Getting There: Overcoming Barriers to Reproductive and Maternal Health Services Access in Northern Togo—A Qualitative Study

• Author: Jennifer Schechter,Gbeleou Christophe Sesso,Judie Arnold,Mélanie Samson,Sandra Braganza,Alicia Singham Goodwin,Kevin Fiori,Andrew Lopez
• Date: 01 September 2016
• DOI: http://doi.org/10.1002/wmh3.195
• Published date: 01 September 2016

Getting There: Overcoming Barriers to Reproductive

and Maternal Health Services Access in Northern

Togo—A Qualitative Study

Judie Arnold, M

elanie Samson, Jennifer Schechter, Alicia Singham Goodwin,

Sandra Braganza, Gbeleou Christophe Sesso, Andrew Lopez, and Kevin Fiori

With a national maternal mortality rate of 401 per 100,000 live births, it is clear that becoming a

mother in Togo carries signif‌icant risk. In order to inform the scale-up of maternal health services,

this qualitative baseline evaluation explored barriers to maternal and reproductive health in the

Kozah district of northern Togo through semi-structured interviews with 21 community stake-

holders and focus group discussions with four groups of six mothers. Inter-related factors including

f‌inancial means, distance from health posts, gender roles, cultural beliefs, and patient–provider

relations all inf‌luence women’s care-seeking behavior. Lack of f‌inancial means renders the cost of

crucial maternal health services prohibitive, and husbands’ resistance to family planning and health-

care f‌inancing compounds the challenges women face meeting essential maternal health needs. Our

f‌indings suggest that waiving user fees, providing facility-based delivery free of cost, improving

transportation options, and fostering trust in and access to health centers could signif‌icantly

improve maternal health in the Kozah district.

KEY WORDS: maternal health, Togo, qualitative

Background

Despite continuing global efforts directed toward improving maternal health

through the Millennium Development Goals (MDGs), and subsequent commit-

ments such as the f‌irst Global Strategy for Women’s and Children’s Health,

maternal death, and related morbidities, remain some of the most pressing health

concerns in low-income countries. This is cause for particular concern in Sub-

Saharan Africa, where 1 out of 40 15-year-old girls will eventually die from a

maternal cause, compared to 1 out of 4,500 in the United States and 1 out of 3,300

in Europe (WHO, UNICEF, UNFPA, World Bank, 2014).

Factors related to accessing maternal health services have been the subject of

signif‌icant analysis. In order to maximize impact, researchers are identifying key

points of intervention along the reproductive and maternal health continuum,

World Medical & Health Policy, Vol. 8, No. 3, 2016

223

1948-4682 #2016 Policy Studies Organization

Published by Wiley Periodicals, Inc., 350 Main Street, Malden, MA 02148, USA, and 9600 Garsington Road, Oxford, OX4 2DQ.

from family planning through antenatal care (Finlayson & Downe, 2013), delivery

by a skilled birth attendant (Bohren et al., 2014), and postnatal care. A number of

studies have described the barriers to and facilitators of access to adequate health

services in various settings, and have considered the strong link between gender

inequality and women’s access to care from both quantitative and qualitative

perspectives (Ganle et al., 2015).

Most of this research has focused on specif‌ic aspects, not on intertwined

factors that explain poor access along the maternal health continuum. However,

as highlighted in the recently adopted Global Strategy 2016–2030, a holistic

approach is essential for reaching the new Sustainable Development Goals

(SDGs), which aim to reduce the global maternal mortality rate to fewer than

70 per 100,000 live births by 2030 (Target 3.1 of the Sustainable Development

Goals, 2015).

While clear progress has been made, some countries remain far from this

ambitious goal. This is the case for Togo, where between 2007 and 2014, the

maternal mortality rate was 401 per 100,000 live births (DHS 2013–2014).

Although this shows a signif‌icant decline from the 2005 rate of 510 per 100,000,

efforts are still needed to improve maternal health at the national level. With

4.8 children per woman, the fertility rate in Togo remains high, yet only

16.7 percent of women are using a modern contraceptive method. While a

signif‌icant difference can be seen between urban areas (72 percent) and rural

areas (49 percent), approximately 57 percent of expectant mothers nationally

attended the four antenatal visits recommended by the World Health Organiza-

tion guidelines, and only 59 percent of births received the assistance of a skilled

birth attendant. Women’s poor access to health services is closely associated with

gender inequality and a lack of autonomy in making decisions about their own

health. Indeed, according to the latest Togo DHS (2013–2014), in only 12 percent

of cases were women the principal decision makers for attending health services.

Hope Through Health (HTH) is a U.S.-based not-for-prof‌it organization

founded in 2004, which works together with the government of Togo to make

high quality health care accessible to all. In partnership with the Togolese

Ministry of Health (MOH), HTH set out to deliver improved maternal and child

health (MCH) services by designing and implementing an innovative integrated

clinic- and community-based health care delivery model in the Kozah district of

northern Togo. Launched in August 2015, this program was designed to increase

access to, as well as timeliness of and quality of health-care services for pregnant

women and children under f‌ive, and aims to effect long-term decreases in rates of

maternal and child morbidity and mortality. The program includes proactive

case-f‌inding and home-based treatment provided by trained, paid, and super-

vised community health workers (CHWs); mentoring for clinic-based providers;

improved supply chain management; and elimination of user fees. In concert,

these interventions seek to address both the supply and demand sides of the local

health-care system.

The present qualitative study is part of a larger mixed-methods baseline

formative evaluation designed to inform key elements of HTH’s new program.

224 World Medical & Health Policy, 8:3