Improving access to skilled facility-based delivery services: Women’s beliefs on facilitators and barriers to the utilisation of maternity waiting homes in rural Zambia

Demographics

Table 1 summarizes the demographic characteristics of the 32 respondents included in the
study. The mean age was 26.8 years old and the majority (84.4 %) of the respondents
were married, and had an average of 3 children. Most of the respondents (68.8 %) were
farmers and about two in five (38.7 %) had an income of less than 100 ZMW per month.
The estimated walking time to the clinic from the place of the respondents’ residence
was one hour and 40 min and the majority (87.5 %) had delivered their youngest child
at the health care facility. Of the 32 respondents, 22 were interviewed at a health
care facility with a MWH and 10 were interviewed at a health care facility without
a MWH. Only 2 out of 22 (9.1 %) of the respondents interviewed at a health care facility
with a MWH had a home delivery compared to 2 out of 10 (20 %) that were interviewed
at a health care facility without a MWH. Of the 22 respondents interviewed at a health
care facility with a MWH, 6 (27.3 %) utilized a MWH and 16 (72.7 %) did not. Out of
the 32 respondents interviewed, 6 (18.75 %) experienced complications during labour.

Theme 1: perspective on maternity waiting homes

The first theme focused on women’s perspectives regarding MWHs as well as accessibility
and utilisation of MWHs.

All respondents mentioned that MWHs were important since they helped pregnant women
to overcome the problem of having to travel long distances to healthcare facilities.
They explained that during the last month of their pregnancy, pregnant women could
go and stay in the MWHs and wait for their labour near the health care facility. Respondents,
especially those from healthcare facilities without MWHs, added that, with a MWH at
the health care facility, women could decide themselves when to leave home to go and
stay there instead of having to travel to the clinic when they are already in established
labour. They stated that women could either walk from home to the MWHs when they still
had the strength to do so or they could use private transport. Respondents mentioned
that women who resided far from the health centres experienced delays in reaching
the health care facility and that MWHs were especially important for these women.
It was also mentioned that MWHs were especially convenient for the women who experienced
labour and delivery at night. They explained that MWHs were important for the pregnant
women who lived far from the health care facility as it was extremely difficult for
them to find transport during the night. They explained that while staying at the
MWH, women had immediate access to health care and felt protected against labour complications.
Moreover, respondents explained that women were happy that they were able to rest
in the MWH before they went into labour. When labour started, it was easy for them
to access facility based delivery.

“It’s a good idea. You can come here if you don’t have transport at your place. You
may walk when you still have strength, then you overcome the distance, you stay here
waiting for the right time to come, rather than being at home until your time comes
and walking a long distance while something is paining” (20-year-old respondent)

In contrast, most respondents who lived close to the health centres with MWHs believed
that they did not need the MWHs because their place was near to the health care facility.
Furthermore, most multigravida older respondents preferred to wait at home as they
believed they would recognise the labour in time to go to the healthcare facility.
They explained that it was only necessary to go to the MWHs if the woman had complications
during pregnancy. The young respondents explained that they didn’t have enough knowledge
on the MWHs as they had just experienced their first pregnancy. Therefore, they just
decided to stay at home and only went to the clinic when they were in established
labour.

When asked whether most women had access to the MWHs, all 22 respondents from the
health care facilities with a MWH explained that it was easy for women to go and stay
there, as there were no rules or regulations regarding the use of the service. In
contrast, the 10 women from the health care facilities without MWHs argued that it
was hard for them to reach the centres which had MWHs.

Regarding their experience while staying in the MWHs, the 6 respondents who had used
the MWHs and most of the older women from the health centres with MWHs complained
that women felt abandoned by the healthcare staff as nurses did not check on them
and that it was a waste of time staying at the MWHs as it was possible for one to
reside there for weeks without being attended to by nurses or midwives. Moreover,
the 13 out of the 22 (60 %) respondents who lived close to health care facilities
with a MWH but had not used the service were concerned with pregnant women’s inactivity
when staying in the MWHs waiting for labour. They argued that it was not good for
pregnant women to stay in the MWH because the nurses advised them to rest while staying
there. Most older women stated that they preferred to have their labour start earlier
and felt that staying active would assist pregnant women have their labour start early.
Therefore, respondents explained that some women preferred to stay at home and keep
working until the onset of their labour.

When asked whether they would use the MWHs if they were available, all 10 respondents
from the health centres without MWHs reported that they would like to see MWHs provided
at their health care facility, and that most women would utilise it. They explained
that that most women would stop worrying about transport if MWHs were available at
their health care facility.

“If the clinic had the maternal waiting home, the mother shelter here, most pregnant
women would come here and stay to wait for her time” (44-year-old respondent)

When asked whether most women used MWHs where they were available, all the respondents
from both the facilities with MWHs and those without reported that most women did
not utilise the service. They mentioned that most women did not go to stay in the
MWHs because they delayed making the decision to leave home. They explained that although
they had planned to stay in the MWH, some women, especially the older ones with many
children, went into labour while they were still at home due to lack of transport
to take them to the MWHs. Respondents explained that especially young women delayed
utilising the MWHs because they had difficulties in estimating the right time to go
to the MWHs.

“I wanted to stay there but the problem was that it was my first pregnancy so I didn’t
know when labour would start. So I am planning to come there next time” (24-year-old
respondent)

Regarding the reasons for utilising the MWHs all reported long distances and lack
of transport from home to the health care facility as the main reason for utilising
the MWHs. Additionally, fear of complications was another important reason for utilising
the MWHs. They explained that, often, they were advised by the nurses during antenatal
care (ANC) visits to stay in the MWHs. Women who attended ANC at a clinic without
a MWH were advised to go and wait for delivery at the district hospital or at a health
centre with a MWH.

“I had some complications; I had some problems so I was told to stay at the clinic
before time of delivery” (25-year-old respondent)

Theme 2: decision making process and barriers to utilising a maternity waiting home

The second theme focused on the decision-making process regarding whether or not to
utilise MWHs as well as the factors that influence the decision-making process.

Asked about who makes the decision for pregnant women to use the service, most young
respondents with few (that is one or two) children from both the health care facilities
with MWHs and those without mentioned that the husband is the one who decides whether
or not the woman should go and stay at the MWH during the last months of pregnancy.
They explained that although most women discussed with their husbands the importance
of their stay at the MWHs and often persuaded them to allow their wives to use the
MWHs, the final decision whether the woman should use the MWH or not was made by the
husband. In addition, young respondents mentioned that the women’s mother and mothers-in
law were also involved in the decision-making process. Furthermore, all respondents
from both the health care facilities with MWHs and those without also mentioned that
nurses at the clinic play an important role in the decision-making process as they
often advise women during ANC visits to come and stay at the MWH, especially when
there were indications of complications. However, most older respondents mentioned
that they made the decision alone and that they did not receive help from anyone in
the decision- making process.

“The husband is the one who decides” (23-year-old respondent)

“When we are in the month of 8, the nurses at the clinic tell us to come and wait
for our time here, yes” (18-year-old respondent)

Regarding the factors affecting the decision-making process, respondents who had used
MWHs and those who had experienced complications during previous pregnancies mentioned
the risk of complications as the major reason to utilise MWHs. Young respondents with
no experience with childbirth indicated that fear of complications was the major reason
for using MWHs. They explained that as the husband made the final decision, he considered
the advice from the nurses at the clinic. They indicated that sometimes during ANC
women were told that their baby was not in the right position in the womb, which could
cause problems during delivery. Additionally, respondents explained that some women,
especially the young ones, were advised by nurses that they would not be able to push
the baby out and needed medical help with this process. They also explained that some
women, especially the old ones with many children were advised to go and deliver at
the clinic because they might bleed a lot after giving birth. If they stay in the
MWH before giving birth, women who experience these kinds of complications receive
immediate medical help, as they do not experience delays in reaching the clinic.

Asked about which group of women were more at risk of developing complications, respondents
mentioned that all women were at risk of developing complications. They explained
that especially young women who had no experience with childbirth were at greater
risk of developing complications such as prolonged or obstructed labour than older
ones with many children. Furthermore, older women who had complications during their
previous pregnancies and deliveries were believed to be at a higher risk of developing
complications in future pregnancies. Moreover, respondents explained that women (regardless
of their age) who were told by nurses during ANC visits that they had pregnancy complications
such as the baby not lying well in the uterus, having high blood pressure, etc, were
also believed to be more at risk of developing complications during labour. Respondents
explained that, compared to the older women with many children, young mothers were
more likely to anticipate complications because they were scared of labour complications
and believed that they had no experience with childbirth. They explained that many
multigravida older respondents believed that they had enough experience with childbirth
and that they knew themselves quite well, and that they would know whether they would
develop complications or not.

“Complications, that’s what they look at. Maybe when you deliver at home and you bleed
a lot, they won’t help you. But here at the hospital they can control the bleeding.
So that is what they consider before deciding with the husband” (23-year-old respondent)

Another important factor that the families considered during the decision making process
is distance. Most respondents interviewed from both the health care facilities with
a MWH and those without explained that walking from home to the clinic while in labour
pain was difficult when living far from a health centre. Thus, it might be safer to
stay at the MWHs before delivering. Additionally, respondents mentioned that availability
of transport also plays an important role as the couple decides on whether the woman
should go and stay in the MWH or not.

“The distance, it’s difficult for the woman to walk when she feels the labour pains
from home coming here. It’s better for her to come here and stay” (28-year-old respondent)

Regarding challenges in the decision making process, more than half (18 out of 32)
of the respondents interviewed from both the health care facility with a MWH and those
without indicated that the lack of a family member to take care of the children and
another one to accompany the woman to the MWH and help her while staying there usually
made it difficult for the pregnant woman to leave home to go and stay at the clinic.
They explained that many women had young children who could not stay by themselves
while their mother was away at the MWH awaiting labour. Respondents explained that
often, the husband was not able to stay at home to take care of the children due to
various commitments, including working in the field.

Another factor that was considered by the wife and husband as they made the decision
was the availability of funds to buy the requirements for the baby and mother to use
during labour at the clinic. Respondents mentioned that during ANC, nurses advised
pregnant women to prepare for childbirth, and that as they went to give birth at the
clinic they should carry baby clothes and requirements for the mother such as a wrapper
and cleaning materials like bleach. Respondents explained that the husband was expected
to find the money for the baby and mother requirements at the clinic. However, respondents
explained that most families did not have enough money to buy these items and husbands
who failed to provide these requirements refused to allow their wives to go and stay
at the MWHs.

Moreover, when making the final decision, husbands considered the availability of
people to work in the field. Most respondents who had not used MWHs interviewed at
a health centre with MWHs mentioned that some women had not used MWHs because their
husbands refused to allow them to leave home due to difficulties of having someone
to work in the field, especially during harvest time.

“There is a challenge of how, who should take care of the children” (36-year-old respondent)

“There is no problem, unless this time when we are harvesting, but we have to ask
from the husband and say I want to go to the clinic. Husbands will then give us permission”
(18-year-old respondent)

Theme 3: factors affecting staying in maternity waiting homes

Respondents were asked if they faced challenges regarding the utilisation of MWHs.
Most respondents from both the health care facilities with MWHs and those without
mentioned that pregnant women faced many challenges when using the MWHs. Respondents
who had used MWHs complained that many MWHs had no beds or mattresses and pregnant
women had to carry their own beddings from home. They mentioned that those who failed
to carry their own beddings and mattresses had to sleep on the floor. Respondents
explained that this was a huge challenge for pregnant women as they had to walk long
distances and could not carry beddings on their heads. Similarly, respondents from
the health care facilities without a MWHs stressed the need for pregnant women to
be comfortable during their stay at the MWHs and that beds and mattresses should be
made available.

“As for now we just sleep on the floor. There are no mattresses unless you bring them
from home” (35-year-old respondent)

“If they put beds and mattresses it could help women to be delivering at the hospital”
(17-year-old respondent)

Furthermore, respondents who had used the MWHs and most respondents from the healthcare
facilities with MWHs stated that the available MWHs had limited space for sleeping.
They explained that some MWHs were very crowded because pregnant women came with an
accompanying relative. They explained that sometimes women had to sleep outside because
of the lack of space.

“There is no much space in the shelter. Pregnant women need space as they stay at
the mother’ shelter. Because of not having enough space women have problems” (25-year-old
respondent, IDI30)

In contrast, all the 7 respondents from the two mission health facilities were happy
with the quality of MWHs and the services provided there. They mentioned that the
MWHs in the two health facilities had enough space for women and their accompanying
relatives and that they had enough beds and mattresses for pregnant women to use.
They also indicated that pregnant women staying in these MWHs were provided with blankets
by the healthcare staff.

Another important challenge was the lack of food for pregnant women when staying in
the MWHs. Respondents who had used MWHs and those from the health care facilities
with MWHs mentioned that food was not provided to the pregnant women who stayed in
the MWHs. They stated that women had to carry their own food from home. Respondents
explained that it was hard for pregnant women to take their own food to the MWHs because
they had limited food supplies which were not even enough to share with the other
family members remaining at home. Additionally, respondents who had used MWHs indicated
that it was usually unknown how long women would stay at the MWHs, and this made it
difficult to estimate how much food they needed to take with them. They explained
that often, the food ran out before women gave birth. In order to get extra food,
women had to travel back home. They explained that while walking home, women risked
giving birth on the way.

“The issue of carrying their own food is a problem. You find that she just has a small
amount of food then she has to share it with the family, with children and husband.
So it’s a challenge” (41-year-old respondent)

“It’s difficult for a mother if the food finishes. She has to go back home. Some women
delivered on the way when they went back home to get food” (32-year-old respondent,
IDI29)

Another important problem was lack of water at the MWHs. Most respondents from health
care facilities with MWHs stated that most MWHs had no water and women had to walk
long distances to get it. They explained that, although in most cases, the accompanying
relatives would draw water for the pregnant women, but when the pregnant woman was
alone, she had to walk the distance herself. In contrast, the respondents from the
two mission health facilities were happy with the quality of the water supply, cooking
facilities, and sanitary conditions. They indicated that MWHs in these facilities
had running water and pregnant women did not have to walk long distances to look for
water as the case was in the other health facilities.

“As for me, I can’t stay there for one simple reason; there is no water here. It is
far where we get water from. They have to improve on the issue of water…” (35-year-old
respondent)

Furthermore, respondents who had used MWHs and those interviewed at a health care
facility with MWHs mentioned that the sanitation was poor in the MWHs and needed improvement.
They mentioned that some MWHs had no toilets and bathrooms.

In addition, respondents who had used MWHs explained that nurses and midwives did
not visit the mothers in the MWHs. They explained that some mothers stayed for a long
time in the MWHs without the nurses or midwives checking on them to ensure whether
they needed help or not. Respondents explained that the non availability of nurses
put most women at risk of complications even if they stayed at the MWHs. They stated
that it is important that nurses and midwives make regular visits to the women staying
in the MWHs so that those who need care are identified and assisted on time. On the
contrary, the 7 respondents from the mission facilities said that most women from
these facilities were happy with the way nurses treated them when they used the MWHs.
They indicated that nurses usually visited the pregnant women staying in the MWHs
and asked those who had problems to go and see the nurse or midwife at the clinic.
Moreover, during these visits, the nurses identified the women who had no resources
to buy the mother baby requirements and assisted them by providing them with these
requirements from the clinic.

“If nurses are there, there is no problem; even if some of the things are missing
there is no problem, just nurses are important” (24-year old respondent)