Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study

Aminu Mohammed; Neima Ridwan Abdu; Leyla Abrar Bedru; Bezabih Amsalu; Abdusellam Yimer

doi:doi:10.11648/j.jfmhc.20251101.11

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Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study

Aminu Mohammed^*, Neima Ridwan Abdu, Leyla Abrar Bedru, Bezabih Amsalu, Abdusellam Yimer

Published in Journal of Family Medicine and Health Care (Volume 11, Issue 1)

Received: 13 September 2024 Accepted: 24 January 2025 Published: 13 March 2025

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Abstract

Background: There is a dearth of research regarding the reasons behind self-referrals from public to private hospitals, both nationally and within the research community. Purpose: This study aimed at exploring factors for self-referral to private hospitals for childbirth in the Dire Dawa, Ethiopia. Methods: A qualitative design was applied for this study. Study settings and participants were selected through purposive sampling techniques and interviewed individually using an interview guide, with the assistance of a voice recorder and field notes. The interviews were then transcribed verbatim, analyzed using an inductive thematic approach. The study was conducted in three private hospitals between August and September 2023. A total of thirteen participants (self-referred to a private hospital for childbirth) were involved in the study and interviewed over a two-month period. Findings: Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Conclusions: Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.

Published in	Journal of Family Medicine and Health Care (Volume 11, Issue 1)
DOI	10.11648/j.jfmhc.20251101.11
Page(s)	1-9
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2025. Published by Science Publishing Group

Keywords

Reasons, Self-referral, Dire Dawa

1. Introduction

One of the fundamental components of the Sustainable Development Goal (SDG), a major global strategy to reduce preventable maternal and newborn obstetric problems, including fatalities that may occur during labor and childbirth, is birthing at a health facility by a skilled birth attendant

[1, 2]

. Maternal mortality is one of the most glaring health inequalities around the globe, but obstetric complication variations are another

[3, 4]

. And nations with limited resources, like Ethiopia, are particularly affected by this

[5, 6]

. Obstetric problems such as antepartum hemorrhage, fetal distress, cord prolapse, uterine rupture, and others, as well as fatalities, are exacerbated by avoiding nearby medical facilities

[7-9]

. This is true, particularly if the woman travels a considerable distance, such as from rural to urban health facilities

[10, 11]

. In addition, it can harm a facility's reputation in the community, which might discourage other expectant mothers from using public hospitals for institutional delivery

[12-16]

Additionally, self-referral places a burden on the other health facility (the one chosen for self-referral), which again has an indirect impact on other women who require obstetric care there soon

[10, 14, 17, 18]

. This includes long waiting times, delayed emergency obstetric care, and related complications of labor and delivery

[4, 18, 19]

. The lack of emergency obstetric care functionality failing to meet the obstetric care needs of pregnant women during their antenatal care, such as laboratory tests, and a lack of drugs and equipment are among the main causes of self-referral

[21-25]

. Similarly, studies include other reasons like a history of pregnancy-related difficulties, and perceived quality

[13, 14, 21]

. Moreover, a lack of respect, and maltreatment by medical professionals when providing care are among the reported causes

[15, 26-29]

. However, there is a dearth of research regarding the reasons behind self-referrals for childbirth from public to private hospitals, both nationally and within the research community. So, this needs to be explored, and therefore, this study was aimed at exploring these reasons, which could help in interventions.

2. Methods

Study area and design

The study was conducted between August and September 2023, in Dire Dawa, located about 515 kilometers east of Addis Ababa, the capital city of Ethiopia, and 311 kilometers west of Djibouti port. Dire Dawa has two public and four private hospitals and 17 public health centers

[30]

. Due to the qualitative nature of the research questions and the purpose of the study, a qualitative descriptive design was used. A facility-based qualitative descriptive approach was utilized in this study. This approach was chosen to involve participants undergoing rereferrals from public to private hospitals. It does not assume a specific mindset and helps in describing the experiences of participants, ultimately facilitating the generation of themes. A qualitative description design is particularly relevant where information is required directly from those study subjects and where time and resources are limited

[31, 32]

. The Standards for Reporting Qualitative Research check-list guided all components of the writing and reporting of this study.

Researcher and interviewer characteristics

All four authors hold master’s degrees in different health fields: two in maternity and neonatal nursing, one in public health, and one in clinical midwifery. Three of them reside and work in Dire Dawa City and two lives in Werabe City and work at Werabe University. The principal researcher (AM) provided overall leadership for the work. The research team consisted of one female and three males with experience in teaching at public universities, qualitative research studies, and community services in urban and rural areas. The research team had no prior relationship with the participants, and the participants were unaware of the researchers. The interviewers, three men with MSc degrees in Nursing and Midwifery and experienced in qualitative research interviews, were selected from Dire Dawa City. They all spoke local languages (Afan Oromo and Amharic).

Sampling strategy

Both the study setting and study participants were selected using a purposive sampling technique. Participants were selected based on information obtained from the selected private hospitals (Bilal, Delt, and ART General Hospitals). Participants were eligible to participate in the study if they were legally adults (18 or older years), attended ANC at public hospitals, and self-referred for child birth to private hospitals (by themselves or enforced by others like husbands). However, individuals who were severely ill and unable to respond were excluded.

Data collection methods

Participants were oriented to the study by interviewers who explained the aims and objectives in Afan Oromo and Amharic. Ethical clearances were obtained, and written informed consent was secured from individual participants. Interviews were conducted at hospitals’ postpartum room, in a quiet place, individually. Data was collected using interviews, observations, and audio recordings. Interviews were conducted in the local language until saturation was reached

[33]

Data collection instruments and analysis

In-depth interviews were recorded using audio recorder and field notes were taken. An interview guide was used, translated in to local languages, and designed by qualitative experts. The guides are available in the appendices (Appendix I and II). Interviewing a diverse group for research purposes and conducting member checks like a pilot study with participants enhances credibility

[32-38]

. This study, to enhance trustworthiness, the pilot interview guide was tested two weeks before the actual interview with four participants.

Interviewers received two days of training on procedures, approaching participants, discussing sensitive issues, and using audio recordings and field notes. Additionally, to ensure rigor, transcripts were returned to participants for feedback and corrections. All transcripts of interviews, audio recordings, and field notes were coded in parallel by research members (AM and NR) fluent in the local languages and qualitative data experts (AM, NR, LA, BA, and AY).

All interviews, field notes, and audio recordings were transcribed and translated into English before being uploaded to NVivo V.12 qualitative data analysis software for analysis.

The analysis team met regularly to discuss the coding process. Any conflicts during the independent coding process were resolved by group consensus. Following coding and the identification of initial categories, data from interviews, audio recordings, and field notes were combined. The preliminary coding of transcripts was conducted using an inductive thematic approach. Inductive coding was followed by grouping consistent codes in-to themes and thematic analysis was performed. The final list of themes was reviewed and agreed upon by the entire investigator team. Factors related to self-referral to private hospitals for childbirth were included based on a single mention, and the document was thoroughly reviewed using the COREQ (Consolidated Criteria for Reporting Qualitative Studies) check-list.

Operational Definition

Self-referral: postpartum women who avoided the nearest public hospitals (by themselves or enforced by others like husbands), whether they were attending their ANC, and delivered at another private hospital where they chose it

[21, 24, 25]

3. Results

Participant characteristics

A total of thirteen participants were involved in the study and interviewed over a two-month period. The majority (69.2%) were under 35 years old, married (84.6%), and multiparous (76.9%). All participants (100%) reported having had an antenatal visit at public hospitals (Table 1).

Table 1. Demographic and obstetric data of participants, Dire Dawa, Ethiopia, 2023.

Variables	Category	Frequency and percentage
Age	<35	9 (69.2)
Age	35-40	4 (30.8)
Residence	Urban	6 (46.1)
Residence	Rura1	7 (53.9)
Marital status	Married (have husband)	11 (84.6)
Marital status	Single	2 (15.4)
Education level	No formal education	1 (7.7)
	primary level(1-8)	7 (53.8)
	high school(9-12)	1 (7.7)
	Diploma	4 (30.8)
Occupation	housewife	11 (84.6)
Occupation	Merchant	2 (15.4)
Religion	Muslim	4 (30.8)
	Orthodox	5 (38.5)
	Protestant	4 (30.8)
Parity	Multiparous	10 (76.9)
Parity	primiparous	3 (23.1)
Had antenatal care visit (at public hospitals)	Yes (all)	13 (100)
Number of ANC	</=3	5 (38.5)
Number of ANC	>3	8 (61.5)
Medical/obstetrics complications	No	8 (61.5)
Medical/obstetrics complications	Yes	5 (38.5)
Types of medical/obstetrics complications	Anemia	1 (7.7)
	post pregnancy	1 (7.7)
	Gestational hypertension	1 (7.7)
	Oligohydramnios	1 (7.7)
	Decreased fetal movement	1 (7.7)
Who decided the referral?	Self	8 ( (61.5)
	Husband	3 (23.1)
	Other family	2 (15.4)

Themes

Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions.

Theme 1: Hospital Resources

The study found that women opt to self-refer because public hospital resources do not adequately meet their obstetric needs during antenatal care. This includes a lack of laboratory tests, ultrasound, and specific medications. A participant narrated, “During my ANC visit, a laboratory test was ordered, but unfortunately, it was not available at that hospital. Another time, a drug called ranitidine was prescribed for my gastric problem, but when I inquired with the pharmacist, I was informed that it was out of stock and could be purchased at a private pharmacy.” Another one stated that "I would have been pleased to receive the necessary medication, but the doctors at the pharmacy informed me that the drug was unavailable and suggested purchasing it from a private pharmacy. Due to this, I chose to go to a private hospital for my childbirth now.” Consequently, even though women attend antenatal care at public hospitals, they choose to give birth at private hospitals. A participant stated that "I had previously visited a public hospital for antenatal care, but they failed to provide me with iron sulfate. So, I avoided going there and self-referred to this private hospital.”

Theme 2: Staff Attitude

Subtheme 2a: Disrespect

Participants mentioned that healthcare staff lacked respectful care and ethics; leading to insults, and serving as a barrier to utilizing ANC services. A participant said, "Guardians, including health professionals, lack ethics; they disrespect and insult me at a nearby hospital. I hate such behavior; that is why I decided to go to a private hospital."

Additionally, participants noted a lack of concern and empathy from health professionals. They did not prioritize pregnant women entering a health facility for ANC visits, resulting in insults and delays. Medical staff showed negligence or lacked concern for pregnant women. Pharmacy staff did not prioritize or show concern while giving medication explanations. Finance staff also did not prioritize participants during medicine purchases or laboratory test payments. A participant narrated, "Some professionals have gaps in performing their responsibilities properly, and some even show a tendency to neglect their duties. During my ANC follow-up, they did not always check my blood pressure, did not inquire about any problems that occurred between my ANC visits, did not provide adequate counseling, and did not inquire about my concerns.” As a result, the majority reported self-referring to private hospitals. Most participants believed that ANC services should not only be accessible but that healthcare staff should also show respect to pregnant women.

Subtheme 2b: Privacy Breach

Healthcare staff often breached patients’ privacy. Medical staff violated participants’ privacy during obstetrics examinations at ANC visits. A participant stated that “Doctors violate my privacy; when I speak up, they retort, "Did you come here for antenatal care, or to teach us, or to order us?”. This lack of privacy led participants to skip follow-ups and be more reluctant to seek medical check-ups in case there were obstetric complications between visits. Three participants even reported negative experiences, such as being exposed during examinations.

Theme 3: Staff Communication

Subtheme 3a: Health Information

Participants emphasized a lack of health information during antenatal care as a common reason for self-referring to private hospitals for childbirth. This was attributed to poor communication between pregnant women and healthcare staff. Pharmacy and medical staff were not effective in their communication, creating barriers to health information for pregnant women during ANC visits, ultimately leading to self-referral during child birth. A participant narrated, “Medical staff do not provide detailed and adequate health information during antenatal counseling, which is due to a lack of empathy. When I mention that I have a problem, they dismiss it by saying that many women are waiting outside.” Participants also described a lack of appropriate communication by healthcare staff as a reason for self-referral. A participant stated that "I have visited public hospitals many times, but nobody has informed me about the real issue I have and the health of my fetus.”

Subtheme 3b: Antenatal Counseling

A common barrier identified was the lack of counseling during ANC visits, which was attributed to poor communication with healthcare staff. A participant said, “When I ask health professionals for advice or information, it is difficult to gauge their responses. Due to this, I have developed a strong dislike for public hospitals. I have chosen to seek care from private facilities instead.”

Participants reported that this lack of appropriate counseling often resulted in them either limiting or avoiding their childbirth visits, ultimately leading them to self-refer. A participant narrated, "I have completely stopped going to public hospitals because they do not properly address societal beliefs that can impact pregnancy. Medical staff do not adequately address these concerns, so, I prefer to seek care elsewhere.”

Theme 4: Perception of Participants

Subtheme 4a: Service Expectations

Reasons for self-referral were found to include participants’ own expectations. The participants expressed their displeasure, claiming that they should be provided with all healthcare services in one place, including laboratory tests, ultrasound and medications. A participant said, “I paid a high price for medications and laboratory tests during two antenatal care visits. As a pregnant woman, I believe I should not have to visit public health facilities.”

Some participants considered themselves disadvantaged citizens who needed affirmative action by the government or public health facilities during pregnancy and the postpartum period. A participant stated that "Why don’t public hospitals cover the costs of antenatal care for pregnant women, including medication and laboratory tests?”

Subtheme 4b: Perceived Discrimination

Reasons for self-referrals were found to include participants' perceptions of prejudice from healthcare staff. A participant said, “Security guards in public hospitals discriminate against individuals when entering a hospital.”

This is due to the fact that they perceive healthcare staff as discriminating against them, including in medication payment at finance, counseling in ANC, and medication information in pharmacies. A participant said, “Pharmacy staff in public hospitals discriminate when explaining how to take medications, their side effects, and alternatives. They also discriminate during the payment process.” The other one stated that “finance staff in public hospitals discriminate based on wait times and payment methods. Some medical staff intentionally prescribe expensive medications, which I view as discrimination.”

This perceived discrimination disappointed participants and led them to self-referral. Some participants claimed that healthcare staff did not provide them with adequate counseling during ANC visits; healthcare staff did not clarify the side effects of medicines and under what conditions pregnant women should return to health facilities. Since medical staff did not clarify during ANC counseling, participants claimed to self-refer to private hospitals. A participant narrated, “During antenatal counseling, medical staff discriminate by not providing detailed explanations of what to do, not do, avoid, or expect, especially considering individual pregnant women’s concerns.”

Subtheme 4c: Perceived Healthcare Quality

Women also choose to self-refer to private hospitals because of their perceptions regarding the quality of obstetric care at public hospitals. The perceived quality of obstetric care at public hospitals influenced participants’ decision to seek obstetric care at private health facilities. Many participants stated that public hospitals have poor health care quality, which is a major reason for their decisions to go to a private hospital for childbirth. A participant narrated, "The obstetric care provided in the public hospital is of poor quality; the bed, blankets, and blood pressure measuring equipment are old and sometimes torn. The walls are dirty, and they use the same glove on different bleeding women, which raises concerns about infection, including HIV transmission. This is why we choose to go to a private hospital for delivery.”

Theme 5: Community Rumors

Community rumors suggesting that public hospitals lack healthcare quality or that health professionals lack professional ability or skill were cited as reasons for self-referral. When women hear this information from someone in the community, they choose to refer themselves to private hospitals. A participant stated that “I have heard that public hospitals lack many resources, such as adequate medications, laboratory tests, and low concern for patient care. As a result, I made the decision to seek care at a private hospital.” Another one narrated, "I had antenatal follow-up at a hospital, and I was initially informed that it was a twin pregnancy. However, it was later confirmed to be a single pregnancy at a different facility. Additionally, my neighbor also had an antenatal care at a public hospital. During the ninth month of her pregnancy, she experienced severe crampy abdominal pain. The health care provider advised her to take medications, assuming it was caused by gastrointestinal parasites. Later, she realized she was actually in true labor. As a result, both she and I were forced to have our child delivered at a private hospital. This experience significantly eroded my confidence and trust in health professionals.”

Theme 6: Autonomous Decisions

Women often choose to go to private hospitals not only of their own accord but also due to pressure from their husbands or other family members. A participant stated that "I was attending all my antenatal care visits at a public hospital, and I had planned to give birth there. However, for some reason, my husband insisted on taking me to a private hospital for the actual childbirth. I did not question him at the time; he may have heard about instances of poor obstetric care in public hospitals." This lack of autonomy in decision-making can lead to self-referral. A participant narrated, “Both my husband and other family members urged me to go to a private hospital, claiming that public hospitals are negligent towards human life and lack necessary medications. They warned me that if I didn’t want to risk my life, I had to go to a private hospital."

4. Discussion

Exploring the gaps in healthcare facilities from the perspective of service users is essential for improving the quality of healthcare, especially in resource-limited countries like Ethiopia. This study aims to specifically understand the reasons for self-referral from public to private hospitals for childbirth. This research is significant in the context of global efforts to provide inclusive and high-quality care for pregnant women throughout the stages of pregnancy, delivery, and postnatal care in order to reduce obstetric-related morbidity and mortality.

The present study explored six main themes regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions.

Women, despite receiving antenatal care at public hospitals, often choose to self-refer to private hospitals for childbirth. This decision is typically deriven by the scarcity of resources in public hospitals, such as a lack of laboratory tests or essential medicines. Studies have shown that some women opt for private hospitals due to concerns about the inability of public hospitals to provide necessary obstetric care during labor and delivery

[39, 40].

These factors contribute to the persistently high rates of maternal and newborn deaths in low-resource countries

[2, 5, 13, 20]

. This implies that access to a health care facility does not always guarantee a safe childbirth.

Women may also choose to refer themselves to private hospitals for childbirth because of the attitudes of healthcare staff, both medical and non-medical. These attitudes can include disrespect, insults, negligence, and breaches of privacy.

Studies have revealed that self-referral is often due to unwelcoming reception, non-consented care, and physical and verbal abuse

[13, 15]

. This suggests that addressing women's experiences with ANC, including privacy, respect, and the presence of competent and disciplined health professionals providing obstetric services, is crucial and should be effectively addressed.

Women's self-referral to private hospitals for childbirth is influenced by their perceptions of the quality of healthcare in public hospitals. Studies confirm that women’s own perceptions are a significant factor in their decisions to self-refer to a private health facility

[16, 41]

. This is because it matters how healthcare service clients perceive the quality of healthcare services, including the competence of healthcare workers

[39, 40]

. This implies the need for not only healthcare access but also addressing the perceptions of women in their obstetrics care. Therefore, public hospitals can enhance healthcare quality by addressing women's perceptions, improving access, providing emotional support, meeting physical, emotional, and psychological needs, and involving patients in their care plans.

Moreover, unlike previous studies, the present study delved in to two key factors influencing women's decisions to self-refer to private hospitals. These factors are women’s autonomy in decision-making and community rumors. Therefore, in order to deliver top-notch care, maternity services, must take into account and respond to the desires and experiences of women and their families. This underscores the importance of understanding the viewpoints of pregnant women and the community, as well as dispelling misconceptions about the quality of care in public hospitals. As a result, the findings of this study have implications for society, healthcare practices, and future research. Health care leaders and staff must prioritize the quality of health care services. These efforts will help reduce barriers to services abd pregnancy complications, aligning with the Sustainable Development Goals (SDGs) to achieve these goals by 2030.

Societal implications include the need to raise community awareness to debunk myths about public hospital care quality. Furthermore, research should encompass multiple perspectives, including those of service providers and users in both public and private healthcare facilities.

Study strengths

The study design enabled in-depth inquiry into self-referral factors. The study included a diverse sample. The accuracy of the data was improved by the use of primary data and experienced interviewers.

Study limitation

The study only included participants’ perspectives and did not assess service providers’ perspectives, which was a limitation of this study.

5. Conclusion

Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.

Abbreviations

ANC	Antenatal Care
SDG	Sustainable Development Goal

Acknowledgments

The authors are grateful to the data collectors, Dire Dawa Administration Health Bureau, hospital managers, and postnatal ward staffs of ART, Delt, and Bilal General Hospitals, study participants. Our thanks also go to those individuals who directly or indirectly contributed their skills and knowledge toward the accomplishment of this study.

Author Contributions

Aminu Mohammed: participated in conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Software, Resources, Supervision, Validation, Visualization, writing original draft, Writing review and editing

Neima Ridwan Abdu: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Software, Resources, Supervision, Validation, Visualization, writing original draft, Writing review and editing

Leyla Abrar Bedru: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, writing original draft, Writing review and editing.

Bezabih Amsalu: Formal analysis, Funding acquisition, Investigation, Methodology, Project Administration, Software, Resources, Supervision, Validation, Visualization, writing original draft, Writing review and editing.

Abdusellam Yimer: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Software, Resources, Validation, writing original draft, Writing review and editing.

All authors agree to take responsibility and be accountable for the contents of the article, agree on the journal to which the article will be submitted, and read and approve the final manuscript.

Ethics Approval and Consent to Participate

Ethical approval was obtained on July 9, 2022, from the Ethical Committee of the Dire Dawa Administration Health Bureau (DDAHB) (File-DDAHB-112/July/2022). Written consent was obtained from hospital administrations, and informed written consent was obtained from all study participants. All protocols were carried out in accordance with the relevant guidelines and regulations of Helsinki.

Declaration

We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets collected and analyzed for this study are available from the corresponding author and can be obtained upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix

Appendix I: Preamble

Thank you so much for meeting with me today and agreeing to participate in this interview. I want to remind you that what you say here is confidential and will not be linked back to you or your baby or families or identify you in any way. I am recording this interview so that I can transcribe it. This means I will type out the words said in this interview into a secure document for analysis. There will be no identifiers on the transcripts. The de-identified transcripts will be accessed by other members of the research team to perform the analysis. The purpose of this interview is to explore your health care experiences in order to better understand the health care services. We are here to learn from you, so anything you have to share is welcome. Nothing you say here will affect in any way the care you and your baby received. There are no right or wrong answers.

Appendix II: Semi-structured Question Guide

Good morning!

Did you attend antenatal care visit? (If yes, where?)

Where did you attend antenatal care (ANC) visits, I mean in public or private hospitals?

How many times?

How do you explain the ANC services given to you in -----------(public) hospital?

How do you explain the support given to you by health professionals in -----------(public) hospital?

How do you feel about your relationship with health professionals in -----------(public) hospital?

How do other people, like your neighbors, family, relatives, or friends, react when they hear the obstetrics cares given in that public hospital? (Probe for the blame of community, families, relatives, neighbors, and friends for the obstetrics cares of that hospital)

We really appreciate your time and insight. Thank you once again.

What were the most difficult challenges you faced during ANC visits in -----------(public) hospital?

...just related to the (hospital, health professional, any others…………

Really to the last, since you were attending ANC visits in -----------(public) hospital, but you did not give birth there, are you referred by the -------------(public) hospital or how did you get this (private) hospital?

We have finished, anything you want to say... Is there anything else that you think we should know---------?

Thank you very much!

References

[1]	Hug L, Alexander M, You D, Alkema L, for Child UI-aG. National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis. The Lancet Global Health. 2019; 7(6): e710-e720.
[2]	Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low-and middle-income countries: a scoping review of implementation factors. Health policy and planning. 2021; 36(6): 955-973.
[3]	Shennan AH, Green M, Ridout AE. Accurate surveillance of maternal deaths is an international priority. bmj. 2022; 379.
[4]	Atmadja S. A New Method for Obtaining Global Estimates of Maternal Mortality. ADI Journal on Recent Innovation. 2022; 3(2): 115-120.
[5]	Gage AD, Carnes F, Blossom J, et al. In low-and middle-income countries, is delivery in high-quality obstetric facilities geographically feasible? Health Affairs. 2019; 38(9): 1576-1584.
[6]	Ayele B, Gebretnsae H, Hadgu T, et al. Maternal and perinatal death surveillance and response in Ethiopia: achievements, challenges and prospects. PloS one. 2019; 14(10): e0223540.
[7]	Banke-Thomas A, Avoka CK-o, Gwacham-Anisiobi U, et al. Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study. BMJ global health. 2022; 7(4): e008604.
[8]	Chen YN, Schmitz MM, Serbanescu F, Dynes MM, Maro G, Kramer MR. Geographic access modeling of emergency obstetric and neonatal care in Kigoma Region, Tanzania: transportation schemes and programmatic implications. Global Health: Science and Practice. 2017; 5(3): 430-445.
[9]	Schmitz MM, Serbanescu F, Kamara V, et al. Did Saving Mothers, Giving Life expand timely access to lifesaving care in Uganda? A spatial district-level analysis of travel time to emergency obstetric and newborn care. Global Health: Science and Practice. 2019; 7(Supplement 1): S151-S167.
[10]	Wanaka S, Hussen S, Alagaw A, Tolosie K, Boti N. Maternal delays for institutional delivery and associated factors among postnatal mothers at public health facilities of Gamo zone, Southern Ethiopia. International Journal of Women's Health. 2020; 12: 127.
[11]	Chavane LA, Bailey P, Loquiha O, Dgedge M, Aerts M, Temmerman M. Maternal death and delays in accessing emergency obstetric care in Mozambique. BMC Pregnancy and Childbirth. 2018; 18(1): 1-8.
[12]	Khatri RB, Dangi TP, Gautam R, Shrestha KN, Homer CS. Barriers to utilization of childbirth services of a rural birthing center in Nepal: a qualitative study. PLoS One. 2017; 12(5): e0177602.
[13]	Mgawadere F, Smith H, Asfaw A, Lambert J, van den Broek N. “There is no time for knowing each other”: Quality of care during childbirth in a low resource setting. Midwifery. 2019; 75: 33-40.
[14]	Ansu-Mensah M, Danquah FI, Bawontuo V, Ansu-Mensah P, Kuupiel D. Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review. BMC health services research. 2020; 20(1): 1-11.
[15]	Arsenault C, English M, Gathara D, Malata A, Mandala W, Kruk ME. Variation in competent and respectful delivery care in Kenya and Malawi: a retrospective analysis of national facility surveys. Tropical Medicine & International Health. 2020; 25(4): 442-453.
[16]	Tancred T, Schellenberg J, Marchant T. Using mixed methods to evaluate perceived quality of care in southern Tanzania. International Journal for Quality in Health Care. 2016; 28(2): 233-239.
[17]	Amare YW, Dibaba B, Bayu M, Hussien M. Factors associated with maternal delays in utilising emergency obstetric care in Arsi Zone, Ethiopia. South African Journal of Obstetrics and Gynaecology. 2019; 25(2): 56-63.
[18]	Ayalew Tiruneh G, Melkamu Asaye M, Solomon AA, Tiruneh Arega D. Delays during emergency obstetric care and their determinants among mothers who gave birth in South Gondar zone hospitals, Ethiopia. A cross-sectional study design. Global Health Action. 2021; 14(1): 1953242.
[19]	Avoka CK-o, Banke-Thomas A, Beňová L, Radovich E, Campbell OM. Use of motorised transport and pathways to childbirth care in health facilities: Evidence from the 2018 Nigeria Demographic and Health Survey. PLOS Global Public Health. 2022; 2(9): e0000868.
[20]	Salazar M, Vora K, De Costa A. Bypassing health facilities for childbirth: a multilevel study in three districts of Gujarat, India. Global health action. 2016; 9(1): 32178.
[21]	Jepkosgei D. DETERMINANTS OF BYPASSING COUNTY PUBLIC HEALTH FACILITIES AMONG WOMEN SEEKING CHILDBIRTH SERVICES AT THE MOI TEACHING AND REFERRAL HOSPITAL, ELDORET, MMUST; 2020.
[22]	Karkee R, Lee AH, Binns CW. Bypassing birth centres for childbirth: an analysis of data from a community-based prospective cohort study in Nepal. Health policy and planning. 2015; 30(1): 1-7.
[23]	Shah R. Bypassing birthing centres for child birth: a community-based study in rural Chitwan Nepal. BMC health services research. 2016; 16(1): 1-8.
[24]	Kruk ME, Hermosilla S, Larson E, Mbaruku GM. Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania. Bulletin of the World Health Organization. 2014; 92: 246-253.
[25]	Bell G, Macarayan EK, Ratcliffe H, et al. Assessment of bypass of the nearest primary health care facility among women in Ghana. JAMA network open. 2020; 3(8): e2012552-e2012552.
[26]	Galle A, Manaharlal H, Cumbane E, et al. Disrespect and abuse during facility-based childbirth in southern Mozambique: a cross-sectional study. BMC pregnancy and childbirth. 2019; 19(1): 1-13.
[27]	Siraj A, Teka W, Hebo H. Prevalence of disrespect and abuse during facility based child birth and associated factors, Jimma University Medical Center, Southwest Ethiopia. BMC pregnancy and childbirth. 2019; 19(1): 1-9.
[28]	Bekele W, Bayou NB, Garedew MG. Magnitude of disrespectful and abusive care among women during facility-based childbirth in Shambu town, Horro Guduru Wollega zone, Ethiopia. Midwifery. 2020; 83: 102629.
[29]	Asefa A, Bekele D, Morgan A, Kermode M. Service providers’ experiences of disrespectful and abusive behavior towards women during facility based childbirth in Addis Ababa, Ethiopia. Reproductive health. 2018; 15(1): 1-8.
[30]	DDHB. Dire Dawa Health Bereau Health Demographic Statistics. 2024.
[31]	Flick U. An introduction to qualitative research. sage; 2022.
[32]	Muzari T, Shava G, Shonhiwa S. Qualitative research paradigm, a key research design for educational researchers, processes and procedures: A theoretical overview. Indiana Journal of Humanities and Social Sciences. 2022; 3(1): 14-20.
[33]	Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PloS one. 2020; 15(5): e0232076.
[34]	Belotto MJ. Data analysis methods for qualitative research: Managing the challenges of coding, interrater reliability, and thematic analysis. The Qualitative Report. 2018; 23(11): 2622-2633.
[35]	Nyirenda L, Kumar MB, Theobald S, et al. Using research networks to generate trustworthy qualitative public health research findings from multiple contexts. BMC Medical Research Methodology. 2020; 20: 1-10.
[36]	Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Medical teacher. 2020; 42(8): 846-854.
[37]	Tracy SJ. Qualitative research methods: Collecting evidence, crafting analysis, communicating impact. John Wiley & Sons; 2019.
[38]	Morris A. A practical introduction to in-depth interviewing. Sage; 2015.
[39]	Koce F, Randhawa G, Ochieng B. Understanding healthcare self-referral in Nigeria from the service users’ perspective: a qualitative study of Niger state. BMC health services research. 2019; 19(1): 1-14.
[40]	Bohren MA, Titiloye MA, Kyaddondo D, et al. Defining quality of care during childbirth from the perspectives of Nigerian and Ugandan women: A qualitative study. International Journal of Gynecology & Obstetrics. 2017; 139: 4-16.
[41]	Kambala C, Lohmann J, Mazalale J, et al. How do Malawian women rate the quality of maternal and newborn care? Experiences and perceptions of women in the central and southern regions. BMC pregnancy and childbirth. 2015; 15(1): 1-19.

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APA Style

Mohammed, A., Abdu, N. R., Bedru, L. A., Amsalu, B., Yimer, A. (2025). Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. Journal of Family Medicine and Health Care, 11(1), 1-9. https://doi.org/10.11648/j.jfmhc.20251101.11

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ACS Style

Mohammed, A.; Abdu, N. R.; Bedru, L. A.; Amsalu, B.; Yimer, A. Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. J. Fam. Med. Health Care 2025, 11(1), 1-9. doi: 10.11648/j.jfmhc.20251101.11

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AMA Style

Mohammed A, Abdu NR, Bedru LA, Amsalu B, Yimer A. Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. J Fam Med Health Care. 2025;11(1):1-9. doi: 10.11648/j.jfmhc.20251101.11

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@article{10.11648/j.jfmhc.20251101.11,
  author = {Aminu Mohammed and Neima Ridwan Abdu and Leyla Abrar Bedru and Bezabih Amsalu and Abdusellam Yimer},
  title = {Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study
},
  journal = {Journal of Family Medicine and Health Care},
  volume = {11},
  number = {1},
  pages = {1-9},
  doi = {10.11648/j.jfmhc.20251101.11},
  url = {https://doi.org/10.11648/j.jfmhc.20251101.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.jfmhc.20251101.11},
  abstract = {Background: There is a dearth of research regarding the reasons behind self-referrals from public to private hospitals, both nationally and within the research community. Purpose: This study aimed at exploring factors for self-referral to private hospitals for childbirth in the Dire Dawa, Ethiopia. Methods: A qualitative design was applied for this study. Study settings and participants were selected through purposive sampling techniques and interviewed individually using an interview guide, with the assistance of a voice recorder and field notes. The interviews were then transcribed verbatim, analyzed using an inductive thematic approach. The study was conducted in three private hospitals between August and September 2023. A total of thirteen participants (self-referred to a private hospital for childbirth) were involved in the study and interviewed over a two-month period. Findings: Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Conclusions: Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.
},
 year = {2025}
}

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TY  - JOUR
T1  - Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study

AU  - Aminu Mohammed
AU  - Neima Ridwan Abdu
AU  - Leyla Abrar Bedru
AU  - Bezabih Amsalu
AU  - Abdusellam Yimer
Y1  - 2025/03/13
PY  - 2025
N1  - https://doi.org/10.11648/j.jfmhc.20251101.11
DO  - 10.11648/j.jfmhc.20251101.11
T2  - Journal of Family Medicine and Health Care
JF  - Journal of Family Medicine and Health Care
JO  - Journal of Family Medicine and Health Care
SP  - 1
EP  - 9
PB  - Science Publishing Group
SN  - 2469-8342
UR  - https://doi.org/10.11648/j.jfmhc.20251101.11
AB  - Background: There is a dearth of research regarding the reasons behind self-referrals from public to private hospitals, both nationally and within the research community. Purpose: This study aimed at exploring factors for self-referral to private hospitals for childbirth in the Dire Dawa, Ethiopia. Methods: A qualitative design was applied for this study. Study settings and participants were selected through purposive sampling techniques and interviewed individually using an interview guide, with the assistance of a voice recorder and field notes. The interviews were then transcribed verbatim, analyzed using an inductive thematic approach. The study was conducted in three private hospitals between August and September 2023. A total of thirteen participants (self-referred to a private hospital for childbirth) were involved in the study and interviewed over a two-month period. Findings: Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Conclusions: Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.

VL  - 11
IS  - 1
ER  -

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Author Information

Aminu Mohammed

Department of Midwifery, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia

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Neima Ridwan Abdu

Department of Midwifery, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia
Leyla Abrar Bedru

Department of Midwifery, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia
Bezabih Amsalu

Department of Public Health College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
Abdusellam Yimer

Department of Midwifery, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia

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Table 1

Table 1. Demographic and obstetric data of participants, Dire Dawa, Ethiopia, 2023.

Plain Text BibTeX RIS

APA Style

Mohammed, A., Abdu, N. R., Bedru, L. A., Amsalu, B., Yimer, A. (2025). Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. Journal of Family Medicine and Health Care, 11(1), 1-9. https://doi.org/10.11648/j.jfmhc.20251101.11

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ACS Style

Mohammed, A.; Abdu, N. R.; Bedru, L. A.; Amsalu, B.; Yimer, A. Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. J. Fam. Med. Health Care 2025, 11(1), 1-9. doi: 10.11648/j.jfmhc.20251101.11

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AMA Style

Mohammed A, Abdu NR, Bedru LA, Amsalu B, Yimer A. Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study. J Fam Med Health Care. 2025;11(1):1-9. doi: 10.11648/j.jfmhc.20251101.11

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@article{10.11648/j.jfmhc.20251101.11,
  author = {Aminu Mohammed and Neima Ridwan Abdu and Leyla Abrar Bedru and Bezabih Amsalu and Abdusellam Yimer},
  title = {Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study
},
  journal = {Journal of Family Medicine and Health Care},
  volume = {11},
  number = {1},
  pages = {1-9},
  doi = {10.11648/j.jfmhc.20251101.11},
  url = {https://doi.org/10.11648/j.jfmhc.20251101.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.jfmhc.20251101.11},
  abstract = {Background: There is a dearth of research regarding the reasons behind self-referrals from public to private hospitals, both nationally and within the research community. Purpose: This study aimed at exploring factors for self-referral to private hospitals for childbirth in the Dire Dawa, Ethiopia. Methods: A qualitative design was applied for this study. Study settings and participants were selected through purposive sampling techniques and interviewed individually using an interview guide, with the assistance of a voice recorder and field notes. The interviews were then transcribed verbatim, analyzed using an inductive thematic approach. The study was conducted in three private hospitals between August and September 2023. A total of thirteen participants (self-referred to a private hospital for childbirth) were involved in the study and interviewed over a two-month period. Findings: Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Conclusions: Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.
},
 year = {2025}
}

Copy | Download

TY  - JOUR
T1  - Exploring Factors for Self-Referral to Private Hospitals for Childbirth, Dire Dawa, Ethiopia: A Qualitative Study

AU  - Aminu Mohammed
AU  - Neima Ridwan Abdu
AU  - Leyla Abrar Bedru
AU  - Bezabih Amsalu
AU  - Abdusellam Yimer
Y1  - 2025/03/13
PY  - 2025
N1  - https://doi.org/10.11648/j.jfmhc.20251101.11
DO  - 10.11648/j.jfmhc.20251101.11
T2  - Journal of Family Medicine and Health Care
JF  - Journal of Family Medicine and Health Care
JO  - Journal of Family Medicine and Health Care
SP  - 1
EP  - 9
PB  - Science Publishing Group
SN  - 2469-8342
UR  - https://doi.org/10.11648/j.jfmhc.20251101.11
AB  - Background: There is a dearth of research regarding the reasons behind self-referrals from public to private hospitals, both nationally and within the research community. Purpose: This study aimed at exploring factors for self-referral to private hospitals for childbirth in the Dire Dawa, Ethiopia. Methods: A qualitative design was applied for this study. Study settings and participants were selected through purposive sampling techniques and interviewed individually using an interview guide, with the assistance of a voice recorder and field notes. The interviews were then transcribed verbatim, analyzed using an inductive thematic approach. The study was conducted in three private hospitals between August and September 2023. A total of thirteen participants (self-referred to a private hospital for childbirth) were involved in the study and interviewed over a two-month period. Findings: Six main themes were identified regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Conclusions: Six main themes emerged regarding the reasons for self-referral from public hospitals to private hospitals for childbirth: hospital resources, staff attitude, staff communication, participants’ perceptions, community rumors, and autonomous decisions. Therefore, it is imperative to develop culturally sensitive and inclusive antenatal care programs and conduct additional multi-perspective research to better address these factors.

VL  - 11
IS  - 1
ER  -

Copy | Download