This evaluation reveals some progress in maternal and infant health service utilization in the two study districts. In particular, the results suggest an increase in the percentage of pregnant women among settled communities that attended ANC at least once, and that attended postnatal care within 3 months of delivery. Smaller improvements were found for mobile pastoralists, however, the ANC attendance rates remained low and PNC rates even decreased. The rate of home delivery remained also very high for both population groups. The vaccination coverage based on parental recall of their last child improved considerably amongst mobile pastoralists. Compared to the last national demographic and health survey (DHS) of 2014–2015, 55% of women attended at least one ANC (compared to 90% among settled communities and 56% among mobile pastoralists in this study). As for ANC3+, according to the last DHS, 31% attended at least three ANC, which is in line or higher than our findings with 34% for the settled communities and 14% for mobile pastoralists. However, these findings also point to some important challenges concerning interventions aiming to improve maternal and infant health outcomes. Healthcare during pregnancy is a priority. Poor antenatal attendance is associated with pregnancy complications, delivery of low birthweight babies and more newborn deaths . The benefits of a pregnant woman attending ANC are also in terms of nutritional and health checks, such as whether a woman has a disease like malaria or has been exposed to other infectious diseases . According to Mbuagbaw and Gofin , interventions to reduce maternal mortality may focus on three periods. The first is during pregnancy (ANC); the second is the intrapartum period, i.e. during labour and delivery, and the third is in the postpartum period (after delivery, PNC) . The pregnancy period is the more stable period of these three, whilst the intrapartum period is much shorter and less predictable. Accordingly, it is often more challenging to provide universal care during this short period of labor and delivery, than in the longer and more stable ANC period .
The potential of ANC in improving maternal and neo-natal health has long been recognized since the 1990s . In developing countries however, many pregnant women still fail to benefit from comprehensive ANC. Several factors have been identified for late initiation of ANC uptake, such as women’s education, husband’s education, women’s employment, affordability of services and access to the clinics , but also factors related to the poor quality of ANC services, such as the shortage of supplies and drugs and unskilled health personnel [20,21,22]. Although the findings of our study suggest that ANC attendance seem to have increased recently for settled communities mainly, our qualitative study shows that there remain serious issues with regards to quality of care and the availability of medicines , but also with regards to cultural factors (habits) and distance to primary health centers. This holds especially true for mobile pastoralists. Results from a scoping review on access to modern reproductive health services conducted amongst nomadic populations across the world highlighted that nomadic people face complex barriers to healthcare access, which were largely characterized as external (geographic isolation, socio-cultural dynamics, logistical and political factors) or internal (lifestyle, norms and practices, perceptions) factors. Furthermore, low awareness of modern reproductive and maternal health services and their benefits reinforced by a lack of culturally sensitive approaches to communicating about them, were mentioned as major barriers to utilization . This is in line with the findings from our baseline survey and qualitative assessment, highlighting not only the importance of the availability, affordability, quality of care and distance to primary health centers but also of the health practitioners competencies in welcoming and cultural communication and the practices and customs of the target population [10, 25] – all of which interact to influence women’s likelihood to seek out or accept health services .
The emerging consensus is that in order to improve maternal and newborn health, a range of health system strengthening interventions at every level of the continuum of care, from the community to the health facility and hospital, are necessary, instead of fostering more traditional vertical programmatic strategies . In these programmes, single elements of care are often implemented without making the needed connections to ensure comprehensive care . Within the continuum of care, all women should have access to reproductive health choices and care during pregnancy and childbirth, and all newborns should be able to grow into healthy children . This approach calls for the integration of programmes for maternal, neonatal, and child health that include a package of services including community-based family planning, health and nutrition services [29,30,31]. It has however also become increasingly evident that high coverage of essential interventions in healthcare facilities is not enough to reduce maternal mortality , mainly due to the services not being utilized . Additionally and most importantly, women’s capacity and capability to take ownership and decide about their care at the right time needs to be strengthened. Too often, women are still dependent on others to make these decisions for them. According to Elmusharaf et al. , gender norms are often too little considered in the design, implementation and research of interventions and strategies to improve access to maternal healthcare. Unequal power in the decision-making process within households often restrict women’s autonomy, her negotiation power with her partner, increase fertility rates and unwanted pregnancy, and hence negatively affect maternal health outcomes . Thus, in future more attention needs to be given to gender-specific messaging, and to improving demand side barriers for both women and men (education, empowerment, employment/ income) to change the environment in which the decisions are being made in order for women to access care . Moreover, attention must be paid to better understand where delays in timely medical intervention occur, which is a significant contributor to maternal and infant mortality and morbidity . Last, more investment is needed in improving the overall quality of maternal and child health services, especially ANC and PNC provision at public healthcare facilities in Chad aimed at reducing maternal and child mortality and morbidity.
In spite of the efforts deployed by the government to improve mobile population’s health in Chad, access to basic care remains a major challenge to most people, due to socioeconomic and geographical reasons , but also due internal factors related to cultural practices and norms . The results of this study suggest an increase in vaccination coverage among children of mobile pastoralists as a result of the implementation of joint human and animal vaccination campaigns (One Health). In the thrive towards universal access to health, it will however be important to implement complementary strategies to provide hard-to-reach and marginalized population groups with adequate health services and infrastructures by moving from only mobile outreach campaigns and services to an approach that ensures that these populations visit and access fixed health services .
There are several limitations to our study. First, the power calculation of this study was conducted for the initial cross-sectional baseline study with the aim of comparing the use of health services among settled communities and mobile pastoralists across the two districts. The study has therefore limited power to formally test longitudinal hypotheses, and particularly the effectiveness and changes of the PADS programme interventions over time, as no control group was included. Second, most indicators were based on self-reporting which bears the risk to over- or under-estimate the actual utilization ratios [35, 36].