Rural Zambian Women’s Relationships Help or Hinder Facility-Based Birth.

The proportion of women delivering babies at health facilities in sub-Saharan Africa has been increasing, but many women throughout the region still deliver at home with relatives or with an undertrained birth attendant who is less able to identify and handle labor complications. Global health researchers working to reduce maternal mortality tend to focus on individual characteristics like a woman’s education level or number of previous deliveries, or on structural factors like distance to a health facility, limited transportation, costs, and the quality of health services provided.

But interpersonal relationships also help or hinder a woman’s decision and ability to access facility delivery in rural Zambia, according to a new study led by School of Public Health researchers.

The study, published in Social Science and Medicine, identifies the culturally expected roles that husbands, female relatives, and community health workers fulfill—or do not fulfill—to help a woman deliver her baby in a health facility in Zambia’s Southern Province.

“For example, female relatives are expected to go with the pregnant woman to the health facility and care for her before, during, and after labor, with specific tasks laid out, including disposing of the placenta after delivery, and massaging the woman’s body to prevent blood clots,” says study lead author Jeanette Kaiser, a research fellow in the Department of Global Health. “If the pregnant woman does not have anyone—or multiple people—to fulfill these roles, she will have a much harder time accessing maternity care.”

This is the first study to combine an examination of social ties with the traditional “Three Delays Framework,” which looks at barriers to deciding to seek care, actually accessing that care, and receiving quality care, Kaiser says.

Kaiser and her colleagues analyzed data from a survey and focus groups conducted by study senior author Nancy Scott, assistant professor of global health, as part of the MAHMAZ project. The participants were members of the communities served by four rural health facilities in Choma and Kalomo districts, and included 92 women who were pregnant or had a child under the age of two, 85 men with a child under the age of two, 55 community elders, 32 mothers-in-law, and 38 community health workers and traditional birth attendants.

The researchers found that female relatives had the most roles throughout pregnancy, delivery, and the baby’s early infancy. Female relatives are responsible for escorting women to the health facility, assisting facility staff, cooking for the mother, and providing general care. The female relatives are also responsible for upholding traditions and customs, including ensuring the woman does not cook until the umbilical cord drops.

The study participants identified husbands as being primarily responsible for providing resources for pregnancy and delivery, including the items a woman is expected to bring with her to the facility: baby clothes and delivery supplies such as cord clamps, bleach, and a razor blade.

Many participants noted that men often fail to fulfill this role, either because of lack of money or because they do not want their wives to deliver at a facility, with female relatives needing to step in and supply the items—or the woman delivering at home.

Many men reported that the decision to deliver at a facility should be a joint one, and that the decision not to is normally based on lack of resources. However, the women, female relatives, community health workers, and elders described the decision-making process as getting a “husband’s permission.” They reported that husbands deny permission because men want women to be home for cooking, caring for children, and sex, because they lack knowledge about safe pregnancy and delivery, and because of concerns about male healthcare workers caring for their wives and the required HIV testing at facilities.

The participants also identified important tasks that were not any specific person’s role, including arranging transportation to the facility, and taking on a woman’s household chores and caring for her other children.

Participants identified the role of community health workers primarily as teaching community members the importance of facility delivery and helping them prepare. The authors write that community health workers therefore offer the best opportunity for birth preparedness interventions, which the authors recommend should include counseling on saving for the necessary delivery supplies, and helping identify which female relatives will assist at home and at the health facility.

The study was co-authored by Rachel Fong, a research fellow in the Department of Global Health; Davidson Hamer, professor of global health; and Brittany Tusing (SPH’15), who was a student during the study. The other co-authors were Godfrey Biemba, executive director of the National Health Research Authority in Zambia, and Thandiwe Ngoma of the Zambia Center for Applied Health Research and Development.

—Michelle Samuels