Delay in reaching care

In their 'three delays model', Thaddeus and Maine (1994:1091-1110) explained that the accessibility of health services, influenced by distance and availability of transportation, is considered to play a dual role in the health care seeking process. On the one hand, it influences people’s decision-making and on the other hand, it determines the time

spent in reaching a facility after the decision to seek care has been made. Reaching an appropriate obstetric care facility early is influenced by the location and geographical distribution of these facilities. Once a decision to seek medical care has been made, other obstacles must be overcome in reaching there.

In Ethiopia, the modes of transportation mainly vary based on where you are (geographically) and who you are (economically). With the very strenuous landscape of the country and the meagre economy, it can easily be assumed that the Ethiopian transportation system in general is among the nastiest in the world. The participants were asked about the modes of transportation they were using²; distances they cover;

and, time lapse before they actually reach health facility (reaching care). About one out of ten participants said that the pregnant women went on foot (walking); about one out of four said that the pregnant women went by shouldering using 'Qareza'³ /chair/mini-bed or cart; and, nearly half of them said that they took some sort of vehicle such as bus/lorry/ taxi/rickshaw, etc. Virtually half of mothers said that the distance between their home and the appropriate health facility was more than 20 kilometres and it is only about 15 percent of mothers said that the distance was less than 5 kilometres. Factors such as topography, connection with paved roads and availability of transportation facilities, all play a role in accessibility and in reaching the health facility. Nearly 55 percent of the mothers need up to six hours to reach the appropriate health facility/provider and the remaining about 45% need more than six hours to reach the appropriate health facility/provider. The average time needed to reach an appropriate health facility/ provider found to be 6.32 hours; whereas, the average distance was 26.97 km.

2 In most cases, the modes of transportation are a mix of two or more means such as walking, Qareza, vehicle, etc. In this study, the major mode of transportation is identified for classification.

3 'Qareza' refers to stretcher made from bamboo, wood, hide, or other natural material. The patient is tied to the stretcher and covered with clothes. Four men at a time take turn to carry the stretcher. It needs to gather around 20 or more people from the village depending on the distance they will cover.

Table 4.21: Modes, distance and time for reaching care common. People may have to travel long distances over difficult terrain to reach the few functional medical facilities that exist. Secondly, the scarcity of transportation means that rural people often have to walk simultaneously with transportation to reach a medical facility. During this time the patient’s condition can deteriorate making the condition more difficult to treat on arrival. In addition, reaching a health facility does not necessarily mean the end of the journey as the nearest facility may not be equipped to

4 'Qareza' refers to stretcher made from bamboo, wood, hide, or other natural material. The patient is tied to the stretcher and covered with clothes. Four men at a time take turn to carry the stretcher. It needs to gather around 20 or more people from the village depending on the distance they will cover.

treat the condition or even administer essential first aid so patients are referred to another facility that is better equipped.

In this study among the 93 maternal cases and 185 mothers of the deceased newborn cases autopsied, almost all had some level of delay in reaching an appropriate obstetric care facility. From the testimonies contained in the data collected the constant reasons identified resulting in a delay in reaching an appropriate obstetric care facility can be grouped into three subcategories: lack of transportation; chain of transfer up until appropriate source of care; and, prolonged transportation.

4.4.1.2.1Lack of transport

Transportation constraints contribute to the late arrival of patients to a hospital. This is particularly the case for women with obstetric complication. Community factors such as poor road conditions, lack of readily available transport or inadequate means of transportation are responsible. Relatives of the deceased women experienced transportation difficulties during the process of seeking health care. Transportation difficulties encountered in some instances led to the use of alternative means of transportation such as cart (donkey, mule or horse) or in extreme case they had to shoulder her on a 'qareza'/chair/mini-bed and walk. The family of a deceased woman who has difficult-breathing explained that they had to stay at home over night because transport was not available:

“It was late in the evening just after cattle hording that she had fast and difficult breathing. We took her to the road to look for transport. We were there up to midnight but couldn’t get any. We had to go back home and get up early to catch the first vehicle in the morning”.

Overcoming transportation difficulties in the community and reaching a medical facility does not mean the transportation hardship is over. Some health facilities are without an ambulance, and even among those with an ambulance it serves multiple purposes. It may be practically unavailable at certain times. This shows the transportation difficulties that could happen when obstetric emergencies are to be referred from one medical facility to another. Health officer at a health centre testify:

“Her case can't be manage here at the health centre, so we have to transport her to the hospital. But the ambulance had already left for the health office head's zonal meeting. We looked for other transport and get very late afternoon.”

Here, a key remark is that the specified ambulance was donated through UNFA for exclusive maternal and newborn care (not for office use at all). In another health centre, concerned maternity ward health workers stipulated:

"It is not uncommon to use the MNC-Ambulance for government officials transportation. And when the health centre's ambulance may be available, lack of fuel makes it practically out of order. So, the pregnant women or her relatives are asked to provide fuel cost."

4.4.1.2.2 Chain of transfer up until appropriate source of care

In Ethiopia, there are at least three levels of maternal and child health services. Seeking care at an inappropriate level of facility, in fact, delays access to appropriate treatment.

Peripheral and/or first level health facilities’ inability to provide comprehensive obstetrical services forces them to transfer all those cases needing such services from one facility to another ending up in the hospital. Most of the cases in this study visited at least two different medical facilities. Sixty-two (67%) of the maternal and One hundred and seventeen (63%) of the mothers' of deceased newborn cases visited two different facilities; and, another twenty-eight (31%) deceased maternal and sixty-three (34%) of mothers' of the deceased newborn babies cases visited three different medical facilities.

The Ethiopian health system organisation; which is characterised by a three-tier health care delivery system might significantly contribute to these chain of transfer. From the testimonies of a deceased women mother:

".... she was not delivered the placenta and was persistently bleeding. We run to the health post, and it was difficult for the health extension workers to remove the retained placenta. So, they referred us to the nearest health centre (37 km away). The nurse at the health centre tried but it was difficult to take it out, again.

In the following morning, they referred us to the next health centre (26 km away) where there is a health officer. Nevertheless, after sometime, the health officer told us she need to go to hospital (42 km away), where there is blood transfusion and other facilities. But when we reach the hospital, she passed away.

4.4.1.2.3 Poor infrastructure (road network)

On top of long distance to health facilities; bad terrains, flooding of river valleys and muddy roads during rainy seasons, poor state of the vehicle and visiting more than one health facilities all contribute to delay in reaching care. As comprehensive emergency obstetrical care services are not available in the peripheral health facilities, obstetric emergency cases travelled up to the hospitals. Particularly, this is more frequent if there are vehicles (transportation) to travel in. Several testimonies highlighted poor infrastructure (road network) where there is better means to transport:

“She can't deliver the whole day. The TBA advise us to took her to the health centre at our village where she was transferred to another health centre (21 km away); she was again transferred to the hospital (47 km away). It was market day, there were plenty of cars and we start to travel. But after about 15 km, the heavy rain stops all vehicles. We spent the day out there, until hot sun dried the mud. We start to continue the journey after six hours, but she died before we reach the hospital”.