Descriptive statistics of study participants
The sample (Table 1) was largely female (75%), with the majority being previously or currently pregnant women (50%) with mean age of 35 ± 10 years. All of them self-identified as Cameroonian. Most of the participants were married (84%), and the majority (84%) had completed at least high school. There were slightly more participants who resided in rural (55%) compared to the urban settings. The average duration of interviews was 31 ± 13 min and that of FGDs was 41 ± 9.6 min.
Structural themes
Identified structural barriers to maternity care in Cameroon from our research participants’ accounts converged on three common themes: 1) civil unrest, 2) health system, and 3) physical infrastructure. Each theme is further explored in the following section and illustrated with quotes. Additional illustrative quotes for the themes and sub-themes can be found in Table 2.
Theme 1: persistent civil unrest
Civil unrest, which consists of the Anglophone regional crisis, has been a persistent barrier to maternity care for years in Cameroon. Pregnant women in focus group discussions explained that unpredictable and periodic violent confrontations between the separatists and the regular military threatened civilians’ personal security, made transportation unsafe, and disrupted medical transport systems.
Sub-theme 1A: threats to personal security
Focus group discussions with pregnant women revealed that tensions arising from the civil unrest frequently force civilians to flee for safety. Many people may not have the security in their own homes, let alone access to healthcare facilities for maternity care.
…on several occasions they (the military) have broken my door, entered my house, and scattered everything but it is always fortunate that when they are coming, we are aware in the quarter so, I pack a few of my belongings; carry my little children coupled with my pregnancy and run to the bush…
-Focus group, currently pregnant woman
A currently pregnant woman described how such tensions led to potentially fatal complications in her previous pregnancy.
When I was 3 months pregnant for my baby, military attacked my quarter and in the course of running, I had slight bleeding… We were in the market on Saturday, and they started shooting, we left and ran home. Then from Monday, the baby started coming out when it was just 34 weeks.
–Focus group, currently pregnant woman
Sub-theme 1B: unsafe transportation
Focus group participants indicated that violent confrontations could occur anywhere at anytime, and with gunshots fired in public places, transportation is especially difficult.
…the military saw them (Amba boys) and started firing guns… Now for us, there was no way to run… the boys instead, they ran and fell on top us with their guns on their back… there was no bike, every place was just like a dead zone. I rushed to one woman… and we had to trek from Mveh under the heavy rain to this hospital.
-Focus group, currently pregnant woman
According to focus group participants, some areas where the separatist camps are located, were off-limits to civilians. Therefore, travel time to the hospital had significantly increased, and some women were forced to deliver in bushes which put the mothers at risk for complications and in fatalities.
This lady was referred from Ndu and took almost 2 weeks to reach (the hospital)… there were gunshots, and they get back to the bush. The man had carried her on the back and was tired… and finally when they reached the hospital the baby was no more. The woman was tired with swollen legs, and finally she died… these are just 2 I have seen, what about those who have died that I have not seen?
-Maternity provider, 49, Female
Sub-theme 1C: disruption of the emergency medical transport system
To further complicate the situation, the crisis has halted previously operating medical transport services.
…before the northwest and southwest crisis erupted, the CBCHS used to have helicopters or planes to transport women up who were in distress from remote areas to the hospitals ….but with the coming of the crisis the planes are no longer being flown.
-Administrator, 64, Male
When things were normal… we will immediately try to rescue with the helicopter that we had at that time… the crisis came and stopped even the vehicles we could use to go rescue the women; the roads were blocked, no way to go do that…
-Administrator, 44, Male
Theme 2: inadequate healthcare system
Challenges identified within the Cameroonian health system included critical shortages of skilled personnel and medical equipment, lack of commitment to evidence-based practices, power outages, poor provider or institutional reputation related to clients’ previous negative experiences, flawed communication systems between health units, low healthcare worker compensation affecting quality of care, and subpar documentation system for feedback.
Sub-theme 2A: lack of maternity care providers
Hospitals and health facilities are currently experiencing serious staffing shortages which threaten access to maternity care in the communities they serve. Finding a midwife or nurse in some parts of Cameroon might be difficult, and if they were available, there might only be one single person managing the entire health facility.
Staffing in health centers is not the best, so it’s in rare situations where you may have two people available… In the maternity (unit) most of the times it’s one person.
-Administrator, 37, Female
Participants said even when health personnel were available, they might not be trained to provide maternity care, much less identify and manage common maternal and fetal complications.
…sometimes, a woman has seen a provider 4 times with an elevated blood pressure, and they have not done a complete urinalysis to find out whether that is impacting the organs of the pregnant woman… they end up having eclampsia or pre-eclampsia and HELLP syndrome.
Sub-theme 2B: lack of specialists
Our participants noted a lack of sufficient specialists, such as obstetricians and pediatricians, as well as nurses specialized in neonatal care, to keep up with the increasing number of deliveries and to cover all of the healthcare facilities.
I think service providers, nurses, midwives, and our clinicians need to have skills on newborn care. There seem to be increase in deliveries with children who are underweight, and they have to be in the incubator… there is a need to improve on the skills of our service providers on how to manage these neonates so that they gain the required weight and thrive.
…we also need specialists, people who will take care of complications when they occur… I think CBCHS has gynecologists only in 3 facilities whereas we have over 8 hospitals… We do not have pediatricians who will take care of newborns if they have certain problems.
Sub-theme 2C: lack of commitment to evidence-based practices
Providers acknowledge that some clinicians still perform outdated practices, emphasizing the need for standardized trainings such as basic (BLSO) and advanced life support in obstetrics (ALSO) aside from annual refresher courses for continuous professional development. Some providers do not want to update their skills with current scientific evidence, resulting in life-threatening consequences for patient care.
…a patient had an IUFD and the baby was big… they did not want to go ahead and operate… they induced her and… when she delivered the head she had a stuck shoulder and it was not easy… we did have knowledge on how to deliver this four kilogram baby
-Maternity provider, 47, Female
…(during) my first pregnancy, … in the process of delivery in the hospital, (I) labored for 3 days. After that, (I was) induced labor on the third day and finally they had to take me for operation which I even lost the baby… the carelessness was really too much… they want to remain at the level at which they are….
-Focus group, currently pregnant woman
Sub-theme 2D: critical shortage of medical equipment
Some hospitals lacked the appropriate medical equipment to provide maternity and newborn care altogether, while others had substandard or even defective equipment. Consequently, patients had to be referred to other hospitals, delaying treatments.
I also had an experience where I gave birth and got home, the baby made 2 weeks; I came to a small hospital. It showed that they should put the baby on oxygen whereas they did not have the oxygen… and the child finally died.
-Focus group, currently pregnant woman
Healthcare providers noted that the lack of a central blood bank system in the region contributed to the challenges in the management of postpartum hemorrhage.
…we have a very big challenge when it comes to managing post-partum hemorrhage because we don’t have a blood bank in the region… Most blood banks are found in the health facilities. …but they will not have a central blood bank that mobilizes blood from the population and distribute to all these other health facilities.
-Ministry of Health, 33, Male
Sub-theme 2E: poor communication system between health units
Health care providers explained that each health unit in Cameroon has a designated level at which it can function, according to classification by the Ministry of Health. When they face limitations, they refer patients to the district, then the regional level, and the referral hospitals. However, communication across the various levels was flawed, resulting in treatment delays.
…if we could have the means before you refer a case you already call and notify the hospital that you are sending to… so that they can prepare when the client comes. It is going to help reduce client waiting time and also help in reducing the poor outcomes we usually have.
-Maternity provider, 28, Male
It is only when that woman started bleeding profusely, that he tried to control the bleeding; he was unable to and rushed this woman to the health facility. …we had no idea that a case like that was even coming… These are things that if they would have called, you would have said ok, check the blood pressure… this is what you have to do to contract the uterus to prevent further bleeding… give magnesium sulphate and bring the woman directly to the hospital. We will start preparing blood, knowing that the woman is bleeding before the woman arrives the health facility. So, communication is essential.
–Ministry of Health, 33, Male
Sub-theme 2F: lack of incentives to provide quality care
Policies that promote safe maternity practices must be reinforced at all levels from the top down. However, different health facilities are managed and staffed by different personnel who might have varied objectives. For reasons of prestige and financial advantage, some providers might wish to retain their patients in their care, even if they were incapable of managing them.
There are some providers who think they know it all especially some of the traditional birth attendants, even when they have difficult cases, it is difficult for them to refer. They want (to) swell their statistics and with the (up)coming of the performance-based financing many of them want to keep their patients.
… As I said, one of the challenges we have at the level of the periphery is the lack of motivation. Some of them are not paid, they go for months without being paid. Some of them depend on other income generating activities. So, setting up this program, they need to find their heads up, how is it going to help them to boost their activities at the periphery.
-Ministry of Health, 45, Female
Sub-theme 2G: inadequate data collection systems / processes
Some participants argued effective documentation is burdensome because it is an additional task for providers who are already overburdened. Nonetheless, such information is fundamental as feedback on current practices and to continuously inform and enhance maternal and neonatal health.
…quality data, which can be analyzed will give us the information that we need… Staff frequently are not collecting the data we need because we collect data manually. …when it looks cumbersome and somebody needs to choose between putting in the right data or taking care of a patient, they may choose to take care of the patient and the data is lost.
The data quality is not good, people are not trusted. As a typical example in 2016, there were very few deaths, …in a year maybe 13 or 14 deaths. …I said no, the community is showing that women are dying and being buried but it is not reported anywhere, it is only when they started tracking and finding out that there were so many unreported deaths in the community…
-Ministry of Health, 45, Female
Theme 3: insufficient physical infrastructure
Sufficient physical infrastructure has been a challenging factor in ensuring quality maternity care. This theme consists of inadequate facilities which lead to logistical challenges and unstable electricity issue.
Sub-theme 3A: inadequate facilities lead to logistical challenges
According to providers, gaps in the geographical distribution of health facilities exist, notably in rural communities where women are required travel long distances in an unfavorable condition to seek maternity care. This can be a substantial burden which also endangers both the mother and child.
There are some women who will trek for more than 5 kilometers before they access a health center… it actually makes them feel reluctant to go… Some start antenatal care very late. Some will want to go two times or once before delivery. They will go at 36 weeks and at times there are complications that cannot even be rectified at that moment.
-Maternity provider, 37, Female
The roads in remote areas are either non-existent or sometimes can only accommodate bicycles, forcing individuals to walk long distances through rugged terrains. Even in the city, the roads are very narrow and congested.
…most do not even have access to do bikes or motorbikes and you can imagine the remote community that people can only trek long distances… and under very harsh conditions.
-Administrator, 47, Male
Sub-theme 3B: power outages
The unstable electricity supply in Cameroon with frequent power outages adversely affects the operation of health facilities and may impair the quality of maternity services provided due to the inability to operate certain medical equipment (Table 2). Health care providers noted that in certain villages, power outages might last for days or even months which greatly diminish the capacity to accommodate new patients.
…the power shortage in Cameroon is a big problem… there is always failure in electricity.
…to implement this project and function 24/7 as you rightly said, we should have in mind that we may look to alternative means…
-Maternity provider, 29, Female
It is possible that there will be (a situation) that… if electricity is off for some days or some months as is the case in our village now, then if you call when the phone is down, then you will not get to the person.
-Maternity provider, 44, female
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