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Background: Maternity waiting homes (MWHs) are aimed at improving access to facility-based skilled delivery services in rural areas. This study explored women’s experiences and beliefs concerning utilisation of MWHs in rural Zambia. Insight is needed into women’s experiences and beliefs to provide starting points for the design of public health interventions that focus on promoting access to and utilisation of MWHs and skilled birth attendance services in rural Zambia. Methods: We conducted 32 in-depth interviews with women of reproductive age (15-45 years) from nine health centre catchment areas. A total of twenty-two in-depth interviews were conducted at a health care facility with a MWH and 10 were conducted at a health care facility without MWHs. Women’s perspectives on MWHs, the decision-making process regarding the use of MWHs, and factors affecting utilisation of MWHs were explored. Results: Most women appreciated the important role MWHs play in improving access to skilled birth attendance and improving maternal health outcomes. However several factors such as women’s lack of decision-making autonomy, prevalent gender inequalities, low socioeconomic status and socio-cultural norms prevent them from utilising these services. Moreover, non availability of funds to buy the requirements for the baby and mother to use during labour at the clinic, concerns about a relative to remain at home and take care of the children and concerns about the poor state and lack of basic social and healthcare needs in the MWHs – such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities as well as failure by nurses and midwives to visit the mothers staying in the MWHs to ensure their safety prevent women from using MWHs. Conclusion: These findings highlight important targets for interventions and suggest a need to provide women with skills and resources to ensure decision-making autonomy and address the prevalent gender and cultural norms that debase their social status. Moreover, there is need to consider provision of basic social and healthcare needs such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities, and ensuring that nurses and midwives conduct regular visits to the mothers staying in the MWHs.
The study was qualitative in design and used in-depth interviews (IDIs) to provide a detailed understanding of the women’s experiences and beliefs concerning utilisation of MWHs in Kalomo district. The Tropical Diseases Research Centre Ethics Review Committee and the Ministry of Health Research and Ethics Committee in Zambia granted ethical approval. The study was conducted in Kalomo district, located 360km south of the capital Lusaka, and covering a total surface area of 15 000 km2. It has an estimated population of 275, 779 [23] with an annual growth rate of 4.4 %. Most of the population (92 %) live in rural areas with subsistence farming and cattle rearing being the major economic activities. The district is one of the poorest in the country, with more than 70 % of its population living on less than a dollar per day [24]. Administratively, the district is divided into three constituencies, four chiefdoms and twenty political wards. The health system in the district comprises two hospitals, thirty-four health centres and several health posts. Furthermore, only 52 % of the health care facilities have access to reliable electricity [25] The district is one of the rural districts in the country with low maternal healthcare service utilisation rates, where less than 30 % of the women receive assistance from a skilled birth attendant in a health facility, compared with 80 % of the births in urban women [4, 7, 8, 25]. The main players in the maternal health programmes are the Ministry of Health, missionaries, non-governmental organisations, community leaders and various community-based health agents, including traditional birth attendants. The study participants were selected from the women of reproductive age (aged between 15 and 45 years) who had given birth within one year prior to the study and were visiting the local health centre for their children’s routine under five clinics. To be eligible to participate in the interview, women must have had resided in the area for more than six months; those who had lived there for less than six months were excluded because the investigators thought these women would not have had enough local experience on utilisation of MWHs in the area. In addition, women aged below 15 and above 45 years were excluded from participation. Selection of study participants was done using a purposeful homogeneous sampling technique. This technique was used in order to select respondents with similar experience regarding utilisation of MWHs and childbirth services, while, at the same time, allowing for recruitment of respondents with different characteristics in terms of their age, number of children, marital status, and education level, which helped provide insight into the similarities and differences in their experiences [26, 27]. To begin with, all the ten health centres with a MWH in the district were identified and included in the research with the help of the district managers at the District Medical Office. In addition, five (5) out of a total twenty five health centres without a MWH were also purposefully selected and included in the study. A month prior to the interview, the principal investigator contacted respective health centre in-charges to inform them about the study. Due to logistical challenges, it was not possible to hold meetings with respective health centre in-charges. Instead, they were contacted by phone and the purpose and objective of the study were discussed in detail. The health centre in-charges were then asked to inform the mothers attending the under five clinics about the study and to explain its purpose and objectives−, that is, the study aimed to gain insight into their experience and knowledge about MWHs in their areas, how the decisions for pregnant to use the service were made and what they thought were the main factors affecting utilisation of the service. This information was shared by health centre in-charges during the health promotion sessions conducted by nurses and midwives during each under five clinic visit, and involved all the women attending the under five clinics on a particular day. Women who were willing to participate in the study were advised on the interview date and were asked to return to the clinic for the interview on an agreed upon date. The date for the interview was set by the health centre in-charge and then communicated to the research team through the principal investigator. The IDIs were conducted from the second week of March, 2014 to the end of May, 2014 and lasted for ten weeks. The research team travelled to the health centre on the day of the interview. To ensure privacy and confidentiality, each IDI was conducted in a quiet place, outside health centre premises, normally under a tree for shade and lasted between 30 and 50 min. The IDIs were conducted in Tonga, the local language in the area. Before each IDI, written consent was obtained from each participant by requesting them to read and sign the consent form, which was translated into the local language. Research assistants read the consent form aloud for those who could not read. After obtaining consent, research assistants requested each respondent to complete a short demographic questionnaire which included questions such as the respondent’s age, number of children, marital status, level of education, occupation, level of income, estimated walking time to the clinic, place of delivery for the youngest child, history of complications during the previous delivery, and use of a MWH. The last question was only applicable for the respondents located at a health care facility with a MWH. After completing the questionnaire, the interviews were conducted. Each IDI was facilitated by two trained research assistants using a semi-structured interview guide which was translated into Tonga. One research assistant conducted the interview, while the second one recorded using a digital voice recorder. The principal investigator attended interviews at random to ensure the data collection protocol was consistently followed by the research team members. A total of 32 IDIs were conducted in 9 health centres, 22 of whom were interviewed in 7 health centres with a MWH, and 10 were interviewed in 2 health care facilities without a MWH, although 10 health centres with MWHs and 5 health centres without MWHs were initially identified to be included in the study. After 15 interviews involving respondents from five health centres with MWHs, and 10 interviews from health centres without MWHs, data saturation was achieved; that is, no more substantial information was obtained. At this point, the research team decided to stop the interviews and, thus, leave out the remaining selected health centres. Rather, they decided to only conduct the interviews in the two mission-owned health centres with MWHs in the district. The rationale for this decision was to obtain extra insight into the study from these respondents because, compared to the MWHs in the other health facilities in the district, MWHs in the mission facilities were of better quality and provided better social services such as a larger sleeping space, mattresses, beds and blankets. In addition, the facilities had better cooking facilities and sanitary conditions with piped water. Seven (7) extra respondents were interviewed from these two health centres, giving a total of 32 respondents. The age of the respondents ranged between 17 and 44 years old. A semi-structured interview guide was developed that had three pre-determined themes. The first theme focused on women’s perspectives and experience regarding MWHs and its role to improve facility-based skilled birth attendance, and included questions on women’s experience regarding utilisation of MWHs. For example, what they thought about MWHs; whether they had stayed in a MWH before or not; how they felt about their stay in a MWH; what they thought about accessibility to MWHs in their area; whether they would you use it if they were pregnant again and why; what they thought about whether mothers’ shelters were important in helping women deliver at a health centre or not; and if so to explain why and how. The second theme was on the decision-making process regarding utilisation of MWHs and included questions about how the decision is made and who makes it when women want to go to the MWHs. The third theme focused on the important factors which affect women’s actual utilisation of MWHs. Since there were two different settings (with or without MWHs present) in which the interviews took place, two interview guides were developed reflecting these different settings. The overall themes were the same for both interview guides, however some questions were different. For example, at the health care facility with a MWH, women were asked if and why they did or did not go to stay at the MWH in the last period of their pregnancy. If they did stay in the MWH, their perspectives were explored. At the health care facility without a MWH, women were asked to share their view on MWHs. Furthermore, the women were asked if they would use the MWH if available at the health care facility and why. Demographic information was entered into the excel sheet and transferred into IBM SPSS Statistics 21 for processing. Descriptive statistics and frequencies were used to summarise the demographics of the respondents and respective percentages were computed (see Table 1 below). Background characteristics of the respondents The voice recordings from the interviews were transcribed and translated into English by the research assistants. To check for accuracy, a few transcripts (20 %) were back − translated into Tonga. Members of the research team then compared the Tonga and English versions for differences and similarities while listening to the original voice recording. After verification of accuracy in translation, each transcript was then thoroughly read by one research assistant while the other one was listening to the corresponding voice recording. Each translated transcript was compared with the hand-written field notes that the research assistants had prepared during the interviews. After proof-reading and making corrections, the transcripts were saved on a password-protected computer. The word documents were then exported into Nvivo 10 MAC for processing. The exported data were then coded and the categories and key sub-themes were identified. In order to make it easy to compare the perspectives of women from the facilities with a MWH and those from health care facilities without a MWH, the data from the two groups of respondents was coded separately. Data analysis was based on the three predetermined themes. An inductive approach was used to derive the sub-themes from the main themes by content-analysing and grouping all the similar statements made with respect to particular themes. Several sub-themes emerged from the data analysis; all sub-themes are described below in the respective sections for the main research themes.
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