Home deliveries in the capital: A qualitative exploration of barriers to institutional deliveries in peri-urban areas of Lusaka, Zambia

Background: A shortage of skilled birth attendants and low quality of care in health facilities along with unattended home deliveries contribute to the high maternal and neonatal mortality in sub Saharan Africa. Identifying and addressing context-specific reasons for not delivering at health care facilities could increase births assisted by skilled attendants who, if required, can provide life-saving interventions. Methods: We conducted 22 in-depth interviews (IDIs) with midwives at three health facilities in peri-urban communities and 24 semi-structured surveys with mothers in two areas served by health facilities with the highest number of reported home deliveries in Lusaka, Zambia. Both IDIs and surveys were audio-recorded, transcribed and coded to identify themes around delivery and birthing experience. Results: We found that most women preferred institutional deliveries to home deliveries, but were unable to utilize these services due to inability to recognize labour symptoms or lack of resources. Midwives speculated that women used herbal concoctions to reduce the duration of delivery with the result that women either did not present in time or endangered themselves and the baby with powerful contractions and precipitous labour. Respondents suggested that disrespectful and abusive maternity care dissuaded some women from delivering at health facilities. However, some midwives viewed such tactics as necessary to ensure women followed instructions and successfully delivered live babies. Conclusion: Difference in beliefs and birthing practices between midwives and mothers suggest the need for open dialogue to co-design appropriate interventions to increase facility usage. Further examination of the pharmaceutical properties and safety of herbal concoctions being used to shorten labour are required. Measures to reduce the economic burden of care seeking within this environment, increase respectful and patient-centred care, and improve the quality of midwifery could increase institutional deliveries. This qualitative study draws on semi-structured in-depth interviews (IDIs) with midwives and a semi-structured survey with mothers to explore how individual’s views, cultural teachings, experiences and perceptions affect the utilisation of healthcare facilities for delivery. Additionally, we explored the influence of midwives’ experiences and conduct during labour and pregnancy, both in health facility settings and in their personal lives. Lusaka city, the capital of Zambia, is predominantly urban. Lusaka has the largest population among all districts in Zambia with an estimated population of 1,854,907 according to the last census [18]. Lusaka province has the lowest fertility rate among the ten provinces in the country at 3.7 births per woman and is relatively wealthier [19]. Public health facilities in Lusaka operate several outreach initiatives in conjunction with SMAG volunteers. Female relatives accompany women to the clinic but are not allowed in the labour ward. Midwives conduct facility-based deliveries, referring complicated cases to doctors. Of the 193 health facilities in Lusaka, only 15 (both private and public) offer delivery services within Lusaka city [20]. Currently, the average percentage of facility deliveries within Zambia is 67% for both rural and urban areas, and above average at 89% for Lusaka province [19]. This study was conducted as part of the Preterm Resources, Education and Effective Management for Infants (PREEMI) programme implemented to improve the quality of maternal and child health services in Lusaka district between 2014 and 2017. PREEMI was implemented in three peri-urban health facilities in Lusaka city, namely Chawama Hospital, Chipata Hospital and George Clinic. The hospitals are designated as First Level Hospitals, the equivalent of District hospitals which are defined by the Zambian government as referral hospitals found in all districts that are intended to serve a population of between 80,000 and 200,000 [20]. IDIs were conducted in the three peri-urban Lusaka health facilities served by the PREEMI program. These health facilities provide antenatal, post-natal, delivery, basic or comprehensive emergency obstetric and neonatal care (EmONC), among other services. Most women within the peri-urban areas of Chawama, George and Chipata ‘compounds’ (informal settlements) deliver at their local health facilities, which are within a 5 km radius [21]. However, the PREEMI project received persistent reports of home deliveries occurring within these areas and particularly within Chipata Hospital’s catchment area. Two zones (Zone 8 [Kabanana, approximately 4 km away from Chipata Hospital] and Zone 2 [Maziopa, approximately 2 km away from Chipata Hospital]) were purposively selected as survey sites because they had the highest number of home deliveries among the Chipata Hospital catchment zones. A convenience sample of 24 mothers, who met the inclusion criteria of being resident in Zone 2 and Zone 8 of Chipata catchment area for at least 3 months and who had delivered a child within the catchment area in the last two years, participated in the survey. Convenience sampling is a non-random sampling technique whereby convenient cases who meet the required criteria are located and selected on a first-come-first-served basis until the sample size quotient is full [22]. Participants who were below 18 years old could participate if they gave consent together with their guardian. All eligible participants were conversant in either Bemba, Nyanja or English. Twenty-two qualified midwives working within the Labour or Maternal and Child Health Wards at the three facilities were recruited for IDIs using convenience and snowball sampling to accommodate the shift-work and staff shortages at all facilities. Snowball sampling, where participants recommended colleagues who might meet the inclusion criteria, who in turn referred other colleagues, allowed the researchers to access midwives who would have been otherwise excluded because they worked at night or were absent on the day of interview [23]. All participants were identified, recruited and enrolled during the same week they took part in the study. All the midwives were conversant in English and aged 18 years old and above. Two Zambian Research Fellows and one Research Assistant conducted IDIs with midwives in English, the language of practice. All IDI study team members possessed at least a diploma (a non-university tertiary education qualification in any subject) and had varying levels of experience conducting qualitative research. They underwent Human Subjects Protection (HSP) training and IDI refresher training before data collection. One-on-one IDIs were conducted in a private, quiet room in the three health facilities and were audio recorded following written consent. The interview guide (see Additional file 1) developed based on published literature on traditional birthing beliefs, disrespect and abuse and determinants of facility usage for delivery in SSA. This was then reviewed by senior supervisors. Examples of questions include: “How was what you learned in your training different from what is taught traditionally?”; and “How would you describe your delivery experience for your last child?”. Disrespect and abuse were defined as any references to shouting, hitting, purposeful neglect or use of demeaning language towards women delivering in the labour ward [24, 25]. For these interviews, the terms ‘cultural teachings’ and ‘traditional teachings’ were used interchangeably and defined as any teachings or practices held in common by a group of people that originate from the same tribe or similar social group [26]. One of the Research Fellows conducted debriefing sessions with other data collectors at the end of each day and information from these sessions were used to decide which topics should be further probed during the next IDIs. The interviews with mothers were conducted using a semi-structured questionnaire (see Additional file 2) adapted from the close-ended Barrier Analysis Survey for behaviour change tool to include some open-ended questions to explore topics in greater depth and to ensure freely given responses by removing judgemental categories of ‘doers’ and ‘non doers’ [27]. The questionnaire collected information on perceived advantages and disadvantages of using health facilities for delivery, expressed knowledge of possible labour complications and the influence of participants’ social circles on the decision to use a health facility for delivery. All questionnaires were translated into Bemba and Nyanja to allow participants to decide in which language they preferred to be interviewed. Data collectors comprised of eight women, three of whom were involved in the IDIs and one of whom worked at Chipata Hospital as Community Liaison Officer under the PREEMI programme. The other four members of the team were SMAG volunteers from Zones 2 and 8, familiar with women in the hospital catchment areas. SMAG volunteers were paired with the other study team members, all of whom underwent HSP and data collection training prior to data collection. Two pairs of data collectors were allocated to each zone to avoid duplication. Each pair interviewed four mothers who had delivered at Chipata Hospital and two mothers who had delivered at home. Both illiterate and literate mothers with varying levels of educational attainment participated in the survey. The survey was conducted in each participant’s home, preferably in a quiet place. To improve the accuracy of responses recorded on data forms, all interviews were audio-recorded. Of the mothers recruited, two were under 18 years old and participated with their guardians’ consent. Thematic analysis was used to systematically identify and code recurring patterns within the textual data to describe social reality around birthing experience and the meaning that both women and midwives assigned to it as described below [28]. Research assistants transcribed the audio recording of each interview directly into English, of which the first two authors reviewed a sample for accuracy. Research Assistants and authors discussed the most appropriate English translation for words that did not have direct English equivalents. Research Assistants transcribed both interviews and responses to open-ended questions in the survey centrally onto a secure, password-protected laptop. The first two and the last authors coded the first three IDI transcripts using inductive and deductive reasoning to identify emerging themes [29]. The codes and their use were standardized and the code book finalized through this initial coding of transcripts. Survey responses were deductively coded using pre-existing codes in the literature and the original Barrier Analysis Survey. The first two authors manually coded IDIs and textual data from the survey using Microsoft Word [30]. Responses to close-ended survey questions were subjected to descriptive and comparative analysis in Excel. Themes were created by converting units of analysis, extracted from interview text, into codes, sub-themes and eventually themes through a stepwise process. Table 1 illustrates how relevant sections of text were extracted as meaning units and summarised into condensed meaning units to create codes. Examples of meaning units, condensed meaning units, sub-themes and themes from thematic analysis of interviews with midwives The two researchers discussed and contrasted the various codes before further categorising them into sub-themes based on similarities between underlying meanings. Finally, similarities between the overarching message of the sub-themes was used to develop themes. Relevant themes have been clustered into three overriding themes that illustrate that behaviours around labour and delivery for both parties are driven by cultural influences that either compete or are utilised alongside medically driven reasoning and individual characteristics.