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Background: Postnatal care (PNC) is an important set of services offered to the mother and her newborn baby immediately after birth for the first six weeks to prevent maternal and neonatal complications and death. This qualitative study explored user and provider perspectives on quality of PNC services in the selected health facilities within the context of the Maternity Homes Access in Zambia project in the Saving Mothers Giving Life districts in rural Zambia. Methods: Between October 2018 and February 2019, forty focus group discussions (FGDs) (n = 160 participants) and twelve in-depth interviews (IDIs) were conducted in four districts in Southern and Eastern provinces. FGDs comprised women who delivered within the last year, fathers, community elders, and volunteers. IDIs comprised health workers at facility, district, and provincial levels. Data were analysed using content analysis guided by the international quality of care domains derived from the World Health Organization quality of care framework. Findings were triangulated to understand perceptions. Results: Overall, study participants perceived PNC services to be beneficial. Nevertheless, respondents had mixed feelings on the quality of PNC services and expressed a stark difference in their perception of factors affecting service quality. Service users described challenges arising from ineffective communication about the new PNC guidelines, and non-adherence of service providers to quality standards regarding respect, preservation of dignity and emotional support. Other factors were long waiting hours, small examination rooms providing inadequate privacy, and low levels of confidentiality. In contrast, service providers attributed poor service quality to various health system-related factors including low staffing levels, dysfunctional referral services, low supply of essential medicines, supplies, vaccines and equipment for optimal routine emergency obstetric and newborn care and management of complications. Conclusion: These findings highlight important intervention opportunities to improve quality of PNC services in Zambia through better communication and raising awareness on PNC guidelines, respect, preservation of dignity and emotional support to mothers. Interventions should also focus on addressing contextual health system challenges including staffing levels, supply chain for essential medicines and commodities, shortening waiting time, and ensuring functional referral system.
This was a cross-sectional, qualitative study employing focus group discussions (FGDs) with PNC service users and community-level stakeholders, and in-depth interviews (IDIs) with PNC service providers. FGDs were conducted in April and May, 2018; IDIs were conducted in February, 2019. FGDs have been used in public health research for over three decades [20]. They aim to explore participants’ experiences, beliefs and attitudes towards a target behaviour, by using group processes to stimulate responses and gain insights through participants’ exchanging views, questioning and challenging one another [21]. IDIs enable the researcher to understand participants’ lived experiences through their own words and perspectives [22, 23]. Use of both FGDs and IDIs allows for in-depth exploration and understanding of various aspects regarding the subject under investigation. The approach also allows for triangulation and corroboration of the FGD and IDI findings, which, in turn, increases the internal validity of the study [24–26]. The study was conducted in four rural districts of Southern (Choma, Kalomo, and Pemba) and Eastern (Nyimba) Provinces at ten primary health centres within the Maternity Homes Access in Zambia (MAHMAZ) project. The MAHMAZ project was a quasi-experimental controlled before-and-after intervention design trial [27], implemented by Boston University and Right to Care Zambia (2015 to 2018) to evaluate the impact of newly constructed maternity waiting homes (MWHs) on reducing the distance barrier and increasing access to quality maternal health care services for rural women in Zambia [28, 29]. The MAHMAZ project did not directly address PNC services offered in the health facility but did construct new MWHs or upgrade existing ones; they also offered beds for postnatal women if they wanted to remain close to the health facility for PNC. MAHMAZ operated in the Saving Mothers Giving Life (SMGL) project districts [30] − a five-year public–private partnership implemented in the selected districts of Zambia and Uganda between (2012 to 2016) as part of a concerted response by the U.S. government through President Barack Obama’s Global Health Initiative. SMGL’s goal was to reduce maternal deaths by up to 50% in targeted districts in Uganda and Zambia—particularly during the critical window during labour, delivery, and the first 24–48 h postpartum when an estimated 2 of every 3 maternal deaths and 45% of neonatal deaths occur [30]. To achieve this goal, SMGL employed a systems approach focused on the health district level to ensure that every pregnant woman had access to clean and safe normal delivery services and, in the event of an obstetric complication, lifesaving emergency care within 2 h. The model served to strengthen the existing public and private health networks within each district and integrated maternal and newborn health services with HIV services. It provided intensive supply and demand side interventions focusing on improved staffing levels, medical stock availability and demand generating activities implemented by Safe Motherhood Action Groups (SMAGs) [31]. SMAGs are community-based volunteer groups (traditional birth attendants, community health workers, and local traditional and religious leaders) that aimed to reduce critical delays that occur at household level with regard to decision-making about seeking life-saving maternal healthcare at health facilities [31]. They were selected and trained by SMGL to encourage women to seek care during pregnancy and the critical first few days of life postpartum. SMAGs taught pregnant women and their spouses about the importance of having a birth plan, delivering in a health facility, and practicing healthy behaviours during pregnancy and early childhood. They also offered guidance and instructions to pregnant women regarding use of MWHs, decision-making process regarding childbirth preparedness and place of delivery and the importance of attending PNC visits. SMGL phase 1 (2012–2013) project results showed a 31% increase in access to and coverage of emergency obstetric and newborn care (EmONC), a 44% increase in the number of women delivering in health facilities, a 41% reductions in mothers dying across target districts, a 38% decline in health facility maternal mortality, and a 36% decrease in total stillbirths in the facility along with a decrease in perinatal mortality [32]. According to the most recent census conducted in 2010, the populations of the study districts were approximately 250,000 each for Kalomo and Choma districts (which administratively included Pemba district at the time) and approximately 77,000 for Nyimba district [33, 34]. The districts are all primarily rural, ranging from 76% (Choma/Pemba) to 93% (Kalomo) of the population living in rural areas [33, 34]. The health system of the districts comprises hospitals, health centres and several health posts. The primary stakeholders in the maternal health programmes are the Ministry of Health, Churches Health Association pf Zambia (CHAZ), non-governmental organisations, community leaders, and various community-based volunteers in health, including traditional birth attendants and SMAGs [35]. Zambia implemented new PNC guidelines in 2014 (see Table Table2)2) [36], which sought to address the timing, number, and place of postnatal contacts, and content of PNC for all mothers and babies during the six weeks postpartum [37–39]. After an uncomplicated vaginal delivery in a health facility by a skilled birth attendant, which is strongly recommended by the WHO, women and their new-borns are advised to remain within the health facility for a minimum of 24 h for observation of danger signs, and prevention and treatment of postpartum complications, such as excessive bleeding, raised blood pressure or eclampsia. Women who give birth at home are encouraged to visit the health facility within 24 h postpartum. Subsequent visits are at day 2–3, day 7–14, and day 42 postpartum [37–39]. This changed previous guidelines which required women to remain in the hospital for a shorter period of 6 h postpartum and return to the health facility after 6 days and 6 weeks. 2013 WHO Recommendations on Postnatal care 1.1. Timing of discharge from a health facility after birth • After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 h after birth 1.2. Number and timing of postnatal contacts • If birth is in a health facility, mothers and newborns should receive postnatal care in the facility for at least 24 h after birth • If birth is at home, the first postnatal contact should be as early as possible within 24 h of birth • At least three additional postnatal contacts are recommended for all mothers and newborns on day • Day 3 (48–72 h) • Between days 7–14 after birth • 6 weeks after birth 1.3. Home visits for postnatal care • First week after birth for care of the mother and newborn 2.1. Assessment for the baby • Feeding • History of convulsions • Breathing, severe chest in-drawing • Spontaneous movement • Fever (temperature ≥ 37.5 °C), low body temperature (temperature 54 years) or mothers-in-law. IDI participants were purposively selected from the two provincial health offices, the four district health offices, and the ten health facilities. To be included, IDI participants needed to be: a) a maternal and child health (MCH) coordinator at the provincial and/or district level, or b) PNC providers from the selected health facilities. Selection of IDI participants was based on the individual’s position at the health facility, district, or provincial health office, experience in MCH policies and activities in the relevant sites, and availability during the times of data collection. FGD participants were included based on the following criteria: age 18 years or older; women who were pregnant (any gestation age) or had recently delivered (gave birth in the 12 months prior to the FGD); men with a child aged less than 12 months; SMAG member; community elder (aged 54 years or more). To participate in the IDIs, respondents needed to be health staff providing PNC services in a health facility or health staff in charge of maternal and child health (MCH) services at the district or provincial health office levels. Individuals aged less than 15 years and those who resided less than three months in the area were not eligible for participation in the FGDs or IDIs. Individuals who were unable or unwilling to provide informed consent were excluded from the study, as well as minors (15–17 years of age) without a guardian able or willing to provide assent. FGD and IDI data were collected using two separate paper-based interview guides which were prepared by the research team and included the following domains: awareness, utilization, and quality of MWHs, barriers and facilitators to facility delivery, preparedness and costs for delivery, quality of ANC services, and quality of PNC services. Only the PNC quality domain was analysed for this study. Questions for this domain were structured using the WHO quality of care framework (Table (Table1).1). Each question included probes to increase the depth of participant responses. To make it easy for the respondents, the domains were combined into four themes (Table (Table1).1). One domain, an actionable information system, was not assessed. Each instrument included a demographics section. Both the FGD and IDI interview guides were piloted during training of the research assistants and revised accordingly before starting the actual data collection exercise. A total of 20 FGDs were conducted with each of the four respondent groups: 10 with pregnant or recently delivered women; 5 with men with a child aged less than 12 months; 2 with SMAG members; 3 with community elders) at each of the ten study sites. FGDs were conducted by a pair of research assistants trained in interview techniques, the interview guide, and in ethical conduct of research involving human subjects. FGDs were conducted in the local languages of Tonga and Nyanja and were audio recorded. Each FGD was conducted at the health facility, included 6 to 8 participants, and lasted between 2.5 and 3 h. The PNC component lasted between 45 and 60 min. In addition, a total of twelve IDIs were conducted with six midwives from BEmONC health facilities, four district health office managers, and two provincial health office managers (Table (Table3).3). IDIs with midwives were conducted by research assistants; those with district and provincial managers were conducted by one of the research team members. All IDIs were conducted in English and audio recorded. Focus Group Discussions (n = 300) and IDIs Audio recordings of the FGDs and IDIs were transcribed and translated into English. A codebook was developed using a deductive approach [40] in which sub-themes were derived from the instrument questions and WHO quality of care framework. Similar statements were coded to the same nodes and nodes were grouped into themes. To allow for comparison of responses among FGD respondent type and between service users and providers, sets were created which allowed for comparison of the data by respondent attributes. Coding and analysis were conducted in Nvivo 11 MAC by a research team member (CS), who conducted four IDIs with MCH coordinators but was not part of the MAHMAZ project implementation team (CS) and was not involved in the FGD data collection, transcription, or translation processes. CS was attached to the MAHMAZ project for his research as a postdoctoral Fogarty fellow under a consortium of Harvard University, Boston University, Northwestern University, and University of New Mexico. Due to logistical and administrative challenges it was not possible to have multiple coders from other research team members. However, the codebook was shared with other research team members to ensure credibility of the coding process and validity of findings. Descriptive statistics and frequencies were used to summarise the respondent demographic data using SPSS Statistics 21. The most frequently discussed qualitative themes are presented by respondent type, supported by illustrative quotations.
