Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan

Abstract

BackgroundSouth Sudan has one of the worst health and maternal health situations in the world. Across South Sudan, while maternal health services at the primary care level are not well developed, even where they exist, many women do not use them. Developing location specific understanding of what hinders women from using services is key to developing and implementing locally appropriate public health interventions.MethodsA qualitative study was conducted to gain insight into what hinders women from using maternal health services. Focus group discussions (5) and interviews (44) were conducted with purposefully selected community members and health personnel. A thematic analysis was done to identify key themes.ResultsWhile accessibility, affordability, and perceptions (need and quality of care) related barriers to the use of maternal health services exist and are important, women’s decisions to use services are also shaped by a variety of social fears. Societal interactions entailed in the process of going to a health facility, interactions with other people, particularly other women on the facility premises, and the care encounters with health workers, are moments where women are afraid of experiencing dignity violations. Women’s decisions to step out of their homes to seek maternal health care are the results of a complex trade-off they make or are willing to make between potential threats to their dignity in the various social spaces they need to traverse in the process of seeking care, their views on ownership of and responsibility for the unborn, and the benefits they ascribe to the care available to them.ConclusionsGeographical accessibility, affordability, and perceptions related barriers to the use of maternal health services in South Sudan remain; they need to be addressed. Explicit attention also needs to be paid to address social accessibility related barriers; among others, to identify, address and allay the various social fears and fears of dignity violations that may hold women back from using services. Health services should work towards transforming health facilities into social spaces where all women’s and citizen’s dignity is protected and upheld.

‘You have a child who will call you “mama” ’: understanding adolescent pregnancy in South Sudan

“…The project was implemented between 2012 and 2016 and was geared towards supporting the State Ministries of Health of three states (including WBeG) to improve the quality and responsiveness of the sexual and reproductive health services. Findings from research done amongst adults have been reported earlier [17][18][19][20]. Insights from this research, particularly about how social norms and gender relations shape women's sexual and reproductive health in South Sudan, have also extensively informed this inquiry; it particularly helped us to develop the interview questions and to locate the analysis in the broader social context of the study community.…”

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

“…"His relatives will come and argue about 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?'" [30].…”

“…Perceptions of poor quality of care The poor quality of care perceived by the population was also reported as a major barrier to access to healthcare services [30,35]. Poor quality of care was described as a lack of medicines, supplies, and skilled staff and poor attitudes towards patients among health staff [35,43].…”

Making a Case for the Critical Examination of Assignments of Responsibilities in the Reproductive Realm: Insights From South Sudan

“…In another paper , we have discussed the gendered nature of inequalities in the domestic, social, and economic spheres of Fertit society; we show how these inequalities intersect to constrain Fertit women's agency in the reproductive realm. Drawing on the same dataset, in the third paper (Kane et al, 2018), we show the importance of social accessibility of reproductive health services as a key determinant of Fertit women's use of the available services. While analyzing this large dataset, and in the process of writing these three papers, there emerged in the data a narrative around reproductive responsibility, its assignments, its upholdment, and its abrogation, by men; this narrative related to the themes covered in these three papers, but yet was distinct and unique.…”

“…Because these days people are failing in life and the failure comes from men. (Traditional leader male) In earlier work, we have discussed how in the study community, women expect their pregnancy to be appreciated, legitimated, and dignified by the man and his family-among other things, by them taking responsibility for it and showing that by taking good care of the pregnant woman (Kane et al, 2018). In the study community, this social expectation was so important that if not met, many women, despite being aware of the benefits of using the services, would choose to forego care and stay at home.…”