According to the results from the FGDs and IDIs, there are two main problems: One is poverty, which prohibits the family from seeking obstetric care. The second is a lack of an empowerment of women. From the viewpoint of the women interviewed, the decision-making process to use a health facility for skilled care is mainly managed by the husband, his parents (mother- or father-in-law) or his brothers.
A study carried out in rural Tanzania, resulting in similar findings, has shown that decision makers in maternal referrals are husbands and relatives
. The process in deciding to seek referral care is influenced by a community’s perception of the seriousness of the condition, the difficulty of access and the cost involved in transport, living expenses at the hospital, and perceived quality of care at the facility level. In our study, the husband and his relatives were also found to be the main decision-makers, the reason for this being that the husband is the manager of the income of the family. He is the head of the family and all matters concerning the household must have his clearance
. This situation is favored by tradition; generally men are considered more powerful than women in society; the consequence is that women do not have enough power to participate in the decision-making concerning the household and their health. They refer to the husband or the mother-in law. The importance of the mother-in-law in this process is that in some situations, several households live as one family with the mother-in-law as a key person for all things concerning women (such as cooking, pregnancy and delivery, health of newborn, children and women). She is perceived as a model for the household wives and also the evaluator of the behavior of the wives. In general, the mother-in-law is much respected and her viewpoint is important in the decision-making process. Generally problems of health, sex and reproduction related to women are managed by the mother-in-law. Obstetric problems, generally called “women’s problems” are not often discussed with partners but with the mother-in-law or mothers. When the mother-in-law perceived the importance and the need to use health care, she can be a facilitator and aid for the choice to use a health facility. If not, the mother-in-law can decide that the woman can give birth without the assistance of the clinic. This happens when the mother-in law herself gave birth at home for all her pregnancies without apparent complications. A daughter-in-law could be considered as a lazy woman if she insisted on delivering in a health facility. Also, as has been shown in the case of the Gambia, post-menopausal women are seen as experts on pregnancy and childbirth and are consulted if a complication is noticed during pregnancy, labor or during the puerperium; their words are hardly challenged in Gambian society
The low status of women has consequences for the decision-making process. Delay in reaching the health facility is sometimes catastrophic for women
; but what can they do if they cannot always decide by themselves?
In both districts, in general, men get married to have children and to have someone to help them for agricultural work. This situation sometimes does not take the care for women’s health into account.
Traditions heavily influence the decision-making-process; women play a secondary role to men in this culture. In our study, all the women living in couples have recognized that expenses are the responsibility of the husband. It means that society, traditions do not provide enough power to women to make them autonomous. It has been described in a study
that payment of antenatal clinic bills might not even be associated with the wife’s ability to pay, but as a traditional responsibility of the husband. No matter how financially stable a woman is herself, it is the responsibility of the husband to pay the antenatal care bills and all bills associated with the emergency obstetric conditions. The reasons evoked are related to the role of each partner. Women attributed to themselves the role of reproduction. In return, they do not have to suffer to find money for care. But the problem is if men do not have money since the decision-making to go to a health facility is related to money. When there is money, it is possible for man to decide to go to a health facility for care; but, if there is no money, it is difficult for the man to decide to go; if they go, how will he pay for care and drugs? So, we think that some actions must be taken to help women to be somewhat autonomous financially by helping them to implement small projects in agriculture or cattle farming or others things which could be helpful for them in their context. The empowerment of the women could be such an opportunity.
The empowerment of women (both daughters-in-law and mothers-in-law) is vital to the reduction of maternal mortality. Both groups need to be involved in strategies to strengthen their power. It is true that in this context, the most important thing is the internal empowerment of daughters-in-law in opposition to mothers-in-law. It is equally true that, in some situations, mothers-in-law contribute to the poor status of daughters-in-law. But in the process of empowering women, what can be done? The empowerment of women is a process in which many elements need to be considered. But, the most important area in which an impact can be made in our context is to facilitate the right for women to have access to land and to improve their economical status. In both districts, women cannot be landowners even while the economy of the country is based on agriculture. The relationship between the capacity to pay and decision-making could be overridden, if women would have a better status in the society.
It is now clear that to reach the fifth Millennium Development Goal (MDG 5), whose objective is to reduce maternal death by 75% by 2015, urgent strategies have to be implemented not only in the reinforcement of health supplies but also at the demand level by considering the factors that prevent women’s use of health facilities.