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Home is best: Why women in rural Zimbabwe deliver in the community.

ABSTRACT: Maternal mortality in Zimbabwe has unprecedentedly risen over the last two and half decades although a decline has been noted recently. Many reasons have been advanced for the rising trend, including deliveries without skilled care, in places without appropriate or adequate facilities to handle complications. The recent decline has been attributed to health systems strengthening through a multi-donor pooled funding mechanism. On the other hand, the proportion of community deliveries has also been growing steadily over the years and in this study we investigate why. We used twelve (12) focus group discussions with child-bearing women and eight (8) key informant interviews (KIIs). Four (4) were traditional birth attendants and four (4) were spiritual birth attendants. A thematic approach was used to analyse the data in Ethnography software. The study shows that women prefer community deliveries due to perceived low economic, social and opportunity costs involved; pliant and flexible services offered; and diminishing quality and appeal of institutional maternity services. We conclude that rural women are very economic, logical and rational in making choices on place of delivery. Delivering in the community offers financial, social and opportunity advantages to disenfranchised women, particularly in remote rural areas. We recommend for increased awareness of the dangers of community deliveries; establishment of basic obstetric care facilities in the community and more efficient emergency referral systems. In the long-term, there should be a sustainable improvement of the public health delivery system to make it accessible, affordable and usable by the public.

SUBMITTER: Dodzo MK

PROVIDER: S-EPMC5549963 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Project description:BackgroundYoung children require high-quality care for healthy growth and development. We defined "maternal capabilities" as factors that influence mothers' caregiving ability (physical and mental health, social support, time, decision-making autonomy, gender norm attitudes, and mothering self-efficacy), and developed survey tools to assess them.ObjectivesWe hypothesized that mothers with stronger capabilities during pregnancy would be more likely to practice improved care behaviors after their child was born.MethodsWe assessed maternal capabilities among 4667 pregnant women newly enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial. Several improved child-care practices were promoted until 18 mo postpartum, the trial endpoint. Care practices were assessed by survey, direct observation, or transcription from health records during postpartum research visits. We used logistic regression to determine the predictive association between maternal capabilities during pregnancy and child-care practices.ResultsMothers with more egalitarian gender norm attitudes were more likely to have an institutional delivery [adjusted OR (AOR), 2.06; 95% CI, 1.57-2.69], initiate breastfeeding within 1 h of delivery (AOR, 1.38; 95% CI, 1.03-1.84), exclusively breastfeed (EBF) from birth to 3 mo (AOR, 2.55; 95% CI, 1.95-3.35) and 3-6 mo (AOR, 1.75; 95% CI, 1.36-2.25), and, among households randomized to receive extra modules on sanitation and hygiene, have soap and water at a handwashing station (AOR, 1.76; 95% CI, 1.29-2.39). Mothers experiencing time stress were less likely to EBF from birth to 3 mo (AOR, 0.79; 95% CI, 0.66-0.93). Greater social support was associated with institutional delivery (AOR, 1.53; 95% CI, 1.37-1.98) and, among mothers randomized to receive extra complementary feeding modules, feeding children a minimally diverse diet (AOR, 1.18; 95% CI, 1.01-1.37). Depressed mothers were 37% and 33%, respectively, less likely to have an institutional delivery (AOR, 0.63; 95% CI, 0.44-0.88) and a fully immunized child (AOR, 0.67; 95% CI, 0.50-0.90).ConclusionsInterventions to reduce maternal depression, time stress, inadequate social support, and inequitable gender norms may improve maternal child caregiving.

Project description:Maternal mortality has declined by 43 % globally between 1990 and 2013, a reduction that was insufficient to achieve the 75 % reduction target by millennium development goal (MDG) five. Kenya recorded a decline of 18 % from 490 deaths in 1990 to 400 deaths per 100,000 live births in 2013. Delivering at home, is associated with higher risk of maternal deaths, therefore reducing number of home deliveries is important to improve maternal health. In this study, we aimed at establishing the proportion of home deliveries and evaluating factors associated with home deliveries in Kilifi County.The study was conducted among mothers seeking immunization services in selected health facilities within Kilifi County using Semi-structured questionnaires administered through face to face oral interviews to collect both quantitative and qualitative data. Six Focus Group Discussion (FGD) and ten in-depth interviews (IDIs) were used to collect qualitative data. A random sample of 379 mothers was sufficient to answer the study question. Log-binomial regression model was used to identify factors associated with childbirth at home.A total of 103 (26 %) mothers delivered at home. From the univariate analysis, both mother and the partners old age, being in a polygamy marriage, being a mother of at least two children and staying ≥5 Kms radius from the nearest health facility were associated with higher risk of delivering at home (crude P < 0.05). Both mother and partner's higher education level were associated with a protective effect on the risk of delivering at home (RR < 1.0 and P < 0.05). In multivariate regression model, only long distance (≥10Kms) from the nearest health facility was associated with higher risk of delivering at home (adjusted RR 3.86, 95 % CI 2.13 to 7.02).From this population, the major reason why mothers still deliver at home is the long distance from nearest health facility. To reduce maternal mortality, access to health facility by pregnant mothers need to be improved.

Project description:BackgroundCommunity health workers (CHWs) are utilized in many health systems to provide education and messaging to families in their catchment areas. However, CHWs responsible for large geographic areas often must make important decisions about whom to visit. Factors that influence these decisions are understudied.ObjectivesThis study assessed coverage and targeting for home visits by CHWs within a large social and behavioral change health program in rural Tanzania.MethodsThis implementation research was a cross-sectional, mixed-methods study. Data collection included a census with households and surveys with females, surveys with CHWs, and interviews with CHWs. Survey data also included the collection of household location data for females and CHWs. Quantitative data were analyzed using linear probability models, and qualitative data were analyzed using inductive thematic analysis.ResultsOnly 13% of eligible households in our study sites reported receiving a home visit from a CHW. Although CHWs were more likely to reach households with infants, other program priority populations, such as poor and food insecure households, were frequently missed. Global positioning system data showed that distance was 1 of the greatest barriers for CHWs in providing home visits. Qualitative data indicated that although CHWs were motivated and engaged to improve maternal and child health in their communities, they faced challenges in visiting households that were further away or lacked economic resources to improve their health behaviors. CHWs also found it difficult to provide health education during home visits to mothers with no formal schooling.ConclusionsPrograms relying on community volunteers need to set realistic workloads, especially when volunteer CHWs also work full-time in their primary occupations. Implementation could also be strengthened by providing extra support for CHWs so that they can effectively provide services to community members who are more difficult to visit but may be the most in need.

Project description:BACKGROUND:Maternal mortality remains a major challenge to health systems in low and middle-incoming countries. Some pregnant women develop potentially life-threatening complications during childbirth. Therefore, home delivery is a precursor for maternal mortality. In this study, we aimed at not only estimating the percentage of deliveries occurring at home and examining the factors associated with home delivery, but we also explored the reasons for home delivery among women in rural Ghana. METHODS:The study was conducted among mothers with delivery experience in selected communities in the Builsa South district located in the Upper East Region of Ghana. Both quantitative and qualitative data were collected using semi-structured questionnaires and Focus Group Discussion (FGD) guide respectively. A total of 456 mothers participated in this study. Regression models were used in the quantitative analysis whereas a thematic analysis approach was used to analyze the qualitative data. RESULTS:Of the 423 mothers in the quantitative research, 38.1% (95% CI: 33.5-42.8) delivered their index child at home. In adjusted analysis, women who were not exposed to information (AOR = 13.64, p<0.001) and women with 2 (AOR = 4.64, p = 0.014), 3 (AOR = 4.96, p = 0.025) or at least 4 living children (AOR = 9.59, p = 0.001) had higher odds of delivering at home. From the qualitative analysis, the poor attitude of nurses (midwives), lack of, and cost of transportation, cost of delivery kits, and traditional beliefs and practices were cited as reasons for home delivery. CONCLUSION:Despite the government's efforts to provide free maternal care services to women in Ghana, a significant proportion of rural women still deliver at home due to other 'hidden costs'. Addressing poor staff attitude, transportation challenges, and negative traditional beliefs and practices through awareness creation may contribute to improving health facility delivery by rural pregnant women in Ghana.

Project description:BackgroundHypertension contributes significantly to cardiovascular and renal diseases. It can be controlled by lifestyle modifications, however in poor communities there is lack of awareness, and treatment and control of hypertension is often poor. The aim of this study was to determine hypertension knowledge, attitudes and practices in a disadvantaged rural community in Matebeleland South province of Zimbabwe.MethodsWe conducted a descriptive cross-sectional survey on hypertensive patients in the community. A pre-tested and validated interviewer-administered questionnaire was used to collect demographic, awareness, treatment and control data among consenting hypertensive patients.Results304 respondents were enrolled into the study (mean age, 59 years), and a majority were women (65.4%). The treatment default rate was 30.9%, and 25% of respondents on medication did not know their blood pressure control status. Knowledge on hypertension was poor, with 64.8% of respondents stating that stress was its main cause, 85.9% stated that palpitations were a symptom of hypertension and 59.8% of respondents added salt on the table. The more education respondents had received, the more likely they were knowledgeable about hypertension (odds ratio for secondary education, 3.68 [95% CI: 1.61-8.41], and for tertiary education, 7.52 [95% CI: 2.76-20.46], compared to those without formal education). Those who believed in herbal medicines (50.7%) and those who used traditional medicines (14.5%) were 53% (95% CI: 0.29-0.76) and 68% (95% CI: 0.29-0.76) less likely to be knowledgeable about hypertension compared to those who did not believe in or use traditional medicines, respectively.ConclusionMembers of the community had poor knowledge on hypertension. This was associated with a lack of education and with strong beliefs in herbal and traditional medicines in the community, which influenced attitudes and practices on hypertension. Dietary risk factors were linked to poor knowledge. Hypertensive medicine shortages at the clinic resulted in worsened hypertension care and poor hypertension outcomes in the community.

Project description:BackgroundZimbabwe, like most low-income countries, faces health worker shortages. Community health workers (CHWs) bridge this gap by delivering essential health services and nutrition interventions to communities. However, as workloads increase, CHWs' ability to provide quality services may be compromised. We studied influences upon CHWs' performance related to pregnancy surveillance and nutrition and hygiene education in rural Zimbabwe.MethodsIn the context of a cluster-randomized trial conducted in 2 rural districts between November 2012 and March 2015, 342 government-employed CHWs identified and referred pregnant women for early antenatal care and delivered household-level behavior change lessons about infant feeding and hygiene to more than 5,000 women. In 2013, we conducted a survey among 322 of the CHWs to assess the association between demographic and work characteristics and task performance. Exploratory factor analyses of the Likert-type survey questions produced 8 distinct and reliable constructs of job satisfaction and motivation, supervision, peer support, and feedback (Cronbach ? range, 0.68 to 0.92). Pregnancy surveillance performance was assessed from pregnancy referrals, and nutrition and hygiene education performance was assessed by taking the average summative score (range, 5 to 30) of lesson delivery observations completed by a nurse supervisor using a 6-item Likert-type checklist. Poisson and multiple linear regressions were used to test associations between CHW demographic and work characteristics and performance.ResultsCHWs who referred more pregnant women were female, unmarried, under 40 years old, from larger households, and of longer tenure. They also perceived work resources to be adequate and received positive feedback from supervisors and the community, but they were less satisfied with remuneration. CHWs with high scores on behavior change lesson delivery were from smaller households, and they received more supportive supervision but less operational supervision. Measures of job satisfaction and motivation were not associated with either task.ConclusionAmong CHWs responsible for multiple tasks in rural Zimbabwe, factors associated with performance of one task were not the same as those associated with performance of another task. Our methods and findings illustrate ways to examine heterogeneity in CHW performance and to identify organizational factors associated with quality of program delivery.

Project description:BackgroundSeveral trials of community-based HIV self-testing (HIVST) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017.MethodsAnalysis of representative population-based trial survey data collected from 7146 individuals following community-based HIVST distribution to households was conducted. Factors associated with having never heard of HIVST were determined using multivariable mixed-effects logistic regression adjusted for clustered design.ResultsAmong survey participants, 1308 (18.3%) self-reported having never heard of HIVST. Individuals who were between 20 and 60 years old {20-29 years: [aOR = 0.74, 95% CI (0.58-0.95)], 30-39 years: [aOR = 0.56, 95% CI (0.42-0.74)], 40-49 years: [aOR = 0.50, 95% CI (0.36-0.68)], 50-59 years [aOR = 0.58, 95% CI (0.42-0.82)]}, who had attained at least ordinary level education [aOR = 0.51, 95% CI (0.34-0.76)], and who had an HIV test before [aOR = 0.30, 95% CI (0.25-0.37)] were less likely to have never heard of HIVST compared with individuals who were between 16 and 19 years old, who had a lower educational level and who had never tested for HIV before, respectively. In addition, non-household heads or household head representatives [aOR = 1.21, 95% CI (1.01-1.45)] were more likely to report never having heard of HIVST compared to household head and representatives.ConclusionsAround one fifth of survey participants remain unaware of HIVST even after an intensive community-based door-to-door HIVST distribution. Of note, those least likely to have heard of self-testing were younger, less educated and less likely to have tested previously. Household heads appear to play an important role in granting or denying access to self-testing to other household members during door-to-door distribution. Differentiated distribution models are needed to ensure access to all. Trial registration PACTR, PACTR201607001701788. Registered 29 June 2016, https://pactr.samrc.ac.za/ PACTR201607001701788.

Project description:Inadequate care during early childhood can lead to long-term deficits in skill development. Parenting programs are promising tools for improving parenting practices and opportunities for healthy development. We implemented a non-masked cluster-randomized controlled trial in rural China in order to assess the effectiveness of an integrated home-visitation program that includes both psychosocial stimulation and health promotion at fostering development and health outcomes of infants and toddlers in rural China. All 6-18 month-old children of two rural townships and their main caregiver were enrolled. Villages were stratified by township and randomly assigned to intervention or control. Specifically, in September 2015 we assigned 43 clusters to treatment (21 villages, 222 caregiver-child dyads) or control (22 villages, 227 caregiver-child dyads). In the intervention group, community health workers delivered education and training on how to provide young children with psychosocial stimulation and health care (henceforth psychosocial stimulation and health promotion) during bi-weekly home visits over the period of one year. The control group received no home visits. Primary outcomes include measures of child development (i.e. the Bayley Scales of Infant and Toddler Development, third edition-or Bayley-III) and health (i.e. measures of morbidity, nutrition, and growth). Secondary outcomes are measures of parenting practices. Intention-to-treat (ITT) effects show that the intervention led to an improvement of 0·24 standard deviations (SD) [95% CI 0·04 SD-0·44 SD] in cognitive development and to a reduction of 8·1 [95% CI 3·8-12·4] percentage points in the risk of diarrheal illness. In addition, we find positive effects on parenting practices mirroring these results. We conclude that an integrated psychosocial stimulation and health promotion program improves development and health outcomes of infants and toddlers (6-30 month-old children) in rural China. Because of low incremental costs of adding program components (that is, adding health promotion to psychosocial stimulation programs), integrated programs may be cost-effective.

Project description:BackgroundThe relationship between the risk of acquiring human immunodeficiency virus (HIV) infection and people's choices about life course events describing the transition to parenthood-sexual debut, union (in the form of marriage, cohabitation, or long-term relationship), and parenthood-is still unclear. A crucial role in shaping this relationship may be played by the sequence of these events and by their timing. This suggests the opportunity to focus on the life courses in their entirety rather than on the specific events, thus adopting a holistic approach that regards each individual's life course trajectory as a whole.MethodsWe summarise the individual life courses describing the transition to parenthood using ordered sequences of the three considered events. We aim to (i) investigate the association between the sequences and HIV infection, and (ii) understand how these sequences interact with known mechanisms for HIV transmission, such as the length of sexual exposure and the experience of non-regular sexual partnerships. For this purpose, we use data from a general population cohort study run in Manicaland (Zimbabwe), a Sub-Saharan African area characterised by high HIV prevalence.ResultsFor both genders, individuals who experienced either premarital or delayed childbearing have higher HIV risk compared to individuals following more standard transitions. This can be explained by the interplay of the sequences with known HIV proximate determinants, e.g., a longer exposure to sexual activity and higher rates of premarital sex. Moreover, we found that people in the younger birth cohorts experience more normative and safer sequences.ConclusionsThe shift of younger generations towards more normative transitions to parenthood is a sign of behaviour change that might have contributed to the observed reduction in HIV prevalence in the area. On the other hand, for people with less normative transitions, targeted strategies are essential for HIV prevention.

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Home is best: Why women in rural Zimbabwe deliver in the community.

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