Table 3 Synthesis of qualitative findings on the role of social capital on maternal and child health services uptake in LMICs

Finding: Across network support patterns, most women indicated that network members were showed empathy in their interactions with them.

Reflection: “I have a friend here from my native place; with her only I am sharing my feelings.” (26 year old, high school educated) Raman et al., page 132

Reflection: “we are free and open with each other…Cecilia too shows me love [inaudible] so she chats with me about things that will bring laughter” ( Woman, Student, 19 yrs.) Cofie et al., page 8

Reflection: “I was telling her not to worry, but I myself was worried deep inside.” (32-year-old farmer).

Sapkota et al., page 48

Emotional support

Social supports enabled women to use MCH care.

Finding: Network members visited frequently during her pregnancy.

Reflection: “When I am not able to go visit her [mother], she comes to visit me and asks about me, that made me know she loves me” (Woman, Student, 19 yrs.) Cofie et al., page 8

Finding: Religious leaders provide emotional and spiritual support to their followers.

Reflection: “In the Orthodox Church while the religious leaders pray, they also pray for pregnant women and for women in postpartum period” (Female FGD participant from Gomma district) Mamo et al., page 7

Finding: Most women received advice to use ANC and health facility delivery care.

Reflection: “The public hearing generates the awareness of the public that pregnancy is not a very simple thing …that they have to come to the facilities for the technical support.” (PGO-1) Papp et al., page 455

Reflection: “The role of the mosque is broad; the first one is advising the community to believe what health professionals order us to do is essential you die if you are ordered to die and live if you are ordered to live by God but you should believe the advice given by health professionals is true.” (Muslim religious leader from Seka district) Mamo et al., page 8

Informational support

Finding: Family members, particularly Mother in laws[MIL], mothers and grandmothers advice women and provides suggestions on how to experience safe pregnancy and delivery

Reflection: “My mother had 11 children, out of which seven surviving… therefore she gave all advice (during pregnancy). And I followed her advice.” (32 years, working woman) Raman et al., page 132

Reflection: “Not lift heavy things…eat well”( FGDs with MILs) Cofie et al., page 8

Finding: Network members lived in close proximity provide advice to the pregnant women

Reflection: “Hamdia (brother-in-law’s wife). . .and my husband. They told me to not work as hard as I used to because now that I am pregnant I need to be cautious of the kind of work that I do. .Bintu (Friend) was also involved. .if I was not feeling well, I would call her and tell her. She would then tell me to go to the hospital because that is where we will find out what is actually wrong with me. . .”( woman in the facility birth group) Cofie et al., page 8

Finding: Close network members were ready to avail a transport vehicle for travelling to health facility during child birth.

Reflection: “When her husband is not there. .you [MIL] would then talk to any family member available at that time, for that person to look for a motorbike, fuel it and take her to hospital” (FGD, MIL) Cofie et al., page 9

Reflection: “My auntie helped in supporting my wife to sit on the motorbike. My auntie sat at the back as we took my wife to the clinic”. [Husband, Farmer, 27 yrs.] Cofie et al., page 9

Instrumental support

Finding: Network members able to help her access and utilize facility delivery

Reflection: “The women health development army exists in the form of AFOSHA (cultural self-help system). They help one another not only when someone dies, but also when someone gives birth and during festivals. They even help one another financially. They contribute money and buy basic household materials.” (Male FGD participant from Gomma district) Mamo et al., page 6

Finding: Some women had numerous sources of support, their own mothers, female relatives and friends.

Reflection: “There are enough people around me to talk to and support, (but) mainly I would tell my mother about everything. She has been very supportive throughout.” (29 years, educated) Raman et al., page 132

Reflection: “When I was vomiting for the first few months, three different friends used to cook different dishes for me every day; they looked after me so well.” (27 year old, nuclear family) Raman et al., page 133

Finding: MDA and WDA leaders are good in passing different knowledge to mothers and members of the community during community meetings, women’s association meetings, antenatal outreach sessions, and coffee ceremony

Reflection: “We are doing many activities like advising women to prepare before delivery. There could be different problems during delivery and they may need money, so I inform them to save certain money and keep it with them.” (MDA from Gomma district) Mamo et al., page 6

Promotion of MCH services

Receiving health information from trusted people enhanced uptake of MCH services.

Finding: HEWs, WDA and religious leaders are also participating on community mobilization activities including use of full ANC services, health facility delivery and PNC

Reflection: “What I should do for pregnant women during pregnancy is taking them to health facility for regular check-up and helping them to go and deliver in health facility and taking the children to health facility for vaccination.” (Muslim Religious leader from Kersa district) Mamo et al., page 6

Finding: Assistance with community, husbands and WDA support women during and after pregnancy period.

Reflection: “…when she is ready to deliver, I will take her to the health center and then come back home with her… after delivery I am responsible for preparing food and giving her advice about not working beyond her capacity and for washing the baby clothes.” (WDA leader from Seka district) Mamo et al., page 7

Reflection: “My son is always behind his wife. He is not only helping, but also supporting her all the time.” (Mother-in-law 3) Simkhada et al. page 7

Provision of continuous support

Finding: Integrating activities between community leaders to be enhance strong relationship and communication between HEWs, primary health care units and community members

Reflection: “What makes women health development army leader support special is that, they involve starting by enrolling the pregnant women and reporting to health extension worker at the termination of first menstrual cycle”(HEWs from Kersa district) Mamo et al., page 8

A link between communities and health system

Findings: Some members of the community cannot go to the hospital for health care services for whatever problem without first going to herbalists. Ill health is as a result of evil spirits and traditional systems of health care were best-placed to deal with them

Reflection: “…in the olden days of our grandfathers and grandmothers, we just used to stay like that when a woman got pregnant; she would just use some roots (herbs) and she would deliver without any problem.”(Female FGD participant, 63 years, Married, 10 children, Viphalani village) Mochache et al., page 4

Influence of socio-cultural norms

Socio-cultural factors influenced uptake MCH services

Finding: Women prefer facility delivery if complications arise during the birthing process

Reflection: “They [women] did not easily go to the hospital or clinics, furthermore when a woman got pregnant, she just stayed at home … and in case of any complications there was always traditional means of treatment. Certain plants were used to relieve women of abdominal pains and it has really taken long to change. ” (Male FGD participant, 50 years, Married, 3 children, Magodzoni village) Mochache et al., page 5

Finding: In the culture of some community, a woman has to stay indoors for a long period of time without accessing MCH services

Reflection: “In my community, a woman has to stay indoors [for a month to 40 days] until the baby’s skin lightness disappears, that’s when you get out (local phrase used: ‘mpaka mtoto afunike jua’).” (Female IDI participant, 28 years, Married, 1 child, Kwale town) Mochache et al., page 5

Findings: Maternal figures play a critical role in the decision-making pathway for choice of place of delivery. Some network members tended to first seek the involvement of a traditional birth attendant (TBA) during women’s labor and did not make timely arrangements to transport women to a facility.

Reflection: “My mother-in-law said that pregnant women didn’t go for antenatal check-ups in the old days. She told me that she had all her children without any antenatal check-ups and all are fine. She questioned why different foods and antenatal check-ups are necessary for pregnant women. That’s why I didn’t go” (Non-user Woman 1). Simkhada et al., page 5

Reflection: “she told me to wait for a while because she was going call Esi Eyeh [TBA] for her to come and check whether my pregnancy was due.” (woman, Trader, 20 yrs.) Cofie et al., page 10

Reflection: “Long time ago, our grandmothers, even our mothers, if a woman was in labor, the father would say we should wait first, and the mother would take charge … and that time, people never went for clinic, they did not know if the load they were carrying [pregnancy] was safe or not.” (Female IDI participant, 28 years, Married, 4 children, Mtsamviani village) Mochache et al., page 6

“I assisted my first daughter to deliver, I also assisted my sister in-law, my granddaughter … I am not [a TBA], but I thank God …” (Female FGD participant, 46 years, Married, 7 children, Viphalani village) Mochache et al., page 6

Reflection: “we only take women to hospital if the mkunga [TBA] has failed, that is what I always see … Nobody will take a woman to hospital at the onset of labor, and if you hear a woman has been taken there (hospital), then it is because the mkunga has failed … if you realize as per the woman’s condition she can deliver on her own, because most of the time she delivers at home, you don’t have to go to the hospital. You can bring the mkunga and she will deliver the baby.” (Male FGD participant, 43 years, Married, 2 children, Kiruku village) Mochache et al., page 6

Reflection: “I will ask my husband first … then he will find out what his mother thinks. After that, we will do what his mother says …” (Female IDI participant, 23 years, Married, 2 children, Kwale town) Mochache et al., page 7

Role of significant matriarchal figure

Finding: Religious norms influence women’s decision making on the use of MCH services. Women would avoid seeking a health facility delivery service if no female provider was available

Reflection: “Religion says that, but those who are employed there [at the hospitals] have the experience required to serve both men and women. You cannot force the government and say that you only want female employees at the hospital. So, it is true religion refuses (sic) us, but if you get to the hospital with a woman in labor, you cannot choose and insist that you want only a woman to attend to your wife. You must accept the service to be given by anybody”. (Male FGD participant, 42 years, Married, 2 wives, 5 children, Mkoyo) Mochache et al., page 7

Influence of religious norms

Finding: Islam religious norm might forbid women from being seen by other men except their husbands.

Reflection: “In the Digo way of life, they are all Muslims and religion has refused (sic) us and says women must only be assisted by fellow women during child delivery.” (Male FGD participant, 51 years, Married, 8 children, Mkoyo sub-location) Mochache et al., page 6

Finding: The role of a woman in this community was mainly to give birth and have many children

Reflection: “The pregnancy is yours, I′ m only waiting for the babies; my role as a husband is for the wife to inform me when there is no flour in the house and I provide, that is all.” (Male FGD participant, 70 years, Married, 11 children, serves as the local sheikh, Kifuku village) Mochache et al., page 7

Role of gender stereotypes

Finding: Gender-related power imbalances in decision making related to MCH services.

Reflection: “There is male dominancy all over India. The pregnant lady is not able to take her decision individually. She has to depend upon her mother-in-law, her husband or the society itself. This decision-making is also very late and they are coming to the institution very late. In spite of all efforts done by the ASHA, pregnant women are not getting the effective maternal check-ups and early transportation.” (HP-1) Papp et al., page 456

Reflection: “If it is a matter of giving birth you have already done so. What is this business of you going to the health facility every other time? You must be having an affair with someone there.” (Female FGD participant, 63 years, Married, 10 children, Viphalani village) Mochache et al., page 7

Reflection: “He wants four children, not me. He himself said he wants four. From his opinion he does not want me to use family planning.” (Female IDI participant, 23 years, Married, 1 child, Simkumbe village) Mochache et al., page 7