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Introduction: poor access to maternal health services is a one of the major contributing factors to maternal deaths in low-resource settings, and understanding access barriers to maternal services is an important step for targeting interventions aimed at promoting institutional delivery and improving maternal health. This study explored access barriers to maternal and antenatal services in Kaputa and Ngabwe; two of Zambia´s rural and hard-to-reach districts. Methods: a concurrent mixed methods approach was therefore, undertaken to exploring three access dimensions, namely availability, affordability and acceptability, in the two districts. Structured interviews were conducted among 190 eligible women in both districts, while key informant interviews, in-depth interviews and focus group discussions were conducted for the qualitative component. Results: the study found that respondents were happy with facilities´ opening and closing times in both districts. By comparison, however, women in Ngabwe spent significantly more time traveling to facilities than those in Kaputa, with bad roads and transport challenges cited as factors affecting service use. The requirement to have a traditional birth attendant (TBA) accompany a woman when going to deliver from the facility, and paying these TBAs, was a notable access barrier. Generally, services seemed to be more acceptable in Kaputa than in Ngabwe, though both districts complained about long queues, being delivered by male health workers and having delivery rooms next to male wards. Conclusion: based on the indicators of access used in this study, maternal health services seemed to be more accessible in Kaputa compared to Ngabwe.
Study setting: the study was conducted in Zambia´s two rural and hard-to-reach districts of Kaputa and Ngabwe, located in the county´s worst performing provinces of Northern and Central provinces, respectively, in as far as maternal indicators are concerned. Data collection was done between June and July, 2016. Research design: a convergent parallel design was conducted to address the study objectives. Both quantitative and qualitative data were collected at the same time and results interpreted together [15]. A mixed methods approach offers potential for identifying, exploring and understanding accessibility of maternal health services in rural Zambia. Quantitative component: a multi-stage sampling technique was employed for the quantitative study. First, purposive sampling was used to select the two worst performing provinces in maternal health indicators, based on the 2013/14 Zambia Demographic and Health Survey (ZDHS) [16], followed by the selection of the worst performing district in the selected provinces. Cluster sampling was then employed to select three communities per district, after which households with either pregnant women or women who had given birth in the five years preceding this study, were identified from a household listing exercise. A random sample of 95 households were selected per district using simple random sampling. Randomization was utilized to address sample selection bias [17]. The sample size was determined using the prevalence formula [18]. Quantitative data was collected using a pretested structured questionnaire, and information collected included participants´ demographic information and questions measuring indicators of availability, affordability and acceptability of maternal health services. Specifically, availability was measured by travel time, mode of transport used to get to a health facility, and the convenience of facility opening and closing times. Affordability was measured by the expenditure on maternal services, medication, transport, accommodation, food, communication and paying someone to take care of the children at home. Employment status was used as an indicator of respondents´ ability to pay. Acceptability was measured by how respondents felt about length of queues, health workers´ attitudes and respect, and cleanliness of facilities. Qualitative component: qualitative data was collected through four (4) Focus Group Discussions (FGDs) per district with women utilizing maternal health services. In addition, a total of eight (8) Key Informant Interviews (KIIs) per district were conducted; four (4) with Traditional Birth Attendants (TBAs) and four (4) with the facility in-charges. The FGDs were conducted in the community while KIIs were done from the facilities. Participants for the FGDs were identified from the household listing exercise while TBAs were identified with the help of facility-in-charges. The triangulation methods were used to enhance the validity of the findings. Data analysis: the quantitative data was analysed using STATA version 11 for windows [19]. Descriptive statistics were computed to describe the access indicators relating to availability, affordability and acceptability of maternal health services. Qualitative interviews were transcribed verbatim, while those conducted in local language were transcribed then translated to English. The transcripts were checked for completeness and read thoroughly to ensure that no information was lost due to translation. The transcripts were then analysed thematically following already predetermined themes generated from the three access dimensions. The data analysis was conducted with the aid of Nvivo [20]. Ethical consideration: ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) (Reference Number: 937-2020) and permission from the Zambia National Health Research Authority (ZNHRA). Additional permission was obtained from respective provincial and district health offices. Informed consent was obtained from all participants prior to the interviews.
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