While the study did not dwell into the details of level and nature of knowledge about SRH matters, all community members – women and men across age groups, and all traditional leaders, recognized the benefits of modern maternity care, and were aware about the importance of antenatal care, institutional delivery, and to some extent, post-natal care. Reliable, state and county level data on availability, accessibility and utilization of maternal health services is not available in South Sudan. However, in the study area, services were available and accessible; and study participants indicated that they appreciated the presence of these services, and used these services. Issues related to geographical access, financial access, and perceived quality of care were reported as being important barriers to the use of services by our study participants. These barriers are important, however they are not the focus of this paper, and hence not presented and discussed here.
This section presents other social reasons why inspite of being knowledgeable about and having maternal health services in their vicinity, many women still did not use these services. Findings are presented as themes; three major themes emerged. The first theme presents how various social fears shape women’s care seeking. The second theme presents how women’s social expectations and social interactions around the act of visiting a health facility shape their care seeking behavior. In the third theme, women’s and society’s views about pregnancy are presented with a view to locate the findings of the first two themes in the local context, and to better explain them.
Women, both young and old, talked of fear and of ‘being afraid’ in some form or the other. They often did so without probing, indicating that the experience probably had wide relevance, and was an important feature of women’s interaction with the maternal health services, specifically of why women, used the maternal health services, or not. The importance of this cognitive process was acknowledged by professional informants too; although their observations were limited to and primarily referred to fears related to painful medical procedures and to the insecurity involved in the act of travelling to health facilities.
Fear of being embarrassed
Women were afraid of being embarrassed during the care encounter; in our study, this feeling had two broad facets. One related to not having enough money to cover the expenses incurred, and another related to not having one’s husband by one’s side.
Maternal health services in South Sudan are free in primary care facilities, although some user fees are levied in hospitals. However, the facilities in the study area often did not have enough supplies and drugs; patients were asked to buy these from private pharmacies. In Wau, people had to spend money to buy goods (soap, cloth, cotton, medicines etc) that are needed when delivering in a health facility, for transport, for stay if one were from another place (as is often the case around Wau), and also to pay for fees (including for informal payments to health workers). Not having enough money was clearly cited as a reason for not using services by both men and women. As the following quote illustrates, one of the underlying mechanisms through which not having money also shaped care seeking decisions, was that women were afraid that if they were to be asked to pay, and they did not have enough money on them, they would be shamed or even be belittled.
“It might be money, some things go back to the economy, maybe there is no money and she is afraid that when she goes they will charge her a lot of money.” [Woman under 35, Not In Union].
Another underlying mechanism through which not having money affected care seeking decisions, was that women were afraid that if they did not have enough money to pay for the expenses incurred at the hospital, they might not be allowed to return home. This led some to not only not use the hospital facilities, it also led them to turn to (and often to prefer) the services offered by traditional birth attendants (TBAs). Unlike hospitals, TBAs were flexible; they did not necessarily expect cash, and could be paid in instalments, over a longer period of time.
“TBAs can wait even for a year for the women to pay them, but if you go to the hospital and you don’t pay they won’t let you go home, so women fear.” [FGD, Women above 35].
Women who were widowed, or did not have a husband, or whose husband was away, or had been abandoned the husband, or had no family to support them, were afraid that health workers would ask them about their husbands, and would insist that their husbands be present. In South Sudan, a pregnancy is a matter of pride, and it is important that it is dignified by and seen to be valued by the man and his family. It is deeply embarrassing to women if they are seen to be on their own, and with no man to dignify their pregnancy. Women fear this embarrassment, and instead of going to health facilities, prefer to stay at home to avoid the embarrassment.
“She is also afraid that they might tell her to bring her husband … and the man is not there. Because of fear they stay at home” [Woman under 35, Not in Union].
For such women, as was often the case, not having enough money, further amplified the problem. They were particularly worried that if they did not have enough money on their person, the health workers might ask them to bring their husband, further exposing them to embarrassment.
Fear of being ill-treated
There is a large body of literature from low and middle-income countries which documents ill-treatment of patients by workers in health facilities. To some extent, and linked to the fear of being embarrassed, women in the study community were also afraid of the midwives being rude to them. In the following quote, a young woman points out how some women are so afraid, that they would rather deliver at home, inspite of knowing well that to do so, is dangerous.
“The people who do not want to go to the hospital are people who are afraid. They fear delivery, and fear that the midwives will be rude to them. So that is why they don’t go to the hospital but still deliver at home .. (even when they know that it).. is dangerous.” [Woman under 35, Not in Union].
Senior health workers and SRH service managers, recognised this situation. They were well aware of, and felt ashamed about the poor attitudes of some of their staff. Privately, some expressed frustration at the situation – pointing out that the shortage of health workers in the area meant that hey had very little room to reprimand and discipline errant health workers.
“Yes I do agree, this situation is very embarrassing … some midwives are verbally abusive and have bad attitudes. Some women will prefer not to come back to the hospital because of the maltreatment.” [Health Facility Personnel - Manager].
Fear of being denied services
Many steps are being taken to improve maternal health services in South Sudan; for instance, to improve the continuity of care, a paper card is issued to every pregnant woman. In this card, health workers record the progress of the pregnancy and the pregnant woman’s medical situation. We found that health workers diligently use these cards, and impress upon women the importance of carrying these cards when they visit health facilities; most women also understood the importance of these cards. However, it was these very cards that paradoxically appeared to hinder the use of maternal health services. Some women could not afford these cards (approximate price = 0.25 EUR), and therefore hesitated to visit the health centres. We found that many women lost their cards, had their cards torn, or soiled; as the following quotes show, women in such situations were afraid of being reprimanded by the health workers, and denied services.
“This will affect you, if you have a child (are in the process of delivery) and you do not have a follow up card no one will accept you even the trained midwives they will not assist you. Even the hospital will not accept you.”[Woman under 35, Not in Union].
"If the midwife finds that you do not have a hospital card, she will tell you that she cannot go to you because you did not go for checkups. If a crime comes to me, what will I say? I will not go to you. We have this kind of situations here." [FGD, Women over 35].
These quotes also illustrate how the way these check-ups and cards related processes were implemented in practice; perhaps unwittingly, these service delivery improvement processes, paradoxically gave some women the impression that not carrying these cards, or not attending earlier antenatal check-ups, was akin to committing a crime. An impression that seemed to be enough to make some women afraid, and to not use maternal health services.
Insecurity related fear
Poor rule of law is a problem in much of South Sudan. The state apparatus is unable to protect people from antisocial elements, including but not limited to ethnic militias. The prevailing insecurity featured prominently in both men and women’s explanations for not using health facilities. People were afraid of being accosted on the way to the health facilities at night, but also during the day.
“If labour pains start at around 2 am, and there is no way to go to the hospital, and there is no transport, and you fear criminals on the way.” [Woman under 35, Not in Union].
“There is no transport, so people fear to move at night to go to the hospital and people can attack you on the way” [FGD, Men under 35].
The health workers, the healthcare managers all admitted that this was a major problem. They acknowledged the circumstances and they recognized people’s fears as understandable, pointing out that this was the price society paid on a daily basis for the chronic insecurity and unrest.
“And for people to access services there must be security, people should have peace of mind that if I walk five kilometers, I will go and come back without any problem. So one of the factors is .. if I go there and I feel threatened (on the way to getting to the facility), it will affect the utilization.” [NGO Representative].
The findings above reveal that a variety of social fears also shape decisions around seeking maternal health care. In the discussion section, these fears, and the social processes driving them, are discussed in view of the theoretical insights on ‘social fears’.
Dignity expectations not being fulfilled
In the study community, as in all communities in South Sudan, pregnancy is a matter of personal pride for women. It is something to be celebrated and dignified by the man’s family. As the following quotes from an FGD among men illustrate, it is expected that a pregnant woman is treated nicely and is seen to be so too in society, particularly when she ventures out of the house and into public spaces.
“When you (a pregnant woman) get up to go to the health center, the culture and traditions are like … the shoes on your feet and the clothes … when you want to leave your house, you need to take a shirt and wear (good clothes).” [FGD, Men over 35].
Being able to dress nicely, and to be presentable in public spaces like the clinic, was very important to women. It was important to the extent that if they did not have soap to bathe and did not have a clean dress to wear, they would rather not go to the clinic – inspite of knowing well the importance of the antenatal, natal or postnatal visits.
“When they get pregnant, they want their husbands to buy them new dresses, new shoes, to braid their hair … and to give her money … then after … that is when you leave home and go (out into public places, like the health centre).” [Woman under 35, Not in Union].
Women whose husbands were either away, or who had been abandoned by their husband, or had nobody to provide for them, would rather not be seen in public in an unpresentable state. Appearing disheveled and uncared for would give people an impression that this was someone whose pregnancy was not being celebrated and dignified by the family. Women in such circumstances would rather forgo care, than open themselves to dignity violations. While reliable data are not available, many women in the study community, and in South Sudan at large are in such a situation.
The ‘pregnancy’ - for the man’s family, and also the man’s responsibility
In some ways linked to all of the above themes, and in many ways shaping women’s care seeking decisions and actions, albeit at a cognitively different level, is the status and role of women in the local society, and how women see themselves within and interact with these social arrangements. We found that women’s role in society is seen to primarily be about bearing children for the man’s family. The entrenched social norm is that women must bear as many children as the man and his family members wish; this norm relates to the idea that children replace the dead, and they allow inheritance and the continuation of the man’s family name. The following two FGD interactions illustrate the local social reality and how men and women relate to it. The first interaction below, in an FGD among young women, illustrates how women see and experience their situation and role in the man’s family; it also highlights how not bearing children as demanded by the man and his family, incurs the risk of being abandoned by the man.
Participant 1: “If you are married and already living with your husband and do not have a child, the husband can leave you and tell you to go back to your family.”
Participant 2: “His relatives will come and argue that why you are not getting pregnant …the man’s relatives will complain why is this woman brought and eating our food for free if she is not going to deliver children.”
Participant 1: “The relatives will tell the husband to leave you and go and get another woman who can have children.”
Participant 3: “Or the (man’s) relatives themselves will go and get a wife for their son.” [FGD, Women under 35].
The second interaction below, in an FGD among men, men nonchalantly discuss their inalienable claim on the woman’s womb and her fertility potential. They refer to the woman as ‘our’ wife – it signifies not just the man’s claim, but rather the family’s, for they have bought her, and brought her into the family, with the purpose of bearing children for the family. The discussion shows how the man, and the man’s family not just expect the woman to give them children, her not doing so, is considered sufficient grounds to abandon her and replace her.
Participant 1: “Because this is
married her with money. Of course, marrying a woman is like business … is like business. Meaning that if you start a business you must profit from it.”
Participants 2,3,4 (In chorus): “Yes, Yes.”
Participant 1: “And if you take a woman with money and she does not give you children, that is not good.”
Participant 2: “Yes, the family … if a woman is pregnant your family is happy.”
Participant 3: “They will say that this woman is now giving birth replacing the person who had died … the one inside now is in place of the person who had died. The family will be happy.”
Participant 4: “Like … this is my son here. He married a woman. His wife is bearing children. I will be happy. Some people meet me and say … Oh Peter! Your son’s wife delivered. I’ll be happy... But if my son married a woman and she does not bear a child, eating the ‘Asida’ (food) for free, I will not be happy.” [FGD, Men under 35].
Women’s awareness of their status in the man’s household, and their cognizance of the social reality that they had been brought (even, bought) into the man’s household to bear children, appeared to result in an ambivalent attitude towards pregnancies generally, including towards their own pregnancy. This layered sociality also shaped women’s approach towards using maternal health services. Women seemed to view the (unborn) child as the man’s family’s, and also seemed to view the process of using maternal health services as not being about their own health, but rather being about the health of the (unborn) child, and thus the responsibility of the man and his family, and not their own.
Facilitator: “Some women do not go to the hospital what makes them not to go?”
Participant: “Sometimes the man says he does not have money that was why she could not go for check-up. So, she decides not to go and if the baby dies it is a loss for her husband’s family and not her family.” [FGD, Women under 35].
That having been said, this approach to pregnancy and maternity care was not universal. Many women, even when their husband did not provide them with the money, still used antenatal and delivery services; they did so through raising money from other sources. In such situations some women also resorted to using the services offered by traditional birth attendants who charged less, were open to being paid in kind, and to being paid in instalments.