'Born before arrival': user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia

Understanding maternal choices and experiences of care by skilled providers: Voices of mothers who delivered at home in selected communities of Lusaka city, Zambia

Background

Significant proportions of women living in urban areas including the capital cities continue to deliver at home. We aimed to understand why mothers in a selected densely populated community of Lusaka city in Zambia deliver from home without assistance from a skilled provider during childbirth.

Methods

Using a phenomenological case study design, we conducted Focus Group Discussions and In-depth Interviews with mothers who delivered at home without assistance from a skilled provider. The study was conducted between November 2020 and January 2021 among 19 participants. Data were analysed using content analysis.

Results

Individual-related factors including the belief that childbirth is a natural and easy process that did not require assistance, lack of transport to get to the health facility, influence and preference for care from older women who were perceived to have the experience and better care, failure to afford baby supplies, and waiting for partner to provide the supplies that were required at the health facility influenced mothers' choices to seek care from skilled providers. Health system-related factors included mistreatment and disrespectful care such as verbal and physical abuse by skilled healthcare providers, stigma and discrimination, institutional fines, and guidelines such as need to attend antenatal care with a spouse and need to provide health facility demanded supplies.

Conclusion

Individual and health system access related factors largely drive the choice to involve skilled providers during childbirth. The socioeconomic position particularly contributes to limited decision-making autonomy of mothers, thus, creating challenges to accessing care in health facilities. The health system-related factors found in this study such as mistreatment and disrespectful care suggests the need for redesigning effective and sustainable urban resource-limited context maternal health strategies that are culturally acceptable, non-discriminatory, and locally responsive and inclusive. Rethinking these strategies this way has the potential to strengthening equitable responsive health systems that could accelerate attainment of sustainable developmental goal (SDG) 3 targets.

Where, why and who delivers our babies? Examining the perspectives of women on utilization of antenatal and delivery services in a developing country

BACKGROUND

The differences in maternal mortality between developed and developing countries is due to differences in use of antenatal and delivery services. The study was designed to determine the views of women on utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria.

METHODS

Community based descriptive exploratory study design was employed. Qualitative data was collected through use of pre-tested focus group discussion (FGD) guide. Eight FGDs were conducted among women who were pregnant and others who have delivered babies one year prior to the study. Four FGDs each were conducted in urban and rural communities. QDA Miner Lite v2.0.6 was used in the analysis of the data.

RESULTS

Most of the participants in urban and rural areas prefer the man and woman deciding on where to receive antenatal and deliver care. All the participants in urban and rural communities wish for the support of their husbands when pregnant. Perceived quality of care is the major reason the women choose a facility for antenatal and delivery services. Others reasons included cost of services and proximity to a facility. Participants in rural communities were of the opinion that traditional birth attendants deliver unique services including helping women to achieve conception. For participants in urban, traditional birth attendants are very friendly and perhaps on divine assignment. These reasons explain why women still patronize their services. The major criticism of services of traditional birth attendants is their inability to manage complications associated with pregnancy and delivery. The major reasons why women delivery at home included poverty and cultural beliefs.

CONCLUSIONS

All efforts should be made to reduce the huge maternal death burden in Nigeria. This may necessitate the involvement of men and by extension communities in antenatal and delivery matters. There is need to train health workers in orthodox health facilities on delivery of quality healthcare. Public enlightenment on importance of health facility delivery will be of essence. Encouraging women to deliver in health facilities should be prioritized. This may entail the provision of free or subsidized delivery services. The deficiencies of primary health centers especially in rural communities should be addressed.

Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia

BACKGROUND

Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility.

METHODS

During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD).

RESULTS

After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery.

CONCLUSION

Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Background

Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components.

Methods

This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation.

Results

The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them.

Conclusion

The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

Lived Experiences and Perceptions of Childbirth among Pastoralist Women in North-Eastern Ethiopia: A Multimethod Qualitative Analysis to the WHO Health Systems Responsiveness Framework

Maternity should be a time of hope and joy. However, for women in pastoralist communities in Ethiopia, the reality of motherhood is often grim. This problem is creating striking disparities of skilled birth uptake among the agrarian and pastoral communities in Ethiopia. So far, the depth and effects of the problem are not well understood. This study is intended to fill this research gap by exploring mothers’ lived experiences and perceptions during skilled birthing care in hard-to-reach communities of Ethiopia. An Interpretive Phenomenological approach was employed to analyse the exploratory data. Four key informant interviews, six in-depth interviews, six focus group discussions, and twelve focused observations were held. WHO responsiveness domains formed the basis for coding and analysis: dignity, autonomy, choice of provider, prompt attention, communication, social support, confidentiality, and quality of basic amenities. The skilled birthing experience of nomadic mothers is permeated by a deep-rooted and hidden perceived neglect, which constitutes serious challenges to the health system. Mothers’ experiences reflect not only the poor skilled delivery uptake, but also how health system practitioners are ignorant of Afar women’s way of life, their living contexts, and their values and beliefs regarding giving birth. Three major themes emerged from data analysis: bad staff attitude, lack of culturally acceptable care, and absence of social support. Nomadic mothers require health systems that are responsive and adaptable to their needs, beliefs, and values. The abuse and disrespect they experience from providers deter nomadic women from seeking skilled birthing care. Women’s right to dignified, respectful, skilled delivery care requires the promotion of woman-centred care in a culturally appropriate manner. Skilled birthing care providers should be cognizant of the WHO responsiveness domains to ensure the provision of culturally sensitive birthing care.

Normative beliefs and values that shape care-seeking behaviours for skilled birth attendance (SBA) during birthing by mothers in Africa: a scoping review protocol

BACKGROUND

Skilled birth attendance (SBA) during delivery has been associated with improved maternal health outcome. However, low utilisation of SBA during childbirth has continued in many developing countries including Zambia. The proposed scoping review aims to map literature on beliefs and values and how mothers are influenced by relational normative motivations in utilisation of SBAs in health facilities.

METHODS

We designed and registered a study protocol for a scoping review. Literature searches will be conducted in multiple electronic databases (from January 2000 onwards), including PubMed, EMBASE, Scopus and Web of Science. Grey literature will be identified through searching dissertation databases, Google Scholar, EBSCOhost and ResearchGate. Keyword searches will be used to identify articles. Only articles published in English, related on beliefs and values surrounding childbirth, and on perceptions towards facility delivery or skilled health care providers will be considered eligible for inclusion. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. The study methodological quality (or bias) will be appraised using the Mixed Method Appraisal Tool. A narrative summary of findings will be conducted. We will employ NVIVO version 10 software package to extract the relevant outcomes from the included articles using content thematic analysis. This protocol is registered with the Open Science Framework (osf.io/9gn76).

DISCUSSION

Understanding how individual mother's health seeking behaviours for SBA and those close to them are influenced by their beliefs and values is critical to informing health systems on the possible 'hidden' barriers and facilitators to utilisation of SBA in public health facilities. The review will complement evidence base on normative beliefs and values shaping care-seeking behaviours for skilled birth attendance by mothers in Africa.

"Back to Eden": An explorative qualitative study on traditional medicine use during pregnancy among selected women in Lusaka Province, Zambia

BACKGROUND AND PURPOSE

No qualitative study on traditional medicine use among Zambian pregnant women has ever been conducted. Accordingly, this study was performed to explore the perceptions, motivations and experiences of Zambian women with regard to traditional medicine use during pregnancy.

MATERIALS AND METHODS

In-depth, semi-structured interviews were conducted in June/July 2019 with 8 adult women residing in Lusaka, Zambia, who used traditional remedies during their pregnancies, and who were recruited through purposive and snowball sampling.

RESULTS

Reported reasons behind traditional medicine use during pregnancy included labour induction, prevention of childbirth complications in case of sexual infidelity by either spouse, and prevention and/or treatment of anaemia. In addition, family members and faith leaders played an important role in influencing traditional medicine use.

CONCLUSION

Multiple, interconnecting factors influence traditional medicine use among pregnant women in Lusaka, Zambia. Traditional medicine use during pregnancy will likely continue to be widespread across Zambia.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care

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Mothers caring for newborns have a maternal dualism between cultural and health system obligations.

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Traditional newborn protective rituals were identified to help nurses provide health education.

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Family and community expressed a strong need to protect the newborn using traditional belief systems.

Background

- Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health.

Objective

- The goal of this study was to describe the factors associated with newborn care in rural Zambia.

Design

- Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs.

Setting

– Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts.

Participants

- The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213).

Findings

- The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups.

Key conclusions

– Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes.

Implications for practice

- There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study

Purpose

Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home).

Methods

We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis.

Results

Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery.

Conclusion

These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.

Building financial management capacity for community ownership of development initiatives in rural Zambia

BACKGROUND

Building financial management capacity is increasingly important in low- and middle-income countries to help communities take ownership of development activities. Yet, many community members lack financial knowledge and skills.

METHODS

We designed and conducted financial management trainings for 83 members from 10 community groups in rural Zambia. We conducted pre-training and post-training tests and elicited participant feedback. We conducted 28 in-depth interviews over 18 months and reviewed financial records to assess practical application of skills.

RESULTS

The training significantly improved knowledge of financial concepts, especially among participants with secondary education. Participants appreciated exercises to contextualize financial concepts within daily life and liked opportunities to learn from peers in small groups. Language barriers were a particular challenge. After trainings, sites successfully adhered to the principles of financial management, discussing the benefits they experienced from practicing accountability, transparency, and accurate recordkeeping.

CONCLUSION

Financial management trainings need to be tailored to the background and education level of participants. Trainings should relate financial concepts to more tangible applications and provide time for active learning. On-site mentorship should be considered for a considerable time. This training approach could be used in similar settings to improve community oversight of resources intended to strengthen developmental initiatives.

Outcome of labor among women admitted at advanced cervical dilatation

Objective: To identify in our setting the outcome of labor among women admitted at advanced cervical dilatation.Methods: This prospective cohort study was carried out between 1 December 2015 and 31 March 2016. Women carrying live term singletons in vertex presentation admitted with a cervical dilatation >5 cm (late arrival group) or ≤5 cm (early arrival group) were followed up till delivery. The main variables studied included mode of delivery, genital lacerations, and postpartum hemorrhage (PPH). Data from women in both groups were compared. Fisher's exact test and t-test were used for comparison. p < .05 was considered statistically significant.Results: Late arrival in the labor ward was observed in 52.5% of women (126/240). Late arrival in the labor ward was significantly associated with a reduction in the cesarean section (CS) risk (Relative risk (RR) 0.34, 95%CI 0.12-0.94), but with an increased risk of lower genital tract lacerations (RR 2.3, 95%CI 1.3-3.8), PPH (RR 4.5, 95%CI 1.04-20.2), and admission of the newborn in the neonatal intensive care unit for neonatal asphyxia or infection (RR 3.6, 95%CI 1.04-12.5).Conclusion: Late arrival in the labor ward was associated with an increased risk of maternal and neonatal morbidity. Therefore, women should be encouraged to arrive early in the labor ward.

Prevalence and correlates of home delivery amongst HIV-infected women attending care at a rural public health facility in Coastal Kenya

BACKGROUND

Home delivery, referring to pregnant women giving birth in the absence of a skilled birth attendant, is a significant contributor to maternal mortality, and is encouragingly reported to be on a decline in the general population in resource limited settings. However, much less is known about home delivery amongst HIV-infected women in sub-Saharan Africa (sSA). We described the prevalence and correlates of home delivery among HIV-infected women attending care at a rural public health facility in Kilifi, Coastal Kenya.

METHODS

A cross-sectional design using mixed methods was used. Quantitative data were collected using interviewer-administered questionnaires from HIV-infected women with a recent pregnancy (within 5 years, n = 425), whilst qualitative data were collected using focused group discussions (FGD, n = 5). Data were analysed using logistic regression and a thematic framework approach respectively.

RESULTS

Overall, 108 (25.4%, [95% CI: 21.3-29.8]) participants delivered at home. Correlates of home delivery included lack of formal education (aOR 12.4 [95% CI: 3.4-46.0], p<0.001), history of a previous home delivery (2.7 [95% CI:1.2-6.0], p = 0.019) and being on highly active antiretroviral therapy (HAART, 0.4 [95% CI:0.2-0.8], p = 0.006).Despite a strong endorsement against home delivery, major thematic challenges included consumer-associated barriers, health care provider associated barriers and structural barriers.

CONCLUSION

A quarter of HIV-infected women delivered at home, which is comparable to estimates reported from the general population in this rural setting, and much lower than estimates from other sSA settings. A tailored package of care targeting women with no formal education and with a history of a previous home delivery, coupled with interventions towards scaling up HAART and improving the quality of maternal care in HIV-infected women may positively contribute to a decline in home delivery and subsequent maternal mortality in this setting.

Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana

Background

Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana.

Methods

The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings.

Results

The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood.

Conclusion

Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

Patient and provider determinants for receipt of three dimensions of respectful maternity care in Kigoma Region, Tanzania-April-July, 2016

BACKGROUND

Lack of respectful maternity care (RMC) is increasingly recognized as a human rights issue and a key deterrent to women seeking facility-based deliveries. Ensuring facility-based RMC is essential for improving maternal and neonatal health, especially in sub-Saharan African countries where mortality and non-skilled delivery care remain high. Few studies have attempted to quantitatively identify patient and delivery factors associated with RMC, and none has modeled the influence of provider characteristics on RMC. This study aims to help fill these gaps through collection and analysis of interviews linked between clients and providers, allowing for description of both patient and provider characteristics and their association with receipt of RMC.

METHODS

We conducted cross-sectional surveys across 61 facilities in Kigoma Region, Tanzania, from April to July 2016. Measures of RMC were developed using 21-items in a Principal Components Analysis (PCA). We conducted multilevel, mixed effects generalized linear regression analyses on matched data from 249 providers and 935 post-delivery clients. The outcomes of interest included three dimensions of RMC-Friendliness/Comfort/Attention; Information/Consent; and Non-abuse/Kindness-developed from the first three components of PCA. Significance level was set at p < 0.05.

RESULTS

Significant client-level determinants for perceived Friendliness/Comfort/Attention RMC included age (30-39 versus 15-19 years: Coefficient [Coef] 0.63; 40-49 versus 15-19 years: Coef 0.79) and self-reported complications (reported complications versus did not: Coef - 0.41). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair pay: Coef 0.46), cadre (Nurses/midwives versus Clinicians: Coef - 0.46), and number of deliveries in the last month (11-20 versus < 11 deliveries: Coef - 0.35). Significant client-level determinants for Information/Consent RMC included labor companionship (Companion versus none: Coef 0.37) and religiosity (Attends services at least weekly versus less often: Coef - 0.31). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair: Coef 0.37), weekly work hours (Coef 0.01), and age (30-39 versus 20-29 years: Coef - 0.34; 40-49 versus 20-29 years: Coef - 0.58). Significant provider-level determinants for Non-abuse/Kindness RMC included the predictors of age (age 50+ versus 20-29 years: Coef 0.34) and access to electronic mentoring (Access to two mentoring types versus none: Coef 0.37).

CONCLUSIONS

These findings illustrate the value of including both client and provider information in the analysis of RMC. Strategies that address provider-level determinants of RMC (such as equitable pay, work environment, access to mentoring platforms) may improve RMC and subsequently address uptake of facility delivery.

Skilled delivery service utilization and its association with the establishment of Women's Health Development Army in Yeky district, South West Ethiopia: a multilevel analysis

Background

Because of the unacceptably high maternal and perinatal morbidity and mortality, the government of Ethiopia has established health extension program with a community-based network involving health extension workers (HEWs) and a community level women organization which is known as “Women’s Health Development Army” (WHDA). Currently, the HEWs and WHDA network is the approach preferred by the government to register pregnant women and encourage them to link in the healthcare system. However, its association with skilled delivery service utilization is not well known.

Methods

A community-based cross-sectional study was conducted from January to February 2015. Within 380 clusters of WHDA, a total of 748 reproductive-age women who gave birth in 1 year preceding the study, were included using multistage sampling technique. The data were entered into EPI info version 7 statistical software and exported to STATA version 11 for analysis. Multilevel analysis technique was applied to check for an association of selected variables with a utilization of skilled delivery service.

Results

About 45% of women have received skilled delivery care. A significant heterogeneity was observed between “Women’s Health Development Teams (clusters)” for skilled delivery care service utilization which explains about 62% of the total variation. Individual-level predictors including urban residence [AOR (95% CI) 35.10 (4.62, 266.52)], previous exposure of complications [AOR (95% CI) 3.81 (1.60, 9.08)], at least four ANC visits [AOR (95% CI) 7.44 (1.48, 37.42)] and preference of skilled personnel [AOR (95% CI) 8.11 (2.61, 25.15)] were significantly associated with skilled delivery service use. Among cluster level variables, the distance of clusters within 2 km radius from the nearest health facility was significantly associated [AOR (95% CI) 6.03 (1.92, 18.93)] with skilled delivery service utilization.

Conclusions

In this study, significant variation among clusters of WHDA was observed. Both individual and cluster level variables were identified to predict skilled delivery service utilization. Encouraging women to have frequent ANC visits (− 4 and above), enhancing awareness creation towards the delivery care attendance, constructing more health facilities and roads in hard to reach areas and establishing telemedicine services are recommended.

From favours to entitlements: community voice and action and health service quality in Zambia

Social accountability is increasingly invoked as a way of improving health services. This article presents a theory-driven qualitative study of the context, mechanisms and outcomes of a social accountability program, Citizen Voice and Action (CVA), implemented by World Vision (WV) in Zambia. Primary data were collected between November 2013 and January 2014. It included in-depth interviews and focus group discussions with program stakeholders. Secondary data were used iteratively-to inform the process for primary data collection, to guide primary data analysis and to contextualize findings from the primary data. CVA positively impacted the state, society, state-society relations and development coordination at the local level. Specifically, sustained improvements in some aspects of health system responsiveness, empowered citizens, the improved provision of public goods (health services) and increased consensus on development issues appeared to flow from CVA. The central challenge described by interviewees and FGD participants was the inability of CVA to address problems that required central level input. The mechanisms that generated these outcomes included productive state-society communication, enhanced trust, and state-society co-production of priorities and the provision of services. These mechanisms were activated in the context of existing structures for state-society interaction, willing political leaders, buy-in by traditional leaders, and WV's strong reputation and access to resources. Prospective observational research in multiple contexts would shed more light on the context, mechanisms and outcomes of CVA programs. In addition to findings that are intuitive and well supported in the literature we identified new areas that are promising areas for future research. These include (1) the context of organizational reputation by the organization(s) spearheading social accountability efforts; (2) the potential relationship between social accountability efforts and making ambitious national programs operational at the frontlines of the health system and (3) the feasibility of scale up for certain types of local level responsiveness.

'We saw she was in danger, but couldn't do anything': Missed opportunities and health worker disempowerment during birth care in rural Burkina Faso

Background

Facility-based births have been promoted as the main strategy to reduce maternal and neonatal death risks at global scale. To improve birth outcomes, it is critical that health facilities provide quality care. Using a framework to assess quality of care, this paper examines health workers’ perceptions about access to facility birth; the effectiveness of the care provided and obstacles to quality birth care in a rural area of Burkina Faso.

Methods

A qualitative study was conducted in 2011 in the Banfora Region, Burkina Faso. Participant observations were carried out in four different health centres for a period of three months; more than 30 deliveries were observed. In-depth interviews were conducted with 12 frontline health workers providing birth care and with two staff of the local health district management team. Interview transcripts and field notes were analysed thematically.

Results

Health workers in this rural area of Burkina Faso provided birth care in a context of limited financial resources, insufficient personnel and poorly equipped facilities; the quality of the birth care provided was severely compromised. Health workers tended to place the responsibility for poor quality of care on infrastructural limitations and patient behaviour, while our observational data also identified missed opportunities that would not demand additional resources throughout the process of care like early initiation of breastfeeding and skin-to-skin contact after birth. Health workers felt disempowered, having limited abilities to prevent and treat birth complications, and resorted to alternative and potentially harmful strategies.

Conclusions

We found poor quality of care at birth, missed opportunities, and health worker disempowerment in rural health facilities of Banfora, Burkina Faso. There is an urgent need to provide health workers with the necessary tools to prevent and handle birth complications, and to ensure that existing low cost life-saving interventions in maternal and new-born health are appropriately used and integrated into the daily routines in maternity wards at all levels.

Poverty, partner discord, and divergent accounts; a mixed methods account of births before arrival to health facilities in Morogoro Region, Tanzania

Background

Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur.

Methods

Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania.

Results

Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners.

Conclusion

As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1058-x) contains supplementary material, which is available to authorized users.

Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso

The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso between September 2011 and January 2012. A total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members were conducted. The data were analyzed using qualitative content analysis and interpreted through Merton’s concept of unintended consequences of purposive social action. The study found that community members experienced a strong pressure to give birth in a health facility and perceived health workers to define institutional birth as the only acceptable option. Women and their families experienced verbal, economic and administrative sanctions if they did not attend services and adhered to health worker recommendations, and reported that they felt incapable of questioning health workers’ knowledge and practices. Women who for social and economic reasons had limited access to health facilities found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seek skilled care at birth. The study demonstrates how the global and national policy of skilled pregnancy and birth care can occur in unintentional ways in local settings. The promotion of institutional care during pregnancy and at birth in the study area compromised health system trust and equal access to care. The pressure to use facility care and the sanctions experienced by women not complying may further marginalize women with poor access to facility care and contribute to worsened health outcomes.

Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala

Background

Health inequalities disproportionally affect indigenous people in Guatemala. Previous studies have noted that the disadvantageous situation of indigenous people is the result of complex and structural elements such as social exclusion, racism and discrimination. These elements need to be addressed in order to tackle the social determinants of health. This research was part of a larger participatory collaboration between Centro de Estudios para la Equidad y Gobernanza en los Servicios de Salud (CEGSS) and community based organizations aiming to implement social accountability in rural indigenous municipalities of Guatemala. Discrimination while seeking health care services in public facilities was ranked among the top three problems by communities and that should be addressed in the social accountability intervention. This study aimed to understand and categorize the episodes of discrimination as reported by indigenous communities.

Methods

A participatory approach was used, involving CEGSS’s researchers and field staff and community leaders. One focus group in one rural village of 13 different municipalities was implemented. Focus groups were aimed at identifying instances of mistreatment in health care services and documenting the account of those who were affected or who witnessed them. All of the 132 obtained episodes were transcribed and scrutinized using a thematic analysis.

Results

Episodes described by participants ranged from indifference to violence (psychological, symbolic, and physical), including coercion, mockery, deception and racism. Different expressions of discrimination and mistreatment associated to poverty, language barriers, gender, ethnicity and social class were narrated by participants.

Conclusions

Addressing mistreatment in public health settings will involve tackling the prevalent forms of discrimination, including racism. This will likely require profound, complex and sustained interventions at the programmatic and policy levels beyond the strict realm of public health services. Future studies should assess the magnitude of the occurrence of episodes of maltreatment and racism within indigenous areas and also explore the providers’ perceptions about the problem.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District

Background

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.

Method

A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.

Results

A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76).

Conclusions

Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

BACKGROUND

The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data.

METHODS

We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010.

RESULTS

Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas.

CONCLUSIONS

Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

Why are babies born before arrival at health facilities in King Sabata Dalindyebo Local Municipality, Eastern Cape, South Africa? A qualitative study

INTRODUCTION

Babies born before arrival at a health facility have a higher risk of neonatal death and their mothers a higher risk of maternal death compared with those born in-facility. The study explored the reasons for mothers giving birth before arrival (BBA) at health facilities and their experiences of BBA.

METHODS

A qualitative research design was used. Individual and focus group interviews of BBA mothers and of nurses were undertaken at a community health centre and a district hospital in King Sabata Dalindyebo Local Municipality.

RESULTS

Reasons for BBA included a lack of transport, a lack of security at night that deterred mothers from travelling, precipitate labour, failure to identify true labour, and a lack of waiting areas at health facilities. Traditional and cultural beliefs favouring childbirth at homeand nurses' negative attitudes during antenatal care and labour influenced mothers to go to health facilities when in advanced labour. Mothers were aware of possible complications associated with BBA.

CONCLUSION

Socio-economic, individual, cultural and health system factors influence the occurrence of BBA. Relevant parties need to address these factors to ensure that all babies in the King Sabata Dalindyebo Local Municipality are delivered within designated health facilities.

Women's Satisfaction of Maternity Care in Nepal and Its Correlation with Intended Future Utilization

The impact of rapid increase in institutional birth rate in Nepal on women's satisfaction and planned future utilization of services is less well known. This study aimed to measure women's satisfaction with maternity care and its correlation with intended future utilisation. Data came from a nationally representative facility-based survey conducted across 13 districts in Nepal and included client exit interviews with 447 women who had either recently delivered or had experienced complications. An eight-item quality of care instrument was used to measure client satisfaction. Multivariate probit model was used to assess the attribution of different elements of client satisfaction with intended future utilization of services. Respondents were most likely to suggest maintaining clean/hygienic health facilities (42%), increased bed provision (26%), free services (24%), more helpful behaviour by health workers (18%), and better privacy (9%). Satisfaction with the information received showed a strong correlation with the politeness of staff, involvement in decision making, and overall satisfaction with the care received. Satisfaction with waiting time (p = 0.035), information received (p = 0.02), and overall care in the maternity care (<0.001) showed strong associations with willingness to return to facility. The findings suggest improving physical environment and interpersonal communication skills of service providers and reducing waiting time for improving client satisfaction and intention to return to the health facility.

Impact of Pregnancy-Related Deaths on Female Life Expectancy in Zambia: Application of Life Table Techniques to Census Data

INTRODUCTION

Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia.

METHODS

We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide.

RESULTS

Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth.

CONCLUSION

Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.

Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study

Background

Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women’s preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia.

Methods

We conducted ten focus group discussions (n = 100) with women of reproductive age (15–45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored.

Results

Our findings show that women’s lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them.

Conclusion

Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.

Birth preparedness and complication readiness - a qualitative study among community members in rural Tanzania

BACKGROUND

Birth preparedness and complication readiness (BP/CR) strategies are aimed at reducing delays in seeking, reaching, and receiving care. Counselling on birth preparedness is provided during antenatal care visits. However, it is not clear why birth preparedness messages do not translate to utilisation of facility delivery. This study explores the perceptions, experiences, and challenges the community faces on BP/CR.

DESIGN

A qualitative study design using Focused Group Discussions was conducted. Twelve focus group discussions were held with four separate groups: young men and women and older men and women in a rural community in Tanzania. Qualitative content analysis was used to analyse the data.

RESULTS

The community members expressed a perceived need to prepare for childbirth. They were aware of the importance to attend the antenatal clinics, relied on family support for practical and financial preparations such as saving money for costs related to delivery, moving closer to the nearest hospital, and also to use traditional herbs, in favour of a positive outcome. Community recognised that pregnancy and childbirth complications are preferably treated at hospital. Facility delivery was preferred; however, certain factors including stigma on unmarried women and transportation were identified as hindering birth preparedness and hence utilisation of skilled care. Challenges were related to the consequences of poverty, though the maternal health care should be free, they perceived difficulties due to informal user fees.

CONCLUSIONS

This study revealed community perceptions that were in favour of using skilled care in BP/CR. However, issues related to inability to prepare in advance hinder the realisation of the intention to use skilled care. It is important to innovate how the community reinforces BP/CR, such as using insurance schemes, using community health funds, and providing information on other birth preparedness messages via community health workers.

The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review

BACKGROUND

Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.

METHODS AND FINDINGS

We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.

CONCLUSIONS

This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

Exploring inequities in skilled care at birth among migrant population in a metropolitan city Addis Ababa, Ethiopia; a qualitative study

Introduction

Ethiopia records high levels of inequity in skilled birth care (SBC), where the gaps are much wider among urban migrant women. An intervention project has been conducted in Addis Ababa, intending to improve quality and to ensure equitable access to maternal and newborn care services. As part of the project, this study explored the inequities in maternal health care among migrant women in Addis Ababa, Ethiopia.

Methods

A qualitative community based study was conducted from April to May 2014 among 45 purposefully selected internal migrant women. Eleven women who give birth at home and eight who gave birth at health facility in the last year preceding the study participated in in-depth interviews. Four primiparas’ young women, 18 women who have children and four grandmothers participated in focus group discussions. Guides were used for data collection. Using framework and content analysis three themes and four sub-themes emerged.

Results

According to the informants, patterns of service utilization varied widely. Antenatal care and infant immunization were fairly equally accessed across the different age groups of informants in their most recent birth irrespective of where they gave birth, yet obvious access gaps were reported in SBC and postpartum care. There were missed opportunities to postpartum care. Only few women had received postpartum care despite, some of the women delivering in the health facility and many visiting the health facilities for infant immunization. The four emerged sub-themes reportedly influencing access and utilization of SBC were social influences, physical access to health facility, risk perceptions and perceived quality of care and disrespect. Of these social, structural and health system factors, informants presented experiences of disrespectful care as a powerful deterrent to SBC.

Conclusions

Migrant women constitute disadvantaged communities in Addis Ababa and have unequal access to SBC and postpartum care. This happens in the backdrop of fairly equitable access to antenatal care, infant immunization, universal health coverage and free access to maternal and newborn care. Addressing the underlying determinants for the inequities and bridging the quality gaps in maternal and newborn services with due emphasis on respectful care for migrant women need tailored intervention and prioritization.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-014-0110-6) contains supplementary material, which is available to authorized users.