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\title{Maternal Health Care Utilization in the Eastern Cape, South Africa: A Qualitative Investigation}
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             \author[1]{Appunni Sathiya  Susuman}

             \affil[1]{  University of the Western Cape}

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\date{\small \em Received: 4 February 2015 Accepted: 28 February 2015 Published: 15 March 2015}

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\begin{abstract}
        


Background: This study presents qualitative investigations showed in Mdantsane a township in the Eastern Cape Province of South Africa. The aim of the study is to examine the socio-demographic determinants of maternal health care utilization in this province. Conclusion: The study has indicated that most health professionals and patients (women) are not aware of the available maternal health services, and this lack of awareness leads to a minimal utilization of such services. Methods The qualitative investigation revealed some information with regard to the determinants of maternal health care utilization in the study area. Results: The investigation suggests that lack of awareness about the maternal health services offered within the public health system is an important determinant of the frequency in which maternal health services are used. Conclusion:The study has indicated that most health professionals and patients (women) are not aware of the available maternal health services, and this lack of awareness leads to a minimal utilization of such services. MethodsThe qualitative investigation revealed some information with regard to the determinants of maternal health care utilization in the study area. Results: The investigation suggests that lack of awareness about the maternal health services offered within the public health system is an important determinant of the frequency in which maternal health services are used.

\end{abstract}


\keywords{utilization; antenatal care; postnatal care; public health; maternal health; private health; primary health care; millennium development goals.}

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\let\tabcellsep& 	 	 		 
\section[{Background}]{Background}\par
outh Africa is working very hard to reduce maternal mortality. The South African Department of Health has adopted several initiatives to reduce the maternal mortality rate, and thus move closer to the 2015 Millennium Development Goal Five (of reducing maternal mortality by at least 75\%). One such strategy is the adoption of the UNFPA's Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) by the Department of Health. The department of health plans to usethis campaign to fast-track the reduction of the maternal mortality rate, which is estimated at 300 maternal deaths per 100 000 live births, in order to meet the 2015 targets1. Another strategy that the department of health has adopted is the Strategic Plan for Maternal, New-born, Child and Women's Health (MNCWH). The objective of the MNCWH is to reduce maternal mortalityrates by at least 10\% by 2016, and to ensure that all women have access to reproductive health services 1.\par
In South Africa, Primary Health Care (PHC) is an initiative implemented by the government to provide basic health care within the public health sector. Primary health care has also been initiatedin many other developing countries to deliver health care needs for their populations. This health care system is aimed at providing health care services to many people who cannot afford them fromthe private health sector \hyperref[b1]{2,}\hyperref[b2]{3,}\hyperref[b3]{4} . Within South Africa, this system faces many challenges, including management, health coverage, access to health care and health care utilization 3, 4, 5. Moreover, some health care facilities are not adequately equipped to handle the needs of the population (especially in rural areas), and some of these facilities do not provide the health services that are required of them \hyperref[b5]{6,}\hyperref[b6]{7} . Most of the challenges are attributed to the apartheid regime, which is argued to have laid the backdrop for the "failing" and "inadequate" primary health care system 8. The primary health care sector is often surrounded by much controversy when it comes to the availability of resources, especially in rural areas. Health resources are unequally "distributed among rural and urban areas," including the unequal distribution of health facilities9. This uneven distribution presents problems when it comes to health care use in both rural and urban areas. The availability and accessibility of health care facilities are some of the determinants of health care use in South Africa, but are even more so for most of the rural areas therein \hyperref[b9]{10,}\hyperref[b10]{11,}\hyperref[b11]{12} .Maternal mortality is defined as the death of women during pregnancy, childbirth, or within 42 daysafter delivery \hyperref[b12]{13,}\hyperref[b13]{14} . Throughout the world, women's health is a priority for many countries, especially those with high mortality rates \hyperref[b14]{15} . Another author argues that maternal mortality is higher for women living in rural areas and those living in poorer communities \hyperref[b15]{16} . The current maternal mortality rate for South Africa is estimated at 300 maternal deaths per 100 000 live births; this is a considerable decrease (at 73\%) when compared to the 2008 estimates of 410 maternal deaths per 100 000 live births \hyperref[b13]{14,}\hyperref[b16]{17} . But still MMR is quite high in South Africa. Nevertheless, South Africa has high maternal mortality rates, which are rising and this presents major challenges in terms of the country's prospects of achieving the Millennium development Goals 15. There are less than two years left to achieve the targets set under Millennium Development Goal 5, and it seems that South Africa is not anywhere near to reaching these Millennium Development targets set by the United Nations. Reducing the current maternal mortality rate by 75\% would mean that South Africa's target for 2015 would be 225 maternal deaths per 100 000 live births, which is still quite high. According to the 2010 estimates of the World Health Organization, the maternal mortality rate in developing countries (of 240 maternal deaths per 100 000 live births) is 15 times higher than that of developed countries 14. It seems that many developing countries will not be able to reach, by 2015, maternal mortality statistics similar to those of developed countries. Therefore, given the current maternal mortality statistics, the prospects of South Africa achieving the Millennium Development Goals relating to maternal mortality seem very unlikely 4,18. Moreover, South Africa's estimated average annual percentage change in the maternalmortality rate between 1990 and 2010 is 0.9\%, which shows that the country is not making progresswith regards to improving maternal health by 2015 14. Therefore, improving the country's currentapproaches to health care and specifically, implementing new directions in maternal health carecould improve the country's health and thus ensure that, over time, the Millennium DevelopmentGoals are met19. In planning for the reduction of maternal mortality, attention should be given to the socioeconomic-demographic determinants of health, as this will improve maternal health20. A number of strategies could be implemented in this area, in order to try and reduce the high maternal mortalityrates within developing countries. These strategies would play a big role in campaigning for betterimplementation and use of maternal health services. These could include (a) the inclusion of themedia, (b) educational programmes aimed at enhancing the literacy skills of women (especially inrural areas), (c) implementing better policies that are aimed at shaping or focusing on the livelihoodsof women, and (d) implementing better maternal health care delivery 11, 21. It is important thatdeveloping countries implement strategies that will improve the socio-economic status of women, inorder to accelerate health care use and thus enhance the utilization of maternal health care services22. 
\section[{a) Aim of study}]{a) Aim of study}\par
The aim of this study is to examine the determinants of the use of maternal health careservices in the Eastern Cape of South Africa. Moreover, the study aims to examine the kind ofbarriers that contribute to the lack of (or minimal) use of maternal health care services. 
\section[{b) Research questions}]{b) Research questions}\par
The research questions for the qualitative study are as follows 1. What determines maternal health care use in the Eastern Cape?\par
2. What can be done to improve maternal health use in the province? 3. What challenges or problems do mothers experience while attending maternal healthservices?\par
II. 
\section[{Methods}]{Methods}\par
The qualitative investigation used, which were obtained from a study that made use of both quantitative as well as qualitative methods to collect data. Researcher very much interested to emphasis on qualitative issue here. This study makes use of mixed methods to study the determinants of health care utilization among women from the Eastern Cape province of South Africa. A qualitative investigation was obtained from health care professionals, using one-onone interviews as the data collection method. A range of questions were asked to gain the health professionals' views on certain maternal health care problems or challenges, as well as some of the barriers that hinder women from utilizing such services. 
\section[{a) Qualitative Investigation}]{a) Qualitative Investigation}\par
In this section makes use of transcriptions from health care professionals in the Eastern Cape. The instrument used was an individual interview, wherein a range of questions were asked from the respondents (health care professionals) with regards to their views on certain health matters involving women and their reproductive health. For the analysis and interpretation, responses from two health professionals from each of the different professions, i.e., two doctors, two nurses, and two maternal health care specialists) were selected. This made it possible for rich qualitative data to be extracted from these health professionals, thus ensuring that there was variety in terms of views expressed. 
\section[{III.}]{III.} 
\section[{Results}]{Results} 
\section[{a) Qualitative Results: Determinants of maternal health care use}]{a) Qualitative Results: Determinants of maternal health care use}\par
Staff shortages became a major theme in the investigation when it came to trying to understand the challenges faced by health professionals while working within the antenatal care unit. Shortages of health care staff can have serious implications for the utilization of maternal health services, and it serves as a barrier that hinders the use of maternal health services. 
\section[{b) One nurse stated that "The waiting time is long"}]{b) One nurse stated that "The waiting time is long"}\par
A study finding argues that shortages in health professionals and longer waiting times reduce patients' satisfaction with the health-related services they receive22. Moreover, this then leads to a decline in the utilization of health services. For instance, this can influence patients not seeing the need to seek maternal health care services, whereby they will argue, "Why go to the hospital if I will not receive the adequate care that I need?' Additionally, one health professional argued that mothers who attend antenatal care services face a number of challenges, including having to travel long distances, financial problems, and the attitudes of health professionals. Having no money and having to travel (often by walking) long distances to get to a hospital plays a role in the delayed use of antenatal service. c) One nurse stated that "[Most mothers and those who are expecting face] financial problems, [whereby] they won't come on time here when referred and they will tell us that they didn't have money to come here." Digressing from time-sensitive appointments and not seeking the available help can also be viewed in relation to the attitudes of health professionals. 
\section[{d) One doctor observed that:}]{d) One doctor observed that:}\par
"Sometimes the attitude from the health care workers [hinders the satisfaction and use of maternal health services]." One could argue that, due to the shortage of health professionals, there is a burden placed on the available staff to attend to a large number of women seeking maternal health services. This then has a repercussion on the type and quality of service offered, whereby some staff members will often take their frustrations out on the patients. Moreover, the attitudes of health professionals towards their patients are often driven by stigmas surrounding some health problems and certain social circumstances. For instance, with regards to teenage pregnancy and HIV, there seems to be a general stigma among health professionals. The doctors interviewed noted that teenage pregnancy and HIV were among the challenges they faced while working within the antenatal care unit. With regards to the treatment received by pregnant and HIV-positive teenagers, 
\section[{e) One doctor observed the following "The clinic [staff], they just chase them away and send them without helping them, which is really a problem. And the other clinics the still chas[ing] them for being HIV positive to the hospital which ? is not a good thing because we've to treat people the same."}]{e) One doctor observed the following "The clinic [staff], they just chase them away and send them without helping them, which is really a problem. And the other clinics the still chas[ing] them for being HIV positive to the hospital which ? is not a good thing because we've to treat people the same."}\par
The way in which patients are treated in most public hospitals-or rather, the way in which health care professionals behave in such settings-can be seen as a barrier that hinders the use of maternal health services. For instance, teenage girls are often treated differently for seeking health care when pregnant, as compared to adults. This leads to many cases of young girls not seeking medical care in time, due to being ashamed of what the nurses will think or say about them. In most instances, the hospital that one uses is the same hospital in which friends, family, or acquaintances work. This creates a barrier to use, in the sense that a pregnant teenager might decide not to go to a hospital where there is someone who knows her, and would rather stay at home until there are too many complications.\par
The health professionals noted a number of other reasons why most women are not utilizing maternal health services available at the hospital. They cited a lack of knowledge as one of the factors that contribute to women not using maternal health services. Most women are not even aware that they should be going for antenatal care when they are pregnant. 
\section[{f) One maternal health care specialist argued that "Lack of knowledge [is the leading contributing factor to the less-frequent use of maternal health services]. They are not aware that they should be coming to maternal health care [sessions] when they are pregnant; they don't even know what maternal health care is."}]{f) One maternal health care specialist argued that "Lack of knowledge [is the leading contributing factor to the less-frequent use of maternal health services]. They are not aware that they should be coming to maternal health care [sessions] when they are pregnant; they don't even know what maternal health care is."}\par
Besides not being aware of maternal health services offered at the hospital, most women "are not being referred" to antenatal care by their nurses and doctors.\par
g) One maternal health care specialist stated that pregnant women are:\par
"Only referred for maternal health care services when there is a problem" or complication, and these problems could be prevented if referrals could be done at initial contact.\par
Common riskfactors during pregnancy and the role that maternal health care specialists can play.\par
Apart from HIV, women who seek medical attention at the hospital present with a number of other pregnancy-related complications. The health professionals noted the following list of the most common pregnancy-related complications that women who seek medical attention present with: hypertension (high blood pressure); TB due to HIV; intra-uterine growth restriction (properly diagnosed and sometimes not diagnosed); and gestational proteinuria hypertension. All of these complications are serious risk factors that can alter a woman's pregnancy experience. Doctors and nurses in the study argued that maternal health care specialists can assist them in ensuring that the above-mentioned pregnancy-related complications are prevented. Both the nurses and doctors also said that exercises are a good starting point in ensuring that pregnant women become active, in terms of strengthening their bodies during pregnancy, thus preparing their bodies for delivery.  
\section[{Discussions}]{Discussions}\par
The qualitative results suggest that there are several determinants of maternal health care utilization in the province. These determinants have an influence on the frequency with which women use the available maternal health services. Women who have had bad experiences tend to not utilize maternal health services as frequently as those who have had good experiences. For instance, a woman who must wait for a long time before being attended (perhaps even going home unattended) might see no need to return to the clinic, unlike the one that received attention within a reasonable amount of time. Moreover, if a patient receives poor treatment, then that patient will view the health system in a different light. In some cases, she might even choose to seek medical attention from privately paid doctors, as opposed to waiting for hours on end at public hospitals or clinics.\par
Financial problems were also noted as one of the most significant factors that influence the use of maternal health services. One health professional noted: "Most of the women who go to seek maternal health services have to travel long distances, since most of them stay in rural areas, and sometimes they do not have enough money to get to the clinics or hospitals."\par
The quantitative analysis shows that more than 40\% of the women reported that they do not have a source of employment. In such situations, financial problems become a barrier to the frequency with which these women seek medical attention.\par
Besides financial problems, lack of information also poses a serious hindrance to the utilization of maternal health services. The study has indicated that most health professionals and patients are not aware of available maternal health services, and this lack of awareness leads to a minimal utilization of such services. Health professionals do not refer pregnant women for antenatal services, and when those women have delivered, they are not referred for postnatal care, which then contributes to less frequent use of maternal health services. Sometimes, women do not go back to clinics for check-ups after they have delivered; they see no need to do so, unless certain complications arise. This then contributes to the low numbers of those seeking postnatal care.\par
Cultural factors are an important variable when it comes to understanding the factors that influence the use of maternal health care services. In South Africa, culture is an important concept that influences the way people live, as well as their belief systems. For instance, there are women that believe in utilizing traditional birth attendants, rather than seeking professional health care, due to their cultural beliefs; these women tend to opt for home-based deliveries, assisted by traditional birth attendants, rather than going to a hospital or clinic. The independent variable Do you have access to medical aid? has an influence on whether or not people have access to maternal health services. One could deduce a number of reasons for this relationship. Generally, people who have access to medical aid tend to use private doctors rather than public hospitals (or clinics). This is due to a number of reasons, some of which will be further explained in the qualitative phase of the discussion. One such reason is the kind of treatment people generally receive in public hospitals; for instance, public hospitals are short-staffed and as such, adequate care of patients is often overlooked.\par
V. 
\section[{Conclusion}]{Conclusion}\par
A lot can be done to improve the delivery and utilization of maternal health services. One such improvement would be to ensure that information relating to the importance (and utilization) of maternal health services is properly disseminated, so that more people can have knowledge of such services. There also needs to be something done with regards to how information is distributed to the relevant stakeholders. Policy makers should extend their efforts and work within the objectives of campaigns such as CARMMA (adopted by the department of health) and other organisations, in trying to reduce the state of maternal mortality in the country. The health sector also needs to inspect the way in which public health care professionals conduct themselves. If one could change the attitudes of nurses, then utilization of maternal health services (especially among pregnant youths, and those who get stigmatised for being HIV positive) might increase and thus lead to a decrease in maternal mortality. Therefore, from an observational and evaluative point of view, South Africa needs more initiatives that will strengthen its objectives of reducing the country's maternal mortality before the target year of 2015. Such initiatives must speak and add on to what programmes such as CARMMA has already achieved. Currently, the maternal mortality rate is at a level where it seems unlikely that the country will achieve its Millennium development Goal of reducing maternal mortality rate by 75\% by 2015. This means that there is a lot that needs to be done in terms of coming up with initiatives that will reduce this rate, and thus save many lives. Moreover, a number of strategies could play a significant role in campaigning for better use of maternal health services, especially in rural areas. These campaigns could include (a) the inclusion of the media, in terms of broadcasting information relating to maternal health services and the importance of such services, (b) educational programmes aimed at enhancing the literacy skills of women (especially in rural areas), (c) implementing better policies that shape or focus on the livelihoods of women, and (d) implementing better maternal health care delivery. The qualitative results showcase the status of the South African public health system. The responses from the health professionals point to the fact that the public health system is not properly functioning. Many hospitals, especially those in townships and rural areas, tend to be neglected and usually do not have the adequate staff to render health services to scores of people who seek them. It should also be noted that health care use is determined by the way which health professionals treat patients. There are still stigmas associated with certain health conditions and social situations. For example, there are still health professionals who refuse to assist, or may even maltreat, young girls who fall pregnant in their teenage years; these professionals even go so far as to mistreat pregnant women who are HIV positive. These girls and women do not adequately receive the care they would otherwise receive if their status were different. \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore \textunderscore  
\section[{Authors' contribution}]{Authors' contribution}\par
Mr. M Tsawe is a post graduate student. Professor A Sathiya Susuman is a thesis supervisor. MT and AS worked together, contributed equally. 
\section[{a) Ethical considerations}]{a) Ethical considerations}\par
Ethical issues such as plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc., have been completely observed by the authors. 		 		\backmatter   			 
\subsection[{Acknowledgement}]{Acknowledgement}\par
The authors would like to thank Statistics South Africa for providing data sets and offer special thanks to Prof. Richard Madsen, University of Missouri, United States, for his valuable suggestions and critical comments. 
\subsection[{VII. Funding source}]{VII. Funding source}\par
This work was supported by the National Research Foundation, South Africa. 
\subsection[{VIII. Competing interest}]{VIII. Competing interest}\par
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