Community perspectives and maternal health programme uptake : the Sidama region of Ethiopia

Abstract

This thesis investigates the complex factors influencing maternal healthcare service utilisation in the Sidama region of Ethiopia, where preventable complications remain major contributors to elevated levels of maternal mortality. A qualitative approach successfully delivered rich and nuanced data collected among a diverse group of participants, including mothers and members of their communities, as well as health professionals. The research offers a comprehensive analysis of how systemic barriers, access to resources, health-facility-related factors, social norms, cultural beliefs, and individual perspectives interact to shape maternal health-seeking behaviour in a resource constrained rural context. Poor transportation, unreliable electricity, and weak referral systems restrict access, while shortages of essential supplies, hidden costs, and facility-based experiences erode trust in the formal health system. Together with cultural preferences and social norms, these factors deter health service uptake, and interrupt continuity across antenatal, delivery, and postpartum care. A major contribution of the study lies in showing how structural failures are experienced relationally: women’s trust declines when promised referrals, transport, or respectful treatment do not materialise. Intra-household power dynamics, particularly the authority of husbands and mothers-in-law, further constrain women’s autonomy. The findings demonstrate that late initiation of antenatal care reduces the likelihood of skilled delivery and postpartum follow-up, while privacy concerns, cultural preferences (warmth during labour, prayer, traditional rituals), and a strong reliance on traditional birth attendants significantly deter facility deliveries. Both the Theory of Planned Behaviour, and the Socio-Ecological Model, in isolation accounted inadequately for these factors. Drawing on the work of Lee et al (2017), the thesis proposes an adaptation of these frameworks culminating in an integrated, context-sensitive conceptual framework. This framework highlights the importance of multi-level interventions that address institutional challenges such as inadequate infrastructure and disrespectful care practices, engage cultural norms, and promote women’s autonomy. The thesis argues that improved maternal health outcomes require holistic strategies that go beyond service expansion to address the layered systemic, social, cultural, and material realities faced by women in rural Ethiopia, and provides a refined, context-sensitive framework to guide more effective maternal health interventions in low-resource settings.