services. This Study has specific Objectives:

• To explore factors affecting women’s utilization of prenatal care services including context specific socio-cultural factors.

• To investigate in-depth how such factors affect women’s service utilization

• To measure the association between the identified variables and women’s prenatal care service utilization.

• To identify the more determinant factors in affecting women’s prenatal service utilization.

Research questions

According to the identified gaps in the previous sections, this study is intended to answer the following research question/s according to the identified gaps in the previous sections

• What are the factors affecting the service utilization of women in the study area?

• What are the contexts specific socio-cultural factors affecting the service utilization of women in the study area?

• How do such factors affect women in that particular context?

• Do these factors have an association with prenatal care service utilization?

• Which factors are more determinants to affect the prenatal care service utilization of Gumuz women?

• Significance of the Study

Sustainable development recommends the involvement of all people in all activities to benefit all. Hence, for this to happen there should be equal and full participation among men and women without any discrimination in all activities. So, local and national development policy makers may use the findings of this study as a source of information to formulate maternal health policies which takes in to consideration challenges from the socio-cultural perspective. Moreover, this study may give a clue for other individual researchers who have interest to undertake studies on similar issues in the area. Again, the recommendations which have been made based on the findings of this study may be used as a mirror for the government or other practitioners to see the situation and design their intervention programs to address the problem.

Finally, since there is limited study made in Gumuz community, this study may have a special significance for non-governmental and civic society organizations which have interest to intervene in maternal health sector. Here, it might provide them with important information to design and implement their short and long term projects.

Delimitations of the study

Incorporating all woredas of Gumuz Community in this study seems to be uneconomical and can take a considerable time to be accomplished. Hence, taking this and other practical difficulties in to consideration, the researcher tried to limit the research to focus on studying factors affecting women in using prenatal care services in the three selected kebeles of Dibatie woreda namely, Qido, Wobigish and Gesses. Here, the rationale for preferring Dibatie woreda to other woredas is due to the fact that this particular district has kebeles with relatively Gumuz dominant population which is the nucleus of this study, accessible kebeles for transport which can ease mobility to undertake the study. Besides, the researcher has long term working experience with the community and is familiar with the area to conduct this research properly.

The target participants of this study were women with experiences of pregnancy or child birth, under the reproductive age of 18-49 years and who have access to service centers. The researcher prefers this age category to get authentic data as the regional and national family laws state as the minimum age for marriage is 18 years old and biologically most women cease bearing children around the age of 49 years old. Due to the very interest of the researcher to study factors apart from accessibility factors, he selected those women who have access to service centers. Moreover, the researcher included those key informants from different categories to strengthen the findings through interview and focus group discussion.

Limitations of the study

According research undertakings were not adequate in Ethiopian peripheries until recently. This fact also applies to particular border land people like Gumuz community about which very little is known. This was the main limitation the researcher has encountered. Specifically, the problem of accessing adequate sources not only on factors affecting the prenatal care service utilization of Gumuz women, but also about the Gumuz community in general. Moreover, the findings of this study may not be representative to all areas inhabited by Gumuz people as the study focused on a specific area due to time and financial constraints. On top of these, language barrier might have its own impact on the reliability of data even though the researcher has tried his best to use translators with great care.

Prenatal care service utilization

Pregnancy has three major phases which need a medical follow up and treatment based on scientifically observable changes up on woman and/or her fetus; these are the prenatal, intra partum and postpartum periods. Prenatal care service is a treatment which ought to be given for a pregnant woman in the first phase of her pregnancy that is in the prenatal period. Prenatal care treatment is one of the basic components of public health that contribute for maternal health care. In other words, Prenatal care service is the first phase of care service given for a pregnant woman targeting at making a serious follow up on changes in relation to both women’s and the fetus’s health status. Basically, such follow up is very vital to check whether there is life threatening cases and abnormalities on both the fetus and mother [16].

The purpose is to take timely medical measure or action before such cases cause women to have pregnant related complications that expose women to serious illness and death. As a social phenomenon prenatal care service is recently incorporated under the general framework of public health issues. This is because the issue of maternal health care is the vital element of public health issues that contributes for the cumulative out comes of social wellbeing [13].

Therefore, prenatal care service utilization can have different features in accordance with culture, economy, political and social realities across the globe. This is to mean that prenatal care service accessibility, availability and level of utilization vary across cultures, societies, countries, continents, regions and sub regions. This indirectly shows that prenatal care service utilization behaviour and opportunity is the direct effect of social, cultural, economic and political realities of that specific society. According to the prenatal care service utilization level in developing countries is significantly lower than the utilization level in those countries which are more advanced in economy and civilization. International studies on prenatal care service utilization revealed that disparity in terms of utilization of these services among the developing and advanced countries is due to limited health infrastructure and physical barriers to service delivery sites. These studies have said nothing in detail about possible factors which contribute for the creation of this big rift in utilization of prenatal care services among developed and developing countries. However, they roughly estimated that 80% of pregnancy related deaths in developing countries occurred as a result of lack of prenatal care service utilization of women in their localities [11].

The result of a research conducted on prenatal care service utilization of women in one of the developed nations, Kahm district of Japan, only 46.1% of the pregnant women got the prenatal care service and the associated reasons for this poor utilization are no time (93.4%), not necessary (83.8%), feeling embarrassed (74.3%), and living far away from the ANC facility (71.3%). In addition, educational level, income, cost of transportation, cost of service were found to be significant predictors of prenatal care service utilization in this particular district [17]. The research concluded that educational level, economic status, cost of services in addition to physical inaccessibility and limitation in health infrastructure have a great contribution for the inadequate utilization of the service in that particular area.

The 2006 WHO report indicated that the major contributing factors determining the utilization of prenatal care services in developing countries are mentioned to be the socio-demographic characteristics of women, cultural contexts and accessibility of these services. According to that particular report, awareness level of women and their education level also determine their utilization behavior of the service. The report further points out that the prenatal care service utilization level in developing countries is much lower than those of the developed countries as most women in developing countries are less educated, culturally bound and victims of different harmful traditional practices. This is because socio-cultural factors and traditional practices of societies have the power to alter the intention and behavior of women to use prenatal care services in their localities. Due to such and other hindering factors the issue of prenatal care service needs due attention in less developed countries than the developed ones [18].

In addition, the use of different health services and medical need is determined not only by the presence of physical disease but also by cultural perception of illness. That is why in most African rural communities, prenatal care services coexist with indigenous health care services; and therefore, women in those communities are forced to choose and use between these two options. The use of modern health care services in such a context is often influenced by individual perceptions of the effectiveness of modern prenatal care services and the religious beliefs of individual woman. Moreover, in many parts of Africa, women’s decision making power is extremely limited, particularly in matters of reproduction and sexuality. In this regard, decisions about prenatal care often made by husbands or other family members [19].

Attitude of women towards prenatal care services

Attitude of women towards prenatal care services may or may not affect the utilization of prenatal care services. Results of some studies indicated as attitude of women towards prenatal care services significantly affect their prenatal care service utilization where as some others revealed as their attitude had nothing to do with their prenatal care service utilization. For instance, attitude of prenatal care services had significant effect on prenatal care service utilization of women in Japan. The result of another study indicated that attitude of women towards prenatal care services in Assaita and Dubti towns had a significant effect on prenatal care service utilization of women in that particular area [20].

The findings of another research in Amhara regional state also indicated that attitude of women towards prenatal care services had no significant effect on prenatal care service utilization of women in that respective area.

Decision making power of women in using prenatal care services

Decision making power to use prenatal care service is one major factor to influence prenatal care service utilization of women. Whenever women lack to control over their own life or health condition, other family members most often husbands, mother-in-law or other family members make decisions whether to use prenatal care services or not. In Pakistan, for example, a study found that two-thirds of women do not used prenatal care services because the husbands or other family members forbid modern prenatal care service utilization in their country. A research undertaken in Afar regional state found that any rural woman in Afar needs a husband’s permission to visit a health service center, particularly when the husbands are away from home [21]. This tradition can severely limit women’s ability to use prenatal care services even in the nearby prenatal care service centers. Generally, these Studies did not explore in-depth factors that have a direct or indirect influence on prenatal care service utilization of women in their specific areas. Moreover, even though most of them indicated as socio-cultural factors are the determinant factors to affect women in using the prenatal care services, these studies again did not show what these socio-cultural factors are and how they affect women under their contexts. Again, none of these researches explored and looked in detail socio-cultural factors affecting the prenatal care services utilization of women in Gumuz community. Hence, exploring in detail those context specific factors affecting women’s prenatal care service utilization is the main focus of this study.

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