Nomads' perceptions of quality, accessibility, and affordability of health services as determinants of using skilled birth attendants in Gossi, Mali.

Aim: More than half of all maternal deaths worldwide occur in sub-Saharan Africa (SSA). For nomadic pastoralists (30 to 60 million) in SSA, the risk of maternal death is very high because of the low proportion of assisted deliveries in the areas where they live. The objective of this research was to understand the determinants of using skilled birth attendants in relation to the perceptions of quality, geographic accessibility, and financial affordability of health services by nomadic women.

Methods: We used a qualitative research design, inspired by ethnography. Research was conducted in the commune of Gossi (Mali), where 90% of the population is nomadic. The study population consisted of 26 nomadic women living in their camps. Saturation and diversification guided sampling. Semi-structured individual interviews and non-participant observation enabled concomitant data collection. Thematic content analysis was performed using QDA Miner software.

Results: Our results show that only 10 women used assisted childbirth for their last delivery. These women thought that health workers were competent and well trained, and they liked the fact that these workers were recruited locally. Similarly, these 10 women deemed the health workers' attitude acceptable and appreciated their availability. In contrast, the majority of participants (16 women) were prevented or discouraged from using skill birth attendants. Some of them did not use them because they were afraid of being undressed, of giving birth on a table, and especially of male staff. They also said that they did not have access to information about health services. In addition, respondents considered health services very difficult to access due to distances, unavailable means of transportation, and costs perceived as being expensive.

Conclusion: Our results identify several determinants of the use or non-use of skilled birth attendants by nomadic women in relation to the context and way of life. In addition, our findings call for future research to better understand these determinants and to deepen, refine, and test emerging strategies that seem potentially hopeful with respect to facilitating the use of skilled birth attendance in SSA.