How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework

Abstract

To reduce maternal mortality, countries must continue to seek ways to increase access to skilled care during pregnancy and delivery. In Zambia, while antenatal attendance is high, many barriers exist that prevent women from delivering with a skilled health provider. This study explores how the individuals closest to a pregnant woman in rural Zambia can influence a woman's decision to seek and her ability to access timely maternity care. At four rural health centers, a free listing (n = 167) exercise was conducted with mothers, fathers, and community elders. Focus group discussions (FGD) (n = 135) were conducted with mothers, fathers, mothers-in-law, and community health workers (CHWs) to triangulate findings. We analyzed the FGD data against a framework that overlaid the Three Delays Framework and the Social Ecological Model. Respondents cited husbands, female relatives, and CHWs as the most important influencers during a woman's maternity period. Husbands have responsibilities to procure resources, especially baby clothes, and provide the ultimate permission for a woman to attend ANC or deliver at a facility. Female relatives escort the woman to the facility, assist during her wait, provide emotional support, assist the nurse during delivery, and care for the woman after delivery. CHWs educate the woman during pregnancy about the importance of facility delivery. No specific individual has the role of assisting with the woman's household responsibilities or identifying transport to the health facility. When husbands, female relatives, or CHWs do not fulfill their roles, this presents a barrier to a woman deciding to deliver at the health facility (Delay 1) or reaching a health facility (Delay 2). An intervention to help women better plan for acquiring the needed resources and identifying the individuals to escort her and those to perform her household responsibilities could help to reduce these barriers to accessing timely maternal care.

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

“…Since delivery supplies were mentioned frequently in our qualitative data and in previous literature,11,20,22,34,35,41 we anticipated that the reported expenditure for these supplies would be much higher than the mean amount of approximately USD4, or about 13% of total expenditures. This is slightly less than the low end of reported delivery supplies expenditure in other countries where women spend USD5 to USD14 37,38.…”

“…The baby clothes category which includes baby clothes themselves and a baby blanket make up over 75% of delivery expenses, and nearly all (95.9%) women reported spending on this category. While previous qualitative studies have discussed baby clothes as a perceived obstacle to facility delivery among Zambian households,11,21,22,33–35,41 it is a novel finding that these baby clothes make up such a high proportion of total reported expenditure among the most rural women. Corroborating this, qualitatively, rural Zambian women report feeling substantial pressure from health center staff to bring new baby clothes with them to delivery and report feeling shamed if they do not, which confirms and elaborates previous findings 11,33,34.…”

“…Nearly all (82.4%) women in this study, regardless of delivery location, reported purchasing delivery supplies in preparation for their delivery. The need to procure supplies for delivery, including disinfectant, cord clamps, and a razor blade, has been explored in other studies11,22,34,35,41 and was cited as potentially a main reason that facility-based deliveries did not increase after the abolition of user fees 20. While the abolition of user fees may have shifted the burden for resource mobilization from the health system to the user, the need to bring supplies for a facility-based delivery is not a new phenomenon in rural Zambia,35 though user fee removal may have expanded the practice.…”

“…The World Health Organization recommends women deliver at capable health centers with trained health care providers, known as skilled birth attendants, to reduce adverse outcomes 7. However, barriers that hinder women from delivering at health facilities exist at many levels including low country-level spending on health (societal level), limited availability of quality health services (community level); long distances or other physical barriers to reaching health facilities and limited access to transport (community level); insufficient social/familial support (interpersonal level); limited household wealth and low maternal education (individual levels), among others 8–11. These barriers interact in complex ways that can limit the likelihood of women delivering with skilled birth attendants.…”

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

“…According to a Zambian study, women’s interpersonal relationships can have an impact on whether or not she seeks professional care at any point in her pregnancy. These interpersonal relationships extend to CHWs from whom they can also get key information and training to assist with their pregnancy [15]. Characterizing strategies used by CHWs to identify pregnant women will help inform CHW programs in Tanzania, as programs prepare to be scaled-up nationally [16].…”