Characteristics of women and their use of maternal health services
The total 18 interviews were conducted with women having at least one child within 7 days. Of the total, 12 women were found with one child where other 6 had a first baby. Further, 5 KIIs with husbands of women were conducted. Respondents' were from the age between 16-34 years age, completed secondary to master's level education. In relation to maternal health care: N=12 women had completed their four times ANC checked-up and all N=18 delivered at hospital, and had PNC checked-up adequately.
Social-ecological model to explore maternal health care-seeking behavior
"Ecological" means multiple levels, beyond the individual (Max et al., 2015). Thus, the Socio-Ecological Model (SEM) demonstrates that behavior is the result of the knowledge, values, and attitudes of individuals as well as social influence, including people with whom they associate, organizations to which they belong, and communities in which they live. The research presents the study findings within four broad categories that were found to influence the health care seeking-behavior of women. The study findings were categorized on the basis of SEM, which are presented level wise like individual, interpersonal, institutional, community, and policy levels.
Individual level factors
The individual characteristics that influence behavior includes skills, knowledge, attitudes, sexual orientation, biology, motivation, gender identity, and spirituality (Mcleroy et al., 2016). As researcher noted, responses obtained from the respondents were sorted out in different four subcategories.
Knowledge and perception of pregnancy and health risk. Almost all of the respondents' women were aware of the pregnancy period. They revealed that it is both risk and opportunity, as illustrated by following quotes;
'I adopted baby in close consultation with gynecologist. I had open heart surgery and taking regular medicine. I still would not adopt baby if gynoecia did not recommend me. It is a great opportunity to have a child like me as a heart patient despite having its potential negative consequences'. (26-30) year's respondents, IDI)
'I have got married at a very young age (14) at that time my body was not physically fit and mature enough to have a child. So, I had miscarriage fourth time, this is my fifth pregnancy who is alive now. To get marry at the age of adolescent is high risk for the child and mother'. (16-20) year's respondents, IDI)
In this scenario, out of 18 respondents, researcher found 5 of them had already one or more children. Despite their knowledge of the adverse effects of adolescent pregnancy, these women were unsuccessful at avoiding pregnancy. Remaining 13 others responded that they have a planned child.
Knowledge and perception about maternal health. All respondents reported that ANC visits and hospital deliveries were crucial, although (n=12) respondents reported that they received at least four times ANC visits where N=18 all delivered at the hospital. Respondent realized the importance of the ANC check up and hospital delivery like this way;
'It is safe to go to hospital as the specialists (gynecologists) have better knowledge, they coordinate with intra specialist like cardiologist, neurologist and other many more if patients have multiple problem. (31-35) year's respondents IDI)
There were few respondents who did not follow ANC systematically and timely due to their negligence and/or overconfidence. In response to why four times ANC visits is crucial for the child and mother of 28 years old revealed:
'I knew that I became pregnant when my menstruation cycle stopped, it was not necessary to go to hospital for check-up. I only visited hospital during the last trimester of my pregnancy. (21-25) year's respondents, IDI)
This is unfortunate, more than knowing a pregnancy state, what mattered the most is, it's implication in real life. There are two main reasons for such ignorance: the first being negligence and the other being mother’s reluctance to share about her pregnancy.
Decision making autonomy. All respondents mentioned that they participated in household decision-making and the maternal health care. Mostly decisions were made with the agreement of spouse or older members of household. In response to the decision of being pregnant, a respondent replied:
'We (spouse) were willing to have a child and didn't consult with any other person; however, family members always pressurized on planning a baby instantly after getting marriage. Further, we decided on having only one child. (31-35) year's respondents, IDI)
The majority of respondents indicated they had decision-making autonomy towards their own health care, including maternal health. Respondents who made four times ANC visits, reported they visit as per the obtained information from differ sources like radio, television, pears, and newspapers.
Interpersonal/family members/relatives factors
Interpersonal factors comprise of relationships with others and effects on social identity. The interrelationships with family members, friends, neighbors and social support, social networking, associations, culture, peer influence, emotional support and acquaintances influence significantly in the health related behavior of individuals. For instance, influences in the decision to visit a physician for non-emergency care, and the timing of doctor visits (Israel, 2015). In similar way, social relationships affect: how individuals value pregnancy period and adopt preventive health behaviors against potential risk in pregnancy ANC and PNC.
Social relationships are essential aspects or social identity. They provide important social resources, including emotional support, information, access to new social contacts and social roles, and tangible and intangible assistance in fulfilling social and personal obligations and responsibilities. These social resources, frequently referred to as social support, are important mediators and important components of overall health care behavior.
Family support
A supportive environment and good relation is essential within family especially between mother-in-law and daughter-in-law during pregnancy. Mothers-in-laws are considered to be the most experienced persons to share advice about maternal health issues. Thus, their decisions about maternal health services were often heeded. One of the respondents reported that her mother-in-law took her to the health care center. Respondents mentioned their female family members play the decisive role for MHCSB.
'My mother-in-law took me to the hospital for pregnancy check-up. (16-20) year's respondents, IDI)
Husband of this respondent stated in relation to mother's responsibility during pregnancy that
'Mother took more responsibility and authority especially during pregnancy period to take care and guide to daughter-in-law in the belief that they understand women's issues and health. (16-20) year's respondents, KII)
This statement illustrates that women reside with their husband's family after marriage, and during pregnancy they depend entirely upon their mother-in-law. Further, it revealed that mother in laws have strong decision-making power in relation to pregnancy and delivery as husbands generally know little about it.
Cultural determinants
The parameters of cultural determinants namely hesitation and ignorance have a strong influence on MHSB (Babalola & Fatusi, 2009). Such factors largely impact on shaping health seeking behavior. Ignorance and hesitations for maternal healthcare during pregnancy are common factors that develop due to cultural practices and beliefs (Bhattacherjee et al, 2013). In this regard, one of respondents revealed that
'I did not visit hospital during my first trimester of pregnancy due to un-availability of male health worker. I visited hospital only after relatives and peers pressure. (16-20) year's respondents, IDI)
Despite having knowledge on MHCSB, women do not want to visit health institution due to negligence on pregnancy. They were neither prohibited by social norms nor family members in fact did they feel shy to expose their pregnancy with the male service providers. Thus, it is the case that respondents do not feel convenience to share their reproductive problem with male doctors.
Organizational/Institutional factors
The third level of Socio-Ecological framework concerns organizations organizational factors Specific areas of concern include how organizational characteristics can be used to support behavioral changes. Organizations provide important economic and social resources. Voluntary organizations, such as neighborhood and professional associations, may serve as important mediators or mediating structures between individuals and outer environment. Organizations are important sources and transmitters of social norms and values; it provides the opportunity to build social support for health related behavior formation.
A context for health behavior, some organizations have been supporting maternal health care activities particularly in their worksites.
'I work only 5 hours at my office during pregnancy, and offered supplementary food in cafeteria to encourage staff like me. (31-35) year's respondents, IDI)
In some cases like when female health service providers are absent, women are hesitant to seek maternal health care. Other factors such as poor infrastructures, non-availability of maternal equipment, and lack of transportation facility, unavailability of ambulance at the time of emergency prove to be discouraging factors to utilize MHCSB. In this concern one respondent mentioned that
'There is no minimum standard infrastructure and health facility and gynecologist for delivery service in our rural health post. So, we came in this hospital despite many discomforts: lock-down, financial crisis, no vehicle (ambulance). (26-30) year's respondents, KII)
In this context, health organization with poor infrastructure and low quality maternal health services are the barriers of MHCSB utilization. It is evident that health services provided by all health posts are not good as it should be, especially in rural areas of Nepal.
Community level factors
Community has been viewed as availability and location of health care services that promote health behavior. The importance of community is its implications for the development and implementation of health promotion.
Community health workers' role. The female community health workers played a significant role to encourage pregnant women to seek healthcare facilities, both for their ANC visits and delivery mode and PNC. Most of the women responded that they received maternal health care information from community members where few reveled from the FCHV. Respondents from the remote areas reported that they obtained information from the FCHV about maternal health care, along with its importance of ANC, PNC, and deliveries at health facilities.
'After third ANC visits, one of the FCHV suggested me to visit hospital with proper equipment and experienced gynecologist in order to minimize the potential health hazards of both child and mother and I did thoroughly. (26-30) year's respondents, IDI)
Role of neighbors. In village, the pregnant women and their pregnant neighbors often went to the nearest health facility for their ANC check-up. On the other hand, in city, most pregnant women visited health facility with their husband; they went with family members only in the absence of their husband.
'I usually went to health facility for ANC check-up with a neighbor with whom my delivery dates was very close. (16-20) year's respondents, IDI)
I have never visited hospital without husband. I once went with my family member when my husband was out of country for his occupational business. (26-30) year's respondents, IDI)
This statement showed that family members have decisive role during pregnancy period with regards to MHCSB.
Public Health Policy
One of the defining characteristics of public health apart from its emphasis on the health of populations rather than the health of individuals is the use of regulatory policies, procedures, and laws to protect the health of community. The use of regulatory policies has had a dramatic effect on the health of the population. The success of these policies in reducing mortality and morbidity has lead to the development of public policy approaches to address potential health risks from maternal period. These includes primarily a policy that restrict behaviors; such as prohibitions on having alcohol and smoking. Secondly, policies that allocate programmatic resources, such as the prevention economic and clothes grants along with grants establishment of free delivery/no delivery charge in each hospital.
Safe Motherhood Program. The Government of Nepal provisions different health policy for their civilian. Safe Motherhood Program is one of the policies under which Government of Nepal provides cash incentives to women making use of maternal health services, including ANC, delivery facility at health institutions, and PNC. Despite delivering at home, women were reported to have visited health facility to receive money and baby clothes.
'I delivered in the hospital because it provided money to the mother and clothes to the child, without any delivery charge. Quite importantly, I felt it was the safest and reliable place to minimize the health risks. (26-30) year's respondents, IDI)
The government hospitals provide NPR 500-1000; Rs. 1000 at the hilly region, and Rs.500 in Terai. Thus, seeking remuneration is secondary; people primarily visit hospital for maternal health services. In some cases, despite public policy, hospitals and centers are unable to address cash incentive and other services people make use of MHCSB.
'Free delivery do not address the transportation costs, other required drugs and equipment on delivery, and hospital ward charges. (31-35) year's respondents (KII)
This is the representative voice of a civilian that nation should include overall expenditure while on delivering.
This civilian voice connotes that the nation should bear overall expenses while on delivering a child. The voice vividly addresses how government policy fails to encourage its civilians to utilize maternal health care facility.