‘I was trying to get there, but I couldn’t’: social norms, vulnerability and lived experiences of home delivery in Mashonaland Central Province, Zimbabwe

Abstract

Increasing facility-based delivery rates is pivotal to reach Sustainable Development Goals to improve skilled attendance at birth and reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). The translation of global health initiatives into national policy and programmes has increased facility-based deliveries in LMICs, but little is known about the impact of such policies on social norms from the perspective of women who continue to deliver at home. This qualitative study explores the reasons for and experiences of home delivery among women living in rural Zimbabwe. We analysed qualitative data from 30 semi-structured interviews and 5 focus group discussions with women who had delivered at home in the previous 6 months in Mashonaland Central Province. We found evidence of strong community-level social norms in favour of facility-based delivery. However, despite their expressed intention to deliver at a facility, women described how multiple, interacting vulnerabilities resulted in delivery outside of a health facility. While identified as having delivered ‘at home’, narratives of birth experiences revealed the majority of women in our study delivered ‘on the road’, en route to the health facility. Strong norms for facility-based delivery created punishments and stigmatization for home delivery, which introduced additional risk to women at the time of delivery and in the postnatal period. These consequences for breaking social norms promoting facility-based delivery for all further increased the vulnerability of women who delivered at home or on the road. Our findings highlight that equitable public health policy and programme designs should include efforts to actively identify, mitigate and evaluate unintended consequences of social change created as a by-product of promoting positive health behaviours among those most vulnerable who are unable to comply.

Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial

“…This cascade of events likely contributed to the two-fold higher risk of stillbirth and neonatal mortality among non-institutional deliveries in our study. This offers a potential explanation for the ndings of a recent study carried out in Zimbabwe which found that women, burdened by multiple interacting vulnerabilities related to poverty, were most likely to deliver 'on the road' whilst attempting to reach a healthcare institution [34].…”

How Can “Community Voices” from Qualitative Research Illuminate Our Understanding of the Implementation of the SDGs? A Scoping Review

“…The women's narratives show how vulnerabilities intersect, including material (food insecurity, available household assets, and access to transportation), social (isolation, distance, and lack of agency for decision-making), and individual-level vulnerabilities (knowledge of signs of labour leading to delays). The women experienced shaming and stigma for delivering at home, making them even more vulnerable to adverse health impacts [13]. The experiences of the women participating in this study illustrate that pursuing progress towards meeting SDG targets at the level of national statistics can lead to negative side effects in some communities, undermining the promise of Agenda 2030 to "leave no one behind".…”

“…In the majority of studies, data was collected from extremely poor rural locations or city slums. Not surprisingly, many research participants reported difficulties in accessing health care, including financial barriers, drug shortages and lack of transport [8][9][10][11][12][13]. Six studies also cited shortages of health-care workers and unfriendly interactions with health-care providers as barriers to accessing health care [11,[14][15][16][17][18].…”

“…One paper presented an interesting analysis of the unintended consequences of a change in socio-cultural mores. Webb et al looked at the experiences of postpartum women in a region of Zimbabwe where numbers of home births remain high [13]. In general, the policy to promote delivery at health facilities has been successful at the national level, with maternal and child mortality rates improving (SDGs 3.1 and 3.2) and cultural attitudes shifting in favour of delivery in health facilities to such an extent that mothers who deliver at home face community opprobrium.…”

Vulnerability in maternal, new-born, and child health in low- and middle-income countries: Findings from a scoping review

“…Eleven studies were quantitative and observational in design [24,[27][28][29][30][31][34][35][36][37][38]. six were qualitative research [26,32,[39][40][41][42], four used mixed-methods design [25,33,43,44], and one was a randomised controlled trial [45]. The details are presented in Table 1 and Fig 2.…”