JPCXXX10.1177/2150132721996892Journal of Primary Care & Community HealthHailemariam et al 996892research-article2021 Original Research Journal of Primary Care & Community Health Volume 12: 1–8 Exploring COVID-19 Related Factors © The Author(s) 2021 Article reuse guidelines: sagepub.com/journals-permissions Influencing Antenatal Care Services DOI:https://doi.org/10.1177/2150132721996892 10.1177/2150132721996892 Uptake: A Qualitative Study among journals.sagepub.com/home/jpc Women in a Rural Community in Southwest Ethiopia Shewangizaw Hailemariam1 , Wubetu Agegnehu1, and Misganaw Derese1 Abstract Introduction: Evidences suggest a significant decline in maternal health service uptake following the coronavirus disease 2019 (COVID-19) pandemic in Ethiopia. However, COVID-19 related factors impacting the service uptake are not sufficiently addressed. Hence, the current study was intended to explore COVID-19 related factors influencing antenatal care service uptake in rural Ethiopia. Methods: A community-based qualitative study was conducted from September 25/2020 to November 25/2020 among selected pregnant women residing in rural districts of Bench-Sheko Zone, and healthcare providers working in the local health care facilities. Six focus group discussions and 9 in-depth interviews were made between pregnant women, and health care providers, respectively. Data was collected by health education and behavioral science professionals who also have experience in qualitative data collection procedure. Data were transcribed, translated, and analyzed thematically using Open Code 4.0 software. Result: The study revealed several COVID-19 related factors influencing the uptake of antenatal care service during the pandemic. Health facility related barriers, perceived poor quality of care during the pandemic, government measures against COVID-19, anxiety related to the pandemic, and risk minimization were the identified factors possibly influencing the current antenatal care service uptake among women in rural Bench-Sheko Zone. Conclusion: COVID-19 preventive measures, and health facility related factors and individual factors were responsible for the current decline in antenatal care service uptake. Preserving essential health care service is critical to prevent avoidable losses of maternal and child lives during the pandemic period. Hence, programs and strategies designed to maintain maternal health services particularly, antenatal care service have better take the above determinants into consideration. Keywords antenatal care, exploring, COVID-19, Southwest, Ethiopia Dates received 7 January 2021; revised 7 January 2021; accepted 31 January 2021. Introduction health, a collateral impact to near-universal disturbance.8,9 This outbreak also changed main concerns of the health The impact of COVID-19 pandemic influence worldwide system, which is finding itself not only overwhelmed but health system, essentially disturbing care provision with 1-5 moreover with limited capacity to supply services it has high levels of morbidity and mortality. With more than been up to this point expanding to communities.10 56 077 335 cases and 1 346 248 and above deaths were reported globally,6 numerous nations have executed strict social distancing rules with full or halfway lockdowns again 1Mizan-Tepi University, Mizan-Teferi, Ethiopia in second wave.7 Corresponding Author: COVID-19 also disturbing health, social welfare and the Shewangizaw Hailemariam, School of Public Health, College of Health economy in an extent unparalleled in present day history. In Science, Mizan-Tepi University, Mizan-Teferi 251, Ethiopia. expansion to the impacts of the disease itself on public Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Journal of Primary Care & Community Health This pandemic may add additional burden and concern Conceptual framework was developed after reviewing for expectant women and for those who give care for them. several related literatures. The below figure reveals the rela- There is no clearly known evidence weather the pregnant tionship of the health facility factors, risk minimization women are more vulnerable to COVID-19 than the others measure, perceived poor quality of care, anxiety, and gov- but due to changes that happens during pregnancy, preg- ernment measures on prevention and control of COVID-19 nant women may be more at risk to viral respiratory with maternal health service utilization (Figure 1). infections.11,12 Since the Covid-19 pandemic, average weekly antenatal Methods care visit was decreased by 16.1%, from 898 to 761 weekly visits.13 Antenatal healthcare services and routine follow- Study Design up at clinics were being delayed at public hospitals due to the temporary reallocation of staff to isolation wards, quar- A qualitative approach, exploratory descriptive design was antine camps and centers, screening units, the national employed. This design allows the investigator to explore lock-down, and also due to the fear among healthcare the participant’s perspective of the phenomena under 25 professionals.14 investigation. The maternal deaths were anticipated to rise by 17% within the best-scenario and 43% within the case of the Study Setting most exceedingly bad situation due to the COVID-19 pan- demics.15 Movement restrictions or lockdown, transport The study was conducted from September 25/2020 to problems and anxiety secondary to being exposed to corona November 25/2020 in Bench-Sheko zone which is located virus possibly are acting as the factors that affect the utiliza- 561 km away from Addis Ababa, the capital city of Ethiopia, tion of maternal health service.16 in Southwest direction with an estimated population of Health professionals may not be able to give the highest 829 493 out of which 418 213 are women, 129 500 are chil- 26 quality of care at the time of COVID-19 pandemic with dren under 5 and 26 462 are under 1 year. The expected basic safeguards in put, client-provider communication is number of households in the zone is about 169 284 and the seriously affected and the time to get the service required primary health service coverage of the zone is 92.6% cover- may take more as health workers attempts to secure them- ing a total catchment area of 19 965.8 km2 with majority selves from the contamination.17 86% (1 061 120) of the population living in the rural areas. There were changes to antenatal care (ANC) in Europe The zone includes a city administration (Mizan-Teferi), 6 designed to reduce the COVID-19 infection risk for preg- Woredas (districts), 246 kebeles (smallest administrative nant women and staff, and whilst phone and online consul- units) (229 rural and 17 urban). The zone has 2 Hospitals, tations can be acceptable and valued by women as an 26 health centers, and 182 health posts. The zone has 12 interim measure18 and also in order to reduce the risk of physicians’ and 511 of health professionals of different infection national policies have proposed that non-manda- ranks and 476 health extension workers.27 tory hospital appointments be removed and replaced with 19 remote support as much as possible. Study Population and Sampling In Ethiopia there was huge burden caused by the COVID- 19 episode is jeopardizing routine service delivery and The study was conducted among pregnant women residing undermining other health priorities20 with 103 395 cases in rural Kebeles of the selected districts: Gurafarda, Sheko, and 1588 death was reported.6 United Nations Population and Debrework and health care providers working in the Fund (UNPF) recently stated that “Ethiopia’s midwives same areas. These districts were purposely selected based grapple with COVID-19 while ensuring safe delivery.”21 on their District Health Information System (DHIS) reports As the COVID-19 continues to spread globally, vulner- on ANC service uptake. Districts that reported a significant able populations living in countries with weak health sys- decline in antenatal care service uptake during the COVID- tems are at high risk of being hit the hardest.22 Given the 19 pandemic, namely Gurafarda, Sheko, and Debrework already existing limited service infrastructure23 and poor were considered for this study. Six Focus Group Discussions health literacy,24 maternal health service uptake in rural (FGDs) were undertaken among pregnant women who did community in Ethiopia would be disproportionately not attend all the recommended ANC visits. Gestational age affected by the advent of COVID-19 pandemic. However, third trimester and above, being able to speak the local lan- very few studies attempted to investigate the COVID-19 guage (Amharic), age group 18 to 45 and residing in the related barriers to service uptake in rural setting. Thus, the area for at least 6 months were considered as inclusion cri- aim of this study was to explore COVID-19 related factors teria when recruiting FGD participants and a convenience influencing ANC service uptake in rural Bench-Sheko sampling technique was used to select pregnant women Zone, Ethiopia. who met the inclusion criteria. In order to explore health Hailemariam et al 3 Figure 1. Conceptual model