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

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.

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.

A total of 46 participants took part: 22 midwives in IDIs and 24 mothers in the survey (Tables 2 and 3). Twelve mothers, four of whom had home deliveries, were recruited from each zone. Data from one mother from ‘Zone 2’ was excluded as she did not meet the inclusion criteria.

Among the 22 midwives recruited for the IDIs, eight were recruited from Chipata Hospital and George Clinic and six from Chawama Hospital. On average midwives were 36.5 years old, Christian and approximately three quarters were married. One midwife was male. Four midwives were trained to university degree level while the rest were trained to college level.

The average age for mothers from both zones fell within the 25–34 age bracket and only two were married. Most mothers from both zones were unemployed while a quarter of women in Zone 2 and over a third of women in Zone 8 were either employed or enrolled as a student.

Women’s education levels were not noted. Literacy levels were assessed by asking women to read one paragraph of the consent form aloud in one of the three languages available (English, Bemba or Nyanja). Four women were unable to read the consent forms in any of these languages and were classified as illiterate.

The three main themes that emerged included traditional beliefs, medical focus on live birth, and individual characteristics/differences. Sub-themes on traditional beliefs were related to maternal and child health, conjugal relations and labour and delivery rituals, all of which influenced women’s practices and midwives’ treatment of women. Overwhelming focus on live births rather than maternal comfort coupled with staff shortages led to disrespectful and abusive behaviour by midwives. Women’s socio-economic status, literacy levels, experience of labour, and interaction with female elders were offered as explanations for individual differences in seeking institutional deliveries.

Midwives revealed that they encountered a multitude of traditional beliefs and practices both among pregnant and birthing women as well as in their personal lives. The midwives alluded to elders, specifically grandmothers, being the primary source of traditional teachings and enforcers of these practices. Both midwives and mothers reported that women are initially exposed to traditional beliefs and practices at the start of puberty. Teachings continue during preparation for marriage and with each pregnancy in increasing levels of detail on labour and delivery. However, information may vary as teachings are given “per individual” and “in secrecy”. As many residents within peri-urban areas hail from different parts of the country, midwives also revealed that the diverse cultural backgrounds of their clients are reflected in the variety of traditional practices witnessed:

“I will give a perfect example of women I have delivered so far from this community, the Ndebeles [Zimbabwean tribe], those who stay in Malapodi. When you have such a woman who comes in labour, you are going to have a proper delivery because for them they are taught that ‘labour is a very painful process and you have to bear with it until the child is born. If there are complications the people at the hospital will help you identify them and they will solve the problem.’ [However,] there were some people who came from Eastern Province and their knowledge is not like what we are taught at school. I heard that if someone is in labour and they want them to deliver they would dig a hole and then they would put something like a cloth down then they would ask that woman to squat there and make them starting pushing [the baby].” (IDI, Health Facility A, Midwife 5)

Thus, midwives thought that some tribes birthing practices align with modern midwifery while others do not fit within the medical model of labour and delivery. However, there was no indication that tribal or regional rivalries played a role in how midwives treated women or perceived their behaviour during the birthing process. Many midwives reported that they actively counteract traditional beliefs and practices through sensitisation in the communities as well as during labour and delivery with variable impact.

Women living within peri-urban communities were exposed to a variety of beliefs and practices other than from their own cultural groups. However, it was unclear from the data whether this exposure had influenced practice. Nonetheless, three distinct categories of traditional beliefs emerged from the interviews with both mothers and midwives related to maternal and child health, conjugal relations, and labour and delivery rituals.

Beliefs related to health and future welfare of the baby and recovery and well-being of women in the post-partum period led to restrictions on women’s diet and movement respectively:

“Pregnant women are not supposed to eat eggs because the babies will be born without hair.” (IDI, Health Facility A, Midwife 3)

“When a woman delivers … mmhhm … they are not allowed to cook or help out with those, you know heavy chores [physically tiring] after delivering.” (IDI, Health Facility B, Midwife 6)

The second category of traditional beliefs were those related to conjugal relationships. The advice based on traditional beliefs around sex could be contrary but we were unable to understand the underlying reasons, such as tribal or regional affiliations. For instance, as the two quotes below show, women could be told to continue or to stop having conjugal relations for the sake of the baby’s health:

“They say you should continue meeting [having sexual intercourse with] your husband until the baby is born to strengthen the baby.” (IDI, Health Facility A, Midwife 2)

“When you are about to deliver, you have to like stop making love with your husband. There are such beliefs. They believe that if they continue doing that, the baby will be born with the semen … The sperm for the husband, it will just be there on the baby’s body and all that.” (IDI, Health Facility C, Midwife 2)

Sexual dalliances by pregnant women and their sexual partners were presented as having short and long-term impact on the baby. Extra-marital affairs were presented as deadly to women as they are believed to result in certain death during labour and deliver as described below:

“When you are pregnant, you are not supposed to sleep with any other guy and all that, any other man. They believe if you do that, you may die on the delivery bed.” (IDI, Health Facility C, Midwife 2)

Some mothers also revealed that complications during labour were sometimes attributed to supernatural causes including charms and curses used by the husband’s mistresses to ensure the wife did not have successful labour:

“if she is bewitched … she cannot manage to deliver the baby but she will feel the pain.” (Zone 2, Mother 8)

Some of the midwives corroborated that this belief led to the use of traditional remedies to ward off charms used by husband’s mistress to avoid labour complications:

“Some women even drink some things, some herbal medicines. They will tell you, ‘No, maybe my husband had a girlfriend so I took this so that I don’t find myself in any complications [during l abour].” (IDI, Health Facility A, Midwife 3)

More commonly, however, there was an overwhelming condemnation of traditional beliefs and practices among the midwives because of the perceived negative impact they have on delivery outcomes:

“It [traditional practices] is really giving us a very negative, negative outcome because even the babies when they are born, sometimes they are asphyxiated…”. (IDI, Health Facility A, Midwife 1)

According to both midwives and mothers, grandmothers and female elders gave mothers in labour “African syntocinon”, a herbal concoction believed to hasten delivery and compromise women’s ability to seek care in a timely manner:

“Some relatives prefer tradition, when you are in labour, they can give you herbal medicine to take and within minutes you would have delivered”. (Zone 8, Mother 1)

Midwives hypothesised that the African Syntocinon did hasten labour and thus, contributed to high numbers of home deliveries, occurrence of foetal distress and some cases of post-partum haemorrhage:

“Even the African syntocinon, the herbal concoction that they drink in order to help them deliver quickly … When a woman is given such concoctions, they normally deliver placentas that are a bit greenish … Most of the babies that I have seen from women who have confessed to have drunk such traditional medicine, we have to resuscitate the babies at birth … It will give a woman such strong contractions, such that a woman may even have a ruptured uterus …”. (IDI, Health Facility B, Midwife 3)

The secrecy around African Syntocinon intake added to the challenges posed to conducting safe deliveries because midwives would prefer to monitor women who have taken herbal concoctions more closely than other pregnant women for unexpected complications from an accelerated labour:

“Am more vigilant because I don’t know to what extent this medicine is going to affect [the delivery]. So am more vigilant on that mother … mmhh … who has taken the medicine”. (IDI, Health Facility A, participant 5)

Other than belief systems, many midwives believed low socio-economic status and literacy levels within their catchment area contributed to the practice of home deliveries:

“With the high class, they believe to say ‘I have to deliver from the hospital,’ including the middle [class]. But with the low [class], for them, it’s either home or hospital, whichever I deliver at, its fine with me.’” (IDI, Health Facility C, Midwife 1)

Midwives insinuated that low socio-economic standing of women was strongly associated with their decision to deliver at a health facility with more affluent women preferring private services. The midwives themselves were of a higher socio-economic status than the women they served, though a few had grown up within these same peri-urban communities. It was unclear whether the socio-economic background of the midwives or the mothers influenced midwives’ treatment of women or their views about the mothers’ behaviours during birthing. However, it is the wealthier among peri-urban residents who make it to the clinic. Mothers reported that economic constraints for some women contributed towards them delivering within their homes even when they intended to deliver at the health facility:

“What leads to delivering at home is suffering -- you don’t have resources.” (Survey, Zone 2, Mother 3)

Participants used the term ‘resources’ to refer to money and the products they are required to purchase and bring to the health facility when they are in labour. Some of these products include a full bottle of bleach, a bucket, a blanket (for the baby), a chitenge (traditional cloth) and a new pair of scissors. Financial circumstances, specifically lack of adequate income, are presented as an important deterrent for women within this community who want to deliver at a health facility. Those without the financial means to pay for transport and buy the items required for delivering at a health facility are forced to choose home delivery:

“I know the benefits of using the local health facilities. If I have all the requirements like transport and if life is generally okay, then I can go to the health facilities. But, for instance, if I don’t have the resources, then I can deliver at home as I would have no option.” ( Survey, Zone 8, Mother 1)

Mothers from Zone 8 were more likely to cite distance and transport constraints as a reason for delivering at home instead of health facilities. Most children in both zones were delivered at their local health facilities or at a Level 3 Tertiary Hospital (Fig. 1). Zone 8 is located 2 km further away from the health facilities in comparison with Zone 2, although the roads in both areas are of the same standard. Figure 1 illustrates that most women in both zones deliver their first children at either a hospital or their local health facility but were more likely to have subsequent deliveries at home.

Other than economic and transport-related constraints, many midwives reported that both nulliparous and multiparous women’s inability to distinguish between the start of labour and pre-labour pregnancy symptoms may lead to home delivery. This view is corroborated by women as illustrated by the quote below where misunderstanding of what labour should feel like, led to home delivery even though they may have preferred to deliver at the health facility:

“I wanted to deliver at the health facility but because of the same feeling of pain here then there, I was confused. So even when I was delivering, I didn’t think I was in labour at a stage that I could deliver.” (Survey, Zone 2, Mother 6).

Some mothers reported a preference for facility-based delivery being aware of the dangers of delivering within their homes based on experiences within their social networks:

“Delivering at home is bad! Because, I remember, a friend of mine who had delivered at home. When she delivered at home, then after delivering, the placenta remained in the uterus. It didn’t come out, so like that, and that is a risk” (Survey, Zone 2, Mother 1)

As a qualitative study, the findings of this study are unique to Lusaka compounds and not generalizable. Our study was limited to the birthing experience in facilities and not at home, so does not explore birth attendants in the home setting and potential incentives for them. While familiarity with the SMAG volunteers involved in data collection may have introduced response bias into the study, other studies show that inhabitants of these compounds prefer to interact with known persons who are familiar with the context within which they live [39]. Also, our study provides in-depth and contextual data on the delivery practices and experiences from both mothers’ and midwives’ perspectives to provide holistic solutions (ones that will address issues beyond those that are purely medical). Similarly, the focus on peri-urban areas is significant given the rapid urbanization of Lusaka along with substantial rural-urban migration which indicate that issues identified in this paper are likely to affect more facilities in the future.