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Cultural Practices, Knowledge, and Beliefs of Newborn Care and Health-Seeking in Rural
Zambia
by
Julie M. Buser
A dissertation submitted in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
(Nursing)
in the University of Michigan
2019
Doctoral Committee:
Professor Jody R. Lori, Chair
Professor Carol Boyd
Assistant Professor Andrew Jones
Assistant Professor Cheryl Moyer
Julie M. Buser
jbuser@umich.edu
ORCID iD: 0000-0002-0346-0710
© Julie M. Buser 2019
ii
DEDICATION
This dissertation is dedicated to the women, health workers, and community members in
rural Zambia who participated in the focus group, case series, and quasi-experimental studies. I
appreciate your openness and willingness to share your experience and knowledge. For the
mothers and newborns – wishing you bright futures. Thank you to my family, friends, and
classmates for your unconditional support.
iii
ACKNOWLEDGMENTS
Thank you to my dissertation committee for their valuable support. I appreciate the
trusted mentorship and advice provided by Dr. Jody Lori throughout my doctoral journey. Her
dedication to global maternal health is inspirational. I am thankful to Dr. Carol Boyd for sharing
her wealth of knowledge about nursing research. I sincerely appreciate Dr. Cheryl Moyer for
providing insightful feedback. I am also grateful to Dr. Andrew Jones for the diverse point of
view he contributed as the cognate member of my committee. I would like to thank my advisor
at the University of Zambia, Dr. Alice Ngoma-Hazemba, for providing leadership in my research
endeavors. I also appreciate the collaborative relationships developed with representatives from
the Zambian Ministry of Health, particularly Dr. Davy Zulu. The collective guidance and
encouragement by committee members and collaborators motivates me to contribute positively
to the discipline of global child health by performing innovative and impactful scientific
research.
I am grateful to the University of Michigan School of Nursing and Rackham Graduate
School for providing support to facilitate this dissertation research. I appreciate funding from a
Rackham Merit Fellowship for my doctoral studies. I humbly acknowledge the following
funding sources for this dissertation research: Bobbe and Jon Bridge Award for Engaged
Scholarship from Rackham Graduate School, University of Michigan International Institute,
iv
African Studies Center, Department of Afroamerican and African Studies and the South African
Initiatives Office, University of Michigan School of Nursing New Research Investigator Award,
University of Michigan School of Nursing Global Outreach Scholarship, Sigma Theta Tau
International Honor Society of Nursing, and the Michigan Chapter of the National Association of
Pediatric Nurse Practitioners.
I would also like to thank the hard-working Africare-Zambia staff for logistical
facilitating my research studies and their willingness to answer my never-ending questions about
rural Zambian culture and way of life. I am indebted to the research assistants, Brenda Moyo and
Mercy Theo in Lundazi, along with Chonda Chola and Marrian Kalaba in Mansa, who provided
invaluable assistance throughout data collection. Finally, I express my appreciation to all of the
nurses, midwives, and community health workers I interacted with in rural Zambia for their on-
going commitment to improving maternal-child health. Their willingness to facilitate my
research process and the recruitment of participants is highly valued.
v
TABLE OF CONTENTS
DEDICATION ii
ACKNOWLEDGMENTS iii
LIST OF FIGURES vii
LIST OF TABLES viii
LIST OF APPENDICES x
LIST OF ABBREVIATIONS xi
ABSTRACT xiv
CHAPTER
1. Introduction 1
2. Literature Review 31
3. Beliefs and Health-Seeking Practices: Rural Zambians’ Views on
Maternal-Newborn Care 75
4. Maternal Knowledge of Essential Newborn Care in Rural Zambia 133
5. A Case Series of Maternal-Newborn Delivery Outcomes in Rural Zambia:
Comparison of Referral to a District Hospital from Facilities with and
Without a Maternity Waiting Home 163
vi
6. Summary 198
APPENDICES 224
vii
LIST OF FIGURES
FIGURE
1.1 Map of Africa highlighting Zambia 5
1.2 Illustrated model of Bronfenbrenner’s Ecological Systems Theory 18
1.3 Operationalization of Ecological Systems Theory for dissertation 20
2.1 PRISMA Newborn Outcomes and Maternity Waiting Homes Flow Diagram 49
3.1 Map of Eastern Province including Lundazi District 92
3.2 Map of Luapula Province including Mansa and Chembe Districts 93
3.3 Maternal Duality between culture and health system in rural Zambia 115
6.1 The maternal-newborn dyad duality 201
6.2 Relevance of operationalized Ecological Systems Theory to three studies in
dissertation 204
viii
LIST OF TABLES
TABLE
1.1 Studies using Ecological Systems Theory in maternal-child health research 15
1.2 Ecological Systems Theory Definitions and Operationalization for Dissertation 19
1.3 Overview of three papers in dissertation 23
2.1 Summary of characteristics of articles reviewed for maternity waiting
homes (MWHs) and newborn outcomes in low resource settings 50
2.2 Summary of characteristics of articles reviewed for maternity waiting homes
(MWHs) and newborn outcomes in low resource settings published between
2016-2018 55
3.1 Overview of studies exploring specific aspects of newborn care in Zambia
and LMICs 76
3.2 Demographics of Eastern and Luapula Province in 2015 91
3.3 Focus group participant characteristics 99
3.4 Summary of themes and categories emerging from focus groups 102
4.1 Summary of maternal-child health education classes taught at MWH sites 138
4.2 Operational definition of variables in Maternal Knowledge of Newborn Care
Questionnaire 143
4.3 Sociodemographic characteristics 146
ix
4.4 Previous obstetric history characteristics 147
4.5 Planned length of breastfeeding and introduction of complementary foods 148
4.6 Most common responses to maternal “Essential Newborn Care” questions 149
4.7 Logistic regression for MWH use and maternal “Essential Newborn Care”
Knowledge 150
4.8 Summary of differences between MWH and non-MWH users 151
4.9 Younger age (n = 158) and “Don’t know” responses 152
5.1 Signal functions used to identify basic and comprehensive emergency obstetric
care services 164
5.2 Population and delivery demographics with two proportion z-score test 171
5.3 Key maternal-newborn health indicators from delivery register at district
hospital 173
5.4 Demographic characteristics of women referred for delivery to district
hospital 176
5.5 Labor complications and conditions requiring special attention 180
x
LIST OF APPENDICES
APPENDIX
A. Consent for Focus Group Study 224
B. Oral Script for Nurse In-Charge/Village Chief Announcement to Village 228
C. Focus Group Interview Guide 229
D. Codebook for focus groups 233
E. Delivery Register Instructions, Zambian Ministry of Health 235
F. Delivery Register Data Collection Tool 237
G. Oral Script for Nurse or Research Assistant Announcement to Women at Lundazi
District Hospital and CEmONC MWH 240
H. Information Sheet, Address of Ethical Issues & Informed Consent for
Quasi-experimental Study 241
I. Maternal Knowledge of Newborn Care Questionnaire 244
xi
LIST OF ABBREVIATIONS
ANC – antenatal care
AOR – Adjusted odds ratio
ARI – acute respiratory infection
BEmOC – Basic Emergency Obstetric Care
BEmONC – Basic Emergency Obstetric and Newborn Care
CEmOC – Comprehensive Emergency Obstetric Care
CEmONC – Comprehensive Emergency Obstetric and Newborn Care
CBR – Crude Birth Rate
CDR – Crude Death Rate
CHW – community health workers
CI – confidence interval
CIA – Central Intelligence Agency
CDC – Centers for Disease Control and Prevention
CPD – cephalopelvic disproportion
DHS – Demographic and Health Surveys
EmOC – emergency obstetric care
ENC – Essential Newborn Care
xii
ERES – Excellence in Research Ethics and Science
FGD – Focus group discussions
GRZ – Government of the Republic of Zambia
HAZ – height-for-age z-score (HAZ)
HIV – human immunodeficiency virus
IDI – in-depth interview
IMNCI – Integrated Management of Newborn and Childhood Illness
IRB – institutional review board
LBW – low birth weight
LMIC – low- and middle-income country
LRT – likelihood-ratio test
MCDMCH – Ministry of Community Development Mother and Child Health
MCS – maternal care-seeking
MDG – Millennium Development Goal
MOH – Ministry of Health
MWH – maternity waiting home
NGO – non-government organization
OR – odds ratio
PCPNC – pregnancy, childbirth, postpartum and newborn care
PNC – postnatal care
PPCT model – process, person, context, and time model
RA – research assistant
SBA – skilled birth attendants
xiii
SDG – Sustainable Development Goal
SF – signal function
SMAG – Saving Mothers Action Group
SMGL – Saving Mothers, Giving Life
SSA – sub-Saharan Africa
STI – sexually transmitted infection
TB – tuberculosis
TBAs – traditional birth attendants
TM – traditional midwife (TM)
UM – University of Michigan
UN IGME – United Nations Inter-Agency Group for Child Mortality Estimation
WCBA – women of child bearing age
WHO – World Health Organization
WHZ – weight-for-height z-score
WLWH – women living with HIV
xiv
ABSTRACT
Purpose: Decreasing newborn morbidity and mortality remains a serious global health
challenge. For this reason, interventions like maternity waiting homes (MWHs) and the Saving
Mothers, Giving Life (SMGL) initiative may improve maternal-newborn newborn health and
delivery outcomes. The overarching goal of this dissertation was to explore and describe the
cultural practices, knowledge, and beliefs of essential newborn care and health-seeking in the
context of MWHs and the SMGL initiative in rural Zambia. Guided by the Ecological Systems
Theory, this goal was met through three studies with the following aims: (1) Describe knowledge
and beliefs of newborn care and illness from the perspective of rural Zambian women,
community members, and health workers, (2) Examine similarities and differences in knowledge
and beliefs of newborn care and illness among rural Zambian women, community members, and
health workers, (3) Explore the social and cultural factors that are associated with the ways
women seek newborn care to identify traditional and professional newborn care practices in rural
Zambia, (4) Compare maternal knowledge of newborn care in two groups of women in rural
Zambia, and (5) Advance an understanding of maternal-newborn delivery outcomes for women
referred from health facilities with and without MWHs to the district referral hospital.
xv
Methods: Study 1 used focus groups (n=646), comprised of community members (n=208),
health workers (n=225), and women with babies younger than 1-year-old (n=213) collected
between June and August 2016 in two rural Zambian districts. A semi-structured guide was used
to collect data on cultural beliefs and health-seeking practices in communities with MWH and
non-MWH facilities. Study 2 employed a quasi-experimental two-group comparison (n=250)
design using a face-to-face survey approach to determine whether MWH use impacted maternal
knowledge of newborn care. For Study 3 (n=234), a retrospective record review of district-level
data recorded by healthcare providers for the Zambian Ministry of Health was performed to
compare maternal-newborn delivery outcomes for cases referred from five health facilities
(n=142) with and five without MWHs (n=92) to a single rural Zambian district referral hospital
for delivery.
Results: The following themes emerged independently from each of the focus groups in Study 1:
from women with infants younger than 1-year-old, (1) traditional newborn protective rituals;
from community members, (2) strong sense of family and community protecting the newborn,
and from health workers, (3) preservation of dignity. A fourth theme, essential newborn care,
was common among all groups. Study 2 found rural Zambians have an understanding of WHO
guidelines whether or not they used an MWH. In Study 3, among all referrals across ten facilities
in the case series, more came from facilities with a MWH than from those without MWHs
(60.7% MWH vs. 39.3% non-MWH).
Conclusions: This dissertation uncovered a maternal duality faced by women caring for
newborns between cultural and health system responsibilities. The finding that referrals were
more likely to come from facilities with MWHs is significant as we enter the post-2015 era of
sustainable development with a goal to reduce the inequities of preventable death by reaching all
xvi
women and newborns. The findings highlight the need for targeted health education by
professional and community health workers towards younger and primigravida women. As
maternal “Essential Newborn Care” knowledge improves through health education, potential
long-term benefits exist for improved maternal-newborn health and delivery outcomes in rural
Zambia.
1
CHAPTER 1
Introduction
Newborn morbidity and mortality remain serious global health challenges in low- and
middle-income countries. In 2016, an estimated 2.6 million children died within 28 days of birth
(UNICEF, 2018). Almost 1 million newborns die in the first day of life (UNICEF, 2018) in these
low-resource countries. A child’s risk of death in the first 4 weeks of life is nearly 15 times
greater than any other time before his or her first birthday (WHO, 2017). The large majority of
newborn deaths (80 percent) are due to complications related to preterm birth, intrapartum events
such as birth asphyxia, or infections such as sepsis or pneumonia (WHO, 2018). Newborn deaths
can be attributed to conditions and diseases associated with lack of quality or skilled care and
treatment immediately after birth (WHO, 2018). Targeting the time around birth with proven
high-impact interventions and quality care for small and sick newborns may prevent up to 80
percent of newborn deaths (UNICEF, 2018).
Maternity waiting homes (MWHs) offer a way to provide better perinatal obstetric care
(Kelly et al., 2006; Lori, Wadsworth, Munro & Rominski, 2013), by targeting the high-risk
period before birth. As defined by the WHO, MWHs are residential facilities, located near a
qualified medical facility, where women defined as high risk can await their delivery and be
transferred to a nearby medical facility shortly before delivery, or earlier should complications
arise (WHO, 1996). Women in LMICs living in rural areas often face geographic and
2
transportation difficulties associated with accessing health care facilities, which jeopardizes the
health of their babies. Maternity waiting homes help overcome distance and transportation
barriers that prevent women from receiving timely skilled obstetric care (Lori et al., 2016). By
addressing distance to health facility and transportation barriers, MWHs could increase the use of
skilled birth attendants, thereby reducing newborn morbidity and mortality in rural, low-resource
areas of Zambia (Lori et al., 2016).
Maternity waiting homes provide a setting where high-risk women can be accommodated
during the final weeks of their pregnancy near a health facility with essential obstetric facilities
(WHO, 1996). The expanded purpose of many MWHs is to not only decrease maternal morbidity
and mortality, but to improve newborn outcomes and increase newborn health knowledge for the
mothers utilizing them. Also, MWHs bring women closer to a health facility so they can deliver
with a skilled attendant and have improved newborn outcomes. In these homes, additional
emphasis is placed on education and counseling regarding pregnancy to improve newborn
outcomes, and delivery and care of the newborn and family (WHO, 1996). Poor knowledge of
newborn danger signs delays care-seeking (Sandberg et al., 2014). Health-seeking behavior of
mothers for newborn care relies heavily on their knowledge, but studies are limited on how to
assess maternal knowledge of newborn care and danger signs (Kibaru & Otara, 2016; Nigatu,
Worku, & Dadi, 2015; Senarath et al., 2007).
Another intervention aimed at reducing maternal-newborn mortality in rural Zambia was
the Saving Mothers, Giving Life (SMGL) initiative. To address maternal mortality and avoid
delays in women seeking, reaching, and receiving timely, quality services, the SMGL initiative
was launched in 2012 using a systems approach at the district level (Quam, Achrekar, & Clay,
2019). Working hand-in-hand with the Zambian government, the initiative set out to make high-
3
quality, safe childbirth services available and accessible to women and their newborns, focusing
on the critical period of labor, delivery, and the first 48 hours postpartum (SMGL, 2019). From
the onset, to promote ownership and sustainability, SMGL was designed to reinforce host
country government structures, policies, guidelines, and priorities (Healey et al., 2019). Strategic,
long-term capital investments were made to enable districts to achieve national standards,
including essential infrastructural renovations of health facilities and MWHs, provision of
required equipment and supplies, training of medical personnel in critical lifesaving skills and
mentorship, and provision of ambulances (Healey et al., 2019).
Maternal health outcomes achieved after 5 years of implementation in the SMGL-
designated pilot districts in Zambia included a 38% decrease in facility and a 41% decline in
district wide maternal mortality rate while facility deliveries increased by 44% (from 62% to
90%) (Conlon et al., 2019). The average annual rate of reduction for maternal deaths in the
SMGL-supported districts in Zambia exceeded that found countrywide by 10.5% versus 2.8%
(Conlon et al., 2019). Meanwhile, the changes in stillbirth rates were significant (36% in
Zambia) but those for pre-discharge neonatal mortality rates were not significant (Conlon et al.,
2019).
Statement of the Problem
To catalyze action in lowering maternal mortality, the United Nations Member States
launched the Sustainable Development Goals (SDGs) mobilizing efforts to end all forms of
poverty, fight inequalities, and tackle climate change while ensuring that no one is left behind
(United Nations, 2018). The third goal (SDG 3) is to ensure healthy lives and promote well-
being for all, at all ages. One target to attain SDG 3 is to end preventable deaths of newborns and
children younger than 5 years of age, with all countries aiming to reduce newborn mortality to at
4
least as low as 12 per 1,000 live births by 2030 (United Nations, 2018). Fortunately, nurses are in
a unique position to accelerate the reduction of newborn mortality in low resource settings. The
research presented here explored MWH use as part of an ecological systems approach to reduce
newborn morbidity and mortality ratios to meet the Sustainable Development Goals.
Historically, the focus of research studies evaluating MWHs have been on maternal
outcomes (Buser & Lori, 2016; Figa'-Talamanca, 1996; Kelly et al., 2006; Lori, Wadsworth,
Munro & Rominski, 2013). Perinatal and newborn health are mentioned in a limited number of
articles (Chandramohan, Cutts & Millard, 1995; Lori, Munro et al, 2013; Tumwine & Dungare,
1996; van Lonkhuijzen, Stegeman, Nyirongo, & van Roosmalen, 2003); however, the research
remains unclear with a fragmentary understanding of newborn outcomes at MWHs (Buser &
Lori, 2016). Given the aforementioned dearth of evidence, it is both relevant and critical that
further research address the gap in knowledge about the impact of MWHs on newborn health.
Background of the Problem
In Zambia, the newborn mortality rate is 34 per 1,000 live births (UNICEF, 2017).
Examination of newborn, infant, and under-5 mortality rates in Zambia over the past 15 years
reveals newborn mortality has decreased at a slower pace than infant and child mortality (DHS,
2014). Newborn deaths are mainly due to birth asphyxia, newborn sepsis, or infection, and these
are affected by poor health care at birth and a lack of access to skilled birth attendants at delivery
(DHS, 2014).
Zambia
Zambia is a land-locked country in south-central Africa (CultureGrams, 2017). Figure 1.1
shows a map of Africa highlighting Zambia (World Atlas, 2016). Zambia is slightly larger than
5
the state of Texas in the United States (CultureGrams, 2017). The president is the chief of state
and head of government (McIntyre, 2012). The cool, dry season is from May to August; the hot,
Figure 1.1 Map of Africa highlighting Zambia (World Atlas, 2016)
6
dry season runs from September to October, and the warm, rainy season is from November to
April (CultureGrams, 2017).
Zambia has a population of 15,510,711 (CIA, 2017). Zambia’s annual population growth
rate is one of the highest in the world, with almost six children per woman (CIA, 2017). In
Zambia, newborn health is affected by widespread and extreme rural poverty and high
unemployment levels among families (CIA, 2017). Poor, uneducated women from rural areas are
more likely to marry young, to give birth early, and to have more children, viewing children as a
sign of prestige and recognizing not all of their children will live to adulthood (CIA, 2017).
Purpose
The overarching goal of this dissertation was to explore and describe the cultural
practices, knowledge, and beliefs of essential newborn care and health-seeking in the context of
MWHs and the SMGL initiative in rural Zambia. Guided by the Ecological Systems Theory
(Bronfenbrenner, 1977, 1979, 1989, 1994), this goal was met through three distinct studies that:
(1) Described knowledge and beliefs of newborn care and illness from the perspective of rural
Zambian women, community members, and health workers, (2) Examined similarities and
differences in knowledge and beliefs of newborn care and illness among rural Zambian women,
community members, and health workers, (3) Explored the social and cultural factors that are
associated with the ways women seek newborn care to identify traditional and professional
newborn care practices in rural Zambia, (4) Compared maternal knowledge of newborn care in
two groups of women in rural Zambia: one group used a MWH prior to delivery and the other
group did not use a MWH, and (5) Advanced an understanding of maternal-newborn delivery
outcomes for women referred from health facilities with and without MWHs to the district
referral hospital.
7
This dissertation is divided into six chapters comprising three studies. All three studies
were inter-connected with varying levels of emphasis on MWH use. Chapter 1 provides an
overview of the research problem, specific aims, and theoretical framework guiding the proposed
dissertation. Chapter 2 consists of a comprehensive literature review of newborn health in low-
and middle-income countries along with MWH and SMGL interventions. Chapter 3 presents
Study 1 describing Zambian women’s knowledge and beliefs about newborn care and illness,
and the perspectives of community members and health workers. In addition, the social and
cultural factors that influence ways women seek newborn care were examined. Study 1 was
conducted as a basis for understanding the rural Zambian context to inform design of subsequent
case series and quasi-experimental studies. Chapter 4 describes Study 2, which assessed maternal
knowledge of newborn care for MWH and non-MWH users referred to a district hospital for
delivery. Chapter 5 reports Study 3, a case series examining newborn and maternal health
outcomes for women with complications referred from rural Zambian health facilities to the
district hospital for delivery. Finally, Chapter 6 summarizes the results from the three studies
(Chapters 3-5) and discusses future implications for nursing practice and potential policy
changes at the national level to increase the allocation of resources for building additional
MWHs in low-resource settings.
Specific Aims, Research Questions, and Hypotheses
I. The specific aims for Study 1, Beliefs and Health-Seeking Practices: Rural Zambians’ Views
on Maternal-Newborn Care, were to:
Aim 1): Describe knowledge and beliefs of newborn care and illness from the
perspective of rural Zambian women, community members, and health workers.
8
Aim 2): Examine similarities and differences in knowledge and beliefs of newborn care
and illness among rural Zambian women, community members, and health workers.
Aim 3): Explore the social and cultural factors that are associated with the ways women
seek newborn care to identify traditional and professional newborn care practices in
rural Zambia.
Research was guided by the following a priori questions:
“What are the cultural beliefs and practices of rural Zambian women with infants
younger than 1-year-old, community members, and health workers that influence
newborn care and health-seeking behavior?”
“What are the similarities and differences in knowledge and beliefs of newborn care
among rural Zambian women, community members, and health workers?”
“What social and cultural factors influence newborn care and health-seeking practices for
rural Zambians?”
Focus groups were used to collect data employing a semi-structured interview guide to
understand cultural beliefs and health-seeking practices of rural Zambians related to newborn
care and illness.
II. Study 2, Maternal Knowledge of Essential Newborn Care in Rural Zambia, addressed the
following:
Aim 1): Compare maternal knowledge of newborn care in two groups of women in rural
Zambia: one group used a MWH prior to delivery and the other group did not use a
MWH.
9
Topics in this two-group comparison study assessing maternal “Essential Newborn Care”
knowledge included: (1) umbilical cord care, (2) thermal and skin care, (3) nutrition, (4)
prevention of diarrhea, and (5) newborn danger signs prompting care-seeking. Research for
Study 2 was guided by the question: “What is the difference in maternal ‘Essential Newborn
Care’ knowledge among women who did and did not use a MWH prior to delivery?” The
research hypothesis was maternal “Essential Newborn Care” knowledge would be higher for
women who used a MWH before delivery than for women who did not use a MWH before
delivery. A quasi-experimental, two-group comparison design was employed using a face-to-face
survey approach to determine whether MWH use has an impact on maternal knowledge of
newborn care.
III. Study 3, A Case Series of Maternal-Newborn Delivery Outcomes in Rural Zambia:
Comparison of Referral to a District Hospital from Facilities with and Without a Maternity
Waiting Home, addressed the following:
Aim 1): Advance an understanding of maternal-newborn delivery outcomes for women
referred from health facilities with and without MWHs to the district referral hospital.
The case series used medical record data from delivery registers located in one district referral
hospital to examine a sample of all women from ten lower-level BEmONC facilities with
complications who were referred to and arrived at the higher-level CEmONC district referral
hospital. Within the larger group of cases, the characteristics of those referred from facilities with
and without MWHs were examined. Newborn delivery outcomes included low birth weight
[LBW <2,500 grams]; condition of baby [alive or dead]; low Appearance, Pulse, Grimace,
Activity, and Respiration [APGAR] score, and breastfeeding within 1 hour. Maternal delivery
10
outcomes included assisted delivery (forceps, vacuum); prolonged/obstructed labor, and
eclampsia. Research for the case series study was conducted through a retrospective hospital-
based record review guided by the questions:
“Do newborns born to mothers referred from facilities with MWHs have fewer poor
delivery outcomes than cases referred from non-MWH health facilities?”
“Do women referred from facilities with MWHs have fewer poor delivery outcomes than
women referred from non-MWH health facilities?”
The research hypotheses were:
Newborns born to mothers referred from facilities with MWHs will have fewer poor
delivery outcomes than women referred from non-MWH health facilities, and
Women referred from facilities with MWHs will have fewer poor delivery outcomes than
women referred from non-MWH health facilities.
A retrospective record review of district level data recorded by health care providers for the
Zambian Ministry of Health was performed for this case series to compare maternal-newborn
delivery outcomes for cases referred from five BEmONC health facilities with and five without
MWHs to a single rural Zambian CEmONC district referral hospital for delivery.
Significance
Maternity waiting homes provide an opportunity to improve newborn outcomes and
increase access to perinatal obstetric care (Chandramohan et al., 1995; Lori et al., 2013; Millard,
1991; Tumwine & Dungare, 1996; van Lonkhuijzen et al., 2003). However, an exceptionally
wide gap in knowledge about the outcomes of newborns born at MWHs exists (Buser & Lori,
2016). More research is needed to understand the effectiveness of MWHs on newborn morbidity
and mortality. Innovative research into newborn outcomes at MWHs has the potential to
positively contribute to the attainment of the SDG to ensure healthy lives for all through the
11
reduction of newborn mortality (Buser & Lori, 2016). Research on the impact of MWHs and the
SMGL initiative on newborn outcomes has the potential to inform future research, practice, and
policy. An increased focus on the study of MWHs and the SMGL initiative for improving
newborn outcomes in low-resource settings merits immediate attention.
The proposed dissertation is timely and significant as we are well into the post-2015 era
of sustainable development. It will provide vital, new knowledge on the impact MWHs have on
improving newborn health outcomes. The goal of this innovate research complements global
efforts to ensure healthy lives and promote well-being for all because it includes three studies
that focus on the cultural practices, knowledge, and beliefs of essential newborn care and health-
seeking in the context of MWHs and the SMGL initiative in rural Zambia.
Theoretical Framework
Ecological Systems Theory
The purpose of nursing science is to develop knowledge using paradigms and theories
that guide both research and practice (Walker & Avant, 2011). Bronfenbrenner’s Ecological
Systems Theory (Bronfenbrenner, 1977, 1979, 1989, 1994) was operationalized to guide this
dissertation. Bronfenbrenner’s Ecological Systems Theory stems from the social ecology
approach to health promotion (Bronfenbrenner, 1977, 1979, 1989, 1994). A core theme of
ecological research is that human health is influenced not only by environmental circumstances
but also by a variety of personal attributes, including genetic heritage, psychological
dispositions, and behavioral patterns (Stokols, 1996).
Within the Ecological Systems Theory, an individual is conceived as a functional whole,
an integrated system in its own right in which various psychological processes—cognitive,
affective, emotional, motivational, and social—operate not in isolation but in coordinated
12
interaction with one another (Bronfenbrenner, 1997). The environment extends beyond the
behavior of individuals to encompass functional systems both within and between settings,
systems that can also be modified and expanded (Bronfenbrenner, 1979). The inclusivity of the
Ecological Systems Theory to view an individual maternal-newborn dyad within the context of
nested hierarchical systems makes an adaption of Bronfenbrenner’s work ideal for global
community health research. Guided by the Ecological Systems Theory, there is a definite need
for development of nursing studies to affirm the potential benefits of MWHs and the SMGL
initiative in rural Zambia to improve maternal-newborn health outcomes.
Ecological theory is rooted in core principles concerning the interrelations among
environmental conditions and human behavior and well-being (Stokols, 1996). The term ecology
is derived from biological science and refers to the interrelationships between organisms and
their environments. Ecological models have been central to health promotion practice for several
decades (Sallis, Owen, & Fisher, 2015). The environmental and policy levels of influence
distinguish ecological models from behavioral theories that emphasize individual characteristics
skills and proximal social influences, such as family and friends, but do not explicitly consider
the broader community, organizational, and policy influences on health behaviors (Sallis, Owen,
& Fisher, 2015). A key strength of ecological models is their focus on multiple levels of
influence, in which policy and environmental changes are expected to affect entire populations,
while a weakness of many ecological models is their lack of specificity about the most important
hypothesized influences (Sallis, Owen, & Fisher, 2015).
First introduced in the 1970s, Bronfenbrenner’s ecological paradigm represented a
reaction to the restricted scope of most research then being conducted by developmental
psychologists (Bronfenbrenner, 1994). The Ecological Systems Theory focuses on a scientific
13
approach emphasizing the interrelationship of different processes and their contextual variation
(Darling, 2007). As with most theories, the Ecological Systems Theory evolved over time: from
an ecological approach to human development during the initial phase (1973–1979), followed by
a stronger emphasis on the role of the individual and developmental processes during 1980–1993
(Eriksson, Ghazinour, & Hammarström, 2018; Rosa and Tudge 2013). Finally, in the last phase
(1993–2006), Bronfenbrenner proposed methods for evaluating developmental outcomes that
emerge as a result of the active participation of the four major concepts: process, person, context,
and time (PPCT model) (Eriksson, Ghazinour, & Hammarström, 2018; Rosa and Tudge 2013;
Tudge et al., 2013). A review by Tudge and colleagues (2013) found that while recent
publications included citations to the mature (mid-1990s) version of Bronfenbrenner’s theory,
few appropriately describe, test, and evaluate all four major concepts.
The research in this dissertation was guided by the two earliest phases of
Bronfenbrenner’s theory. Earlier versions of Bronfenbrenner’s theory were used in this
dissertation because they focus on interventions in the wider social environment (Eriksson,
Ghazinour & Hammarström, 2018). Research presented here views MWHs as an intervention to
improve maternal-newborn health in communities. Later versions, incorporating the PPCT
model, focus mainly on the close/proximal context rather than on broad public interventions
(Eriksson, Ghazinour & Hammarström, 2018). The Ecological Systems Theory is well
established in nursing and other disciplines and is used in various methodologies (Coetzee,
Kagee, & Bland, 2015; Grzywacz & Marks, 2000; Olsen, Baisch, & Monsen, 2017; Rothery,
2001). Onwuegbuzie and colleagues (2013) conceptualized how Bronfenbrenner’s (1979)
ecological systems model could be mapped onto the research process representing qualitative,
quantitative, and mixed research, and it is applicable across the social, behavioral, and health
14
fields. Table 1.1 highlights the use of Ecological Systems Theory in maternal-child health
research including an overview of study design, findings, and limitations.
Early on, Bronfenbrenner developed two propositions specifying the defining properties
of the general ecological model. Proposition 1 states that human development takes place
through processes of progressively more complex reciprocal interaction between an active,
evolving biopsychological individual and the people, objects, and symbols in its immediate
environment (Bronfenbrenner, 1994). To be effective, the interaction must occur on a regular
basis over extended periods of time (Bronfenbrenner, 1994). Proposition 2 states that the form,
power, content, and direction of enduring interaction in the immediate environment affecting
development vary systematically as a joint function of the characteristics of the developing
person: of the environment—both immediate and more remote—in which the processes are
taking place, and the nature of the developmental outcomes under consideration
(Bronfenbrenner, 1994). Propositions 1 and 2 are theoretically interdependent and subject to
empirical testing (Bronfenbrenner, 1994).
Researchers must be concerned with the validity of their designs. Another important
proposition for Bronfenbrenner is that the properties of the environmental contexts in which an
investigation is conducted or from which the experimental subjects come can influence the
process that take place within the research setting, and thereby affect the interpretation and
generalizability of the findings (Bronfenbrenner, 1979). Therefore, Bronfenbrenner formulated a
definition of ecological validity that takes both these principles into account. For Bronfenbrenner
(1979), ecological validity is defined as the extent to which the environment experienced by the
subjects in a scientific investigation has the properties it is supposed or assumed to have by the
investigator.
15
Table 1.1 Studies using Ecological Systems Theory in maternal-child health research
First Author,
Title (year)
Setting
Research
Design
Aims
Sample Size
Results
Implications
Study limitations
Ashaba,
Understanding
coping
strategies
during
pregnancy and
the postpartum
period: a
qualitative
study of
women living
with HIV in
rural Uganda
(2017)
Uganda
Qualitative:
semi-structured
interviews
Explore
women's
perceptions
of how they
cope with the
challenges of
pregnancy
and the
postpartum
period as
HIV-infected
women.
n=20
postpartum
women
living with
HIV
(WLWH)
accessing
ART who
had a
pregnancy
within
2 years prior
to
recruitment
Summarized five coping
strategies within a socio-
ecological framework
according to
Bronfenbrenner's Ecological
Model. Coping strategies on
individual level included
acceptance of self and HIV
status, and self-reliance. On
interpersonal level, coping
through support from
partners, family, and
friends. On organizational
level, coping through HIV-
related healthcare delivery
and system supports. At
community level, coping
through support from
church and spirituality.
Intervention programs
for WLWH must
emphasize
psychosocial care and
incorporate strategies
addressing
psychosocial
challenges in the HIV
care package to
optimize well-being.
Programs that support
WLWH for economic
empowerment and
improved livelihoods
should be strengthened
across all regions in
the country.
Small study
sample that may
limit
generalizability of
findings to all
HIV positive
women during
pregnancy and the
postpartum
period.
Chomat,
Maternal
Stressors
Impact
Maternal
Wellbeing and
Cortisol, and
Infant Growth
in Rural
Guatemala:
Insights from
Qualitative and
Quantitative
Approaches
(2016)
Guatemala
Mixed-
methods:
observational
grounded in
participatory
action research
and
Bronfenbrenner
framework
Characterize
women’s
exposure to
nutrition,
infection and
psychosocial
stressors vs.
resilience
factors,
evaluate
maternal
cortisol as a
mediator in
transmission
of stress
n=155
women,
seen during
pregnancy
and two
cross-
sectional
cohorts (60
early, 56
later)
Diet diversity was low and
only 38% of women were
food secure. Participants
reported low maternal
autonomy, high paternal
support, small social support
networks and common
domestic violence.
Infants of mothers with
greater paternal support,
autonomy and emotional
distress were more likely to
be stunted.
Research highlighted
importance of
integrating
psychosocial
interventions into
research and
intervention programs
targeting early infant
growth, and sheds
light on strategies to
increase resilience and
empower women and
communities to break
the intergenerational
cycle of poor growth.
The homogeneity
of study
population limited
ability to test
effects of
ethnicity, altitude,
and
socioeconomic
status on infant
growth.
16
Reeves, Infant-
feeding
practices
among African
American
women:
Social-
ecological
analysis and
implications
for practice
(2015)
United
States
Literature
review
(a) use social-
ecological
model to
explore
personal,
socio-
economic,
psychosocial,
and cultural
factors
affecting
infant feeding
decision-
making
processes
22 articles
Relevant
information
from each
article was
categorized
by theme
based on
Bronfenbren
ner’s (1994)
social-
ecological
spheres of
influence
Social-Ecological Theory’s
spheres of influence help
show how a woman’s work
environment, neighborhood
and community must also be
taken into account in
analyzing the factors that
affect African American
women’s infant-feeding
choices.
African American
infant-feeding
decisions result of
complex interplay
between demographic,
socioeconomic,
psychosocial, and
cultural factors.
Improving health of
historically
disadvantaged is
critical to fostering a
culture of social
justice.
Viken,
Maternal
health coping
strategies of
migrant
women in
Norway (2015)
Norway
Qualitative:
semi-structured
interviews
Explore the
maternal
health coping
strategies of
migrant
women in
Norway.
n=17 semi-
structured
interviews
with women
from South
America,
Europe, the
Middle East,
Asia, and
Africa.
Results interpreted in the
light of Bronfenbrenner’s
ecological model. One
overall theme is as
follows: keeping original
traditions while at the same
time being willing to
integrate into Norwegian
society, and four themes:
balancing their sense of
belongingness; seeking
information and support
from healthcare
professionals; being open to
new opportunities
and focusing on feeling safe
in new country.
To provide quality
care, healthcare
professionals should
focus on the
development of
migrant women’s
capabilities.
Adaptation of
maternal health
services for culturally
diverse migrant
women requires a
culturally sensitive
approach on the part
of healthcare
professionals.
Interviewers were
both public health
nurses. This could
have affected the
participants’
answers in that
they might have
wanted to be
positive and not
criticize the
Norwegian health
services.
17
Bronfenbrenner defined the ecological environment as conceived topologically as a
nested arrangement of structures, each contained within the next (Bronfenbrenner, 1997).
Moving from the innermost level to the outside, as shown in Figure 1.2, are the microsystem,
mesosystem, exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1989). These
components of the Ecological Systems Theory are defined in Table 1.2.
The operationalized Ecological Systems Theory guiding this dissertation is shown in
Figure 1.3. When the Ecological Systems Theory is modified for maternal-newborn health and
MWH use, the maternal-newborn dyad represents the microsystem. Factors affecting knowledge
and beliefs of newborn care and illness and MWH use within the microsystem include
demographics as well as newborn and maternal health outcomes. The mesosystem includes the
family and community surrounding the maternal-newborn dyad. Interpersonal factors within the
mesosystem include family members (i.e. husband, mother-in-law) and community members.
The exosystem incorporates the health care system in rural Zambia. Health care organization
factors affecting knowledge and beliefs of newborn care and illness along with MWH use within
the exosystem include: (a) professional and community health worker support, (b) quality and
availability of staff, (c) referral capability, and (d) health care facility accessibility and distance.
The macrosystem encompasses culture. The social and cultural factors affecting the macrosystem
include cultural beliefs, financial resources, and laws (i.e. fines for home births). Finally, the
chronosystem is represented by health policy in the adapted Ecological Systems Theory. Public
health policy factors include national and local government agency support and promotion of
maternal-newborn health and MWH use.
18
Figure 1.2 Illustrated model of Bronfenbrenner’s Ecological Systems Theory (Adapted from
Berger, 2007 by Stranger, 2011)
19
Table 1.2 Ecological Systems Theory Definitions and Operationalization for Dissertation
Ecological Systems Theory
Component
Definition
(Bronfenbrenner, 1977, 1979, 1989)
Operationalized Ecological
Systems Theory for Maternal-
Newborn Health and MWH
Use
Microsystem
Pattern of activities, social roles, and interpersonal relations
experienced in a given face-to-face setting with particular
physical, social, and symbolic features.
Mother-Newborn Dyad
Mesosystem
Comprises the linkages and processes taking place between
two or more settings.
Family (husband,
grandmothers) &
Community Members
Exosystem
An extension of the mesosystem embracing other specific
social structures, both formal and informal, that do not
contain the individual but impinge upon or encompass the
immediate settings in which that person is found, and
thereby influence, delimit, or determine what goes on there.
Healthcare System
Macrosystem
Consists of the overarching pattern of micro-, meso-, and
exosystems characteristic of a given culture or subculture,
with particular reference to the belief systems, bodies of
knowledge, material resources, customs, life-styles,
opportunity structures, hazards, and life course options that
are embedded in each of these broader systems.
Social & Culture
Chronosystem
Encompasses change or consistency over time not only in
the characteristics of the individual but also of the
environment in which that person lives.
Health Policy
20
Figure 1.3 Operationalization of Ecological Systems Theory for dissertation (adapted from Berger, 2007; Stranger, 2011)
21
A weakness of many ecological models of health behavior is their lack of specificity
about the most important hypothesized influences putting a greater burden on health promotion
professionals to identify critical factors for each behavior application (Sallis, Owen, & Fisher,
2015). Critics of the ecological perspective have noted that it has a number of inherent problems
and has not provided a clear set of procedures for: (1) assessment, (2) intervention techniques,
and (3) strategies and rationales for their use (Conte & Halpin, 1983; Pardeck, 1998). A major
challenge for those working with ecological models is to develop more sophisticated models that
lead to testable hypotheses and useful guidance for interventions (Sallis, Owen, & Fisher, 2015).
To compensate for these weaknesses, Bronfenbrenner’s Theory was used in this
dissertation to explore interactions among systems in the Ecological Systems Theory for
Maternal-Newborn Health and MWH Use and factors affecting knowledge and beliefs of
newborn care and illness. The three studies reported here addressed social, cultural, and
community processes involved in maternal-newborn health and MWH use in rural Zambia. After
all, a more fully operationalized ecological approach may be key to developing a more thorough
and nuanced understanding of complex health problems and means of addressing them to
promote the public’s health (Richard, Gauvin, & Raine, 2011).
Summary
The overarching goal of this three-study dissertation was to explore and describe the
cultural practices, knowledge, and beliefs of essential newborn care and health-seeking in the
context of MWHs and the SMGL initiative in rural Zambia. Three distinct studies -- using focus
groups, a quasi-experimental approach, and a case series -- with specific aims contributed to this
overall goal. The Ecological Systems Theory is flexible and allows for conducting parallel
studies using different methods. Research for all studies was guided by Bronfenbrenner’s theory
22
using quantitative methods in sequence with different participants to complement and add depth
to the initial qualitative findings. An overview of all three papers for the dissertation is presented
in Table 1.3. The research described in this dissertation adds to the literature on newborn care
and health-seeking practices in rural Zambia. Findings also contribute to nursing knowledge
about rural Zambian culture in relation to maternal-newborn health in the context of MWHs and
the SMGL initiative.
23
Table 1.3 Overview of three papers for dissertation, Culture, Knowledge, and Beliefs of Newborn Care and Health-Seeking Practices
in Rural Zambia
Title
Study 1: Beliefs and Health-Seeking
Practices: Rural Zambian’s Views on
Maternal-Newborn Care
Study 2: Maternal Knowledge of
Essential Newborn Care in Rural Zambia
Study 3: A Case Series of Maternal-
Newborn Delivery Outcomes in Rural
Zambia: Comparison of Referral to a
District Hospital from Facilities with and
Without a Maternity Waiting Home
Aim
Aim 1): Describe knowledge and
beliefs of newborn care and illness
from the perspective of rural Zambian
women, community members, and
health workers.
Aim 2): Examine similarities and
differences in knowledge and beliefs
of newborn care and illness between
rural Zambian women, community
members, and health workers.
Aim 3): Explore the social and
cultural factors that are associated
with the ways women seek newborn
care to identify traditional and
professional newborn care practices
in rural Zambia.
Aim 1): Compare maternal knowledge of
newborn care in two groups of women in
rural Zambia: one group used a MWH
prior to delivery and the other group did
not use a MWH.
Aim 1): Advance an understanding of
maternal-newborn delivery outcomes for
women referred from health facilities with
and without MWHs to the district referral
hospital.
Method
Qualitative
Quantitative
Quantitative
Design
Focus Groups
Quasi-experimental
Case Series
Sample
Zambian women with babies <1 year,
community members, and health
workers
Pregnant and postnatal women referred
from facilities with MWH and non-MWH
facilities for delivery or postpartum care
Medical record data from a delivery
register at one district referral hospital to
examine a sample of all cases from ten
lower-level BEmONC facilities with
complications who were referred and
arrived at the higher-level CEmONC
district referral hospital
24
Setting
MWH and non-MWH facilities in
Lundazi & Mansa Districts in rural
Zambia
Lundazi District Referral Hospital and
Lundazi District Hospital MWH in rural
Zambia
Lundazi District Referral Hospital in rural
Zambia
Instruments
Semi-structured focus group guide
Maternal Knowledge Questionnaire
Ministry of Health Delivery Register
Analysis
Thematic latent content analysis
organized using ATLAS.ti software
Statistical comparison using SPSS to
perform descriptive, inferential, and
logistic regression comparing knowledge
for women referred from facilities with
and without MWHs and assess
associations between independent
variables.
Statistical comparison using SPSS to
perform crosstabulation, tests of
independence, and logistic regressions.
25
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31
CHAPTER 2
Literature Review
Maternal, Child and Newborn Health in Low- and Middle-Income Countries
The role the maternal-newborn dyad plays in the long-term health of each member is
undeniable. What impacts the mother’s health also impacts the newborn’s health and vice versa.
Complications from pregnancy and childbirth are the leading causes of death and disability for
women of childbearing age in low- and middle-income countries (LMICs) (World Health
Organization [WHO], 2017a). Every day, more than 800 women die from preventable causes
related to pregnancy and childbirth (WHO, 2016b) and almost all maternal deaths (99 percent)
occur in developing countries (WHO, 2016b). The major direct causes of maternal morbidity and
mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed
labor (WHO, 2017b). Between 2016 and 2030, as part of the Sustainable Development Goals
(SDGs), the target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live
births (WHO, 2016b).
Morbidity and mortality among newborns in LMICs remains a challenge. Of the
estimated 5.9 million children younger than age 5 who died in 2015, 45 percent were newborns,
with a newborn mortality rate of 19 per 1,000 live births (WHO, 2016c). An estimated 2.7
million newborn babies die globally in the first 28 days of life (UNICEF, 2016). Almost 1
32
million newborn deaths occur on the day of birth, and close to 2 million die in the first week of
life (UNICEF, 2015). The major causes of newborn mortality are prematurity, birth-related
complications (birth asphyxia), and newborn sepsis (WHO, 2016c).
Great strides were made in reducing child mortality in the past two decades as part of an
international effort to attain the Millennium Development Goals (MDGs) proposed by world
leaders at the United Nations at the beginning of the new millennium. However, newborn
mortality declined less steeply than the global under-5 and infant mortality rates, dropping 47
percent compared to 54 percent for under-5s (UNICEF, 2016). If the present newborn rate of
decline continues, it will be more than a century before an African newborn has the same
survival probability as one born in Europe or North America in 2013 (Lawn et al., 2014).
The United Nations Member States launched the SDGs to end preventable deaths of
newborns and to reduce newborn and maternal mortality by 2030 (United Nations, 2018). An
acceleration of the pace of progress is urgently required to achieve the SDG target on child
survival, particularly in high mortality countries in sub-Saharan Africa (UNICEF, 2015). To
reach SDG targets, newborns and their mothers need access to good health care and important
life-saving interventions.
Newborn Health in Sub-Saharan Africa
Sub-Saharan Africa (SSA) includes 46 countries with substantial variation between and
within countries (Friberg et al., 2010) and accounts for 11% of the world's population yet half of
the world's burden of maternal, newborn, and child deaths with 4.7 million deaths per year
(Kinney et al, 2010). The sub-Saharan African region has the highest rates of newborn mortality
in the world (Lawn & Kerber, 2006) and it is much higher for the poorest of the poor (Lawn et
al, 2009). The rural poor have the greatest geographic and financial challenges in accessing care,
33
particularly emergency obstetric care (EmOC). More than 13,000 mothers, newborns, and
children die every day in SSA -- almost nine deaths every minute (Kinney et al, 2010). Most
newborn deaths could be prevented with available, simple, cost-effective solutions (Blencowe &
Cousens, 2013).
The underlying social determinants that contribute to the causes of newborn deaths in
Africa are poverty, low levels of maternal education, and inequities in access to quality health
care (Mason, 2007). High priority needs to be given to identifying approaches in SSA that
overcome existing physical, economic, and cultural barriers to care-seeking and provision of
timely childbirth and newborn care to reduce morbidity and mortality (Blencowe & Cousens,
2013). Local factors must be considered in health planning and prioritization in SSA, such as
epidemiology, coverage and utilization of services at all levels of the health system, and health
system performance potential platforms for scaling up interventions as well as funding
opportunities and constraints (Friberg et al., 2010). Inequity in child health is high in Africa, but
few studies have assessed it with respect to newborn care (Waiswa et al., 2010).
Two-thirds of newborn deaths could be prevented if all mothers and newborns had
access to a small number of interventions that are well known, feasible and deliverable without
complex technology (Mason, 2007). Many newborn deaths could be prevented with facility-
based interventions such as neonatal resuscitation, hygienic practices, and thermal care around
the time of birth for all neonates, as well as antenatal steroids and Kangaroo Mother Care for
preterm babies (Friberg et al., 2010). Depending on many factors, such as the quality of adjacent
facility, training of personnel, availability of supplies and more, MWH use by pregnant women
has the potential to improve access to lifesaving facility-based interventions.
34
Newborn Care Practices in Sub-Saharan Africa
Early detection of newborn illness is an important step toward improving newborn
survival (Sandberg et al., 2014). Poor knowledge of newborn danger signs delays care seeking
(Sandberg et al., 2014). Several studies assessed maternal knowledge of newborn danger signs in
South Asia (Senarath et al, 2007; Shrestha et al., 2015; Syed et al., 2008), and found that mothers
demonstrated a satisfactory knowledge in recognizing danger signs of the newborn with maternal
education and socioeconomic status having a significant, positive association with newborn-care
knowledge. However, there is a paucity of data on newborn health from SSA and few studies
have assessed inequity in uptake of newborn care practices (Waiswa et al., 2010). South Asia and
SSA have different labor/delivery and care-seeking practices, cord care practices, population
densities, mortality rates, and cultural practices (Hamer et al., 2015). A majority of newborn
deaths in SSA occur at home, indicating that few families recognize signs of newborn illness,
and/or a majority of the newborns are not taken to health facilities when they are sick (Lawn et
al., 2010).
The Young Infants Clinical Signs Study Group (2008) developed an algorithm based on
the Integrated Management of Newborn and Childhood Illness (IMNCI) Handbook (2006). The
handbook includes seven signs or symptoms — history of difficulty feeding, movement only
when stimulated, temperature below 35·5°C or greater than or equal to 37·5°C, respiratory rate
over 60 breaths per minute, severe chest retractions, and history of convulsions — to predict the
need for hospitalization in newborns presenting to health facilities, particularly in the first week
of life, to ensure prompt treatment. Researchers in rural Uganda used the algorithm and showed
poor understanding of danger signs in the studied area (Sandberg et al., 2014). This indicates a
need to enhance educational efforts aimed at all pregnant and delivered women in the community
35
(Sandberg et al., 2014). Researchers also recommended the promotion of birth preparedness in
the community as it has been shown to alert women to newborn danger signs (Sandberg et al.,
2014).
Providing mother’s breast milk to infants within 1 hour of birth is referred to as “early
initiation of breastfeeding” and ensures that the infant receives the colostrum, or “first milk,”
which is rich in protective factors (WHO, 2017c) such as immune, growth and tissue repair
factors (Uruakpa, 2002). Jones and colleagues (2013) identified Demographic and Health Survey
data from several sub-Saharan African countries to determine cross-country patterns of
associations of the WHO breastfeeding indicators including child stunting, wasting, height-for-
age z-score (HAZ), and weight-for-height z-score (WHZ). In the Ethiopia and Zambia analyses,
only HAZ and WHZ were assessed (Jones et al., 2013). In all countries, approximately one-
quarter or more of children younger than 24 months old were stunted, with nearly half of all
children stunted in Ethiopia and Zambia (47% and 45%, respectively) (Jones et al., 2013).
Researchers found that 56% of mothers reported early breastfeeding initiation in Zambia, yet the
WHO indicators showed mixed associations with child anthropometric indicators across
countries (Jones et al., 2013). Exclusive breastfeeding of children younger than 6 months of age
was associated with greater WHZ in Zambia (p<0.05) (Jones et al., 2013). Breastfeeding protects
against diarrhea and common childhood illnesses such as pneumonia, and may have longer-term
health benefits for the mother and child, such as reducing the risk of overweight and obesity in
childhood and adolescence (WHO, 2017c). Breastfeeding has also been associated with higher
intelligence quotient (IQ) in children (WHO, 2017c).
In an assessment of socioeconomic differences in use of newborn care practices to inform
policy and programming in Uganda, Waiswa and colleagues (2010) found newborn care
36
practices in this setting were low and did not differ much by socioeconomic group. All mothers
with infants ages 1-4 months (n=414) in a Demographic Surveillance Site were interviewed face-
to-face (Waiswa et al., 2010). Despite a study design relying upon maternal recall alone,
researchers concluded that despite established policy, most neonatal interventions in Uganda
were not reaching newborns, suggesting a "policy-to-practice gap" (Waiswa et al., 2010).
In a study aimed at collecting data on thermal care practices in rural Ghana to inform the
design of a community newborn intervention, narrative and in-depth interviews (IDIs) about
thermal care practices and barriers and facilitators to behavior change were obtained from
recently delivered ⁄pregnant women, birth attendants⁄grandmothers, and husbands through birth
narratives, IDIs and focus group discussion (FGD) (Hill et al, 2010). All 635 women who
delivered in six districts in Ghana in the first 2 weeks of December 2006 were interviewed about
immediate newborn care (Hill et al, 2010). With the exception of wrapping⁄dressing the baby in
the first weeks of life, thermal care practices were not optimally practiced by families in the
study area (Hill et al, 2010). Despite short recall periods, respondents may not have observed
what happened to the baby after delivery or they had difficulty estimating the time between birth
and the behaviors (Hill et al, 2010). Researchers concluded the design of interventions should be
based on an understanding of current behaviors and beliefs (Hill et al, 2010).
In rural southern Tanzania, researchers developed a sustainable and scalable home-based
counseling intervention for delivery by community volunteers to improve newborn care practices
and survival (Penfold et al., 2014). All 132 wards in the six-district study area were randomized
to intervention or comparison groups. Starting in 2010 in intervention areas, trained volunteers
made home visits during pregnancy and after childbirth to promote recommended newborn care
practices including hygiene, breastfeeding, identification and extra care for low birth weight
37
babies. In 2011, in a representative sample of 5,240 households, researchers asked women who
had given birth in the previous year about counseling visits and their childbirth and newborn care
practices. Four newborn care practices were more commonly reported in intervention than
comparison areas: delaying the baby’s first bath by at least 6 hours, exclusive breastfeeding in
the 3 days after birth, putting nothing on the cord, and, for home births, tying the cord with a
clean thread (Penfold et al., 2014). A limitation of the study is that fewer than half of the women
in intervention areas received a postnatal visit and a fifth of the women reporting any counseling
were visited within 2 days of childbirth (Penfold et al., 2014). Researchers concluded a home-
based counseling strategy to promote recommended newborn care implemented by volunteers
and designed for scale within the health system can improve newborn care in rural communities
in southern Tanzania (Penfold et al., 2014).
In a peri-urban area in Kampala, Uganda, using focus group discussions, researchers
explored the perceptions among 30 post-delivery mothers who were purposively sampled from
249 mothers in the postnatal ward of skin-to-skin contact (Kangaroo Care) and newborn baby
care (Byaruhanga et al., 2008). Two main themes emerged from the focus group discussions:
“acceptability of health practices are influenced by knowledge and sensitization” and “pregnant
women's choices are dependent on social, cultural and economic factors” (Byaruhanga et al.,
2008). Mothers expressed varying opinions about the usefulness of skin-to-skin contact: Some
knew about its use to reduce the risk of hypothermia, others were unaware, and some believed
skin-to-skin contact was an intervention used to distract them from the pain in the post-delivery
period (Byaruhanga et al., 2008). The vernix caseosa and the mixture of amniotic fluid with
blood in the post-delivery period were perceived as dirty and infectious (Byaruhanga et al.,
2008). A potential limitation is that two of the focus group leaders were male, and two were
38
health care providers in the hospital. These characteristics could have affected the mothers’
responses, especially when discussing negative practices they perceived in the hospital such as a
lack of privacy (Byaruhanga et al., 2008). Researchers concluded the gap between the knowledge
and practice of skin-to-skin contact in hospital needs to be bridged (Byaruhanga et al., 2008).
Health care providers need to be encouraged to continuously advocate for, educate, and
implement regular skin-to-skin contact (Byaruhanga et al., 2008).
Health care practitioners must be aware of the beliefs held and behaviors practiced by
pregnant women in the community and what can be done to address these in a way that enhances
both cooperation and the well-being of the mother and baby (M'soka, Mabuza, & Pretorius,
2015). Recognizing the importance of being aware of cultural beliefs in Zambia, M’soka and
colleagues (2015) conducted a descriptive, cross-sectional survey of women attending antenatal
care (n=294) in Lusaka who were selected by systematic sampling. A researcher-administered
questionnaire was used for data collection to determine dietary beliefs, behaviors, and use of
medicinal herbs during pregnancy. Regarding health beliefs and diet intake in pregnancy, 33%
believed that eating eggs can cause a baby to be born without hair, 33% believed that ingesting
okra during pregnancy caused excessive salivation of the child, and nearly 75% of respondents
agreed with the belief that salt should be avoided during pregnancy (M'soka, Mabuza, &
Pretorius, 2015). Regarding behaviors, 25% of the women believed that using condoms was
harmful and could lead to a weak child (M'soka, Mabuza, & Pretorius, 2015). Regarding use of
medicinal herbs during pregnancy and childbirth, 66% agreed that herbs could assist in a difficult
delivery and 75% believed herbs should be used for cleansing after a miscarriage (M'soka,
Mabuza, & Pretorius, 2015). Limitations of the study include that the questionnaire did not
establish any explanation for the beliefs held by the pregnant women and the questionnaires were
39
only available in two dominant local languages in the region, excluding participants who spoke
neither, which potentially deprived the study of other important views (M'soka, Mabuza, &
Pretorius, 2015). Researchers concluded that women attending antenatal care hold a number of
beliefs regarding pregnancy and childbirth. Those beliefs that are of benefit to the patients should
be encouraged with scientific explanations, whilst those posing a health risk should be
discouraged respectfully (M'soka, Mabuza, & Pretorius, 2015).
Newborn Care Practices in Zambia
Cultural childbirth practices and beliefs in Zambia lack documentation in the scientific
literature (Maimbolwa et al., 2003). Therefore, researchers in Zambia conducted a study to
explore cultural childbirth practices and beliefs in Zambia as related by 36 women
accompanying laboring women to maternity units using a thematic semi-structured interview
guide (Maimbolwa et al., 2003). Half of the women who accompanied birthing women to
maternity units in Zambia considered themselves a mbusa (traditional birth attendant) and
assisted women during childbirth (Maimbolwa et al., 2003). Apart from certain food taboos, the
women encouraged mothers to eat locally defined nourishing foods, such as cooked vegetables
with pounded groundnuts and nshima, which is the staple food of plain maize flour (Maimbolwa
et al., 2003). Munkoyo (a drink brewed from maize flour) was also believed to be good for
pregnant women (Maimbolwa et al., 2003). Eight of the mbusas said they administered local
traditional medicines to pregnant women to prepare and widen the birth canal (Maimbolwa et al.,
2003). A possible limitation of the study was that the sample was comprised only of women who
accompanied laboring women to maternity units and excluded women who did not accompany
mothers to the selected health facilities who might have other beliefs and experiences of cultural
childbirth practices in Zambia (Maimbolwa et al., 2003).
40
Ten of the mbusas discussed the general belief that any sexual relationship outside
marriage was harmful, and that it could damage the unborn child and cause problems during
labor, such as prolonged or obstructed labor and/or the death of the mother and baby
(Maimbolwa et al., 2003). Pregnant women were advised to avoid having sex from the eighth
month of pregnancy onward to avoid the baby being born with “white stuff’” (vernix caseosa),
which was considered “dirt” (Maimbolwa et al., 2003). The majority (n=28) of the women
reported that the birth of the baby should take place in seclusion, preferably in a hut (Maimbolwa
et al., 2003). Several of the mbusas talked about methods to accelerate labor such as fundal
pressure by tying a chitenge (a fabric Zambian women use to tie around the waist) over the
uterus and giving traditional medicine to precipitate the delivery (Maimbolwa et al., 2003).
The umbilical cord was cut using various devices such as a razor blade or sugar cane peel
then tied with a string (Maimbolwa et al., 2003). The women mentioned different mixtures used
to dress the umbilical cord, such as ash, seashell mixed with oil, scrapings from a pounding stick
(used to pound food), or breast milk (Maimbolwa et al., 2003). Several said that a new mother
should not be allowed to cook until the baby's umbilical cord dropped off, or else the woman
would get a mysterious disease (Maimbolwa et al., 2003). They also reported that a newly
delivered mother and baby should be bathed soon after birth and thereafter twice a day
(Maimbolwa et al., 2003). There was a general belief that a pregnant woman should not make it
known in the neighborhood that labor had begun for fear of attracting evil spirits and witches
believed to have magical powers, which could cause complications during labor and delivery
(Maimbolwa et al., 2003).
Conducting research in areas with diverse cultures requires attention to community
sensitization and involvement (Hamer et al., 2015). For a large community-based, cluster-
41
randomized, controlled trial comparing daily 4% chlorhexidine umbilical cord wash to dry cord
care for neonatal mortality prevention in Southern Province, Zambia, researchers described the
process of community engagement (Hamer et al., 2015). Study preparations required baseline
formative ethnographic research, substantial community sensitization, and engagement with
three levels of stakeholders, each necessitating different strategies. Researchers acknowledge that
conducting a large cluster-randomized, controlled trial at the community level in an African
country with poor road infrastructure, human resource shortages, and widely dispersed rural
populations presents significant logistical barriers that must be addressed in study design and
implementation (Hamer et al., 2015). Cluster-specific birth notification systems developed with
traditional leadership and community members using community-selected data collectors
resulted in a postnatal home visit within 48 hours of birth in 96% of births. Of 39,679 pregnant
women enrolled (93% of the target of 42,570), only 3.7% were lost to follow-up or withdrew
antenatally and 0.2% live-born neonates were lost by day 28 of follow-up (Hamer et al., 2015).
Working closely with traditional authorities to limit the social disruption and suspicion that
might result when people from outside the community conduct research is critically important to
the success of community-based research (Hamer et al., 2015). Focus groups and individual
interviews were conducted in Zambia with a variety of stakeholders to inform the trial design
(Hamer et al., 2015). Using community input on birth notification systems, they were able to
successfully enroll and follow large numbers of pregnant women and newborns in the
community, despite major structural and cultural barriers (Hamer et al., 2015).
In Choma District, rural Zambia, researchers conducted 36 in-depth interviews, five focus
groups and eight observational sessions with recently delivered women, traditional birth
attendants, and clinic and hospital staff from three sites, focusing on skin, thermal, and cord care
42
practices for newborns in the home (Sacks et al., 2015). In this region of southern Zambia,
thermal care practices for newborns were revealed to be largely beneficial, with some significant
exceptions (Sacks et al., 2015). One is the common ritual first bath in cold water after the
umbilical cord separates and the other the practice of bathing the newborn in cold water at night,
both of which increase the risk of hypothermia and could be harmful. (Sacks et al., 2015).
Newborns were generally kept warm with hats and layers of clothing, and extra thermal
protection was provided for preterm and small newborns (Sacks et al., 2015). The vernix was
considered important for the preterm newborn but dangerous for HIV-exposed infants (Sacks et
al., 2015). Applying harmful substances to the skin and umbilical cord, a commonly reported
practice, may amplify exposure to invasive pathogens (Sacks et al., 2015). Mothers applied
various substances to the skin and umbilical cord, most commonly powders made of burnt roots
or ash, with special practices for preterm infants (Sacks et al., 2015). There were several
researcher-acknowledged limitations inherent in the study design including that much of the data
were descriptive and relied on reported information and limited generalizability (Sacks et al.,
2015). Researchers concluded locally appropriate behavior change interventions should aim to
promote chlorhexidine in place of commonly reported application of harmful substances to the
skin and umbilical cord, reduce bathing of newborns at night, and address the immediate bathing
of HIV-infected newborns (Sacks et al., 2015).
Development of further focus group discussions are needed to obtain personal and group
feelings, perceptions and opinions about the newborn health-seeking practices of rural Zambians.
Additional quantitative surveys and secondary data analyses are also needed to better understand
newborn care-seeking behavior in rural Zambia. Use of the Ecological Systems Theory in the
43
exploration of newborn care practices in rural Zambia will promote the preservation of maternal-
child health and well-being of the cultural groups being served.
Maternity Waiting Homes
Nurses have a responsibility to advocate for culturally congruent care and the reduction
of newborn mortality in low-resource settings. One potential mechanism is the use of maternity
waiting homes (MWHs). Maternity waiting homes are residential facilities, located near a
qualified medical facility, where women defined as high risk can await their delivery and be
transferred to a nearby medical facility shortly before delivery, or earlier should complications
arise (WHO, 1996). Maternity waiting homes are an important component of a strategy to
"bridge the geographical gap" in obstetric care between rural areas, with poor access to equipped
facilities, and urban areas where services are more available (WHO, 1996). When staying in a
MWH, women often have access to antenatal care (van Lonkhuijzen, Stekelenburg, & van
Roosmalen, 2012). As one component of a comprehensive package of essential services, MWHs
may offer a low-cost way to bring women closer to needed obstetric care (WHO, 1996). Often,
the time women spend in the MWH is also used to give health education about pregnancy, giving
birth, and neonatal care (van Lonkhuijzen, Stekelenburg, & van Roosmalen, 2012).
The idea of homes for pregnant women with obstetric and social problems is not new
(WHO, 1996). For many centuries, voluntary organizations in Europe have provided shelters for
single mothers in an effort to reduce abortion and infanticide (WHO, 1996). Since the beginning
of the 20th century, waiting homes have existed in Northern Europe, Canada, and the United
States to serve women in geographically remote areas with few obstetric facilities (WHO, 1996).
There is considerable variation in the organizational structures of maternity homes
(WHO, 1996), although one consistent characteristic is that deliveries do not occur in the waiting
44
homes. Maternity waiting homes are a link in a larger chain of comprehensive maternity care, all
the components of which must be available and of sufficient quality to be effective and must be
linked with the home (WHO, 1996). Success in safeguarding pregnant women's health depends
largely on what happens outside the maternity waiting home. A MWH is not a stand-alone
intervention, but rather serves to link communities with the health system in a continuum of care
(WHO, 1996). The level of success in reducing maternal and infant mortality depends on the
following factors: 1) definition of risk factors and selection of women, 2) viable community-
level health service necessary for referral to occur and women's compliance with the referral, 3)
skilled obstetric services (including capacity to handle obstetric emergencies), and 4) community
and cultural support (WHO, 1996).
The way women are cared for in MWHs differs from country to country (van
Lonkhuijzen, Stekelenburg, & van Roosmalen, 2012). Some facilities are completely self-
catering and women provide their own food, water, and firewood. In other facilities, the
economic status of the women determines whether she is provided with food or not (van
Lonkhuijzen, Stekelenburg, & van Roosmalen, 2012). The costs of a MWH are also covered in
different ways. Communities have been involved in building huts while ministries of health or
nongovernmental organizations contribute to building costs (van Lonkhuijzen, Stekelenburg, &
van Roosmalen, 2012).
Recognizing that study findings from other countries on MWHs differ from one
geographical, sociocultural, and economic context to another, Sialubanje and colleagues (2015)
explored women’s experiences and beliefs concerning the use of MWHs in rural Zambia.
Researchers conducted 32 in-depth interviews with women of reproductive age (15–45 years)
from nine health center catchment areas (Sialubanje et al., 2015). A total of 22 in-depth
45
interviews were conducted at a health care facility with a MWH and 10 were conducted at a
health care facility without MWHs (Sialubanje et al., 2015). Their findings showed that most
women appreciate the important role MWHs play in improving access to skilled birth attendance
and improving maternal health outcomes (Sialubanje et al., 2015). However, several individual,
family, and health system-related factors prevent utilization of these services (Sialubanje et al.,
2015). Women’s perceptions of the availability and quality of the basic social and health care
services provided in the MWHs influenced their decision whether to use the service (Sialubanje
et al., 2015). These findings suggest that MWHs could be a useful intervention in improving
access to, and utilization of, facility-based skilled birth attendance services (Sialubanje et al.,
2015). Limitations include that findings are only based on the experiences of the few women
who agreed to participate in the in-depth interviews and researchers did not have information on
the differences between the women who agreed to participate in the interviews and those who
did not (Sialubanje et al., 2015).
Access to MWHs and health care is not only affected by geography and distance or
access to affordable and efficient transport links (van Lonkhuijzen, Stekelenburg, & van
Roosmalen, 2012). Women may have many factors to take into account when deciding where
they spend the last weeks of their pregnancy and, indeed, where they give birth (van
Lonkhuijzen, Stekelenburg, & van Roosmalen, 2012). In-depth interviews by Sialubanje and
colleagues (2016) explored husbands’ experiences and perceptions regarding the use of MWHs
in Zambia with the husbands/partners of women attending the under-5 clinic at a health center
with a MWH (Sialubanje et al., 2016). Men ages 18–50 years whose partner/wife was of
reproductive age and who had lived in the area for more than 6 months were eligible for
inclusion (Sialubanje et al., 2016). Overall, findings showed that husbands had a positive attitude
46
toward MWHs and perceived benefits from using this service, including mitigating long-distance
travel and improving access to facility-based delivery services (Sialubanje et al., 2016).
A study exploring the factors influencing women’s use of MWHs was performed by
Kyokan and colleagues (2016) in Sierra Leone. Researchers used in-depth interviews, key
informant interviews, focus group discussions, document review, and observations. Of the
participants, eight interviews were conducted with women who had delivered in the past year
and used MWHs; eight key informant interviews were with a project manager, MWH hosts, and
community members; and 13 were with women who delivered in the past year without using
MWHs (four interviews and two FGDs) (Kyokan et al., 2016). A limitation of the study noted it
was difficult to recruit women who had not used the MWHs, therefore researchers had to rely on
women who lived closer to the MWHs (Kyokan et al., 2016). Researchers found that past
experiences of childbirth, promotion of the MWHs by traditional birth attendants, family
commitments, and distance and costs of transport to the homes influenced their use (Kyokan et
al., 2016). Family views of the importance of the MWH, childcare, costs of food during the
women’s stay, and education about reasons to use the MWH also influenced their use (Kyokan et
al., 2016). Key recommendations for MWHs included good links with the health system and
strengthening of community participation in monitoring and managing the MWHs for their long-
term success and sustainability (Kyokan et al., 2016).
Before formulating the MWH model used in the rural communities included in this study,
researchers performed a qualitative study to explore Zambian stakeholders' beliefs regarding the
acceptability, feasibility, and sustainability of MWHs. Lori and colleagues (2016) conducted
individual interviews with community leaders (n=46). Focus groups were held with Safe
Motherhood Action Groups, husbands, and women of childbearing age in two rural districts in
47
Zambia (n=500) (Lori et al., 2016). Researchers discovered that Zambian stakeholders were
overwhelmingly in support of MWHs as a way to improve access to facility-based childbirth and
address the barrier of distance (Lori et al., 2016). Participants agreed that a committee to oversee
the MWHs was important, and recommended that the committee oversee all aspects of the
MWH, including building and maintenance of the MWHs (Lori et al., 2016). Although food
security was a pervasive problem in rural Zambia, the community stated a willingness to
contribute toward providing food at a MWH (Lori et al., 2016). The majority of participants
agreed that female relatives, traditional birth attendants, and female community health workers
should be allowed to stay at the MWHs with the pregnant women (Lori et al., 2016).
Gaps in the Literature on Newborn Outcomes and Maternity Waiting Homes
Historically, the focus of research at MWHs has been on maternal outcomes (Figa'-
Talamanca, 1996; Kelly et al., 2006; Lori, Wadsworth, Munro & Rominski, 2013). Perinatal and
newborn health are mentioned in a limited number of articles (Chandramohan, Cutts & Millard,
1995; Lori, Munro et al, 2013; Tumwine & Dungare, 1996; van Lonkhuijzen, Stegeman,
Nyirongo, & van Roosmalen, 2003); however, the research remains unclear with a fragmentary
understanding of newborn outcomes at MWHs (Buser & Lori, 2016).
A wide gap in knowledge examining the outcomes of newborns at MWHs was identified
through a scoping review of the scientific literature (Buser & Lori, 2016). Figure 2.1 provides a
flow diagram summarizing the search process. The scoping review illustrates the need for more
research to understand the effectiveness of MWHs on newborn morbidity and mortality (Buser &
Lori, 2016). Research to date has focused on describing the impact of MWHs on newborn health
in LMICs in nonspecific ways (Buser & Lori, 2016).
48
There is little evidence to support the effectiveness of MWHs on improving newborn
outcomes in low-resource settings over the standard of care (Buser & Lori, 2016). Data from the
scoping review of scientific literature on newborn outcomes and MWHs were analyzed to
identify gaps in research and appropriate next steps (Buser & Lori, 2016). Table 2.1 identifies the
study design and aims, sample size, results, and implication for future research as well as study
limitations of articles included in the scoping review. More research is needed to investigate the
impact of MWHs on newborn outcomes and develop a better understanding of factors affecting
newborn outcomes at MWHs.
The same search strategy outlined in the PRISMA flow diagram (Figure 2.1) was
repeated for the time frame from 2016 to 2018 and found no additional studies meeting inclusion
criteria for the original scoping review examining at the impact of MWHs on newborn health in
low- and middle-income countries. To provide a broad overview of recent literature on MWHs
loosely connected to newborn outcomes, a literature review used the following search strategy
Ovid MEDLINE (R) and Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations for
publications between 2016-2018: (exp Infant, Newborn/ OR infant* OR newborn* OR neonat*
OR small for gestational age OR "low birth weight" OR premature) AND (("maternity waiting
home" OR "maternity waiting homes" OR "maternity waiting house" OR "maternity waiting
houses" OR "maternal home" OR "maternal homes" OR "maternal house" OR "maternal
houses") OR ((maternity OR maternal OR birth OR childbirth) adj3 (waiting OR shelter OR
shelters OR hut OR huts))). Table 2.2 identifies the study design and aims, sample size, results,
and implication for future research as well as study limitations of articles included in the review
of recent literature.
49
Figure 2.1 PRISMA Newborn Outcomes and Maternity Waiting Homes Flow Diagram
50
Table 2.1 Summary of characteristics of articles reviewed for maternity waiting homes (MWHs) and newborn outcomes in low
resource settings (Buser & Lori, 2016)
First Author,
Title (year)
Setting
Research
Design
Aims
Sample Size
Results
Implications
Study limitations
Andemichael,
Maternity
waiting homes:
A panacea for
maternal/
neonatal
conundrums in
Eritrea (2009)
Eritrea
Africa
Quantitative:
Delivery
records
reviewed, self-
administered
questionnaires
to health
workers, TBAs,
mothers
Assess
pregnancy
outcomes
verified
through
maternal
mortality and
perinatal
mortality
rates at
MWHs in
hard to reach
areas
Heads of 11
health
facilities,
community
leaders,
TBAs and
mothers at
MWHs
interviewed
(exact
number not
given), 862
deliveries
reviewed
Deliveries in 11 MWHs
increased by 56% with no
maternal deaths between
Sept 2007-Apr 2009
7 neonatal deaths and 7 still
births, making perinatal
death rate 1.6%
Study recommends up
scaling strategy due to
cost effectiveness and
community support.
Limited
discussion and
recommendations
regarding peri-
natal deaths
except to state that
deaths were
common among
young, unmarried
mothers who
came after long
hours of labor and
failed to deliver
the child at home.
Chandramohan
The effect of
stay in a
maternal
waiting home
on perinatal
mortality in
rural
Zimbabwe
(1995)
Zimbabwe
Africa
Quantitative:
Hospital-based
cohort study
conducted at
district hospital.
Data on
antenatal risk,
use of antenatal
care, access to
hospital and
stage of labor
collected for
every delivery
at hospital from
1989-1991
Evaluate
effect of
MWH on
perinatal
mortality.
n=4488
mothers and
neonates,
1573
mothers in
MWH and
2915 non-
MWH
Women who stayed in the
MWH had a lower risk of
perinatal death compared to
women who came directly
from home to the hospital
during labor. Women from
the obstetric risk group who
stayed at the MWH reduced
their risk of perinatal death
by nearly 50% compared to
those who did not on
multivariate analysis.
The use of MWHs has
the potential to reduce
perinatal mortality in
rural areas with low
geographic access to
hospitals and merits
further investigation.
Data for study
entered in a log
book by six
midwives and are
subject to
limitations of
routine health
information
systems. Study
groups not
selected randomly
and had several
differences in risk
characteristics.
Eckermann,
Maternity
waiting homes
in Southern
Lao
Asia
Quantitative:
demographic,
reproductive
Establish
whether the
MWH
concept
Exact
number of
interviews
not given,
Major barriers to minority
ethnic groups using existing
maternal health services
(reflected in very low usage
Unless MWH are
adapted to overcome
potential barriers, they
will not succeed.
Large
discrepancies
between official
statics on
51
Lao PDR: The
unique ‘silk
home’ (2008)
health and
transport data
Qualitative: 26
questions in
semi-structured
interviews and
focus group
discussions
with villagers,
chiefs, TBAs,
health care
providers, and
community
health workers
would be
affordable,
accessible,
and
acceptable as
a strategy to
improve
maternal
outcomes in
remote areas
the sample
consisted of
18 of the 54
villages
(33%) in
Thateng
District,
total
population
surveyed
n=7876,
total babies
born =326
of trained birth attendants,
hospitals, and clinics) in
Thateng exist. The silk
home project which
combines maternal and
infant health services with
opportunities for micro
credit and income
generating activities and
allowing non –harmful
traditional practices to co-
exist alongside modern
medical protocols is unique
and innovative.
maternal and
infant health
outcomes and
research data.
Sample size of
MWH usage too
low to report
statistical
analysis.
Garcia Prado,
Maternity
waiting homes
and
institutional
birth in
Nicaragua:
policy options
and strategic
implications
(2012)
Nicaragua
Central
America
Quantitative:
econometric
analysis of data
extracted from
surveys
conducted in
2006 on a
sample of
women and
traditional
birth attendants
Qualitative:
interviews with
key informants
Analyze and
examine
factors
associated
with the use
of MWH and
institutional
birth
660 women,
66 TBAs,
18 MWHs
Operation of MWH is
usually satisfactory, room
for improvement: (i)
disseminating information
about the homes to both
women and men; (ii)
strengthening the
postpartum care; (iii)
ensuring financial
sustainability (iv)
strengthening the local
management and
involvement of the regional
government.
Useful for health
policy makers in
Nicaragua and in other
developing countries
considering MWH
strategy.
No solid
qualitative or
empirical
measures of
impact on
neonatal
outcomes.
Gaym,
Maternity
waiting homes
in Ethiopia-
three decades
experience
(2012)
Ethiopia
Africa
Quantitative:
facility
assessment tool,
facility
checklist,
logbook
Qualitative:
focus group
Describe the
current status
of maternity
waiting home
services in
Ethiopia.
Total
number not
provided,
9 MWHs,
maximum
monthly
MWH
admission
averaged at
25
Indirect evidence that
MWHs improved maternal
health outcomes while
caesarean sections were
much higher among clients’
admitted to MWHs
compared to non-users.
Provided MWH service is
standardized and
institutionalized, it can be
Need to standardize
indications for
admission to MWHs
and formalize the
semi-institutionalized
care provided.
Limited
observational
evidence
presented
regarding
reduction in
neonatal
mortality.
52
discussions,
interviews
one approach to improving
access to comprehensive
emergency obstetric care for
rural mothers in Ethiopia
who are challenged by
distance to access services.
Lack of
standardization in
type and
frequency of data
collected and
analyzed.
Lori, Maternity
waiting homes
and traditional
midwives in
rural Liberia
(2013)
Liberia
Africa
Quantitative:
freq of MWH
use, # referrals,
presence of
skilled birth
attendants
(SBA) at
delivery,
proportion of
team births,
perinatal and
maternal
outcomes
collected from
logbooks
completed by
certified
midwives
Qualitative: in-
depth focus
group
discussions
with traditional
midwives
(TMs)
Determine
whether
MWHs
increase the
use of SBAs
as a team and
to describe
the
perceptions
of TMs as
they engage
with SBAs;
and to
determine
whether
MWHs
decrease
maternal and
child
morbidity and
mortality.
n =500
pregnant
women,
n=46 TMs,
5 MWHs
(intervention
group),
5 non-MWH
communities
(control
group)
Communities with MWHs
experienced a significant
increase in team births from
baseline to post-intervention
with greater TMs on their
integration into health
teams. Lower rates of
maternal and perinatal death
were reported from
communities with MWH.
Reduction in
morbidity and
mortality indicates the
establishment of
MWHs is an effective
strategy to increase the
use of SBAs, improve
the collaboration
between SBAs and
TMs, and improve
maternal and neonatal
health.
MWHs opened at
different points in
time, non-MWH
communities
started with a
larger proportion
of team births at
baseline, lack of
randomization in
assigning
communities to
receive an MWH.
Limited
discussion and
recommendations
regarding peri-
natal deaths
except to state
results did not
reach statistical
significance
between the 2
groups.
Millard,
Antenatal
village stay
and pregnancy
outcome in
rural
Zimbabwe
(1991)
Zimbabwe
Africa
Quantitative:
data recorded
on woman’s
age, parity,
antenatal risk
factors,
antenatal clinic
attendance, and
Compare
pregnancy
outcome for
women using
antenatal
village and
those
admitted
n =486
women
using a
MWH,
336 non-
MWH
mothers
Women who stayed in
MWH experienced better
pregnancy outcome than
non-MWH. Birth weight
was greater, perinatal
mortality lower, and
obstetrical intervention less
Establishment of
MWHs should be
evaluated in a broader
context, addressing
issues such as cost and
psychological and
family issues arise
from separating
Lack of
randomization,
differences
between the two
groups in
antenatal risk
factors, and lack
of information
53
outcome
measures.
directly from
community.
often required in the MWH
group.
women from their
families.
relating to socio-
economic status.
Poovan, A
maternity
waiting home
reduces
obstetric
catastrophes
(1990)
Ethiopia
Africa
No discussion
of design or
methods.
Assumed
retrospective
analysis of
MWH and
hospital records
in rural area.
Aims not
clearly
defined.
Presentation
of MWH,
primary
health care,
and lives
saved.
n =151
pregnant
women
admitted to
MWH in
1987,
635 non-
MWH
admissions
In a rural district of
Ethiopia, a MWH for
pregnant women at high risk
led to a significant decline
in maternal and perinatal
mortality. The stillbirth rate
among non-MWH
admissions was ten times
higher than among MWH.
A MWH close to a
rural hospital is vital
where women have to
travel long distances,
transport is poor, and
obstetric disasters are
frequent.
Limited
information about
live births and
neonatal
outcomes.
Poor description
of study design,
methodology and
aims.
Ruiz, Barriers
to the use of
maternity
waiting homes
in indigenous
regions of
Guatemala: a
study of users’
and
community
members’
perceptions
(2013)
Guatemala
Central
America
Qualitative:
interviews with
MWH users,
family
members,
community
leaders, MWH
staff, TBAs,
hospital and
health facility
staff
Identify
barriers
before, during
and after
women’s stay
in MWH.
n =48
people
interviewed
MWH users’ lack of
knowledge about the
existence of the homes,
limited provision of
culturally appropriate care
and a lack of sustainable
funding were most
important problems
identified.
While the strategy of
MWHs had the
potential to contribute
to the prevention of
maternal (as well as
newborn) deaths in
rural Guatemala, they
can only function
effectively if they are
planned and
implemented with
community
involvement and
support, through a
participatory approach
No solid
qualitative
description of
impact on
neonatal outcomes
Tumwine,
Maternity
waiting
shelters and
pregnancy
outcome:
experience
from a rural
area in
Zimbabwe
(1996)
Zimbabwe
Africa
Quantitative:
All deliveries of
MWH and non-
MWH
deliveries
during 2-year
period were
studied.
Statistical
analysis with
chi-squared test.
Evaluate
pregnancy
outcome of
women using
a MWH in a
remote rural
district.
n =280
women
using a
MWH,
773 non-
MWH
mothers
MWHs can contribute to
preventing low birthweight,
and to a lesser extent,
improve perinatal outcome.
Need to strengthen
health care referral
systems and to
increase efforts to
improve other
determinants of
perinatal and maternal
morbidity and
mortality.
Non-statistically
significant
perinatal mortality
rate comparison
between groups
presented and
insufficiently
explained.
van
Lonkhuijzen,
Zambia
Africa
Quantitative:
questionnaire
Assess the
results from
n =218
women
Although the differences in
risk status were statistically
When dependent on a
proper functioning
Difficult to draw
conclusions on
54
Use of
maternity
waiting home
in rural Zambia
(2003)
filled out by
midwives about
SES and
maternal risk
factors from
history and the
current
pregnancy. Chi-
square and
unpaired t-test
used.
the use of a
MWH in
rural Zambia.
using a
MWH,
292 non-
MWH
mothers
significant, no differences
were found in birth weight
and maternal and perinatal
mortality.
referral system,
MWHs can reduce
perinatal mortality.
effectiveness of
MWH by
comparing two
groups delivering
in hospital.
Unknown bias
may account
differences
between groups.
55
Table 2.2 Summary of characteristics of articles reviewed for maternity waiting homes (MWHs) and newborn outcomes in low
resource settings published between 2016-2018
First Author,
Title (year)
Setting
Research
Design
Aims
Sample Size
Results
Implications
Study limitations
Fogliati, A
new use for an
old tool:
maternity
waiting homes
to improve
equity in rural
childbirth care.
Results from a
cross-sectional
hospital and
community
survey in
Tanzania
(2017)
Tanzania
Quantitative:
Secondary
analysis of a
cross-sectional
hospital survey
Determine
whether
Maternity
Waiting
Homes
(MWHs) may
be a tool to
improve
access of
lower socio-
economic
women to
emergency
obstetric
care facilities.
n=1072,
31.3% had
accessed the
MWH.
In multivariable analysis,
age, education, marital
status and obstetric factors
were not significantly
associated with MWH stay.
Adjusted odds ratios for
MWH stay increased
progressively with distance
from the hospital.
In adjusted analysis, poorer
women were more likely to
access the MWH before
hospital delivery compared
with the wealthiest quintile.
Promoting MWHs
near hospitals is a
mitigation strategy
that can reduce
inequity, by improving
poorer women's access
to facilities able to
provide advanced
management of
childbirth
complications.
Two populations
were not time-
matched, with
hospital data
collected 24–
31 months after
the community
survey. Facility
study therefore
population
examined was not
representative of
the general
population.
Henry, The
influence of
quality
maternity
waiting
homes on
utilization of
facilities for
delivery
in rural Zambia
(2017)
Zambia,
Southern
Province
Quantitative:
Facility survey
and
photographs of
structures
Assess the
relationship
between
MWH quality
and the
likelihood of
facility
delivery in
Kalomo and
Choma
Districts
Data sources
from two
separate
studies
included
survey data
from 17,200
pregnant
women, and
both health
facility and
MWH
assessments.
Women whose catchment
area health facilities had an
MWH or a designed waiting
space had higher rates of
facility delivery.
The higher the quality of the
MWH, the more likely a
woman was to deliver at a
facility, regardless of the
facility’s capacity to address
obstetric emergencies.
MWH are a potential
solution to the distance
problem and should be
considered as one
possible intervention
to improve access to
facility delivery in
Zambia.
Unclear if MWH
scored higher due
to increased
facility deliveries,
or if volume
changed due to
launch of or
improved quality
MWH. Deterrents
to utilization not
captured include
increased delivery
costs, lack of
privacy, and lack
of respect from
health staff.
56
Penn-Kekana,
Understanding
the
implementatio
n of maternity
waiting homes
in low- and
middle-income
countries: a
qualitative
thematic
synthesis
(2017)
Worldwide
Qualitative:
Thematic
analysis
countries.
Share with
policy makers
and
implementers
who are
thinking
about
implementing
MWHs key
learnings
from other
implementati
on
experiences,
so that they
can apply
lessons to
their own
contexts.
29 studies
across 17
countries.
Poor utilization was due to
lack of knowledge and
acceptance of the MWH
among women and
communities, long distances
to reach the MWH, and
culturally inappropriate
care.
Facilitators included
reduced or removal of costs
associated with using a
MWH, community
involvement in the design
and upkeep of the MWHs,
activities to raise awareness
and acceptance among
family and community
members, and integrating
culturally-appropriate
practices into the provision
of maternal and newborn
care at the MWHs and the
health facilities to which
they are linked.
MWHs should not be
designed using a
health systems
perspective, taking
account of women and
community
perspectives, the
quality of the MWH
structure and the care
provided at the health
facility.
Improved and
harmonized
documentation of
implementation
experiences would
provide a better
understanding of the
factors that impact on
successful
implementation.
Wide variations in
the organization,
functioning and
operationalization
of MWHs, and
how women were
screened for
MWH residence
means studies are
difficult to
compare.
A number of
factors that may
play a key role on
implementation of
these programs
were not reported
Most papers
didn’t specifically
document the
contextual factors
or assess barriers
and facilitators.
Scott,
Listening to
the
community:
Using
formative
research to
strengthen
maternity
waiting homes
in Zambia
(2018)
Zambia,
Southern
Province
Concurrent
triangulation
study design
and mixed
methods,
primarily
qualitative
Design a
MWH
intervention
that could 1)
overcome
barriers to
facility
delivery; 2)
acceptable to
community;
3) be both
financially
and
operationally
sustainable.
n=167
women, men
with a child
under the
age of two
(n = 53), and
community
elders (n =
55), 17
FGDs (n =
135), 38
semi-
structured
interviews
Distance, roads, transport,
and the quality of MWHs
and health facilities were
major problems facing
pregnant women along with
inadequate advanced
planning for delivery and
the lack of access to
delivery supplies and baby
clothes as other problems.
The annual fixed recurrent
cost per 10-bed MWH was
estimated as $543, food and
charcoal added $3,000.
Development of an
intervention model for
renovating existing
MWH or constructing
new MWH. Basic
strategies of the new
MWH model include
improving community
acceptability, and
building upon existing
efforts to foster
financial and
operational
sustainability.
Results cannot
speak to changes
over time nor are
they generalizable
to all of rural
Zambia.
57
Vian,
Willingness to
Pay for a
Maternity
Waiting Home
Stay in Zambia
(2017)
Zambia,
Southern
Province
Mixed-
methods:
survey and
FGDs
Examine
willingness to
pay for a
night of stay
in a MWH
n=167
women,
men, and
community
elders
surveyed.
16 FGDs
In rural Zambia, most
women, men, and elders
surveyed were willing to
contribute at least a small
sum to stay in a shelter,
suggesting they would gain
utility and satisfaction from
this service.
Contributions, either
individual donations
or annual community
contribution, have
potential to support
long-term financial
sustainability of
shelters.
Women’s
preferences
for birth-related
care, including
maternity home
stay, may change
over the course of
the pregnancy,
and the optimum
time to measure
willingness to pay
in this population
isn’t known
58
The scoping review on newborn outcomes and MWHs highlighted a definite need for
further research to affirm the potential benefits of MWH use to improve newborn outcomes
(Buser & Lori, 2016). Improvements in the newborn morbidity and mortality rates necessitate
the evaluation of the broader cultural context for use of MWHs (Buser & Lori, 2016). As we
continue our efforts to accelerate the worldwide average annual reduction rate in newborn
mortality, an increased focus on the study of MWHs for improving newborn outcomes in low-
resource settings merits immediate attention (Buser & Lori, 2016).
Saving Mothers, Giving Life (SMGL) and Safe Motherhood Action Groups (SMAGs) in
Zambia
Lundazi, Mansa, and Chembe Districts were part of Phase 1 of the Saving Mothers,
Giving Life (SMGL) initiative. The SMGL public-private partnership aimed to significantly
reduce maternal and newborn mortality in sub-Saharan African countries (SMGL, 2018a). The
global partnership sought to leverage strengths, experience, methodologies, and resources of
each partner in pursuit of the SMGL goal (Quam, Achrekar, & Clay, 2019). The SMGL initiative
set out to make high-quality, safe childbirth services available and accessible to women and their
newborns, focusing on the critical period of labor, delivery, and the first 48 hours postpartum
(SMGL, 2019). The SMGL initiative significantly reduced maternal and perinatal mortality in
Zambia by using a district health systems strengthening approach to address the key delays
women and newborns face in receiving quality, timely, and appropriate medical care (Healy et
al., 2019).
To increase the utilization of maternal healthcare services, in 2003 the Zambian Ministry
of Health (MOH) established Safe Motherhood Action Groups (SMAGs) as part of a national
safe motherhood program (Ensor et al., 2013; Sialubanje, Massar, Horstkotte, Hamer, & Ruiter,
59
2017). The SMGL initiative ensured that all SMGL-supported facilities had trained SMAGs
(Serbanescu et al., 2019). The SMGL significantly increased the number and expanded the
functions of SMAGs in all SMGL-supported districts (Serbanescu et al., 2019). The SMAGs
teach pregnant women about the importance of delivering in a facility, having a birth plan and
practicing healthy behaviors during pregnancy and early childhood (SMGL, 2018b). SMAGs
conduct home visits with women throughout their pregnancy to offer guidance and instructions
and inform them about MWHs (SMGL, 2018b). In rural Zambia, SMAGs were also trained to
perform follow-up postnatal home visits for mothers and newborns, identify mothers and
newborns with danger signs, and conduct referrals to health facilities when danger signs were
identified (Serbanescu et al., 2019).
Health in Zambia
One objective of this dissertation was to determine the social and cultural factors that
impact newborn care, illness, and community support in rural Zambia. The dissertation research
conducted on MWHs and the SMGL initiative falls within the Zambian Ministry of Health
framework for facilitating broad-based community ownership and participation in the
governance and delivery of health services. In the Zambian health sector context, community
ownership and participation in the governance and delivery of health services is considered an
important pillar of the health system (WHO, 2014).
Zambian Health System
The government of Zambia abolished user fees on outpatient primary health care
services, first in 2006 in rural areas, extending to urban areas in 2012 (Masiye & Kaonga, 2016).
Public health care in Zambia is funded from three major sources: general tax revenue, out-of-
pocket payments by patients, and donor funding (Masiye, Chitah & McIntyre, 2010). People
60
living in rural and remote areas still face significant financial and other barriers to accessing
public primary health care even though the services are free (Masiye, Chitah & McIntyre, 2010).
Out-of-pocket payment in the form of travel costs, medical expenses for drugs or investigations
not available at public facilities represent remaining challenges for reducing financial barriers to
access (Masiye, Chitah & McIntyre, 2010).
The public health system is structured as a pyramid with health posts at the bottom as the
first point of contact (Masiye & Kaonga, 2016). Health posts are designed to offer basic primary
health services such as health promotion and basic curative care at the community level (Masiye
& Kaonga, 2016). Health posts are usually managed by a public health officer (called an
environmental health technologist) (Masiye & Kaonga, 2016). The staffing profile of health
centers typically includes a clinical officer, a laboratory technician, a pharmacist, nursing staff,
midwives, and an environmental health technologist (Masiye & Kaonga, 2016). Most health
centers only serve as outpatient facilities (Masiye & Kaonga, 2016). District hospitals provide
slightly more advanced curative care and basic surgical services, although they are still
considered to be part of primary health care (Masiye & Kaonga, 2016).
Maternal, Infant, and Child Health in Zambia
In Zambia, increased vulnerability to disease and ill health threaten the lives, well-being,
and livelihood of many Zambians, especially children and women (UNICEF Zambia, 2009).
Human immunodeficiency virus (HIV) and AIDS, tuberculosis (TB), malaria, childhood
diseases, pneumonia, acute respiratory infection (ARI) and sexually transmitted infections (STIs)
persist and create a significant constraint to social and economic development (UNICEF Zambia,
2009). In Zambia, 45 percent of children younger than 5 years of age are stunted (chronically
malnourished) while 28 percent of children younger than 5 are underweight (UNICEF, 2017).
61
There is a general and critical deficiency of micro-nutrients (iodine, iron, and Vitamin A) among
both children and expecting mothers in Zambia (UNICEF, 2017). With children and women
especially vulnerable at the household and community levels, the deficits and demands of ill
health undermine the fabric of Zambian family life, culture, and society (UNICEF Zambia,
2009).
In Zambia, only 47 percent of births are attended by a skilled health worker at health
institutions leaving 53 percent practicing home delivery (UNICEF, 2017). Communities in rural
areas, such as Lundazi and Mansa Districts, have limited access to health care. Currently,
estimates suggest that in urban areas, such as Lusaka, approximately 99 percent of households
are within 5 kilometers of a health facility, compared to 50 percent in rural areas (UNICEF,
2017). Sociocultural factors compound families’ health care seeking behavior such that many
children are taken late to health facilities and pregnancy is not given special care (UNICEF,
2017). Knowledge about postnatal care and practice on infant and young child feeding practices
are low in Zambia (UNICEF, 2017).
As in other LMICs, pregnancy and childbirth represent a leading cause of death and
disability for women in Zambia of childbearing age. In Zambia, 224 maternal deaths occur per
100,000 live births (UNICEF, 2017). The lifetime risk of maternal death in Zambia -- the
probability a 15-year-old girl will eventually die from a complication related to childbirth -- is 1
in 59 (Demographic and Health Surveys [DHS], 2014). Zambia currently ranks 26th out of 184
countries for maternal deaths (Central Intelligence Agency [CIA], 2017).
Under-5 morbidity and mortality also remains a great concern in Zambia. Zambia ranks
17th for infant mortality in the world (CIA, 2017). Infant and under-5 mortality rates from 2008
to 2013 were 45 and 75 deaths per 1,000 live births, respectively, in Zambia (DHS, 2014). At
62
these mortality levels, 1 in every 22 Zambian children dies before reaching age 1 (DHS, 2014).
One in every 13 children in Zambia does not survive to their fifth birthday (DHS, 2014).
In Zambia, infant and child mortality is higher in rural areas than in urban areas (DHS,
2014). Infant mortality in rural areas is 49 deaths per 1,000 live births, compared with 46 deaths
per 1,000 live births in urban areas (DHS, 2014). Rural-urban differences are more notable in the
case of child mortality and under-5 mortality rates (DHS, 2014). Infant mortality ranges from 39
deaths per 1,000 live births in North Western Province to 68 deaths per 1,000 live births in
Eastern Province (DHS, 2014) where Lundazi District is situated. Under-5 mortality is highest in
Eastern and lowest in Copperbelt Province (115 and 63 deaths per 1,000 live births, respectively)
(DHS, 2014).
Newborn care is essential to reduce newborn problems and death. To identify, manage,
and prevent complications, the government of Zambia recommends at least three postnatal
checkups for newborns, the first within 6 hours of delivery, the second 6 days after delivery, and
the third 6 weeks after delivery (DHS, 2014). In Zambia between 2008 and 2013, 16 percent of
newborns were taken for their first postnatal checkup within the critical first 2 days after birth
while 5 percent had a postnatal checkup less than 1 hour after birth (DHS, 2014). Newborns
delivered outside of a health facility were less likely to receive a postnatal checkup within the
first week after birth (85 percent) than newborns delivered in a health facility (72 percent) (DHS,
2014).
Conclusion
The framing of this dissertation using an operationalization of the Ecological Systems
Theory provides a solid theoretical basis for the proposed and novel exploration and description
of the cultural practices, knowledge, and beliefs of essential newborn care and health-seeking in
63
the context of MWHs and the SMGL initiative in rural Zambia. The significant gap in
knowledge about MWHs and newborn outcomes demonstrates the need for timely and
innovative research. The literature reviewed here highlights maternal, child, and newborn health
in Zambia and other low- and middle-income countries. The overview of MWHs and the SMGL
initiative provides background information on interventions to improve newborn outcomes and
perinatal obstetric care. The literature provides a glimpse of the uniqueness of Zambian culture
and the special health challenges facing Zambians in rural areas. The priority research question
to emerge from this review is: “Do MWH and SMGL interventions impact knowledge of
essential newborn care and maternal-newborn health and delivery outcomes in rural Zambia?”
64
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75
CHAPTER 3
Beliefs and Health-Seeking Practices: Rural Zambians' Views on Maternal-Newborn Care
Introduction
Newborn morbidity and mortality remain a serious global health challenge in low- and
middle-income countries (LMICs). Almost 1 million newborns die in the first day of life
(UNICEF, 2016) in LMICs. Globally, a child’s risk of death in the first 4 weeks of life is nearly
15 times greater than any other time before his or her first birthday (WHO, 2017). In Zambia, the
newborn mortality rate is 34 per 1,000 live births (UNICEF, 2017) and the infant mortality rate is
44 per 1,000 live births (UNICEF, 2018). To promote improved newborn health outcomes in
rural Zambia, new knowledge is needed to enhance our understanding of newborn care and
cultural factors that influence the ways women seek newborn care.
Research in Zambia and other LMICs has focused on specific aspects of newborn care
and health-seeking practices such as cultural care practices, umbilical cord care, skin care,
thermal care, antenatal care (ANC) seeking, and postnatal care (PNC) (Table 3.1). As outlined in
Table 3.1, several studies show that cultural beliefs strongly influence behavior during
pregnancy, childbirth, and care-seeking (Lang-Baldé & Amerson, 2018; Lori & Boyle, 2011;
Maimbolwa, Yamba, Diwan, & Ransjö-Arvidson, 2003; Raman, Nicholls, Ritchie, Razee, &
76
Table 3.1 Overview of studies exploring specific aspects of newborn care in Zambia and LMICs
First Author,
Title (year)
Setting
Research
Design
Aims
Sample Size
Results
Implications
Study limitations
Cultural childbirth practices
Gupta,
Grandmothers
as
gatekeepers?
The role of
grandmothers
in influencing
health-seeking
for mothers
and newborns
in rural
northern
Ghana (2015)
Ghana
Qualitative:
Focus group
discussions
(FGDs) with
household
heads,
compound
leaders and
grandmothers &
in-depth
interviews
(IDIs) with
mothers of
newborns,
traditional birth
attendants
(TBAs), local
healers,
community
leaders, &
healthcare
practitioners.
Explore the
role
grandmothers
(typically a
woman’s
mother-in-law)
play in
influencing
maternal
and newborn
healthcare
decisions.
n=253 total
participants,
35 IDIs with
mothers of
newborns, 8
TBAs and
local
healers, 16
community
leaders, 13
healthcare
practitioner,
18 FGDs (n-
181)
Grandmothers play an
integral and multi-faceted
role in maternal & infant
health in rural northern
Ghana. They may act as
primary support providers to
pregnant mothers, care for
newborns following
delivery, preserve cultural
traditions & serve as
repositories of knowledge
on local medicine.
Grandmothers may also
serve as gatekeepers for
health-seeking behavior,
especially with regard to
their daughters and
daughters-in-law.
Research sheds light
on the potential gap
between health
education campaigns
that target mothers as
autonomous decision
makers,
& the reality of a more
collectivist community
structure in which
mothers rarely make
such decisions without
the support of other
community members.
Study not
explicitly to
explore the
decision-making
role of
grandmothers.
Researchers may
have had different
insights had they
explicitly sought
to explore the role
of grandmothers a
priori. Interviews
conducted in local
languages of and
later transcribed
into English for
analysis. Nuances
may have been
lost in that
process.
Lang-Baldé,
Culture and
Birth
Outcomes in
Sub-Saharan
Africa: A
Review of
Literature
(2018)
sub-
Saharan
Africa
Literature
review: Using
PRISMA
guidelines,
review focused
on articles that
defined, directly
or indirectly,
associations of
cultural values,
beliefs, &
lifeways to
pregnancy &
Provide
evidence of
relevant cultural
beliefs and the
impact on birth
outcomes for
women in sub-
Saharan Africa
(SSA).
n=25 studies
included in
final review
Three categories emerged
from the literature: birth
outcomes, maternal care-
seeking (MCS), and
maternal culture care. The
ability to conform to local
birth culture validates a
woman’s individual birth
outcomes for herself and her
child only if she relies on
culturally accepted,
sometimes high-risk
options. Cultural beliefs and
Throughout sub-
Saharan Africa,
motherhood is viewed
as an essential role, a
cultural imperative, for
all women of
childbearing age.
Women’s voices & an
understanding of
cultural constructs of
care are required to
encourage the use of
biomedical health
Review limited by
the vast
geographic
territory of SSA
(49 countries).
Research only
available from
roughly 13
countries
highlighting large
literature gap.
77
birth from the
perspective of
women of
childbearing
age
practices are a key factor
influencing MCS, place of
birth, & understanding
progression of birth. Many
women are not aware of
these negative impacts on
pregnancy outcomes, as all
are culturally prescribed as
beneficial & passed down
from one generation to
another.
system along with the
use of indigenous
practices.
Lori, Cultural
Childbirth
Practices,
Beliefs, and
Traditions in
Postconflict
Liberia (2011)
Liberia
Qualitative:
semi-structured
IDIs of
postpartum
women who
experienced a
maternal
complication,
community &
family members
of women who
died from a
pregnancy or
childbirth
complication
Describe the
sociocultural &
contextual
factors
including
practices,
beliefs, &
traditions that
influence
maternal
health, illness,
& death in
postconflict
Liberia, West
Africa.
n=54 total
participants,
10 post-
partum
women, 18
family
members, 26
community
members
Three major themes
from the data: (a) secrecy
surrounding pregnancy &
childbirth; (b) power and
authority; & (c) distrust of
the health care system.
These themes, linked
together, create the
overarching cultural theme
& interpretive theory,
Behind the House, used to
describe the complexity of
maternal illness & death in
Liberia.
Behind the House
defines complexities
& challenges women
face in reproductive
health such as lack of
decision-making
authority & low social
status of young
women within
communities. When a
human rights
perspective focusing
on the interests &
concerns of women is
embraced, more
relevant, sensitive, &
culturally congruent
public health programs
& policies can be
developed.
Limited
generalizability as
it focused on one
regional area in
one sub-Saharan
African country
Maimbolwa,
Cultural
childbirth
practices and
beliefs in
Zambia (2003)
Zambia
Qualitative:
semi-structured
interview of
women
accompanying
laboring women
to urban and
rural maternity
units
Explore cultural
childbirth
practices and
beliefs in
Zambia as
related by
women
accompanying
laboring women
n=36
Cultural childbirth practices
& beliefs of women
interviewed focused on
prevention of childbirth
complications. If a problem
occurred, it was explained
by something the laboring
woman or her husband had
or had not done. Major
Midwifery curricula
should be revised &
must address cultural
dimensions of
childbirth. Culturally‐
specific knowledge
from this study should
be used to guide
policy‐makers &
Sample comprised
only of women
who accompanied
laboring women
to maternity units.
Excludes women
who did not
accompany
mothers to health
78
to maternity
units.
concern was expressed
about sexual relationships,
infidelity and fertility issues.
TBAs believed by
accompanying laboring
women to maternity units,
they could learn from
trained midwives what to do
at home during childbirth.
health planners in the
future development of
safe motherhood
initiatives in
developing countries.
facilities & who
might have had
other beliefs and
experiences of
cultural childbirth
practices in
Zambia.
Raman, How
natural is the
supernatural?
Synthesis of
the qualitative
literature from
low and middle
income
countries on
cultural
practices and
traditional
beliefs
influencing the
perinatal
period (2016)
LMICs
Literature
review:
Systematic
literature search
of electronic
databases from
1990 to 2014,
including
Medline,
Embase,
CINAHL and
PsycINFO,
using search
terms such as
traditional
beliefs,
practices,
pregnancy,
childbirth.
Review
qualitative
research studies
in low resource
settings around
the perinatal
continuum over
the past two
decades, with
focus on the
cultural realm;
to identify
common themes
in the research-
base, to provide
policy direction
for culturally
appropriate
perinatal
interventions.
n=71
included in
final review
Religious & spiritual beliefs
strongly influenced behavior
over the perinatal period.
Beliefs in supernatural
influences, particularly
malevolent forces were
widespread, such that
pregnancy was concealed in
many parts of Africa and
Asia. In most low resource
settings, pregnancy &
childbirth were seen as
normal phenomena. Rituals
played an important part for
women & their infants,
reinforced by inter-
generational support. Cross-
cutting themes were: (1) the
role of women as mothers,
demonstrating their
‘goodness’ by bearing pain
and suffering; (2) the idea of
the ‘natural’ incorporating
the supernatural; and (3)
negotiating change across
generations.
Diverse cultural
practices influence
perinatal well-being
across low resource
settings. Health
practitioners & policy-
makers need to
acknowledge the
primacy of women's
reproductive roles,
cultural constructions
of motherhood; that
supernatural forces are
believed to exert
powerful influences on
the health of mother &
infant; that inter-
generational tensions
result in resisting or
embracing change.
Need to take culture
seriously & recognize
that it shapes
behaviors & choices
throughout perinatal
continuum & deliver
contextually specific,
culturally responsive
care.
Review broad in
scope & offered
generalizations
with respect to
cultural practices
that could be
odious. Limited to
English language
papers. Many
papers included
presented a
Eurocentric view
that sees
traditional
practices &
beliefs around
childbirth as being
overly restrictive,
disempowering
and risky.
Umbilical cord care
79
Coffey,
Umbilical
cord-care
practices in
low- and
middle-income
countries: a
systematic
review (2017)
LMICs
Literature
review:
searched
domestic &
international
databases for
articles
published in
English from
Jan 2000-Aug
2016. Primary
inclusion
criteria was
description of
substances
applied to
umbilical cord
stump.
Review cord
care practices to
assist
development of
behavior-change
strategies to
support
introduction of
novel cord-care
regimens,
particularly
7.1%
chlorhexidine
digluconate for
umbilical cord
care.
n=46
included in
final review
Documentation of cord-care
practices not consistent
across LMICs, yet existing
literature depicts a firm
tradition of umbilical cord
care in every culture. Cord-
care practices vary by
country & by regions or
cultural groups within a
country & employ a wide
range of substances. Desire
to promote healing & hasten
cord separation are the
underlying beliefs related to
application of substances to
the umbilical cord.
Frequency of application of
substance, source, & cost of
products used is not well-
characterized.
Desire to actively care
for the umbilical cord
of a newborn—as
noted in the variety of
cord care practices and
beliefs identified—
points toward the need
to contextualize any
behavior change
approach to align with
the local culture.
Reporting not
global as review
limited to English.
Doubtful that data
from one country
in a region also
pertains to other
surrounding
countries and/or
nearby ethnic
groups. Few in-
depth, qualitative
assessments of
umbilical cord
care practices.
Herlihy, Local
Perceptions,
Cultural
Beliefs and
Practices That
Shape
Umbilical
Cord Care: A
Qualitative
Study in
Southern
Province,
Zambia (2013)
Zambia
Qualitative:
FGDs with
breastfeeding
mothers,
grandmothers &
TBAs, IDIs
with key
community
informants
using semi-
structured field
guides at urban
and rural sites.
Determine local
perceptions of
cord health &
illness and the
cultural belief
system that
shapes
umbilical cord
care knowledge,
attitudes, &
practices.
n=36 FGDs,
n=42 IDIs
Wide variation in
knowledge, beliefs, &
practices surrounding cord
care was discovered. For
home deliveries, cords cut
with non-sterile razor blades
or local grass. Cord
applications included drying
agents, lubricating agents &
medicinal/protective agents.
Concerns regarding the
length of time until cord
detachment were universally
expressed. Blood clots in
the umbilical cord perceived
to foreshadow neonatal
illness. Management
of blood clots or infected
umbilical cords included
multiple traditional
Umbilical cord care
practices and beliefs
were diverse. Dry cord
care, as recommended
by the WHO at time of
the study, not widely
practiced in Southern
Province, Zambia.
Vast diversity of
knowledge, disease
constructs and
practices regarding
cord function, tying,
cutting, applications,
care, and disposal.
Integration of
traditional practices
with a Western
biomedical model of
Many respondents
shared practices
or beliefs that they
“had heard”
others practiced.
Unclear is how
many of primary
respondents
personally hold
these beliefs or
followed these
practices. Because
it was not a
random sample,
authors cannot
comment on
frequency of cord
application or
commonality of
beliefs expressed.
80
remedies & treatment at
government health centers.
care common in
Southern Province.
Sacks, Skin,
thermal and
umbilical cord
care practices
for neonates in
southern, rural
Zambia: a
qualitative
study (2015)
Zambia
Qualitative:
IDIs, FGDs &
observational
sessions with
recently-
delivered
women, TBAs,
clinic &
hospital staff
from three sites,
focusing on
skin, thermal
and cord care
practices for
newborns in the
home.
Present findings
on neonatal
skin, thermal
and umbilical
cord practices in
an HIV-
endemic region
of rural southern
Zambia
36 IDIs, 5
FGDs, 8
observation
sessions
Newborns generally kept
warm by application of hats
and layers of clothing.
Thermal protection provided
for preterm and small
newborns yet practice of
nighttime bathing with cold
water common. Vernix
considered important for
preterm newborn but
dangerous for HIV-exposed
infants. Mothers applied
various substances to skin &
umbilical cord, with special
practices for preterm
infants. Applied substances
included petroleum jelly,
commercial baby lotion,
cooking oil & breastmilk.
Most common substances
applied to the umbilical cord
were powders made of
roots, burnt gourds or ash.
Thermal care for
newborns commonly
practiced but co-exists
with harmful practices.
Locally appropriate
behavior change
interventions should
aim to promote
chlorhexidine in place
of commonly-reported
application of harmful
substances to the skin
& umbilical cord,
reduce bathing of
newborns at night, &
address the immediate
bathing of HIV-
infected newborns.
Data were
descriptive and
relied on reported
information.
Limited
generalizability.
Observations were
not conducted
directly at birth
but rather within
the first week,
hence conclusions
regarding certain
behaviors
practiced in first
hours after birth
(such as wrapping
& drying the
infant) depend
solely on
interviewee
reports.
Skin & thermal care
Amare,
Current
Neonatal Skin
Care Practices
in Four African
Sites (2015)
Nigeria,
Ethiopia,
Tanzania
Qualitative:
IDIs, FGDs &
observations.
Respondents
were mothers,
grandmothers,
fathers, health
workers, birth
attendants and
people selling
skin-care
products.
Report on
perceptions and
practices related
to on skin care
practices &
emollient use in
four African
sites.
~66 IDIs,
~14 FGDs, 8
observations
~20
newborn
care
narratives
with
mothers
Emollient use was a
normative practice in all
sites, with frequent
application from an early
age in most sites. There
were variations in the type
of emollients used, but
reasons for use were similar
and included improving the
skin, keeping the baby
warm, softening or
strengthening joints/bones,
shaping the baby, ensuring
flexibility and encouraging
Study provides the
first in-depth and
comparative data on
emollient use in
Africa. Given
widespread use of
emollients, repeated
exposure of newborns
in the first month of
life & potential impact
of emollients on
mortality, trials are
needed in a range of
African settings.
Potential for
reporting bias.
Data were
collected from
small geographic
areas, and the
findings may not
apply to other
areas, with results
from Nigerian
sites highlighting
emollient use can
vary within a
country and
81
growth and weight gain.
Factors influencing
emollient choice varied &
included social pressure,
cost, availability & deep-
rooted traditional norms.
between ethnic
groups. Exact
number of
participants not
mentioned.
Bee, Neonatal
care practices
in sub-Saharan
Africa: a
systematic
review of
quantitative
and qualitative
data (2016)
sub-
Saharan
Africa
Literature
review:
published
between
January 2001
and May 2014
on thermal care
(immediate
drying and
wrapping, skin-
to-skin contact
after delivery,
delayed
bathing),
hygienic cord
care & early
initiation of
breastfeeding.
Systematically
review
published and
unpublished
literature from
sub-Saharan
Africa on key
immediate
newborn care
practices.
n=42
included in
final review,
DHS data
was
included
from 33
countries on
early
breastfeedin
g practices.
The importance of keeping
newborn babies warm was
well recognized, although
thermal care practices were
sub-optimal. Similar factors
influenced practices across
countries, including delayed
drying and wrapping
because the birth attendant
focused on the mother;
bathing newborns soon after
delivery to remove the dirt
and blood; negative beliefs
about the vernix; applying
substances to the cord to
make it drop off quickly;
and delayed breastfeeding
because of a perception of a
lack of milk or because the
baby needs to sleep after
delivery or not showing
signs of hunger.
The majority of
studies came from five
countries (Ethiopia,
Ghana, Malawi,
Tanzania and
Uganda). There is a
need for more research
from a wider
geographic area, more
research on newborn
care practices at health
facilities &
standardization in
measuring newborn
care practices. The
findings of this study
could inform behavior
change interventions
to improve the uptake
of immediate newborn
care practices.
Unclear rationale
for incorporating
DHS data - only
available for early
breastfeeding
practices from 33
countries – was
included in the
systematic review.
Lunze,
Prevention and
Management
of Neonatal
Hypothermia
in Rural
Zambia (2014)
Zambia
Qualitative:
FGDs with
mothers,
grandmothers &
IDIs with
community
leaders & health
officers
Characterize
relevant
practices,
attitudes, and
beliefs in rural
Zambia about
practices related
to newborn
hypothermia in
rural Africa.
n=171 total
participants,
14 FGDs, 31
IDIs
Community members were
aware of the danger of
neonatal hypothermia.
Caregivers' & health
workers' knowledge of
thermoprotective practices
included birthplace
warming, drying &
wrapping of the newborn,
delayed bathing, &
immediate and exclusive
breastfeeding. Warm chain
Understanding &
addressing
community-based
practices on
hypothermia
prevention &
management might
help improve newborn
survival in resource-
limited settings.
Possible interventions
include skin-to-skin
Study based on
respondents'
narratives,
limiting
researchers’
ability to quantify
any practice.
82
was not consistently
maintained in first hours
postpartum when newborns
at greatest risk. Skin-to-skin
care not practiced in the
study area. Having to
assume household &
agricultural labor
responsibilities in
immediate postnatal period
was a challenge for mothers
to provide continuous
thermal care to newborns.
care in rural areas &
use of appropriate,
low-cost newborn
warmers to prevent
hypothermia &
support families in
their provision of
newborn thermal
protection. Training
family members could
facilitate practices.
Antenatal care seeking
Lori,
Examining
Antenatal
Health
Literacy in
Ghana (2014)
Ghana
Qualitative:
Explore
Ghanaian
pregnant
women’s
understanding
& recognition
of danger signs
in pregnancy,
birth
preparedness &
complication
readiness, &
understanding
of newborn
care.
n=68 total
participants,
6 FGDs
Women identified danger
signs of pregnancy & in the
newborn, but had difficulty
interpreting &
operationalizing information
received during ANC visits,
indicating health education
did not translate to
appropriate health
behaviors. Cultural beliefs
in alternative medicine, lack
of understanding, & prior
negative encounters with
healthcare professionals
may have led to
underutilization of
professional midwives
for delivery & health
services.
With limited health
literacy, pregnant
women cannot fully
comprehend the scope
of services that a
health system can
provide for them
& families. Since
ANC is widely
available to pregnant
women in Ghana, it is
vital to reexamine how
antenatal education is
delivered. Pregnant
women must receive
health information that
is accurate & easy to
understand to make
informed health
choices that will
improve maternal &
child health.
Limited
generalizability.
FGDs led by a
healthcare
provider, albeit
not a midwife
from the antenatal
clinic, which
could potentially
bias the responses
from participants.
Moyer,‘‘It’s up
to the
Woman’s
People’’: How
Ghana
Qualitative:
FGDs & IDIs
among women
with newborns,
Explore the
impact of social
factors on place
72 IDIs, 18
FGDs
Several ‘‘meta themes’’
permeate the data: (1) This
region of Ghana is
undergoing a pronounced
Social factors
influence women’s
delivery experiences
in rural northern
Nuances in
meaning may
have been lost due
to data collected
83
Social Factors
Influence
Facility-Based
Delivery in
Rural Northern
Ghana (2014)
grandmothers,
household
heads,
compound
heads,
community
leaders, TBAs,
traditional
healers, and
formally trained
healthcare
providers.
of delivery in
northern Ghana.
transition from traditional to
contemporary birth-related
practices; (2) Power
hierarchies within the
community are extremely
important factors in
women’s delivery
experiences; and (3) This
community shares a
widespread sense of
responsibility for healthy
birth outcomes for both
mothers and their babies.
Ghana. Future
research &
programmatic efforts
need to include
community members
such as husbands,
mother-in-laws,
compound heads,
soothsayers, &
traditional healers if
they are to be
maximally effective in
improving women’s
birth outcomes.
in one language &
translated it into
English for
analysis.
Differences across
socioeconomic
status not
assessed.
Moyer,‘They
treat you like
you are not a
human being’:
Maltreatment
during labour
and delivery in
rural northern
Ghana (2014)
Ghana
Qualitative:
FGDs mothers
with newborn
infants,
grandmothers,
household
heads,
compound
heads,
traditional
healers, TBAs,
& community
leaders. IDIs
with formally
trained
healthcare
providers.
Explore
community &
health-care
provider
attitudes
towards
maltreatment
during
delivery in rural
northern Ghana,
& findings
against The
White Ribbon
Alliance's seven
fundamental
rights of
childbearing
women.
n=128 total
participants,
7 FGDs, 43
IDIs
Meta theme one: potential
impact of socio-economic
status on women's delivery
experiences. Second meta
theme is power differentials
within the healthcare setting
appear to have a profound
effect on women's delivery
experiences. Despite the
majority of respondents
reporting positive
experiences, Unprompted,
maltreatment was brought
up in community focus
groups, community
interviews, & interviews
with healthcare providers.
Respondents reported
physical abuse, verbal
abuse, neglect, &
discrimination/denial of
traditional practices.
Maltreatment was
spontaneously
described by all types
of interview
respondents in this
community,
suggesting the
problem is not
uncommon and may
dissuade some women
from seeking facility
delivery. Provider
outreach in rural
northern Ghana is
necessary to address &
correct the problem,
ensuring that all
women who arrive at a
facility receive timely,
professional, non-
judgmental, high-
quality delivery care.
Interviewers did
not explicitly ask
about
maltreatment &
additional types of
maltreatment may
have been
identified had the
topic been asked
about directly.
Lack of individual
sociodemographic
identifiers
collected
precludes ability
to situate
discrepant
experiences
within social &
demographic
groups.
Roberts, The
Role of
Cultural
Beliefs in
Malawi
Qualitative:
face-face,
audio-recorded
interviews, and
Identify the
cultural beliefs
that influence
womens ANC
20 pregnant
mothers and
8 health
workers at
Identified maternal cultural
beliefs included: seeking
advice from village elders,
Cultural beliefs play
an integral role in the
decision-making
process of ANC. The
Limited
generalizability as
it focused on one
regional area
84
Accessing
Antenatal care
in Malawi: A
Qualitative
Study (2016)
a demographic
survey
or pregnancy-
related health
care decisions.
two urban
tertiary care
hospitals
spousal fidelity, and
disclosing pregnancy.
Health workers mentioned
providers often held the
same cultural beliefs and
turned women away if they
tried to go against cultural
norms.
belief and practice of
when to disclose
pregnancy prohibits
women from seeking
ANC in the first
trimester
(urban) in one
sub-Saharan
African country
Taylor,
Associations of
Household
Wealth and
Individual
Literacy with
Prenatal Care
in Ten West
African
Countries
(2016)
West
Africa:
Benin,
Burkina
Faso,
Ghana,
Guinea,
Liberia,
Mali,
Nigeria,
Niger,
Senegal
and
Sierra
Leone
Quantitative:
Data on women
with recent
births obtained
from 2006 to
2010 Demo-
graphic and
Health Surveys
Examine
associations of
household
wealth and
individual
literacy with
prenatal care in
West Africa.
n=58,512
78% of women had any
PNC; 23% had adequate
care. Women who were not
literate had lower odds of
having any PNC & lower
odds of ANC. Women in the
poorest wealth quintile were
substantially less likely to
have any PNC than women
in the wealthiest quintile &
less likely to have ANC.
A substantial
percentage of women
in West Africa have
no PNC. Few have
adequate care.
Illiteracy & poverty
are important risk
factors for having little
or no PNC. Increasing
education for girls,
promoting culturally
appropriate messages
about PNC, &
building trust in
providers may
increase PNC.
Applicability to
other developing
countries may be
limited. The
survey data were
crosssectional,
which do not
provide a basis to
infer causality.
There is potential
for recall bias
regarding PNC
content.
Waiswa, Effect
of the Uganda
Newborn
Study on
careseeking
and care
practices: a
cluster-
randomised
controlled trial
(2015)
Uganda
two-arm
cluster-
randomised
controlled trial:
In intervention
villages
community
health workers
(CHWs) were
trained to
identify
pregnant
women & make
5 home visits (2
during
pregnancy & 3
Assess effect of
a home visit
strategy
combined with
health facility
strengthening
on uptake of
newborn care-
seeking,
practices,
services, & to
link the results
to national
policy & scale-
up. Primary
outcomes were
Intervention:
31 villages,
n=194
baseline
household
survey of
women with
live birth in
4 months,
n=894
endline
household
survey of
women with
live birth in
12 months.
Care-seeking for ANC,
routine & extra care services
increased in both the control
and intervention arms, the
intervention significantly
improved essential newborn
care practices, although
many interventions saw
major increases in both arms
over the study period.
Volunteer CHWs can
be effective in
changing long-
standing practices
around newborn care.
The home visit
strategy may provide
greater benefit to
poorer families.
However, CHW
strategies require
strong linkages &
concurrent
improvement of
quality through health
system strengthening,
Differing recall
periods of the
baseline and
endline surveys
for services that
occurred before &
around time of
birth. Surveys
only captured
women who had
live births in both
the baseline and
endline surveys.
85
in the first week
after birth) to
offer preventive
care
improved
coverage of
services for
PNC, ANC,
birth
preparedness,
skilled birth
attendance,
breastfeeding,
thermal care, &
hygiene.
Control: 32
villages,
n=201
baseline
survey,
n=893
endline
survey.
especially in settings
with high & increasing
demand for facility-
based services.
Postnatal care seeking
Sacks,
Postnatal Care
Experiences
and Barriers to
Care
Utilization for
Home- and
Facility-
Delivered
Newborns in
Uganda and
Zambia (2016)
Uganda,
Zambia
Qualitative:
FGDs with
recently-
delivered
women with
previous home
and facility
deliveries as
part of a larger
evaluation of an
initiative to
promote facility
deliveries in 8
rural districts
Examine
experiences
with, and
barriers to,
accessing
postnatal care
services, in the
context of a
maternal health
initiative.
48 FGDs (6
per district),
n= 393 total
participants
Women who accessed care
largely reported positive
experiences, with Zambian
women generally reporting
more positive interactions
than Ugandan women. The
main reasons given for low
PNC utilization were low
awareness about the need,
fear of mistreatment by
clinic staff, cost and
distance. In half of FGDs,
women described personal
experience or knowledge of
denial or threatened denial
of PNC due to the birth
location. Although outright
denial of care was not
common, women frequently
described various types of
actual or presumed
discrimination because of
having a home birth.
While many women
reported positive
experiences with
postnatal care
utilization, cases of
delay or denial of
postnatal care exist.
As programs
incentivize facility
deliveries, lack of
focus on postnatal
support may place
home-delivered
newborns in “double
jeopardy” due to poor
quality intra-partum
care & reduced access
to PNC.
Relies on
women’s reports
& not broadly
generalizable.
Sivalogan,
Influence of
newborn health
messages on
care-seeking
Zambia
Qualitative:
FGDs & IDIs
with mothers &
health workers
from ten health
Understand the
impact of
newborn care
health messages
on care-seeking
5 FGDs with
6–10
mothers, 26
IDIs
Community perceptions and
local realities were
identified as fundamental to
care-seeking decisions and
influenced individual
The acceptability of
health initiatives, such
as chlorhexidine cord
application, in
community settings, is
Demographic data
were missing for
5 FGDs. Many of
the FGD & IDI
participants
86
practices and
community
health
behaviors
among
participants in
the Zambia
Chlorhexidine
Application
Trial (2018)
centers (5 rural
and 5 peri-
urban/urban).
behavior for
neonates and the
acceptability,
knowledge, and
attitudes
towards
chlorhexidine
cord care among
community
members and
health workers.
participation in particular
health-seeking behaviors.
dependent on
community education,
understanding, &
engagement.
Community-based
approaches, such as
using community-
based cadres of health
workers to strengthen
referrals, are an
acceptable &
potentially effective
strategy to improve
care-seeking behaviors
and practices.
discussed
traditional
perceptions or
practices that they
perceived to exist
or had heard that
individuals in the
community
practiced,
however, the
quantification of
individuals who
actually shared
the discussed
understanding
remains unclear.
Tesfahun,
Knowledge,
Perception and
Utilization of
Postnatal Care
of Mothers in
Gondar Zuria
District,
Ethiopia: A
Cross-
Sectional
Study (2014)
Ethiopia
Community
based, cross-
sectional study
supported by a
qualitative
study conducted
among 15–49
years mothers
who gave birth
during the last
year using
structured
questionnaires
& FGDs
Assess mothers’
knowledge,
perception &
utilization of
PNC.
n=836 total
sample size
distributed
proportion-
ally to each
strata: 131
urban and
705 rural
households
sampled
selected by
systematic
random
sampling
technique
Majority of the women were
aware and considered PNC
necessary; however, only
66.83% of women obtained
PNC. Most frequent reasons
for not obtaining PNC were
lack of time, long distance
to a provider, lack of
guardians for children care,
& lack of service. Place of
residence, distance from a
health institution, ANC visit
& having decision-making
authority for utilization
were factors significantly
associated with PNC
utilization.
Mothers had a high
level of awareness and
perception about the
necessity of PNC.
Urban women & those
who displayed higher
levels of autonomy
were more likely to
use postnatal health
services.
Limited
generalizability as
it focused on one
regional area in
one sub-Saharan
African country.
87
Shafiee, 2016). Grandmothers and other family members play important roles in maternal-
newborn health (Gupta et al., 2015; Moyer et al., 2014). While Maimbolwa and colleagues
(2003) explored cultural childbirth practices and beliefs in Zambia, there remains scant research
documenting recent, broader knowledge and beliefs about newborn care in the country. Health
care providers need to clearly understand the beliefs and health-seeking practices of rural
Zambians from a cultural perspective to provide care and interventions to improve maternal-
child health.
Statement of the Problem
Recognizing the limited research investigating cultural beliefs and health-seeking
practices, the goal of this focus group study was to determine the factors associated with
newborn care in rural Zambia. The specific aims were to:
Aim 1): Describe the knowledge and beliefs about newborn care and illness from the
perspective of rural Zambian women, community members, and health workers.
Aim 2): Examine the similarities and differences in the knowledge and beliefs about
newborn care and illness among rural Zambian women, community members, and health
workers.
Aim 3): Explore the social and cultural factors associated with the ways women seek
newborn care to identify traditional and professional newborn care practices in rural
Zambia.
Research was guided by the following a priori questions:
“What are the cultural beliefs and practices of rural Zambian women with infants
younger than 1-year-old, community members, and health workers that influence
newborn care and health-seeking behavior?”
88
“What are the similarities and differences in knowledge and beliefs of newborn care
among rural Zambian women, community members, and health workers?”
“What social and cultural factors influence newborn care and health-seeking practices
for rural Zambians?”
Theoretical Framework
Bronfenbrenner’s Ecological Systems Theory was operationalized to frame this
qualitative study utilizing focus group discussions for data collection. Acknowledging that
multiple factors affect decision making regarding newborn health, the Ecological Systems Theory
incorporates exogenous ecological environment factors conceived topologically as a nested
arrangement of systems, each contained within the next, including the microsystem, mesosystem,
exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1977, 1979, 1989, 1994). When
the Ecological Systems Theory focuses on maternal-newborn health, the maternal-newborn dyad
represents the microsystem. The mesosystem includes the family and community surrounding
the maternal-newborn dyad. The exosystem incorporates the health care system in rural Zambia.
The macrosystem encompasses culture. Finally, the chronosystem is represented by health policy
in the operationalized Ecological Systems Theory for maternal-newborn health.
Methods
Employing a semi-structured interview guide to orient discussions, focus groups were
used to collect data and gain an understanding of cultural beliefs and health-seeking practices of
rural Zambians related to newborn care and illness. Focus groups were conducted between June
and August 2016 in 20 communities located in Zambia’s rural Lundazi (Eastern province),
Mansa, and Chembe (Luapula province) Districts. Zambian research assistants served as
interpreters. Focus groups in Lundazi District were conducted in the Tumbuka language. In
89
Mansa and Chembe Districts, focus groups were conducted in the Bemba language. Illiteracy in
rural Zambia is substantial with few people able to read or write English. Tumbuka and Bemba
are oral, not written, languages.
Ethical Approval
Institutional Review Board (IRB) approval was sought before beginning the study from
the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board
(HUM00110404), the Zambian IRB equivalent, Excellence in Research Ethics and Science, and
the Zambian National Health Research Authority. Informed, verbal, and written consent were
obtained from focus group participants before discussions (Appendix A).
Setting
The study sites were chosen because they were included in the parent study’s
collaborative research endeavor between 2015-2018 to determine the impact of maternity
waiting homes (MWHs) on facility delivery among women living at least 10 km from health
facilities in rural Zambia (Scott, Kaiser et al., 2018). The purpose of MWHs is to provide a
setting where women can be accommodated during the final weeks of their pregnancy near a
hospital with essential obstetric facilities (WHO, 1996).
Lundazi and Mansa/Chembe Districts.
Research for this focus group study was conducted in the Lundazi District of Eastern
Province along with the Mansa and Chembe Districts of Luapula Province. Table 3.2 displays
the demographic information for Eastern and Luapula Province (Chief Statistics Office, 2015).
The infant mortality rates of 94.9 and 95.6 per 1,000 live births in Eastern and Luapula
Provinces, respectively, are much higher than the overall Zambian national infant rate of 44 per
1,000 live births (Chief Statistics Office, 2015). Figure 3.1 shows a detailed map of Eastern
90
Province in Zambia (Chalo Chatu.org, 2016). The population in the 2010 Census was 308,420
(Chief Statistics Office, 2012). The Tumbuka language is widely spoken in Lundazi District. In
nearly all communities in the district, Tumbuka is the predominant ethnic group (Williams et al.,
1999).
Data were collected in the Mansa and Chembe Districts. Bemba is the language most
widely spoken in Mansa/Chembe Districts; Mansa is the provincial capital of the Luapula
Province of Zambia (Provincial Administration Luapula Province, 2014). Figure 3.2 shows a
map of Luapula Province including Mansa and Chembe Districts (Chalo Chatu.org, 2016).
Chembe is one of the newly created districts in the Luapula Province of Zambia (Provincial
Administration Luapula Province, 2014). Given the newness of Chembe District, limited
district-level health data are available.
Sample
Inclusion criteria.
A purposive sample with three different demographic groups in Lundazi and
Mansa/Chembe Districts in Zambia was used including: 1) Zambian women with infants
younger than 1-year-old; 2) male and female community members older than 18 years, and 3)
male and female professional and community health workers. These three groups were selected
because they were believed to represent different perspectives and beliefs pertaining to health-
seeking practices about maternal-newborn care. Health workers and community members were
included in the focus group study recognizing that their input undoubtedly influences maternal
knowledge of newborn care and support for care-seeking behavior of women with infants
younger than 1-year-old. Women with infants younger than 1-year-old were invited to participate
in the study even if they were younger than 18 years old. All literacy levels were eligible to
91
participate. Only self-identified permanent residents of the study site villages were included. All
other community members were excluded.
Table 3.2 Demographics of Eastern and Luapula Province in 2015 (Chief Statistics Office,
2015).
Demographic
Eastern Province
Luapula Province
Population
1,813,445
1,127,453
Crude Birth Rate (CBR)
45.3 births per 1,000
population
47.2 births per 1,000
population
Crude Death Rate (CDR)
15.6 deaths per 1,000
population
16.9 deaths per 1,000
population
Infant Mortality Rate
94.9 per 1,000 live births
95.6 per 1,000 live births
Total Fertility Rate
6.2 births per woman
6.8 births per woman
92
Figure 3.1 Map of Eastern Province including Lundazi District (Chalo Chatu.org, 2016)
93
Figure 3.2 Map of Luapula Province including Mansa and Chembe Districts (Chalo Chatu.org,
2016)
94
Recruitment
Recruitment for the study was conducted orally by word of mouth through the nurse in
charge at the health facilities and village chiefs. Village chiefs from ten communities in each
district were informed in advance of when the nurse researcher would be coming to their area.
The nurse in charge and village chief announced to community members that the nurse
researcher would arrive on a particular day and stay all day to conduct focus groups (Appendix
B). Focus groups were conducted by the nurse researcher and a Zambian research assistant (RA)
to determine the factors that impact newborn care, illness, and community support in rural
Zambia. The Zambian RA served as an interpreter and was fluent in both English and the local
language (Tumbuka in Lundazi or Bemba in Mansa/Chembe). Participants were provided a small
snack and drink for their time in the focus group.
Data Collection
Data were collected over a period of 3 months between June and August 2016. The study
included (n=646) rural Zambians, comprised of groups of community members (n=208), health
workers (n=225), and women with infants younger than 1-year-old (n=213). The groups of
community members and health workers were heterogeneous with varying ages, compositions of
males and females, number of living children, educational level, and length of time in the
community. The group of women with infants younger than 1-year-old had more homogeneous
demographic characteristics than the other groups.
Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum
of 12 participants. The interviews lasted approximately 60 minutes. The focus groups used a
semi-structured interview guide to explore how rural Zambians understand and describe newborn
care and health-seeking (Appendix C). Before beginning the focus groups, verbal and written
95
informed consent was obtained and each participant completed a demographic questionnaire.
The interpreters asked questions in the local language. The interviews were digitally audiotaped,
transcribed verbatim (and appear that way in the quotations), and 20% were back-translated
before analysis. No names were used in the focus groups or on the audiotapes. The interpreters
and group members were asked to avoid discussing group content outside of the group.
Data Analysis
An inductive iterative process was employed to analyze the focus group data in light of
the operationalized Ecological Systems Theory. Data were analyzed using four main stages
identified by Bengtsson (2016): decontextualization, recontextualization,
categorization, and compilation. To begin, the researcher used a process of decontextualization
to familiarize herself with the transcribed text to obtain the sense of the whole before breaking it
down into smaller coding units (Bengtsson, 2016). The ATLAS.ti (2018) qualitative data
analysis software was used to help organize data from the focus groups. Findings in
transcriptions were coded and evaluated for significance. Coding was deductive, using a
codebook (Appendix D), and inductive, allowing for themes to emerge from the data.
Next, the original text was then reread alongside the final list of meaning units through a
process of recontextualization (Bengtsson, 2016). To ensure focus group context was covered in
relation to the aims, the researcher reread the transcripts and highlighted each quote with a
different color according to identified codes. Few non-highlighted quotes remained. Text that
was not highlighted and did not answer the research questions was excluded from analysis.
Categorization with latent content analysis was used to identify themes and categories. The
researcher sorted and classified by similar thematic content and separated into smaller categories
based on the aims of the focus group study. When saturation was reached, categorization was
96
stopped. Next, the researcher immersed herself in the data to identify meanings in the text and
chose meaningful units to present as quotations (Bengtsson, 2016). Finally, the researcher added
information by performing quantification in which responses within themes and categories were
counted then compared to examine similarities and differences across groups.
Rigor for the focus group study was established using Lincoln and Guba’s (1985) model
for addressing components of trustworthiness that are relevant to this study: (a) truth–value
(credibility), (b) applicability (transferability), (c) consistency (dependability), and (d) neutrality
(confirmability). Credibility, similar to internal validity when using quantitative methods, is the
element that allows others to recognize the experiences contained within the study through the
interpretation of participants' experiences (Thomas & Magilvy, 2011). Transferability refers to
the ability to transfer research findings or methods from one group to another, equivalent to
external validity in qualitative research (Lincoln & Guba, 1985). Dependability, related to
reliability in quantitative terms, occurs when another researcher can follow the decision trail used
by the researcher (Thomas & Magilvy, 2011). Confirmability, similar to objectivity in
quantitative terms, occurs when credibility, transferability, and dependability have been
established (Thomas & Magilvy, 2011).
To preserve trustworthiness, an audit trail was maintained. Audit trails are comprised of a
variety of researcher-generated data that must be consistently recorded and organized throughout
the research process (Rodgers & Cowles, 1993). Lincoln and Guba (1985) discuss six categories
of information that need to be collected to inform the audit process: 1) raw data, 2) data
reduction and analysis notes, 3) data reconstruction and synthesis products, 4) process notes, 5)
materials related to intentions and dispositions, and 6) preliminary development information. A
97
comprehensive audit trail generally has four basic types of documentation including contextual,
methodological, analytic, and personal response (Rodgers & Cowles, 1993).
Detailed field notes were taken through observation, active listening, participation,
reflection, and reconfirmation of findings in the environment with Zambian women, community
members, and health workers to understand and describe newborn care and illness. Critical
reflection entails a deeper level of reflection whereby researchers examine the assumptions (i.e.
beliefs, values, ideas) that guide their actions (Fook & Gardner, 2007). Using Fook and
Gardner’s (2007) model, Maharaj (2016) prepared a list of questions that I kept in mind when
reflecting upon field notes:
• What do these notes suggest regarding my beliefs and values about myself, my
relationships with others, and my assumptions about knowledge, power, and privilege?
• How do I understand my role in this setting (observer/participant, insider/outsider)?
• How well does my account align with my beliefs and values?
• What kinds of words (emotions) and language (formal/informal) did I use?
• What did I leave out of my notes and why?
• How did the fact that I was taking notes impact my understanding of the situation?
• How did my presence as an observer influence others around me?
When taking field notes, I was mindful to avoid using my own beliefs and values in
judging what focus group participants deemed normal and appropriate maternal-newborn care
and health-seeking in rural Zambia. I made a conscious effort to be broad-minded and use
nonjudgmental words in my notes. I also strived to maintain open body language during my
observation of focus groups.
98
Findings
Demographic characteristics of the focus group study participants are shown in Table 3.3.
In the overall sample, most participants were married (86.8%) and female (71.6%). The average
age was 37 years, while the average time living in the community was 25 years. Among the 646
total participants, focus groups were made up of a similar number of participants among
community members (n=213), health workers (n=208), and women with infants younger than 1-
year-old (n=225). In terms of educational level, 6.2% had no formal education, 12.5% had a
lower primary level (Grades 1-4), and 32.7% had an upper primary level (Grades 5-7) of
education.
Women with infants younger than 1-year-old (n=213) were, on average, 26 years old.
The vast majority were married (n=183) with 1-5 living children (n=179). Almost half (n=105)
had a primary education (Grades 1-7) while 7 percent had no education (n=15). Women with
infants younger than 1-year-old had lived an average of 16.8 years in the community.
Community members (n=208) were, on average, 39 years old. A substantial majority
were married (n=190) and 58.2% had 1-5 living children (n=121). Fifty percent (n=103) had a
secondary education (Grades 8-12) while nearly 5 percent had no education (n=10). Community
members had lived an average of 26.9 years in the community.
Health workers (n=225) were, on average, 45 years old. Most were married (n=182) and
nearly half had 1-5 living children (n=105). More than half (n=131) had a secondary education
(Grades 8-12) while 4 percent had a tertiary education (n=9). Health workers had spent an
average of 31.6 years in the community.
99
Table 3.3 Focus group participant characteristics
Demographic
Characteristic
Total
(n=646)
Women w/ Infants <1yr
33.0% (n=213)
Community Members
32.2% (n=208)
Health Workers
34.8% (n=225)
District
% (n)
% (n)
% (n)
% (n)
Lundazi
49.2% (318)
49.3% (105)
51.4% (107)
47.1% (106)
Mansa/Chembe
50.8% (328)
50.7% (108)
48.5% (101)
65.1% (119)
Age (years)
Range
15-88
15-65
18-77
18-88
Mean (SD)
37 (13.3)
26 (8)
39.3 (11.9)
45 (11.5)
Missing
0.5% (3)
0.5% (1)
0.5% (1)
0.4% (1)
Sex
Male
28.4% (183)
None
38.0% (79)
44.0% (99)
Female
71.5% (462)
100% (213)
62.0% (129)
55.6% (125)
Missing
0.2% (1)
None
none
0.4% (1)
Marital status
Married
85.9% (555)
89.2% (190)
88.0% (183)
80.9% (182)
Single
4.6% (30)
1.9% (4)
4.3% (9)
7.6% (17)
Widowed
2.6% (17)
1.4% (3)
2.9% (6)
3.6% (8)
Separated/Divorced
5.9% (38)
6.6% (14)
4.3% (9)
6.7% (15)
Missing
0.9% (6)
0.9% (2)
0.5% (1)
1.3% (3)
Number of living children
0
2.2% (14)
0.5% (1)
4.3% (9)
1.8% (4)
1-5
62.7% (405)
84.0% (179)
58.2% (121)
46.7% (105)
6 and above
34.5% (222)
15.0% (32)
36.5% (76)
50.7% (114)
Range
0-16
0-9
0-16
0-14
Mean (SD)
4.5 (2.7)
3.2 (2.0)
4.7 (2.7)
5.5 (2.7)
Missing
0.8% (5)
0.5% (1)
1.0% (2)
0.9% (2)
Education level
None
4.8% (31)
7.0% (15)
4.8% (10)
2.7% (6)
Lower (1-4) &
42.4% (274)
49.3% (105)
43.8% (91)
34.7% (78)
100
Upper Primary (5-7)
Junior (8-9) & Senior
Secondary (10-12)
49.2% (318)
39.4% (84)
49.5% (103)
58.2% (131)
Tertiary
2.2% (14)
0.9% (2)
1.4% (3)
4.0% (9)
Missing
1.4% (9)
3.3% (7)
0.5% (1)
0.4% (1)
Time in community (years)
Range
1-88
1-65
1-68
1-88
Mean (SD)
25.2 (16.1)
16.8 (11.3)
26.9 (15)
31.6 (17.5)
Missing
0.5% (3)
0.5% (1)
0.9% (2)
none
101
Themes
The following themes emerged from each of the groups independently: from women with
infants younger than 1-year-old, (1) traditional newborn protective rituals; from community
members, (2) a strong sense of family and community to protect the newborn, and from health
workers, (3) an avoidance of shame. A fourth theme, essential newborn care, was common
among all groups. Table 3.4 summarizes themes and categories from the focus groups. A
description of each theme follows in this section along with supporting quotations.
Women with Infants Younger Than 1-Year-Old
Traditional newborn protective rituals.
When conducting focus groups with women with infants younger than 1-year-old,
participants most often mentioned using traditional newborn protective rituals when caring for
newborns. Categories of protective rituals included prevention of cough and pneumonia, care of
the umbilical cord, and early introduction of porridge to the newborn.
Prevention of cough and pneumonia.
Women with infants younger than 1-year-old described the ritual use of fire and sperm to
prevent cough and pneumonia. The belief, as explained by interpreters in both districts, is the
sperm of the man will make the baby strong and prevent cough. The words used to label
traditional practices were different based on whether participants spoke Bemba or Tumbuka, but
the essence of the health belief was similar in both districts. As one woman with an infant
younger than 1-year-old in Lundazi District explained:
When the baby is a month old we prepare fire in the house where we live. Then we will
have sex that night [and] after having sex we will spread the sperms to the joints of the
baby. After this [is] done, we pass the baby back and forth over the fire to make the baby
strong and keep from unnecessary coughs.
102
Table 3.4 Summary of themes and categories emerging from focus groups
Group
Theme
Category
Women with infants
under one year
Traditional newborn
protective rituals
Prevention of cough and pneumonia
Care of the umbilical cord
Early introduction of porridge
Community
members
Strong sense of family
& community to
protect the newborn
Husbands and maternal-newborn health
Grandmothers and maternal-newborn
health
Community members and maternal-
newborn health
Health workers
Preservation of
dignity
Cultural concerns related to maintaining
privacy
Social concerns about partner’s fear of
HIV/STI testing.
Women with infants
under one year,
community
members, &
health workers
Essential newborn
care
Pregnancy and postpartum care
Breastfeeding
Newborn danger signs
Immunizations
103
In both districts, this ritual of preparing a special fire and protective use of sperm is usually
performed when the baby is about 1 month old. Traditional herbs are placed in the fire with the
expectation that the smoke will clear the lungs and avert cough. As a woman with a baby
younger than 1-year-old in Mansa District described:
When a child has a cough it means the father to the child was having sex with other
women and when he returned home he touched the child. They would be advised by
elders to have sex then [the] husband must release his sperms on his hand to spread [over]
the sick baby.
Women with infants younger than 1-year-old in the focus group study acknowledged that they
usually do not talk about traditional newborn protective rituals involving the prevention of cough
and pneumonia at the rural clinics because they’ve been told by health workers not to engage in
cultural newborn care.
Care of the umbilical cord.
Many women with infants younger than 1-year-old mentioned the use of herbs and
powders on the umbilical cord to make it heal and fall off faster so they can carry the baby on
their back. One mother mentioned, “We get traditional herbs and put it round the baby’s cord so
that it falls off faster.” Several women mentioned their grandmothers and mothers-in-law, in
particular, promote the practice of applying traditional herbs to the umbilical cord. They made a
point of mentioning in focus groups that they avoid bringing herbs to the clinic because “they
would be confiscated by nurses.”
There was a commonly expressed belief that the umbilical cord should not fall between
the baby’s legs or else the baby would be at risk for infertility. The baby is not placed on their
back to sleep or carried by the mother on her back until the cord falls off so that the cord will not
fall between the legs.
104
Women often cited traditional rituals involving the disposal of the umbilical cord after
the stump falls off. A woman with a baby younger than 1-year-old from Lundazi explained:
When the cord falls off we dig a hole in the bush under the tree. The part where the
umbilical cord touched the skin should face up and were the doctor tied should face down
when burying it for fear that the mother may not have another child in future.
The special tree chosen by the family is a sacred place blessed by ancestors and the umbilical
cord stump, along with other offerings throughout the year, will bring good harvests. It is
believed that to view the cord stump will lead to future infertility.
Early introduction of traditional porridge.
Another frequently mentioned traditional newborn protective ritual in both districts is the
early introduction of traditional herbs mixed as a porridge when the child is about 1 month old to
“make the baby strong and healthy.” There is a belief that parents should abstain from
intercourse during the newborn period and that they can resume sexual relations when the baby
is a month old as long as they give the baby a protective porridge made of traditional medicine.
According to a woman in Mansa District, “We give herbs mixed with porridge at 1 month to
keep them from getting diseases.” However, women in the study with infants younger than 1-
year-old mentioned that they do not discuss the use of herbs at the clinic because they would be
“scolded by midwives.”
Community Members
Strong sense of family and community to protect the newborn.
Among focus groups with community members, the main theme was a strong sense of
family and community to protect the newborn. In rural Zambia, family and community support
are important influences on newborn care and health-seeking. Husbands and maternal-newborn
health, grandmothers and maternal-newborn health, and community members and maternal-
105
newborn health composed categories within this theme. Focus groups in both geographical areas
with community members expressed a strong desire to protect newborns and play important roles
in maternal-newborn health.
Husbands and maternal-newborn health.
In rural Zambia, men typically occupy the roles of head of households and key decision
makers in whether a woman adheres to traditional newborn cultural care practices or accesses the
professional health system. Husbands propagate and persuade women to maintain traditional
newborn protection rituals in a variety of ways. In an attempt to encourage monogamy, as
described by a female community member in Lundazi District, it is believed:
When a woman is pregnant [she] is not supposed to have sex with any other man but the
husband only for fear that the woman may die while delivering and the man is not to have
sex or have a girlfriend for fear of the same reason.
One female community member in Mansa District noted:
When your husband is seeing someone and it happens that you meet that person you can
collapse and maybe die. Sometimes you can die if your husband is sleeping around while
you are pregnant and no one knows about the pregnancy.
In the same vein, in both Lundazi and Mansa/Chembe Districts of Zambia, it is believed that
vernix caseosa is sperm and makes the baby and woman unsanitary. A male community member
in Mansa mentioned that when the woman is in the eighth month of pregnancy, “she should not
sleep with her husband to avoid the baby coming out with sperms on their head.” Community
members in the study talked about the importance of “following the wishes” of the husband
when deciding how to protect the newborn and when to go to the clinic.
Grandmothers and maternal-newborn health.
Grandmothers also possess a strong sense of responsibility to protect the newborn and
greatly influence a woman’s decision to follow cultural or health system newborn care practices
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in rural Zambia. Several community members in both districts describe the role of grandmothers
and the use of traditional medicine in maternal-newborn health. A female community member in
Lundazi stated:
When we have prolonged labor in the village, our grandmothers prepare medicine to ease
the pain and deliver faster. This is known and it’s not allowed in the hospital
because they say it may destroy both the life of the child and mother.
Traditional herbs are often used in cultural maternal-newborn care practices in rural Zambia, but
women are reluctant to divulge their use because health workers do not allow them to be used in
facilities. In the health system, nurses and midwives spread health education messages about the
potentially harmful effects of traditional medicine used in maternal-newborn care. As described
by a male community member in Mansa, grandmothers assist women who are interested in
speeding labor to avoid pain:
Some women like to deliver from home because their grandmothers or other relatives
give them traditional herbs to deliver without much pain and faster. Where at the hospital
is not allowed it may destroy both the life of the child and mother.
In focus groups, community members expressed the need to follow the advice of the “elder
women” because “they know what is best for mothers.”
Community members and maternal-newborn health.
Along with family, community members in rural Zambia have a strong sense of
responsibility to protect newborns. In focus groups with community members, there was an
often-cited belief that no single or unmarried people in the community should touch the newborn
baby or the baby risks death or infertility. According to a female community member in Mansa
District:
Immediately [after] a baby is born only selected people are to touch the baby like the
grandmothers and other elderly people but not and strictly not the singles or divorces for
fear that the child may die in case they are just from having sex which is considered to be
dirty to touch the baby.
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A female community member in Lundazi commented, “Immediately after a baby is born, anyone
who is unmarried should not touch it for fear that the baby may have or develop a cough.”
Community members in the study spoke about how neighbors and friends of mothers have a
“duty to protect” everyone in the village “no matter what their age.”
Health Workers
Preservation of dignity.
The theme to arise from focus groups with health workers was the cultural and social
preservation of dignity. In both districts, when health workers were asked to discuss reasons for
women not seeking ANC, participants mentioned the following categories: lack of privacy at the
clinic and partner’s fear of HIV/STI (sexually transmitted infections) testing.
Cultural concerns related to maintaining privacy.
Health workers frequently said that a cultural desire by women not to be seen naked by
male nurses in the maternity ward led to hesitancy to deliver at the facility. According to a
female health worker in Lundazi, “Women don’t attend ANC because they feel shy and fear
exposure to opposite sex health personnel at the clinic.” Along this line was the frequent
discussion of a lack of privacy in the tight quarters of a delivery room. A female health worker in
Mansa explained:
There’s no privacy at the facility because they are using a [converted] office as an
examination place. [This] makes the woman uncomfortable to deliver at the facility
because there is no maternity ward. If the midwife wants to talk in a labor ward everyone
outside hears.
There is a widely held belief in rural Zambia that no man outside of the home should see a
woman without clothes on. Furthermore, pregnant women believe it is embarrassing if others
hear them groan or cry during labor.
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Social concerns about HIV/STI testing.
During the first ANC visit, per Zambian Ministry of Health officials, guidelines stress the
importance of partner testing for HIV and various STIs. A female health worker in Mansa
explained, “Men don’t like to be tested with women for HIV/STIs.” A male health worker in
Mansa said, “Three-quarters of our men do not come for tests like HIV, syphilis and other
diseases [because] they say it is for women only. Hence, they end up delivering from home.” In
Lundazi, a health worker stated:
The first antenatal visit is a challenge to most of the pregnant mothers because husbands
refuse to go with their wives for fear of being tested for HIV/AIDS and syphilis.
Husbands say once they know their status is positive he will kill himself to avoid being
known by family members, friends, and community that he is sick.
Health workers in the study said that the most common reason men do not participate in
antenatal pregnancy care is their desire to avoid STI testing.
Common to All Focus Groups
Essential newborn care.
The theme that was common across all types of focus groups was an understanding of
essential newborn care. Responses were placed in the theme of essential newborn care if focus
group participants mentioned newborn care and care-seeking according to pregnancy, childbirth,
postpartum, and newborn care (PCPNC) guidelines published by the WHO and UNICEF (2015).
The PCPNC includes recommendations from approved WHO guidelines relevant to maternal
and perinatal health including: preeclampsia and eclampsia, postpartum hemorrhage, postnatal
care for the mother and baby, newborn resuscitation, prevention of mother-to-child transmission
of HIV, HIV and infant feeding, malaria in pregnancy, interventions to improve preterm birth
outcomes, tobacco use and secondhand exposure in pregnancy, postpartum depression,
postpartum family planning, and post-abortion care (WHO & UNICEF, 2015). The categories
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supporting this theme include pregnancy and postpartum care, breastfeeding, newborn danger
signs, and immunizations.
Pregnancy and postpartum care.
Many participants in all groups were able to state the importance of pregnancy and
postpartum care including attending ANC, facility delivery, and PNC, and correctly identified
maternal-newborn danger signs during delivery and the postpartum period as outlined in the
PCPNC. As one woman with a baby younger than 1-year-old in Mansa mentioned:
Family and friends advise us to go early for antenatal visits because ladies don’t hide any
secrets. They also tell us to go for medications in case the baby is not in a good position
to help your friend from dying. Sometimes if a person is pregnant she is in danger and
should go to the clinic.
In Lundazi, a female community member commented that after birth in the clinic, “They
discharge mothers and tell her to come at 6 days for postnatal checkups for both the baby and the
mother and also third postnatal at 6 weeks to check for the baby.”
Breastfeeding.
Numerous participants in all groups in both districts were able to identify the importance
of breastfeeding. A woman with a baby younger than 1-year-old commented, “At the clinic they
emphasize the mother to start breastfeeding the baby immediately after the baby is born and they
discharge the woman only after first seeing that the baby has start breastfeeding.” A male health
worker in Mansa mentioned, “The mother should breastfeed the child the first milk because it is
the most nutritious milk ever. The mother should be clean always and the baby too.”
Newborn danger signs.
All focus group participants in both districts correctly cited newborn danger signs as
reasons for taking newborns to the clinic, such as convulsions, difficulty breathing, and fever. A
female community member in Lundazi District noted, “These days we take the baby to the clinic
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either coughs, fever or fitting [seizures].” A male community member in Mansa said that the
community health workers, “Emphasize to us to bring the baby to clinic to see if the baby is
gaining or losing because some gain more weight abnormally because some do reach that line
when they have feeding difficulties.”
Immunizations.
In all groups in both districts, most participants expressed understanding of the
importance of returning to the clinic for immunizations as the newborn grows. A woman with a
baby younger than 1-year-old in Lundazi stated, “When the baby is born the nurse will tell us to
be bringing the baby for under five visits to receive some prevention injections like BCG
[Bacillus Calmette-Guerin vaccine for tuberculosis].” As stated by a female community member
in Mansa, “We need to observe hygiene and the food which the baby may eat should be soft and
also the vaccines like polio, BCGs and all the 4 injections rota (rotavirus) and pcv
[pneumococcal conjugate vaccine] are necessary.”
Similarities and Differences Among Focus Groups
Similarities among types of focus groups.
Women with infants younger than 1-year-old, community members, and health workers
in both districts mentioned the same theme pertaining to essential newborn care. Themes
brought up among communities with and without a MWH were similar. The similarity in themes
brought up independently by focus groups across geographic areas was surprising. We expected
there would be distinct differences in responses between districts where focus groups were
conducted. We anticipated finding more differences given the likely range between cultures,
education, stages of development, population diversity, and access to health care between
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districts. Findings point to wide-ranging pervasive cultural and health system influences on
newborn care in rural Zambia.
Differences among types of focus groups.
There were some differences among groups in the frequency in which themes were
mentioned and in how many times categories were mentioned among groups and districts. Also,
there were a few notable differences in expressive style among focus groups. Community
members were least likely to mention the essential newborn care theme compared to women
with infants younger than 1-year-old and health workers in both districts. While it is
commendable that community members mentioned an understanding of newborn care in focus
groups, their discussion of this theme being less frequent than that of other groups focuses our
attention on the importance of targeting community members for maternal-newborn health
education.
On the whole, health workers were more expressive, giving a greater number of total
responses with longer replies to questions than women with infants younger than 1-year-old and
community members. Regarding the understanding of essential newborn care, it is predictable
that health workers mentioned the theme a greater number of times than other groups. This could
be explained by higher levels of education and literacy leading to a greater knowledge of
maternal-newborn health care among health workers.
Geographic differences.
Although few geographic differences existed, focus group participants in Lundazi more
often mentioned traditional newborn protective rituals than participants in Mansa/Chembe
Districts. The greater number of responses in this theme likely demonstrates the continued
adherence to traditional health beliefs in Lundazi District. Moving forward, it is of utmost
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importance to be mindful of the traditional maternal-newborn health beliefs and newborn care
practices in rural regions. The high number of responses in the traditional newborn protective
rituals theme in Lundazi highlights the importance of understanding the local context and
existing beliefs and health-seeking practices before proposing any policy changes. Conversely,
participants in Lundazi focus groups were less likely to mention essential newborn care than
those in Mansa/Chembe. Perhaps this finding signifies that less exposure to health education at
facilities impacts their continued adherence to traditional cultural beliefs.
Participants in Mansa/Chembe were more verbally expressive than in Lundazi in all focus
groups, giving a higher number of responses than in Lundazi even though the numbers of
participants were well matched. Mansa District is in the Luapula provincial capital with a better
road network than in Lundazi District. Focus group participants in Mansa/Chembe more often
mentioned essential newborn care than those in Lundazi. Given the potentially easier access to
health facilities in Mansa due to the better road network, participants could over time have more
exposure to care and health education at health facilities thereby explaining their increased
likelihood of mentioning and understanding essential newborn care.
Discussion
This focus group study described newborn care beliefs and health-seeking practices while
examining the cultural and health system factors associated with the ways women seek care from
the point of view of rural Zambian women with infants younger than 1-year-old, community
members, and health workers. Themes at the levels of culture (macrosystem) and health care
system (exosystem) were uncovered that support the identification of traditional and professional
newborn care practices in rural Zambia. Keeping these themes in mind, along with
Bronfenbrenner’s (1994) proposition that human development takes place through processes of
progressively more complex reciprocal interaction between an active, evolving biopsychological
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individual and the people, objects, and symbols in its immediate environment, nurses and
midwives can engage in health promotion practices aimed at improving newborn care and
reducing illness. This study adds to the literature about cultural beliefs and practices of rural
Zambians related to newborn care and health-seeking practices that influence maternal-newborn
health. Findings from this first study informed the design of the 2nd and 3rd studies by providing a
basis for understanding the rural Zambian context.
Substantiation of themes
Findings from focus groups relating to traditional newborn protective rituals
(macrosystem) are consistent with various other studies in Zambia. Participants relayed
culturally specific prevention of cough, care of the umbilical cord, early introduction of
traditional porridge, familial roles, and community support. The use of traditional herbs and
powders when caring for the umbilical cord corroborates findings from other studies in Zambia
(Hamer et al., 2015; Herlihy et al., 2013; Maimbolwa et al., 2003; Sacks et al., 2015; Siwila,
2015).
Encouragingly, in all focus groups, participants were knowledgeable about essential
newborn care. Overall, knowledge among participants verbalized understanding about the
importance of exclusive breastfeeding while results related to the early initiation of
complementary foods as protective factors is similar to findings reported by Gewa &
Chepkemboi (2016) and Katepa-Bwalya et al. (2015). The importance of familial roles and
involvement of family members in mother-newborn care seeking in Zambia has been
documented previously (Gabrysch, McMahon, Siling, Kenward, & Campbell, 2016; Sialubanje,
Massar, Hamer, & Ruiter, 2015; Sialubanje et al., 2016) as has the use of traditional medicine
during labor (Dika, Dismas, Iddi, & Rumanyika, 2017; M'soka, Mabuza, & Pretorius, 2015).
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Preservation of dignity (exosystem), reasons for not seeking antenatal care, and motives
for home delivery were also identified by other studies in Zambia (Lori, Munro-Kramer, Mdluli,
Musonda, & Boyd, 2016; Phiri, Fylkesnes, Ruano, & Moland, 2014; Sacks et al., 2017;
Sinyange, Sitali, Jacobs, Musonda, & Michelo, 2016). The desire to preserve dignity and avoid
being shamed by lack of privacy at the clinic and fear of receiving partner testing for STIs are
important findings for health care providers to keep in mind when caring for pregnant women.
To preserve dignity, changes are needed in rural Zambia to ensure the environment and facilities
are mother and baby friendly, including:
1. Care is provided in a comfortable, clean, safe setting that promotes the well-
being of women, newborns, families, and facility staff.
2. Women’s needs, preferences, and privacy are respected.
3. The physical environment supports normal birth outcomes for the woman and
baby (International Confederation of Midwives, White Ribbon Alliance,
International Pediatric Association, & World Health Organization, 2015).
Maternal Duality
Linked together, the themes emerging from focus groups point toward a maternal duality
for women in rural Zambia. Women with infants younger than 1-year-old in rural Zambia likely
experience a dualistic sense of responsibility to satisfy both cultural and health system
expectations when caring for their newborns (Figure 3.3). Women are pulled to engage in
traditional protective newborn care rituals while at the same time being pushed to attend ANC
and deliver at the health facility. Contributing to this dueling push-pull felt by mothers, in several
communities in both Lundazi and Mansa/Chembe Districts, women face fines by chiefs and
community leaders for failing to attend ANC or deliver at the health facility. In Zambia, Greeson
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Figure 3.3 Maternal Duality between culture and health system in rural Zambia
116
and colleagues (2016) researched the frequency and perception of penalties for home delivery
and found that while communities largely supported the use of penalties to promote facility
delivery, the penalties introduced a new tax on poor rural women and may have deterred their
utilization of postnatal and child health care services. Researchers viewed the imposition of
penalties as a punitive adaptation that can impose new financial burdens on vulnerable women
and contribute to widening health, economic, and gender inequities in communities (Greeson et
al., 2016). These penalties add an additional layer of complexity and probable pressure on
women to meet health system responsibilities.
The emergence of the strong sense of family and community to protect the newborn
theme in focus groups with community members adds strength to the argument that women are
pulled to meet cultural responsibilities placed on them by those outside the maternal-newborn
dyad. Women likely feel pressured by husbands, grandmothers, and community members to
maintain rural Zambian cultural beliefs about newborn care. In the health workers’ focus groups,
the uncovering of the preservation of dignity theme sheds light on the dichotomy women feel
when considering access to the rural Zambian health system. According to health workers,
women face barriers to meeting health system responsibilities because of a lack of privacy in
facilities and a reluctance by their husbands to undergo partner testing for STIs. Again, even in
the minds of health workers, women are being pulled in two different directions. They might
recognize the need to meet health system responsibilities, but they feel compelled to satisfy
responsibility to culture and family.
The maternal dualism felt by women to fulfill both cultural and health system
responsibilities when caring for their newborns undoubtedly causes undue stress and anxiety for
new mothers. Future studies should explore this maternal duality to better understand how nurses
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and midwives can meet the psychosocial needs of this population. In rural Zambia, individual
interviews with women rather than focus groups could be considered for a follow-up study
allowing for confidentiality to be fostered as participants might be reluctant to express maternal
duality in the open forum of a focus group.
Implications for Practice
Numerous implications for nursing practice emerged from this ecological systems
investigation of cultural beliefs and health-seeking practices of rural Zambians related to
newborn care. Traditional cultural practices reflect values and beliefs held by members of a
community for periods often spanning generations (OHCHR, 1995). Every social grouping in the
world has specific traditional cultural practices and beliefs, some of which are beneficial to all
members, while others are harmful to a specific group, such as women and newborns (OHCHR,
1995). Nurses and midwives can promote the maintenance of cultural beliefs that benefit or at
the very least do no harm to the mother-newborn dyad (microsystem) while encouraging the
reframing of potentially detrimental practices.
Within the traditional newborn protective rituals (macrosystem) and strong sense of
family & community to protect the newborn (mesosystem) themes, there were findings about the
culture-specific prevention of cough, care of the umbilical cord, and early introduction of
traditional porridge that carry implications for nursing practice. Cultural practices that are not
harmful to the maternal-newborn dyad should be encouraged. For example, the traditional
protective rituals to prevent cough and pneumonia involving fire and sperm have long-standing
cultural roots and could be maintained – provided the newborn is not exposed to smoke for
extended periods of time and the risk of burns is mitigated. On the other hand, the application of
potentially harmful herbs and powders on the umbilical cord should be discouraged. Instead, an
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alternative would be for nurses and midwives to advocate the use of daily chlorhexidine (4%)
application to the umbilical cord stump during the first week of life to replace application of a
harmful traditional substance to the cord stump (WHO, 2014).
To address the reluctance of rural Zambians to place newborns on their back to sleep
until the cord falls off, nurses and midwifes can deliver culturally appropriate messages about
safe sleep. Health professionals should educate mothers that when the newborn is not placed in a
supine position to sleep it may contribute to aspiration or choking (NICHD, 2018) or place the
child at risk for Sudden Infant Death Syndrome (AAP, 2016). Meanwhile, the introduction of
traditional herbs mixed as a porridge at 1 month of age should be discouraged. The WHO
(2018b) recommends that infants start receiving complementary foods at 6 months of age in
addition to breast milk.
Regarding familial roles in the macrosystem, nurses and midwives have a duty to foster
those that promote the health of the mother-newborn dyad. Beliefs inspiring monogamy by
partners during pregnancy should not be discouraged--especially in light of the dangers of
mother-to-child transmission of HIV/AIDS. The belief that no single or unmarried person in the
community should touch the newborn baby is a protective ritual practiced by community
members that reduces exposure to infection and controls the spread of disease. The often-
mentioned recommendation by grandmothers to use traditional medicines to speed labor should
be approached with sensitivity by health care professionals. Many countries have their own
traditional or indigenous forms of healing that are firmly rooted in their culture and history
(WHO, 2013). Nurses, midwives, and community health workers can incorporate the potential
for harmful effects to the mother and newborn into health education messages.
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Concerning the preservation of dignity (exosystem) theme, there is an obvious need for
nurses and midwives to promote privacy and modify clinic spaces to allow women to feel more
comfortable seeking care. Furthermore, it is important for nurses and midwives to reinforce the
importance of partner testing for STIs during routine ANC even though there is a desire to
preserve dignity. Achieving higher rates of partner HIV testing and couples testing among
pregnant and postpartum women in sub-Saharan Africa is essential for the success of
combination HIV prevention, including the prevention of mother-to-child transmission (Masters
et al., 2016).
Limitations
Several limitations in this focus group study are worth mentioning. This was a purposive
sample in two rural districts in Zambia and results cannot be generalized nor do they reflect
changes over time. Findings expose the experience of focus group participants recruited at rural
primary care health centers. The viewpoints of those not accessing the Ministry of Health
facilities were not obtained, therefore, findings might not be applicable to those not seeking care
in the clinics.
Furthermore, as with all research based on focus group methodology, an inherent power
differential existed between participants and researcher. Another power differential occurred
because recruitment was conducted by the nurse in charge and village chief, who are leaders in
the community, and potential existed for participant selection biases. To address these
limitations, the principal investigator situated herself within the local context, was mindful of
power dynamics, and cultivated cultural humility through a process of reflection and by
challenging her own cultural biases. I valued the insights offered by interpreters as I attempted to
create a dialogue of understanding between me as an observer/outsider and focus group
participants/insiders. I discussed the interpreters’ description of the cultural meaning of the
120
mother-newborn care phenomenon with Zambian Ministry of Health staff and nongovernmental
organization staff not participating in the focus groups to review what I observed and share
reflections on conversations. I nurtured a strong relationship with partners from within the
Ministry of Health at the district level. I wanted to make sure that I was not misrepresenting or
discounting the culture of the groups included in the study. I also engaged in discussions with
Zambian colleagues to gain a better understanding of the similarities and differences among
focus group participants, potentially in ways that reflect privilege and power in their
communities.
Use of local languages by participants within the communities and the lack of elaboration
on a topic due to low literacy level could influence the researcher’s ability to understand fine
distinctions in meaning. Interpreters mitigated this potential limitation by being fluent in both
local languages and English. They provided assistance in deciphering the cultural meaning of the
mother-newborn care phenomenon while interpreting audio recordings and verbatim
transcriptions of focus groups. Even with back-transcription of 20% of the focus groups, there is
the potential for loss of meaning within the translations. Another limitation could be the
inclusion of only the predominant local language as eligibility to participate in the focus groups.
Conclusion
These findings shed light on the beliefs and practices of rural Zambian women,
community members, and health workers related to newborn care and health-seeking practices.
Traditional newborn protective rituals and professional newborn care practices were identified.
Findings also revealed a strong sense of family and community to protect the newborn using
traditional belief systems. Positively, in general, rural Zambians have an understanding of
essential newborn care according to WHO guidelines. The study uncovered a maternal duality
between cultural and health system responsibilities faced by women caring for newborns.
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While this focus group study provides important information, development of further
research is vital to understand the maternal duality experienced by women with infants younger
than 1-year-old as they strive to balance responsibilities associated with traditional protective
newborn care rituals and essential newborn care practices. This focus group study lays the
groundwork for developing future research to explore the push-pull felt by mothers navigating
cultural practices and health system regulations to inform future interventions aimed at
improving newborn care in rural Zambia where far too many newborns still face serious
morbidity or death. It would be helpful to develop, validate, and collect data using an instrument
to measure understanding of essential newborn care. Then, a mixed-message approach could be
used to conduct individual interviews with women about cultural responsibilities and to collect
data using an instrument measuring understanding of essential newborn care to further explore
the concept of maternal duality in rural Zambia.
Moreover, a targeted exploration of the family’s sense to protect the newborn is
warranted to understand whether it is necessary to recommend policies in Zambian to increase
involvement by husbands and grandmothers in routine professional maternal-newborn health
care. Additional research should investigate the roles of husbands, grandmothers, and community
members and explore their understanding of the benefits of their involvement in pregnancy and
postpartum maternal-newborn care.
In conclusion, this focus group study described knowledge and beliefs about newborn
care while examining the social and cultural factors associated with the ways women seek care
from the perspective of rural Zambian women, community members, and health workers.
Similarities and differences in knowledge and beliefs of newborn care were explored to identify
traditional and professional newborn care practices in rural Zambia. Attention should be given to
122
the maternal duality experienced by women pulled between fulfilling cultural and health system
responsibilities. Findings can be used to inform future interventions aimed at improving
maternal-newborn care.
123
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CHAPTER 4
Maternal Knowledge of Essential Newborn Care in Rural Zambia
Introduction
Newborn care-seeking behavior of mothers relies heavily on their knowledge of newborn
care. Although studies are limited on how to assess maternal knowledge of newborn care and
danger signs (Kibaru & Otara, 2016; Nigatu, Worku, & Dadi, 2015; Senarath et al., 2007), it has
been shown that poor knowledge of newborn danger signs delays care seeking (Sandberg et al.,
2014). The expanded purpose of many maternity waiting homes (MWHs) is to increase newborn
health knowledge (World Health Organization [WHO], 1996). MWHs are accommodations
located near a health facility where women can stay toward the end of pregnancy and/or after
birth to enable timely access to essential childbirth care or care for complications (Penn-Kekana
et al., 2017). The availability of a MWH allows decision making to take place as part of birth
preparedness (Vermeiden & Stekelenburg, 2017). One way to advocate for the health of the
maternal-newborn dyad is by encouraging pregnant women to utilize MWHs (Buser & Lori,
2016).
Maternity waiting homes can be located near facilities that provide Basic Emergency
Obstetric and Newborn Care (BEmONC) or Comprehensive Emergency Obstetric and Newborn
Care (CEmONC). The functions that a BEmONC facility can provide include: (1) administering
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parenteral antibiotics, (2) administering uterotonic drugs, (3) administering parenteral
anticonvulsants, (4) manually removing the placenta, (5) removing retained products, (6)
performing assisted vaginal delivery, and (7) performing basic neonatal resuscitation (WHO,
2009). A CEmONC facility can carry out 1-7 above, plus (8) perform surgery and (9) provide
blood transfusion (WHO, 2009). It is recommended that pregnant women having risk factors
with predictive value for the need of CEmONC, such as multiple pregnancy, previous
postpartum hemorrhage, previous preterm birth, previous caesarian section, severe preeclampsia,
or severe anemia, be admitted to a MWH near a CEmONC facility (Vermeiden & Stekelenburg,
2017).
Relevant to this study, the WHO (2017) released guidelines with recommendations
related to newborn health. The guidelines for newborn health are meant to respond to these
questions: (1) What health interventions should the newborn and young infant less than 2 months
of age receive and when should s/he receive it? and (2) What health behaviors should a
mother/caregiver practice (or not practice)? (WHO, 2017). The WHO Recommendations on
Newborn Health (2017) are divided into sections on the promotion of newborn and young infant
health and prevention of illnesses, along with a section on management of newborn and young
infant illnesses. The WHO recommendations serve as a guideline for assessing maternal
“Essential Newborn Care” knowledge in this quasi-experimental study. Topics assessed in this
study assessing maternal “Essential Newborn Care” knowledge included: (1) umbilical cord care,
(2) thermal and skin care, (3) nutrition, (4) prevention of diarrhea, and (5) newborn danger signs
prompting care-seeking.
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Umbilical cord care
Postpartum infections remain a leading cause of neonatal morbidity and mortality
worldwide (Stewart & Benitz, 2016). A high percentage of these infections may stem from
bacterial colonization of the umbilicus, because cord care practices vary in reflection of cultural
traditions within communities and disparities in health care practices globally (Stewart & Benitz,
2016). Clean, dry cord care is recommended for newborns born in health facilities (WHO, 2017).
Although dry cord care was widely promoted by the WHO as the standard of practice,
researchers in the southern region of Zambia found many who practiced alternative approaches
to cord care, which included a vast diversity of knowledge, disease constructs, and practices
regarding cord function, tying, cutting, applications, care, and disposal (Herlihy et al., 2013).
Thermal and skin care
The WHO (2017) recommendations on newborn health also include initiation of
kangaroo care, or skin-to-skin care, with mothers during the first hour after birth to prevent
hypothermia and promote breastfeeding. The key features of kangaroo care are early, continuous,
and prolonged skin-to-skin contact between the newborn and mother, exclusive breastfeeding,
early discharge from the health facility, and close follow-up at home (Boundy et al., 2016;
WHO, 2003). The Zambian Ministry of Community Development Mother and Child Health
(MCDMCH) adopted kangaroo care in 2013 as part of the national Essential Newborn Care
(ENC) Package and established a kangaroo mother care training center at the University
Teaching Hospital in 2015 (Zambian Ministry of Health, 2015).
Nutrition
According to WHO guidelines (2017), all babies should be exclusively breastfed from
birth until 6 months of age, at which time complementary foods should be initiated. The WHO
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(2017) also recommends that all newborns, including low-birth-weight babies who are able to
breastfeed, should be put to the breast as soon as possible after birth when they are clinically
stable and the mother and baby are ready. The Zambian Ministry of Health recommends
breastfeeding within an hour of birth and adopted exclusive breast feeding as a method of infant
feeding from birth to six months (Tembo, Ngoma, Maimbolwa, & Akakandelwa, 2015).
Prevention of diarrhea
To prevent diarrhea, the WHO and UNICEF integrated Global Action Plan for
Pneumonia and Diarrhea (2013) recommends increased use of improved sources of drinking
water and sanitation facilities, universal immunization, HIV prevention, and healthy
environments, including improved maternal hygiene through hand washing with soap.
Dehydration can be prevented through the early administration of increased amounts of
appropriate fluids available in the home, and promotion of exclusive breastfeeding (WHO,
2013).
Newborn danger signs prompting care-seeking
Regarding newborn health problems and recognition of danger signs, the WHO (2017)
recommends assessment during each postnatal care (PNC) visit of the following signs: (1)
stopped feeding well, (2) history of convulsions, (3) fast breathing, (4) severe chest in-drawing,
(5) no spontaneous movement, (6) temperature >37.5°C, (7) temperature <35.5°C, and (8) any
jaundice in first 24 hours of life or yellow palms and soles at any age. The newborn should be
referred for further evaluation if any of these signs are present (WHO, 2017). Moreover, the
family should be encouraged to seek health care early if they identify any of the above danger
signs between PNC visits (WHO, 2017).
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Lundazi District was part of the Saving Mothers, Giving Life (SMGL) public-private
partnership to dramatically reduce maternal and newborn mortality in sub-Saharan African
countries (SMGL, 2018a). To encourage women to seek care, SMGL trained respected
community members as community health workers known as Safe Motherhood Action Groups
(SMAGs), who teach pregnant women about the importance of delivering in a facility, having a
birth plan, and practicing healthy behaviors during pregnancy and early childhood (SMGL,
2018b). SMAGs conduct home visits with women throughout their pregnancy to offer guidance
and instructions and inform them about MWHs (SMGL, 2018b). SMAGs also conduct maternal-
newborn health talks at health facilities and MWHs. Table 4.1 provides a summary of maternal-
newborn health education classes offered to women staying at the MWHs and family or friends
accompanying them by SMAGs and professional health workers. SMAGs were trained in
focused ANC to identify danger signs, encourage women to start ANC early, attend ANC at least
four times, and deliver with a skilled attendant (Jacobs, Michelo, & Moshabela, 2018). SMAGs
were also trained in essential newborn care, including the provision of effective cord care, early
initiation of exclusive breastfeeding, and reporting maternal-newborn deaths in the community
(Jacobs, Michelo, & Moshabela, 2018).
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Table 4.1 Summary of maternal-child health education classes taught at MWH sites
Maternal-Newborn Health Education Class Schedule
Danger signs for mother, labor, recognition and early signs and postpartum care
Nutrition and exercise during pregnancy
Good sanitation and hygiene to prevent diarrheal diseases
Post-partum family planning
Malaria in pregnancy
Danger signs for neonatal and well-baby care
Early initiation and exclusive breastfeeding
Post-partum family planning
Infant and young child feeding practices
Immunizations
STDs, HIV and AIDS
Statement of the Problem
Understanding maternal knowledge of “Essential Newborn Care” is fundamental when
implementing interventions to reduce newborn mortality. According to the WHO (2017), basic
care for all newborns should include promoting and supporting early and exclusive
breastfeeding, keeping the baby warm, increasing hand washing, providing hygienic umbilical
cord and skin care, identifying conditions requiring additional care, and counselling on when to
take a newborn to a health facility. Recognizing that newborn health-seeking relies heavily on
maternal knowledge of newborn care, it is important to assess awareness of “Essential Newborn
Care” to inform clinical and policy recommendations.
The aim of this quasi-experimental study was to compare maternal knowledge of
newborn care in two groups of women in rural Zambia: one group used a MWH prior to delivery
and the other group did not use a MWH. The primary outcome was maternal “Essential Newborn
Care” knowledge. The research question was: “What is the difference in maternal “Essential
Newborn Care” knowledge among women who did and did not use a MWH prior to delivery?”
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The research hypothesis was that maternal “Essential Newborn Care” knowledge would be
higher for women who used a MWH prior to delivery.
Theoretical Framework
The Ecological Systems Theory, operationalized for maternal-newborn health and MWH
use, was used to guide this quasi-experimental study (Bronfenbrenner, 1977, 1979, 1989, 1994).
Bronfenbrenner’s theory is ideal because it takes a broader view of multi-level factors that
influence health behaviors and is useful for guiding complex interventions (Kaiser et al., 2019).
In this study, maternal-newborn outcome variables could be affected if independent maternal-
newborn health indicators are influenced by factors present in the Ecological Systems Theory for
Maternal-Newborn Health and MWH Use, such as individual maternal-newborn dyad
(microsystem), interpersonal (mesosystem), healthcare organization (exosystem), social and
cultural (macrosystem), and public health policy (chronosystem).
Methods
A quasi-experimental, two-group comparison design was employed using a face-to-face
survey approach to determine whether MWH use has an impact on maternal knowledge of
newborn care. The study protocol and tool received institutional review board (IRB) approval
from the University of Michigan and Zambian Ethics Reviews Converge IRB, and the National
Health Research Authority in Zambia was informed.
Because illiteracy in rural Zambia is substantial, with few people able to read or write in
English, and Tumbuka, the native language in Lundazi District, is a non-written oral language,
recruitment for the evaluation was conducted orally after identifying eligible women from the
delivery register (Appendix G). Zambian research assistants (RAs) (conversant in Tumbuka
language) served as interpreters. They were trained on data collection protocols, identified
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women who met the inclusion criteria, and explained the study (Appendix H). Research
assistants were trained to ask all questions and wait for response without prompting. They were
also trained to record all responses given to questions posed in face-to-face interview.
Sample and Setting
The quasi-experimental study was performed in the Eastern Province of rural Zambia at
Lundazi District Hospital and the CEmONC MWH on the grounds of the hospital. Lundazi
District Hospital is the Zambian governmental Ministry of Health (MOH) CEmONC referral
facility for the area. The last national census in Zambia, conducted in 2010 (Chief Statistics
Office, 2018), lists the total population of Lundazi District as 323,870 (Chief Statistics Office,
2015).
This study built from a larger parent study that evaluated MWHs in rural Zambia using a
controlled before-and-after, quasi-experimental design. A collaborative team of researchers
developed this study to measure the impact of the MWH model on facility delivery among
women living farthest (≥10 km) from their designated health facility, which would inform
decision-making policy in Zambia and globally (Scott et al., 2018). The study began in March
2016 and was completed in December 2018 (Scott et al., 2018). Women coming from study sites
in Lundazi district included in the parent study were also included in this study about maternal
“Essential Newborn Care” knowledge.
The sample consisted of women aged 15 years and above from an area in Lundazi district
with MWHs recently built as part of the parent study. The specific age cut-off was established
because, in Zambia, married, pregnant, or parent-children are considered “emancipated minors”
if aged ≥15. Participants included both those who used a MWH and those who did not use a
MWH prior to delivery. MWHs were located at five BEmONC facilities and one CEmONC
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facility in the region. A purposeful sample of participants including postpartum women referred
from five BEmONC facilities associated with MWHs and five BEmONC comparison facilities
without MWHs admitted in the Lundazi District referral hospital and pregnant women from the
same communities awaiting delivery at the CEmONC MWH were invited to participate in the
study. Participants were identified by directly approaching women in the delivery ward and the
CEmONC MWH and asking whether they live in and were referred from the ten communities
included in the study. All other pregnant and postpartum women were excluded from
participating in the study.
Measurement
Given the absence of a validated tool in the literature, a questionnaire was developed for
this study to assess maternal knowledge of essential newborn care in rural Zambia. The
structured Maternal Knowledge of Newborn Care Questionnaire (Appendix I) was administered
verbally by face-to-face interview to assess maternal knowledge of essential newborn care in
rural Zambia (n=250). Maternal knowledge was defined as participants mentioning at least one
item included in the WHO (2017) guidelines for newborn health or the WHO and UNICEF
integrated Global Action Plan for Pneumonia and Diarrhea (2013) in response to a question.
The Maternal Knowledge of Newborn Care Questionnaire was pre-tested for contextual
appropriateness and meaning-in-context by asking nurses, midwives, local residents, and RAs
familiar with the language and culture to explain their understanding of terms and concepts
posed in the questionnaire. Conceptual and cultural meanings where taken into consideration and
the questionnaire was modified and tested again by asking others familiar with the local culture
to review the modifications and propose any additional adaptations. Interviews were conducted
in a private room at the CEmONC MWH or at the CEmONC facility.
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Study Variables
The main independent variable in this study was MWH use before delivery. Independent
sociodemographic and previous obstetric history variables assessed on the Maternal Knowledge
of Newborn Care Questionnaire included age, education level, marital status, gravida (number of
times pregnant), parity (number of live births), and number of stillbirths and living children
(Table 4.2). Other independent predictor variables that were assessed included referral village,
attendance and topic of health talks at MWHs. Dependent outcome variables assessed included
maternal knowledge of umbilical cord care, thermal and skin care, nutrition, prevention of
diarrhea, and newborn danger signs.
Data Collection
Two team members, the primary investigator and an RA, conducted face-to-face
interviews from September 1, 2017 through January 31, 2018 using the structured Maternal
Knowledge of Newborn Care Questionnaire as a guide. Prior to the verbal interviews,
participants were privately consented. The Teach Back Method (2019) was used to confirm
understanding by asking potential participants to describe their understanding of the study’s
purpose, procedure, risks, and benefits using open-ended prompts and repeating the material
until understanding was achieved. If they agreed, a time was decided upon for the one-time
interview to take place. Participants were not paid to be in the study. Snacks and a juice drink
were provided after the discussion as incentives to thank participants for their time. Per Zambian
government regulations, the cost of snacks and juice drink did not exceed $6.
No certified translation services are available for Tumbuka in rural Zambia; however, the
RA was fluent in verbal Tumbuka dialect and culture as well as in English. The RA
simultaneously translated the responses and filled out the Maternal Knowledge of Newborn Care
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Table 4.2 Operational definition of variables in maternal knowledge of newborn care questionnaire
Independent Variables
Definition
Use of MWH
before delivery
MWH used
Yes or no to used a MWH
Name of MWH used
MWH mother used before delivery
Sociodemographic
Age of mother
Age in completed years as at last birthday
Education
Number of years of school completed
Marital status
Single, married, living together, separated, divorced, or widowed
Previous Obstetric
History
Gravida
Number of pregnancies the woman has had including the current
pregnancy
Parity
Number of previous live births prior to this pregnancy
Stillbirths
Number of previous stillbirths
Living children
Number of living children
Referral Village
Name of mother’s referral village
Mother referred from facility with or without a MWH
Health talks at
MWHs
Attendance of health talk at MWH
Yes or no to attend a health talk at MWH
Topic of health talk at MWH
Any topic of health talk attended at MWH
Person who gave health talk at
MWH
Any person who gave health talk at MWH
Dependent Variables: “Essential Newborn Care”
Umbilical cord
care
Knowledge of umbilical cord care
Any method/item mentioned to care for newborn’s umbilical cord
care at home
Thermal and skin
care
Knowledge of kangaroo care
Any thermal care method/item mentioned to keep newborn warm
Knowledge of newborn skin care
Any newborn skin care method/item mentioned
Nutrition
Knowledge of exclusive
breastfeeding
Any exclusive breastfeeding method/item mentioned
Length of breastfeeding
Number of months mother plans to breastfeed
Timing for introduction of
complementary foods
Age when plans to introduce complementary foods (months)
Prevention of
diarrhea
Knowledge of how to prevent
diarrheal diseases
Any method/item mentioned about good sanitation and hygiene to
prevent diarrheal diseases
Recognition of
newborn danger
signs
Newborn danger signs
Any newborn danger sign mentioned warranting newborn care-
seeking
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Questionnaire. Upon completion of the interview, survey response data were entered into an
electronic database by the RA. All questionnaires were double-checked by the primary
investigator to verify the consistency of the data entered.
At the end of the face-to-face interview, if a woman provided a response to any open-
ended question that was potentially harmful (i.e. use of traditional herbs on umbilical cord), the
RA and primary investigator provided health education on topics included in the WHO (2017)
newborn health guidelines. Also, if a woman answered “Don’t know” in response to a question,
the RAs and primary investigator provided health education about the topic.
The primary “Essential Newborn Care” outcomes (1) umbilical cord care, (2) thermal and
skin care, (3) nutrition, (4) prevention of diarrhea, and (5) newborn danger signs were measured
by dichotomizing women’s unprompted responses on the Maternal Knowledge of Newborn Care
Questionnaire. If women answered “Don’t know” to a question, or provided a response to any
open-ended question that was potentially harmful, the response was coded as = 1. If participants
mentioned at least one item included in the WHO (2017) guidelines for newborn health or the
WHO and UNICEF integrated Global Action Plan for Pneumonia and Diarrhea (2013) in
response to a question, the response was coded as = 0.
Data Analysis
Descriptive statistics were obtained by performing crosstabulation. Pearson chi-square
tests were performed to evaluate associations among sociodemographics, previous obstetric
history, and MWH use. Frequency distributions, percentages, means, and standard deviations
were calculated. To analyze responses on the Maternal Knowledge of Newborn Care
Questionnaire, bivariate analysis was performed to examine the relationship between pairs of
variables and to assess the likelihood of variables having affected maternal knowledge outcomes.
145
The correlation coefficient provided information about the strength of the relationship and
whether the relationship was positive or negative. Odds ratios with 95% confidence interval (CI)
were computed to assess the strength and significance level of the association between variables
in the newborn care questionnaire. Independent t-tests were used to compare knowledge for
women who did and did not use a MWH. The chi-square test was used to control for
confounding variables. In cases where the sample size was too small to use a chi-squared test, a
Fisher’s exact test was used.
Logistic regression with a dichotomized MWH variable (non-MWH = 0, MWH = 1) was
performed. Regression models were also conducted to examine the independent contribution of
variables of interest (such as age and whether women answered “Don’t Know”) to maternal
“Essential Newborn Care”. Regressions were performed controlling for categorized variables
such as age, education, gravida (number of pregnancies), parity (number of live births), which
could interact with maternal knowledge as the outcome variable. P-values < .05 were considered
statistically significant. All statistical analysis was performed using SPSS version 25.
Results
Demographics
Maternal sociodemographic characteristics were comparable for those included in the
study who used a MWH (n = 135) and those who did not use a MWH (n = 115). Seven women
out of 257 approached declined participation in the study. There were no significant differences
between demographic characteristics relating to age, education, and marital status among the
groups of MWH and non-MWH users (Table 4.3). Among women who used a MWH, 28% (n
=37) stayed at the CEmONC MWH located at Lundazi District Hospital while 72% (n = 96)
stayed at BEmONC MWH facilities. Most participants (63.2%) were between 15-24 years of
age (n = 158), 71.6% (n = 179) had less than an eighth grade
146
Table 4.3 Sociodemographic characteristics
MWH Use
Statistical Tests
Maternal-Newborn
Health Indicator
Total
(n=250)
Stayed at
MWH
(n =135)
Did not stay
at MWH
(n = 115)
Pearson
Chi-
Square
P value
% (n)
% (n)
% (n)
(2-sided)
Age group (years)
15 to 19
29.6% (74)
33.3% (45)
25.2% (29)
1.734
.785
20 to 24
33.6% (84)
33.3% (45)
33.9% (39)
25 to 29
12% (30)
11.9% (16)
12.2% (14)
30 to 34
9.2% (23)
8.9% (12)
9.6% (11)
35 and older
12.4% (31)
11.1% (15)
13.9% (16)
Mean (SD)
24.2 (6.8)
Missing
3.2% (8)
1.5% (2)
5.2% (6)
Education level
None
8.8% (22)
8.9% (12)
8.7% (10)
1.451
.694
Lower (1-4) & Upper
Primary (5-7)
62.8% (157)
60.7% (82)
65.2% (75)
Junior (8-9) & Senior
Secondary (10-12)
25.6% (64)
26.7% (36)
24.3% (28)
Tertiary
0.4% (1)
none
0.9% (1)
Missing
2.4% (6)
3.7% (5)
0.9% (1)
Marital status
Single
5.2% (13)
5.9% (8)
4.3% (5)
0.345
.557
Married
94.0% (235)
92.6% (125)
95.7% (110)
Missing
0.8% (2)
1.5% (2)
None
147
education, and the vast majority of participants (94%) were married. The previous obstetric
history characteristics of MWH and non-MWH users were not significantly different (Table 4.4).
When a participant attended a health talk at a MWH, community health workers (SMAGs) gave
45% of education sessions and 22% were given by a nurse. There were no significant differences
among MWH and non-MWH users relating to planned length of breastfeeding and introduction
of complementary foods (Table 4.5).
Table 4.4 Previous obstetric history characteristics
MWH Use
Statistical Tests
Maternal Health
Indicator
Total
(n=250)
Stayed at
MWH
(n =135)
Did not stay
at MWH
(n = 115)
Pearson
Chi-
Square
P value
% (n)
% (n)
% (n)
(2-sided)
Gravida
1
38.4% (96)
42.2% (57)
33.9% (39)
3.821
.281
2-5
51.6% (129)
47.4% (64)
56.5% (65)
6 and above
8.8% (22)
8.9% (12)
8.7% (10)
Mean (SD)
2.7 (1.9)
Missing
1.2% (3)
1.5% (2)
0.9% (1)
Parity
0
19.2% (48)
19.3% (26)
19.1% (22)
0.070
.966
1-5
74.0% (185)
71.9% (97)
76.5% (88)
6 and above
3.2% (8)
3.0% (4)
3.5% (4)
Mean (SD)
1.9 (1.7)
Missing
3.6% (9)
5.9% (8)
0.9% (1)
Stillbirths
0
70.4% (176)
65.9% (89)
75.7% (87)
0.226
.634
1-5
24.4% (61)
24.4% (33)
24.3% (28)
Mean (SD)
0.35 (0.67)
Missing
5.2% (13)
9.6% (13)
none
Living children
0
20.8% (52)
22.2% (30)
19.1% (22)
0.491
.491
1-5
74% (185)
71.9% (97)
76.5% (88)
6 and above
3.2% (8)
3.0% (4)
3.5% (4)
Mean (SD)
1.8 (1.7)
Missing
2% (5)
3.0% (4)
0.9% (1)
148
Table 4.5 Planned length of breastfeeding and introduction of complementary foods
“Essential Newborn Care” knowledge
Table 4.6 presents the most common responses (≥ 5%) to questions posed to both MWH
and non-MWH users about maternal knowledge of “Essential Newborn Care”. The research
study hypothesis that maternal knowledge of “Essential Newborn Care” would be higher for
women who used a MWH prior to delivery was not supported. When controlling for age,
education, gravida, and parity, there were no significant differences among MWH and non-
MWH users on the Maternal Knowledge of Newborn Care Questionnaire assessing (1) umbilical
cord care, 2) thermal and skin care, (3) nutrition, (4) prevention of diarrhea, and (5) newborn
danger signs prompting care-seeking (Table 4.7).
MWH Use
Statistical Tests
Maternal
“’Knowledge of
Newborn Care”
Survey Question
Total
(n=250)
Stayed at
MWH
(n =135)
Did not stay
at MWH
(n = 115)
Pearson
Chi-
Square
P value
% (n)
% (n)
% (n)
(2-sided)
How long do you plan to breastfeed? (months)
1-18
16.8% (42)
18.5% (25)
14.8% (17)
1.894
.595
19-24
62.0% (155)
57.8% (78)
67.0% (77)
25 and above
10.0% (25)
11.1% (15)
8.7% (10)
Don’t know
5.2% (13)
4.4% (6)
6.1% (7)
Mean (SD)
22.7 (6.8)
Missing
6.0% (15)
8.1% (11)
3.5% (4)
When do you plan to give your baby complementary foods? (months)
1-6
38.8% (97)
43.7% (59)
33.0% (38)
3.900
.272
7-12
41.2% (103)
39.2% (53)
43.5% (50)
13-24
1.6% (4)
0.7% (1)
2.6% (3)
Don’t know
17.2% (43)
15.6% (21)
19.1% (22)
Mean (SD)
8.1 (3.4)
Missing
1.2% (3)
0.7% (1)
1.7% (2)
149
Table 4.6 Most common responses to maternal “Essential Newborn Care” questions
Maternal “Essential Newborn Care” Knowledge Survey Question
MWH Use
Statistical Tests
Total
(n=250)
%1 (n)
Stayed at
MWH
(n =135)
Did not stay
at MWH
(n = 115)
Pearson
Chi-Square
P value
(2-sided)
What health problems in your newborn would make you want to take your baby to the clinic?
Fever
66.7% (157)
72.4% (96)
60.0% (61)
89.448
.556
Excessive crying
37.8% (94)
38.8% (52)
36.5% (42)
Weak suckling or feeding
20.1% (50)
15.7% (21)
25.2% (29)
Shivering
16.5% (41)
15.7% (21)
15.7% (20)
Breathing difficulties or rapid breathing
15.7% (39)
12.7% (17)
19.1% (22)
Don’t know
10.4% (26)
8.2% (11)
13.0% (15)
How you will care for your baby’s umbilical cord when you get home?
Plain Water
40.2% (100)
39.6% (53)
40.9% (47)
22.412
.264
Don’t know
36.0% (90)
33.3% (45)
39.1% (45)
Soap (Lifebuoy)
8.8% (22)
10.4% (14)
7.0% (8)
Breastmilk
5.6% (14)
9.0% (12)
1.7% (2)
Traditional Herbs
5.2% (13)
4.5% (6)
6.1% (7)
Have you ever heard the term “Kangaroo Care”, or skin-to-skin care, for the baby to keep them warm?
Yes
21.6% (54)
19.3% (26)
24.3% (28)
2.201
.333
No
78% (195)
80.7% (109)
74.8% (86)
Tell me what you know about “Kangaroo Care”, or skin-to-skin care, for the baby to keep them warm
Baby naked against your skin
6.8% (17)
8.2% (11)
5.2% (6)
14.841
.190
Promotes bonding and/or attachment
5.2% (13)
5.2% (7)
5.2% (6)
How will you care for your baby's skin when you get home?
Petroleum Jelly
35.7% (89)
40.3% (54)
30.4% (35)
20.532
.550
Glycerin
30.5% (76)
27.6% (37)
33.9% (39)
Cooking Oil
18.1% (45)
17.2% (23)
19.1% (22)
Don’t know
8.4% (21)
6.0% (8)
11.3% (13)
Tell me what you know about exclusive breastfeeding
Only give breastmilk for 6 months
85.9% (214)
85.1% (114)
87.0% (100)
14.391
.347
Don’t know
9.6% (24)
9.7% (13)
9.6% (11)
Tell me what you know about good sanitation and hygiene to prevent diarrheal diseases
Maintain hygienic environment
43.8% (109)
46.3% (62)
40.9% (47)
27.840
.315
Take baby to clinic
27.3% (68)
29.9% (40)
24.3% (28)
Don’t know
17.7% (44)
13.4% (18)
22.6% (26)
Wash hands before and after using toilet
13.7% (34)
14.9% (20)
12.2% (14)
Wash hands before and after eating
13.3% (33)
14.2% (19)
12.2% (14)
Exclusively breastfeed
11.9% (16)
3.5% (4)
8% (20)
1All items mentioned were recorded, total percentage of responses to each question will not equal 100%
150
Table 4.7 Logistic regression for MWH use and maternal “Essential Newborn Care” knowledge
Maternal-Newborn Health Indicator
Adjusted ORa
Exp (B)
95% CI for Exp (B)
Lower
Upper
Umbilical cord care
1.027
.135
7.787
Skin care
.776
.205
2.940
Thermal care
1.571
.626
3.939
Exclusive breastfeeding
.196
.023
1.659
Prevention of diarrhea
.525
.233
1.182
Newborn danger signs prompting care-seeking
.651
.188
2.258
acontrolling for age, education, gravida, and parity
Overall Sample Characteristics and Maternal Knowledge of “Essential Newborn Care”
While there were no significant differences in maternal knowledge of “Essential
Newborn Care” among MWH and non-MWH users, some significant differences were found
between predictor variables such as sociodemographic, previous obstetric history, and maternal
“Essential Newborn Care” knowledge. Table 4.8 summarizes differences in independent
variables and maternal “Essential Newborn Care” knowledge among MWH and non-MWH
users. A description of differences in maternal “Essential Newborn Care” knowledge when both
MWH and non-MWH users are combined and examined as an overall sample follows in this
next section.
151
Table 4.8 Summary of differences in overall sample characteristics and maternal knowledge of
“Essential Newborn Care”
MWH Use
Statistical Tests
Maternal-Newborn
Health Indicator
Total
(n=250)
Stayed at
MWH
(n =135)
Did not stay
at MWH
(n = 115)
Pearson
Chi-
Square
P value
% (n)
% (n)
% (n)
(2-sided)
Thermal and skin care
Older women who used a MWH more likely to know how to care for newborn’s skin
15 to 24 years, “Don’t
know” responses
5.2% (13)
1.2% (3)
4.0% (10)
-2.033
.042*
25 and older, “Don’t
know” responses
2.8% (7)
1.2% (3)
1.6% (4)
Prevention of diarrhea
Women with all levels of primary and secondary education who used a MWH more likely to
know about good sanitation and hygiene to prevent diarrheal diseases
Lower & Upper
Primary, “Don’t
know” responses
11.3% (28)
4.4% (11)
6.9% (17)
-2.158
.031*
Junior & Senior
Secondary, “Don’t
know” responses
4.4% (11)
1.2% (3)
3.2% (8)
Women with fewer pregnancies who used a MWH were more likely to know how to prevent
diarrhea
Gravida 1, “Don’t
know” responses
7.6% (19)
3.2% (8)
4.4% (11)
-2.065
.034*
Gravida 2-5, “Don’t
know” responses
8.8% (22)
3.2% (8)
5.6% (14)
Gravida ≥ 6, “Don’t
know” responses
1.6% (4)
0.8% (2)
0.8% (2)
Age
In the overall sample, among both groups, younger women answered “Don’t know” more
often than older women (≥ 25 years) to every question on the Maternal Knowledge of Newborn
Care Questionnaire (n = 158) (Table 4.9). However, in both groups, there was insufficient
evidence to conclude a significant relationship between younger age (< 25 years) and answering
“Don’t know” when asked about umbilical cord (p < .001, 95% CI [0.455, 1.292]), skin care (p
152
= .027, 95% CI [0.186, 1.144]), exclusive breastfeeding (p = .011, 95% CI [0.443, 2.402]), and
newborn danger signs (p = .013, 95% CI [0.258, 1.338]).
Table 4.9 Younger age (n = 158) and “Don’t know” responses
Maternal Essential Newborn Care Question
Fisher’s Exact Test
Tell me about how you will care for your baby’s umbilical
cord when you get home.
< .001
How will you care for your baby’s skin when you get home?
.027
Tell me what you know about “Kangaroo Care”, or skin-to-
skin care, for the baby to keep them warm
.532
Tell me what you know about exclusive breastfeeding
.011
Tell me what you know about good sanitation and hygiene to
prevent diarrheal diseases.
.358
What health problems would make you take your newborn
baby to the clinic?
.013
Education
In both groups of the overall sample, women with lower (1-4) and upper primary (5-7) (n
= 157) education answered “Don’t know” more often than those with any amount of secondary
education (n = 64) to all questions specific to “Essential Newborn Care”.
Previous obstetric history
In the overall sample, women with six or more pregnancies (n = 22) were less likely to
answer “Don’t know” to “Essential Newborn Care” questions. In both groups, more
primigravida women (n = 96) responded “Don’t know” to all questions on the Maternal
Knowledge of Newborn Care Questionnaire than those with more than one pregnancy.
153
Discussion
In general, women in this study demonstrated “Essential Newborn Care” knowledge in
accordance with the WHO (2017) guidelines for newborn health. The overall knowledge of
pregnant and postpartum women included in the study may reflect the success of the SMGL
program and health education of SMAGs at MWHs and in all communities included in the study.
The lack of significant differences in demographic characteristics relating to age, education, and
marital status among groups of MWH users and non-users suggests that the communities were
well matched, with homogenous populations. Younger women need more education by nurses,
midwives, and community health workers about newborn health problems and danger signs,
exclusive breastfeeding, umbilical cord care, and newborn skin care. Additionally, health
education efforts to reinforce the avoidance of traditional herb use for umbilical cord care
(reported by 5.2% of women in this study) are necessary.
Almost all the individual health facility comparisons were not significant; the only
significant difference among MWH users and non-users was in the MWH users’ ability to
identify good hygiene and sanitation to prevent diarrhea. Given that sepsis is a main cause of
newborn deaths in Zambia (UN IGME, 2018), it is encouraging that women in all communities
are aware of newborn danger signs related to infection. However, findings demonstrate that
health talks at MWHs in this study are falling short of their intended benefits and highlight the
importance of placing additional emphasis on providing health talks at MWHs. Since 45% of
health talks at MWHs were given by SMAGs, it might be worthwhile to reinforce the importance
of educating mothers about newborn care and care-seeking while they are using the MWH.
Furthermore, recognizing that nearly 20% of women report learning about newborn care from
family members, it might be worthwhile expanding the SMAG program to include education
154
sessions for family members and/or inviting family members to participate in newborn health
education sessions led by nurses and midwives at the MWH or health facility.
While there were no statistically significant differences in answering “Don’t know” for
any questions among women who used the CEmONC MWH located at Lundazi District Hospital
and those who used BEmONC MWHs in this study, further research is needed to understand
whether there are differences in maternal knowledge of newborn care and care-seeding for
women using MWHs at other CEmONC facilities compared to those using MWHs near, rather
than at, BEmONC facilities.
In this quasi-experimental study, outcomes were likely influenced by factors present in
the operationalized Ecological Systems Theory for Maternal-Newborn Health and MWH Use
including individual maternal-newborn dyad (microsystem) and public health policy
(chronosystem). Factors at the individual maternal-newborn dyad (microsystem) level that may
influence “Essential Newborn Care” knowledge included age, education, marital status,
education, gravida, parity, stillbirths, living children, plan for delivery, referral for delivery,
MWH use, and health talks. Other factors at the microsystem level that likely influenced
responses on the Maternal Knowledge of Newborn Care Questionnaire included maternal
knowledge of the following: newborn health problems and danger signs, umbilical cord care,
skin and thermal care, nutrition (exclusive breastfeeding, introduction of complementary foods),
sanitation and hygiene to prevent diarrheal disease, and timing of first post-natal visit.
When the Ecological Systems Theory was operationalized to focus on maternal-newborn
health and MWH use, factors at the public health policy (chronosystem) level encompasses
change or consistency over time in the characteristics of the individual maternal-newborn dyad
and also of the environment where they live. At the public health policy level, factors influencing
155
outcomes in the study included national and local government agency support for maternal-
newborn health including district-wide participation in the SMGL program. Zambian Ministry of
Health promotion of and funding for maternal-newborn health and MWH use in Lundazi district
also influence study outcomes at the chronosystem level. Based on our operationalization of the
grand Ecological Systems Theory for maternal-newborn health and MWH use, we conclude that
it can be applied globally, which further validates it, especially since, to our knowledge, this
study was the first to apply this theory to healthcare in rural Zambia.
Limitations
Results of this quasi-experimental study examining maternal “Essential Newborn Care”
knowledge may not be generalizable to other districts in Zambia or the broader population in
Zambia or other countries in sub-Saharan Africa due to likely cultural and socioeconomic
differences. Group differences in numerous factors that could not be controlled for, such as
differences in access to and quality of education and/or healthcare in rural study sites, may play a
role in maternal “Essential Newborn Care” knowledge.
Causality cannot be clearly determined in this study. Also, an inherent power differential
existed between participants and researcher, which could potentially have biased the responses
from participants. Another potential limitation is that the sample straddles the actual delivery
period by including pregnant woman at the CEmONC MWH and postpartum women at the
district hospital.
The MWHs at the parent study sites opened at varying times, from one month to nearly a
year, before this assessment of maternal “Essential Newborn Care” was conducted. The varying
lengths of time MWHs were functioning in villages included in this study could have impacted
the amount of exposure to health education received prior to referral for CEmONC care and
156
could partially explain why there were no significant differences in maternal “Essential Newborn
Care” knowledge among MWH users and non-users.
Conclusion
To our knowledge, this study is the first to assess and compare maternal “Essential
Newborn Care” knowledge among women who used and did not use a MWH in rural Zambia.
Generally, both MWH users and non-users in the rural district were knowledgeable about: (1)
umbilical cord care, (2) thermal and skin care, (3) nutrition, (4) prevention of diarrhea, and (5)
newborn danger signs prompting care-seeking, and no significant differences were found among
groups. Nevertheless, younger age and primigravida showed significant relationships with lower
maternal “Essential Newborn Care” knowledge among both MWH users and non-users.
The structured Maternal Knowledge of Newborn Care Questionnaire was developed for
use in this study because of the absence of a validated tool in the literature to assess maternal
“Essential Newborn Care” knowledge. Future directions for research include developing a more
rigorous rating of responses on the questionnaire, with a scale to assess each maternal “Essential
Newborn Care” outcome. The Maternal Knowledge of Newborn Care Questionnaire should be
validated in future research by demonstrating adequate reliability and validity.
Currently, most MWHs are located in rural areas. Recent health policy changes
recommend a shift away from rural delivery facilities toward larger urban facilities for better
maternal-newborn outcomes (Kruk et al., 2018; Montagu et al., 2017). There is an exceptionally
wide gap in knowledge about the interest in and viability of MWH use in urban environments.
Future studies should evaluate MWH use in an urban setting and incorporate a pre- and post-
assessment of maternal “Essential Newborn Care” knowledge into the study design to identify
any trends associated with MWH use.
157
The findings of this quasi-experimental study highlight the need for targeted health
education by professional and community health workers towards younger and primigravida
women. Improvement of maternal “Essential Newborn Care” knowledge through health
education received from health talks at MWHs may potentiate long-term benefits for improved
maternal-newborn health and delivery outcomes in rural Zambia.
158
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CHAPTER 5
A Case Series of Maternal-Newborn Delivery Outcomes in Rural Zambia: Comparison of
Referral to a District Hospital from Facilities with and Without a Maternity Waiting Home
Introduction
In the southern African country of Zambia, 224 maternal deaths occur per 100,000 live
births (UNICEF, 2017) and there are approximately 14,000 newborn deaths each year (38 babies
each day) (WHO, 2018). The newborn mortality rate in rural areas in Zambia is 34 per 1,000
live births (UNICEF, 2017). In Zambia, the main causes of newborn deaths are birth asphyxia,
prematurity, and sepsis (United Nations Inter-Agency Group for Child Mortality Estimation [UN
IGME], 2018).
One of the biggest challenges in achieving access to skilled care in countries with large
rural populations such as Zambia is connecting women with obstetric emergencies to necessary
care (Henry et al., 2018). Universal access to Emergency Obstetric and Newborn Care (EmONC)
is considered essential to reduce maternal mortality and requires that all pregnant women and
newborns with complications have rapid access to well-functioning facilities that include a broad
range of service delivery types and settings (Otolorin, Gomez, Currie, Thapa, & Dao, 2015;
Campbell, Graham, & Lancet Maternal Survival Series steering group, 2006). Emergency
164
Obstetric and Newborn Care facilities are divided into those meeting tiered standards of care for
providing either Basic Emergency Obstetric and Newborn Care (BEmONC) or Comprehensive
Emergency Obstetric and Newborn Care (CEmONC). Signal functions for EmONC are the
major interventions for averting maternal and newborn mortalities (Roy, Biswas, & Chowdhury,
2017) and help differentiate between levels of care provided at a facility. Table 5.1 provides an
overview of signal functions.
Table 5.1: Signal functions used to identify basic and comprehensive emergency obstetric care
services (WHO, 2009)
BEmONC services
CEmONC services
1. Administer parenteral antibiotics
8. Perform signal functions 1–7, plus:
Perform surgery (e.g. caesarean section)
2. Administer uterotonic drugs (i.e.
parenteral oxytocin)
9. Perform blood transfusion
3. Administer parenteral anticonvulsants for
preeclampsia and eclampsia (i.e.
magnesium sulfate)
4. Manually remove the placenta
5. Remove retained products (e.g. manual
vacuum extraction, dilation and curettage)
6. Perform assisted vaginal delivery (e.g.
vacuum extraction, forceps delivery)
7. Perform basic neonatal resuscitation (e.g.
with bag and mask)
A basic emergency obstetric care facility is one in which all functions 1–7 can be performed.
A comprehensive emergency obstetric care facility is one in which all functions 1–9 can be
performed.
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In Zambia, pregnant women are referred from rural primary health facilities, where
BEmONC services are provided, to the district hospital where CEmONC can be provided when a
potential complication is recognized by a skilled birth attendant. Women are often referred to a
CEmONC facility for prolonged labor (1st or 2nd stage), obstructed labor, poor progress, and
cephalopelvic disproportion (CPD). Prolonged labor is defined as labor lasting longer than 24
hours after the onset of regular, rhythmical painful contractions accompanied by cervical dilation
(WHO, 2008a). Meanwhile, obstructed labor implies that, in spite of strong uterine contractions,
the fetus cannot descend through the pelvis because an insurmountable barrier prevents its
descent (WHO, 2008a). Cephalopelvic disproportion occurs when there is a misfit between the
fetal head and the pelvis, making it difficult or impossible for the fetus to pass safely through the
pelvis (WHO, 2008a). In low- and middle-income countries (LMICs), CPD is often due to
stunted growth of the maternal pelvic bones from malnutrition, early childbearing, or
abnormalities of the shape of the pelvis due to rickets or osteomalacia (WHO, 2008a).
The use of maternity waiting homes (MWHs) may offer a possible referral source from
BEmONC to CEmONC in rural Zambia, ultimately serving as an intervention to improve
maternal-newborn delivery outcomes. Maternity waiting homes provide a setting where women
can be accommodated during the final weeks of their pregnancy near a hospital with essential
obstetric facilities (WHO, 1996). In LMICs, MWHs can help overcome distance and
transportation barriers that prevent women from receiving timely skilled obstetric care (Lori et
al., 2016). By addressing distance to a health facility and transportation barriers, MWHs could
increase the use of skilled birth attendants, thereby reducing newborn morbidity and mortality in
rural, low resource areas of Zambia (Lori et al., 2016).
166
This case series was conducted at Lundazi District Hospital, one of the CEmONC
facilities included in a collaborative research endeavor (parent study) between 2015-2018 to
determine the impact of MWHs on facility delivery among women living at least 10km from
health facilities in rural Zambia. Using formative research, a team of researchers developed a
MWH intervention model with three components: infrastructure, management, and linkage to
services (Scott, Kaiser et al., 2018). The larger study evaluated the impact of core model MWHs
employing a controlled before-and-after, quasi-experimental design and using mixed methods
(Scott, Kaiser et al., 2018) to examine outcomes. The parent study was conducted by the
Maternity Homes Alliance, a partnership between the Government of Zambia, Boston
University, and Right to Care Zambia (formerly the Zambian Center for Applied Health
Research and Development), Africare, and the University of Michigan, and was funded by
Merck Sharp and Dohme for Mothers, the Bill & Melinda Gates Foundation, and The ELMA
Foundation (Scott, Kaiser et al., 2018). The Maternity Homes Alliance hypothesized that
MWHs can remove the distance barrier and increase access to facility-based delivery (Scott,
Kaiser et al., 2018).
Lundazi District is part of the Saving Mothers, Giving Life (SMGL) program. The
SMGL public-private partnership aims to significantly reduce maternal and newborn mortality in
select sub-Saharan African countries (SMGL, 2018a). In Zambia, SMGL put in place key
interventions to improve maternal and newborn health across 16 districts (SMGL, 2018a).
Working hand-in-hand with the Zambian government between 2013-2018, the initiative set out
to make high-quality, safe childbirth services available and accessible to women and their
newborns, focusing on the critical period of labor, delivery, and the first 48 hours postpartum
(SMGL, 2018a). The SMGL initiative advocates replicating their endeavors to approach the
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sustainable development goals (SDGs) through engaging a diverse group of partners and
adopting a comprehensive systems approach (SMGL, 2018a).
Lundazi District was included in phase 1 of the SMGL program in Zambia. During
SMGL phase 1, the maternal deaths occurring in health facilities for the four SMGL districts
(Mansa, Lundazi, Nyimba, Kalomo) from direct obstetric causes declined by 36% from 260 per
100,000 live births to 167 per 100,000 (Centers for Disease Control and Prevention [CDC],
2014). The largest reductions were for obstructed labor (-78%) (CDC, 2014). In the mid-
initiative report released by SMGL, nearly 90% of women in target districts in Zambia gave birth
in a facility, compared to just 63% at the start of the initiative; the institutional stillbirth rate was
down by nearly 40%, as compared to the start of the initiative (SMGL, 2015).
Statement of the Problem
This study aimed to advance an understanding of maternal-newborn delivery outcomes
for women referred from health facilities with and without MWHs to the district referral hospital.
The case series study used medical record data from delivery registers located in one district
referral hospital to examine a sample of all women with complications who were referred from
ten lower-level BEmONC facilities and arrived at the higher-level CEmONC district referral
hospital. Of these cases, the characteristics of those referred from facilities with and without
MWHs were examined. Newborn delivery outcomes included low birth weight [LBW < 2500
grams]; condition of baby [alive or dead]; low Appearance, Pulse, Grimace, Activity, and
Respiration [APGAR] score; and breastfeeding within one hour. Maternal delivery outcomes
included assisted delivery [forceps, vacuum], prolonged/obstructed labor, and eclampsia.
Research for the case series study was conducted through a retrospective hospital-based record
review guided by the questions: (1) “Do newborns born to mothers referred from facilities with
168
MWHs have fewer poor delivery outcomes than cases referred from non-MWH health
facilities?” and (2) “Do women referred from facilities with MWHs have fewer poor delivery
outcomes than cases referred from non-MWH health facilities?” The research hypotheses are: (1)
Newborns born to women referred from facilities with MWHs will have fewer poor delivery
outcomes than women referred from non-MWH health facilities; and (2) Women referred from
facilities with MWHs will have fewer poor delivery outcomes than women referred from non-
MWH health facilities.
Theoretical Framework
Bronfenbrenner’s Ecological Systems Theory was operationalized for use in this case
series. Maternal-newborn outcome variables could be affected if independent maternal-newborn
health indicators are influenced by factors present in the Ecological Systems Theory such as
individual maternal-newborn dyad (microsystem), interpersonal (mesosystem), healthcare
organization (exosystem), social and cultural (macrosystem), and public health policy
(chronosystem). This study focuses on the healthcare organization (exosystem) and its
relationship to the maternal-newborn dyad.
Methods
A retrospective record review of district-level data recorded by healthcare providers for
the Zambian Ministry of Health was performed to compare maternal-newborn delivery outcomes
for cases referred from five BEmONC health facilities with and five without MWHs to a single
rural Zambian CEmONC district referral hospital for delivery. Data from the delivery register
(date/time of admission, demographics [name, address, age], delivery outcomes, birth outcomes)
were recorded by the attending nurse or midwife on the labor ward (Appendix E). The delivery
169
register, an institutionally based document that does not leave the labor ward, is a permanent
record that provides information on delivery process and outcome as well as laboratory tests.
Prior to beginning the study, Institutional Review Board (IRB) approval was obtained
from the University of Michigan Health Sciences and Behavioral Sciences Institutional Review
Board (HUM00110404) and from the Zambian IRB equivalent, Excellence in Research Ethics
and Science. The Zambian National Health Research Authority was informed of the case series
study. Verbal permission for data collection was obtained from the Hospital Administrator and
District Health Officer directly responsible for oversight of the facility in Zambia.
Setting and Sample
Lundazi District Hospital is a centrally located referral hospital where women with
obstetric complications from all corners of the district deliver (Moyo, Makasa, Mumbi &
Musonda, 2018). The total population of Lundazi District is 323,870 (Chief Statistics Office,
2015). In Zambia, the fertility rate is 4.98 births per woman (World Bank, 2019). In Eastern
Province, the fertility rate is higher at 5.8 births per woman (DHS Program, 2014). Table 5.2
shows the population (Chief Statistics Office, 2015) and delivery characteristics of cases referred
for delivery to the district hospital from the ten facilities included in the study.
Study sites were chosen based on their inclusion in the larger parent study. Researchers
and implementing partners in the parent study worked with the Zambian Ministry of Health to
identify five intervention sites (Scott et al., 2018). Sites were eligible for inclusion in the parent
study if the BEmONC health facility was located ≤2 hours driving time to a CEmONC capable
referral facility, performed a minimum of 150 deliveries per year and met at least one of two sets
of conditions below (Scott et al., 2018):
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Eligibility condition set 1:
i. Facility is able to provide at least five of seven BEmONC signal functions based on
2015 data.
Eligibility condition set 2:
i. Facility has at least one skilled birth attendant on staff.
ii. Facility routinely provides active management of third stage of labour.
iii. Facility has had no stock-outs of oxytocin in the last 12 months.
iv. Facility has had no stock-outs of magnesium sulfate in the last 12 months.
Five comparison sites were matched to intervention sites on annual delivery volume and distance
to the referral hospital (Scott et al., 2018). Sites with an existing infrastructure that functioned as
an MWH were not considered as an option for comparison sites (Scott et al., 2018). A two
population proportions z-score test, performed to compare the populations of paired MWH and
non-MWH referral facilities, showed they were similar and well matched (Table 5.2). Women of
childbearing age made up 27.1% of the total population.
The case series comparing maternal-newborn delivery outcomes was performed in rural
Zambia at Lundazi District Hospital (Eastern Province). The maternity ward delivery registers
for five full calendar months from September 1, 2017 through January 31, 2018 were reviewed.
The beginning timeframe was used due to publication of a new delivery register by the MOH.
The ending date was chosen due to constraints by the primary investigator to meet scholastic
program responsibilities in her home department. Inclusion criteria included all cases aged 15
years and above (n = 234) who were referred and arrived at the district hospital with a
complication from the ten catchment areas. In Zambia, married, pregnant, or parent-children are
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Table 5.2 Population and delivery demographics with two proportion z-score test
MWH Site
Total
Population
(n)
WCBAa
(n)
BEmONC
facility
deliveries
(n)
CEmONC
district
hospital
deliveries
(n)
non-MWH
Site
Total
population
(n)
WCBA
(n)
BEmONC
facility
deliveries
(n)
CEmONC
district
hospital
deliveries
(n)
Z
Score
P
value
Mwase
Lundazi
19,578
4,767
349
78
Kapichila
10,287
2,729
147
37
.082
.936
Nkhanga
11,193
3,461
165
20
Kamsaro
5,701
1,254
135
6
.029
.976
Lusuntha
6,407
1,840
93
8
Phikamalaza
4,463
982
95
34
-.270
.787
Zumwanda
10,323
2,570
81
34
Chikomeni
6,051
2,303
41
2
.170
.865
Nyangwe
6,670
2,065
116
2
Lukwizizi
7,475
2,278
45
13
-.148
.881
Total
54,171
14,703
804
142
Total
33,977
9,546
463
92
.008
.992
WCBA=women of childbearing age, aFigures provided by the Zambian Ministry of Community Development Mother & Child Health
172
considered “emancipated minors” if aged 15 years and older. From the sample, 60.7% of cases (n
= 142) were referred from five rural facilities with a MWH and 39.3% of cases (n = 92) were
referred from five rural non-MWH facilities. It is important to note that information about
whether a case actually used a MWH was not recorded in the delivery register.
Data Collection
After identifying all cases referred from MWH and non-MWH facilities documented in the
Zambian Ministry of Health (MOH) delivery register in the maternity ward at Lundazi District
Hospital, data were extracted by two local research assistants (RA) trained by the principal
investigator (Appendix F). Both had previous experience performing chart reviews, conducting
household surveys, and facilitating focus groups. One RA read directly from the delivery register
while the other transcribed the data. The principal investigator double-checked each variable and
entered data into an Excel spreadsheet. The key maternal-newborn health indicators used in this
analysis are listed in Table 5.3. Data for conditions requiring special attention and labor
complications were sorted into four sub-categories: prolonged labor (prolonged 1st or 2nd stage,
obstructed or prolonged labor, poor progress, CPD), caesarian section (C-section) (previous or
current C-section), hypertensive disorders (preeclampsia, eclampsia, epilepsy), and
malpresentation (breech, transverse lie, face presentation, hand prolapse, cord prolapse).
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Table 5.3 Key maternal-newborn health indicators from delivery register at district hospital
Independent Maternal-Newborn
Health Indicator Variables
Definition/Rationale (Zambian Ministry of Health, 2017)
Name of mother’s village
Mother referred from facilities with a MWH or without a MWH
Origin code
Location of residence in relation to the district referral hospital
Age of mother
Age in completed years as at last birthday
Gravida
Number of pregnancies the woman has had including the current pregnancy
Parity
Number of previous live births prior to this pregnancy
Dependent Maternal-Newborn
Health Indicator Variables
Mode of delivery
Birth form (Normal delivery, caesarean section, breech, assisted [i.e.: forceps, vacuum])
Conditions requiring special attention
Conditions requiring special attention (i.e.: hypertension, anemia)
Labor complications
Any complication that occurred during labor and delivery (i.e.: prolonged labora, uterine
rupture)
Condition of baby
Alive or dead
Apgar score at 5 minutes
Reading of Apgar score at 5 minutes
Birth weight (grams)
Weight of the baby in grams
Breastfed within 1 hour
Yes or no to breastfed within 1 hour
aNurses and midwives in Lundazi district, use varying terminology for dystocia of labor, therefore, for the purposes of analysis in this
case series, prolonged labor is used to describe: prolonged first or second stage labor; prolonged labor; obstructed labor; poor
progress, and; cephalopelvic disproportion.
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Statistical Analysis
Descriptive statistics were computed for all maternal-newborn variables of interest by
performing crosstabulation. Predictor variables for the maternal-newborn dyad included referral
from a referral facility with or without a MWH, distance of facility from district referral hospital,
age of mother, gravida, and parity. Newborn outcome variables included condition of baby,
Apgar score, birth weight, and breastfeeding within one hour. For Apgar score, per the local
definition, a dummy variable was created by coding, as the reference group, all cases with an
Apgar score less than or equal to 6 as low Apgar score. An Apgar score at 5 minutes of 7 to 10 is
considered normal (Costa et al., 2016; Pediatrics, T. A. A., Newborn, C., & Gynecologists, A.,
2006), while a 5-minute Apgar score of < 7 generally indicates a risk of poor birth outcome
(Cnattingius et al., 2017; Tiemeier & McCormick, 2019). For low birth weight, a dummy
variable was created by coding all cases with a birth weight less than 2500 grams as LBW, in
accordance with the WHO (2014) definition. Maternal outcome variables included mode of
delivery, labor complications, and conditions requiring special attention.
A Pearson chi-square test of independence was performed for relevant variables to
examine whether there was a difference in referral from a facility with a MWH compared to
those referred from a facility without a MWH. In addition, certain numerical variables, such as
age, gravida (number of pregnancies), parity (number of live births), and village community,
were categorized to determine their associations when comparing referrals from a facility with a
MWH to referrals from a facility without a MWH. In cases where the sample size was too small
to use a chi-squared test, a Fisher’s exact test was performed. Frequencies were established to
examine documented labor complications and conditions requiring special attention. Pairwise
175
referral-facility comparisons were conducted as were grouped (MWH vs. non-MWH)
comparisons.
The hypotheses were tested with independent and pairwise referral-facility comparison t-
tests. Given that multiple significance tests were performed, Bonferroni corrections were
performed. Logistic regression with a dichotomized MWH variable (non-MWH = 0, MWH = 1)
was performed. Adjusted logistic regression was performed controlling for categorized variables
such as age, gravida (number of pregnancies), parity (number of live births), and village referral
facility that could interact with the maternal-newborn delivery outcomes. P-values < 0.05 were
considered statistically significant. Statistical analysis was performed using SPSS version 25.
Results
Among all cases referred to a district hospital from facilities with and without MWHs,
referrals were more likely to come from facilities with MWHs (60.7% MWH vs. 39.3% non-
MWH). We had 142 cases referred from facilities associated with a MWH and 92 cases referred
from facilities not associated with a MWH. Most cases (64.1%) were referred from facilities
more than 12km from the district referral hospital. Twenty percent of newborns weighed less
than 2500 grams. The mean age of mothers was 22.9 years with mean gravida of 2.6 and parity
of 1.5. Most cases had a normal spontaneous vaginal delivery (55.6%) while 20.5% had a C-
section with the remainder having an assisted (12.4%) or vaginal breech delivery (11.5%) (Table
5.4). Select demographic and delivery outcome data are shown in Table 5.4. Apart from low
Apgar score, there were no other statistically significant differences in distance, age, gravida, or
parity between women referred from MWH and non-MWH facilities.
176
Table 5.4 Demographic characteristics of women referred for delivery to district hospital
Referring Facility
Statistical Tests
Maternal-Newborn
Health Indicator
Total
(n = 234)
MWH
(n =142)
non-MWH
(n = 92)
Pearson
Chi-Square
Adjusted
P value
Distance
% (n)
% (n)
% (n)
(2-sided)
≤ 12 km
35.5% (83)
34.5% (49)
37.0% (34)
0.118
0.731
> 12 km
64.1% (150)
64.8% (92)
63.0% (58)
Missing
0.4% (1)
0.7% (1)
none
Age group
15 to 19
39.7% (93)
43.0% (61)
34.8% (32)
6.240
0.182
20 to 24
29.1% (68)
30.3% (43)
27.2% (25)
25 to 29
12.0% (28)
10.6% (15)
14.1% (13)
30 to 34
8.1% (19)
4.9% (7)
13.0% (12)
35 and older
9.8% (23)
9.9% (14)
9.8% (9)
Mean (SD)
22.9 (6.9)
22.4 (6.6)
23.8 (7.2)
Missing
1.3% (3)
1.4% (2)
1.1% (1)
Gravida
1
46.6% (109)
52.1% (74)
38.0% (35)
4.475
0.107
2-5
41.9% (98)
38.7% (55)
46.7% (43)
6 and above
11.1% (26)
9.2% (13)
14.1% (13)
Mean (SD)
2.6 (2.1)
2.3 (1.7)
3.1 (2.3)
Missing
0.4% (1)
none
1.1% (1)
Parity
0
47.0% (110)
51.4% (73)
40.2% (37)
3.130
0.209
1-5
48.3% (113)
43.7% (62)
55.4% (51)
6 and above
4.7% (11)
4.9% (7)
4.3% (4)
Mean (SD)
1.5 (1.9)
1.3 (1.8)
1.9 (2.1)
Missing
none
Mode of delivery
Normal delivery
55.6% (130)
54.9% (78)
56.5% (52)
1.506
0.681
Caesarean section
20.5% (48)
19.0% (27)
22.8% (21)
Vaginal Breech
11.5% (27)
13.4% (19)
8.7% (8)
Assisted (forceps or
vacuum)
12.4% (29)
12.7% (18)
12.0% (11)
Missing
none
Condition of baby
Alive
94.4% (221)
94.4% (134)
94.6% (87)
.004
0.948
Dead
5.6% (13)
5.6% (8)
5.4% (5)
Missing
none
177
Apgar score at 5
mins
0-6
15.4% (36)
19.7% (28)
8.7% (8)
7.460
0.024*
7-10
84.6% (198)
80.3% (114)
91.3% (84)
Mean (SD)
7.8 (2.4)
7.6 (2.3)
8.3 (2.1)
Missing
none
Birth Weight (grams)
< 2500
20.9% (49)
21.2% (30)
20.7% (19)
0.008
0.931
≥ 2500
79.1% (185)
78.9% (112)
79.3% (73)
Mean (SD)
2961 (549)
2943 (594)
2988 (473)
Missing
none
Breastfed within 1
hour
Yes
81.2% (190)
78.2% (111)
85.9% (79)
2.168
0.141
No
18.8% (44)
21.8% (31)
14.1% (13)
Missing
none
178
Newborn delivery outcomes
After record review, the hypothesis “Newborns born to women referred from facilities
with MWHs will have fewer poor delivery outcomes (LBW, condition of baby, low Apgar score,
breastfeeding within one hour) than women referred from non-MWH health facilities” was not
supported. Eighteen newborn deaths were reported (7.7%). Fetal distress was noted for 23 cases
(9.8%). Cases with LBW were no more likely to be referred from MWH compared to non-
MWH facilities (X2 = 0.008, p = 0.931) (Table 5.4). Regarding condition of baby (alive or dead),
there was no statistically significant difference for cases referred from MWH compared to non-
MWH (X2 = .004, p = 0.948). Cases from MWH and non-MWH had similar rates of
breastfeeding within one hour of birth that were not statistically different (X2 = 2.168, p = 0.141)
(Table 5.4).
The majority (84.6%) of all newborns in both groups had Apgar scores of 7 or above.
When compared to cases referred from facilities without a MWH, those referred from facilities
with a MWH were more likely to have newborns with an Apgar score from 0-6 (X2 = 7.460, p =
0.024) (Table 5.4). However, a regression model demonstrated no significant difference among
groups referred from MWH and non-MWH facilities for Apgar score when controlling for
variables that could interact with the maternal-newborn delivery outcomes, including
subcategories within distance, age, gravida (number of pregnancies), and parity (number of live
births).
Maternal delivery outcomes
No maternal deaths were recorded in the case series. Seventy-five cases with either labor
complications or those requiring special attention had prolonged labor (Prolonged 1st or 2nd
stage, obstructed labor, poor progress, CPD) (32.1%), while 71 were primiparous (first birth)
179
(30.3%). The second hypothesis was “Cases referred from facilities with MWHs will have fewer
poor delivery outcomes (assisted delivery, prolonged/obstructed labor, eclampsia) than cases
referred from non-MWH health facilities; this was only partially supported. Cases referred from
facilities with MWHs had similar modes of delivery compared to cases referred from non-MWH
health facilities (X2 = 1.506, p = 0.681) (Table 5.5). Frequency distributions for labor
complications and conditions requiring special attention are presented in Table 5.5. Cases with
prolonged labor were more often referred from facilities associated with MWHs (X2 = .032, p =
.033) (Table 5.5). Among all women presenting with complications at the district hospital, cases
with high parity (6 or more live births) were more likely to come from non-MWH facilities than
facilities with MWHs (X2 =.007, p = .012). Similarly, cases experiencing malpresentation as a
labor complication were more likely to come from a non-MWH facility than a facility with a
MWH (X2 =.026, p = .041) (Table 5.5). Pairwise referral facility and grouped (five MWH vs.
five non-MWH) comparisons did not show any significant differences among groups in the
sample.
180
Table 5.5 Labor complications and conditions requiring special attention
Referring Facility
Labor complications
& conditions
Total
(n = 234)
MWH
(n =142)
non-MWH
(n = 92)
Pearson
Chi-
Square
Fisher’s
Exact Test
Figure 1.1
% (n)
% (n)
% (n)
(2-sided)
Prolonged labora
32.1% (75)
37.3% (53)
23.9% (22)
.032
.033*
Primipara
30.3% (71)
32.4% (46)
27.2% (25)
.396
.467
No complications
20.1% (47)
16.9% (24)
25.0% (23)
.131
.137
High parity (>6)
9.8% (23)
5.6% (8)
16.3% (15)
.007
.012*
Fetal distress
9.8% (23)
7.7% (11)
13.0% (12)
.184
.260
Malpresentationd
9.8% (23)
6.3% (9)
15.2% (14)
.026
.041*
Neonatal death
7.7% (18)
8.5% (12)
6.5% (6)
.589
.802
C-sectionb
6.8% (16)
7.0% (10)
6.5% (6)
.878
1.000
Hypertensive disordersc
6.8% (16)
9.2% (13)
3.3% (3)
.081
.111
Twins
5.1% (12)
3.5% (5)
7.6% (7)
.166
.225
aProlonged 1st or 2nd stage, obstructed or prolonged labor, poor progress, cephalopelvic
disproportion
bPrevious or current c-section
cPreeclampsia, eclampsia, epilepsy
dBreech, transverse lie, face presentation, hand prolapse, cord prolapse
181
Discussion
Among all cases referred to a district hospital from facilities with and without MWHs, we
found that referrals were more likely to come from facilities with MWHs (60.9% vs. 39.3%).
More cases of women with prolonged labor were referred from facilities associated with a MWH
than without a MWH (37.3% vs. 23.9%). In this case series, no maternal deaths were recorded.
Because information about MWH use per se was not recorded in the delivery register, and is
therefore unknown, this study could not directly test differences in maternal-newborn outcomes
among cases that used a MWH and those that did not. However, findings demonstrate the
potential positive influence of referral from facilities associated with MWHs, especially for those
with prolonged labor as a complication.
In this case series, access to a MWH may have brought women closer to a BEmONC
facility where prolonged labor was recognized and emergency referral to CEmONC at the
district hospital was made for obstetric management. Untreated prolonged, or obstructed labor
can be dangerous and is a major cause of both maternal and newborn morbidity and mortality
(Dolea & AbouZahr, 2003). Especially for poor, remote, and rural populations where access to
health services may be limited, emergency referral is critical to improving outcomes for time-
sensitive conditions, such as prolonged labor, that underlie many unpredictable problems during
pregnancy, delivery, and the postnatal period. (Bailey et al., 2019). In the newborn, neglected
obstructed labor may cause asphyxia leading to stillbirth, brain damage, or neonatal death (Dolea
& AbouZahr, 2003). Maternal complications include intrauterine infections following prolonged
rupture of membranes, trauma to the bladder and/or rectum due to pressure from the fetal head or
damage during delivery, and ruptured uterus with consequent hemorrhage, shock, or even death
(Dolea & AbouZahr, 2003).
182
The finding that 20% of newborns weighed less than 2500 grams is concerning and
demonstrates a higher prevalence of LBW than the national rate of 9% (DHS Program, 2014). In
a retrospective cohort analysis to identify predictors and outcomes of LBW in Lusaka, Zambia
using data from the public Maternal, Newborn, and Child Health system recorded from 2006-
2012, nearly 11% of newborns met the criteria for LBW (Chibwesha et al., 2016). The high
prevalence of LBW in the rural district is concerning because being undernourished in the womb
increases the risk of death in the early months and years of a child’s life (UNICEF, 2014).
Newborns who survive tend to have impaired immune function and increased risk of disease;
they are likely to remain undernourished, with reduced muscle strength, cognitive abilities and
IQ throughout their lives (UNICEF, 2014). Affordable, accessible and appropriate health care is
critical for preventing and treating LBW along with culturally appropriate care and gender-
sensitive interventions to reach women who face greater barriers in access to health care (WHO,
2014).
To attain Sustainable Development Goal targets, newborns and their mothers need access
to quality health care. The finding that there were few significant differences in maternal-
newborn delivery outcomes, and no cases of maternal deaths, for cases referred from MWH and
non-MWH facilities could be explained by overall improvements in maternal-newborn health
made in Lundazi District over the past five years. The presence of the SMGL program
(chronosystem) for two years prior to starting the MWH intervention study may confound the
results of this case series, since positive trends in improved maternal-newborn mortality were
already associated with the SMGL program when the first MWHs were introduced in Lundazi
District in late 2016. The SMGL initiative, a package of multiple interventions focused on
183
reducing maternal and perinatal mortality during labor, delivery, and postpartum (Conlon et al.,
2019), likely had a positive influence on maternal-newborn dyad (microsystem) health.
In conjunction with stimulus from the SMGL initiative, several explanations are plausible
for why the hypotheses in this case series were not supported. It is plausible the insignificant
differences in maternal-newborn delivery outcomes in the sample reflect quality care provided at
rural BEmONC facilities in the district. It is encouraging that nurses and midwives may be
identifying maternal-newborn health problems early and referring appropriately. The SMGL
initiative implemented several interventions to improve quality of care in rural Zambia (Morof et
al., 2019). Interventions employed by SMGL in Zambia to build capacity and ensure sufficient
trained health care providers at facilities included: (1) recruitment of new nurses and midwives,
(2) training of health professionals in emergency obstetric care and surgeries, and (3) provision
of mentoring and supportive supervision to newly hired and existing personnel (Morof et al.,
2019).
Furthermore, despite potential geographic barriers, such as distance and transportation
difficulties, our findings suggest that a good system is in place in the district for referring cases
to CEmONC when complications arise. Another explanation for insignificant differences in the
sample could be that MWHs had not been open for a sufficiently long period of time to influence
maternal-newborn outcomes. MWHs were opened from between one month to one year prior to
the case series data collection timeframe.
In this study, it was difficult to interpret the findings given the ongoing improvements in
maternal and newborn delivery outcomes from the SMGL interventions. The SMGL initiative
used an integrated systems approach focusing on the following interventions: (1) skilled
attendance at birth; (2) safe facilities and hospitals for delivery; (3) supplies and provision of
184
basic and emergency obstetric services; (4) systems for communication, referral, and
transportation available 24 hours a day, 7 days a week; and (5) quality data, surveillance, and
response (Quam, Achrekar, & Clay, 2019). In a baseline cross-sectional household survey among
SMGL-supported districts in Zambia prior to the opening of MWHs in Lundazi District, Lori and
colleagues (2018) demonstrated that SMGL districts had higher rates of facility delivery than the
general population of Zambia and concluded that MWHs bridge the distance barrier for women
who live greater than 9.5 km from a health facility. As part of a baseline observation of impact
evaluation of MWHs, researchers assessed the determinants of home delivery among remote
women in seven districts targeted by the SMGL initiative; they found that those living in districts
not yet exposed to the SMGL program had significantly increases odds of home delivery (Scott,
Henry et al., 2018). Serbanescu and colleagues (2017) compared baseline maternal outcomes to
those during Year 1 in SMGL pilot districts by reviewing health facility assessments pregnancy
outcome monitoring, enhanced maternal mortality detection in facilities, and population-based
investigation of community maternal deaths. After one year, researchers found that access to
care, infrastructure, and delivery care improved in SMGL districts with the institutional delivery
rate increased by 35% in Zambia (Serbanescu et al., 2017). While it is challenging to tease out
specific maternal-newborn delivery outcomes from the various SMGL interventions, SMGL
provides a framework for how to approach the SDGs through engaging and collaborating with a
diverse group of partners (SMGL, 2018b).
Given that this case series is the first of its kind to explore the delivery outcomes of
women and their newborns referred from health facilities with and without MWHs, no direct
comparisons can be made to other studies. However, findings related to labor complications from
women in this case series can be assessed in light of findings from other studies investigating
185
maternal-newborn health outcomes. In a retrospective observational study involving MWHs in
rural Ethiopia, Braat and colleagues (2018) examined the impact of a MWH by comparing
pregnancy outcomes among users and non-users at hospitals with and without MWHs. The
researchers found that high-risk women who used a MWH had less favorable sociodemographic
characteristics, but better birth outcomes than both women who gave birth at the same hospital
but did not use the MWH and women who gave birth at a hospital without a MWH (Braat et al,
2018). In the cohort study in Ethiopia, MWHs contributed to reducing maternal deaths,
stillbirths, and uterine ruptures by providing an important service to women living in rural areas
who have difficulty accessing facilities providing EmONC (Braat et al, 2018). While in this case
series the sociodemographic characteristics were similar across all cases, referral from facilities
associated with a MWH likely allowed for early and rapid recognition of prolonged labor at a
BEmONC facility. Subsequent timely referral to CEmONC at the district hospital for
management of prolonged labor in this case series lends support to the effectiveness of facilities
associated with MWHs as a potentially lifesaving intervention to improve maternal-newborn
delivery outcomes.
In this case series, maternal-newborn delivery outcomes were likely influenced by
environmental factors consistent with the operationalized Ecological Systems Theory, including
the individual maternal-newborn dyad (microsystem), healthcare organization (exosystem), and
public health policy (chronosystem). As presented in the Ecological Systems Theory,
microsystem factors that play important roles in delivery outcomes for the maternal-newborn
dyad include self-care during pregnancy, and family and social roles. Health-seeking during
pregnancy and ability to follow up on recommendations for referral to a CEmONC facility often
depend on complex relationships between the maternal-newborn dyad and decisions influenced
186
by husbands, grandmothers, and community members. The relationships experienced by women
when accessing antenatal care also influence maternal-newborn delivery outcomes in the
microsystem.
Healthcare organization (exosystem) factors could influence individual maternal-
newborn dyad delivery outcomes. Since no clear guidelines exist, wide variation in classification
of labor complications, conditions requiring special attention, and subjective remarks regarding
stability of maternal-newborn dyad by nurses and midwives at the district referral hospital may
occur. For example, because of potential differences in how nurses and midwives are educated
and trained to recognize maternal and newborn complications and in willingness to report more
than one complication, midwives may register Apgar scores, fetal distress, or prolonged labor
differently. These exosystem factors could influence reporting of maternal-newborn health
indicators.
In this study, maternal-newborn delivery outcome variables could have been affected by
chronosystem factors such as the implementation of the SMGL program in Lundazi District. In
Zambia, the proportion of women with childbirth complications delivering in EmONC facilities
rose by 23% after one year of SMGL (Serbanescu et al., 2017). In the past three years, SMGL
communities saw the maternal mortality ratio decline by 55% and the stillborn and neonatal
deaths decline by 44% in target facilities in Zambia, with an accompanying increase of 38% in
women giving birth in a facility in the target districts (SMGL, 2018a). Furthermore, as part of the
SMGL program, community health workers were active in all study sites and likely influenced
the health-seeking behavior of pregnant women.
187
Limitations
As a case series using data from the delivery register at one district referral hospital in
rural Zambia, the study has several limitations. Results may not be generalizable to other districts
in Zambia, nor to the broader population. The study was also limited by the variables in the
delivery registers; moreover, the data were retrospective and any assumptions about maternal-
newborn outcomes are inferred. The data collected in the delivery register represents only a
snapshot of the time around birth, and are not updated by staff to reflect complications that
occurred after delivery. It was not possible to explore other aspects of antenatal care or
sociodemographic information that could be associated with maternal-newborn delivery
outcomes such as intrauterine infections, maternal smoking or alcohol use, poor fetal growth,
mother’s weight, etc. Exclusion of this information could bias the observed results. Furthermore,
only data for those referred to the one district hospital from BEmONC study sites were available.
We have no data from referrals from study facilities to other hospitals.
Researchers must be concerned with the internal validity of their designs. Historical bias
is a potential threat to the internal validity of this case series. Inconsistencies between the MWH
and non-MWH groups could have occurred within the parent study through a selection threat to
internal validity due to a lack of randomization. Furthermore, a compensatory intervention threat
to internal validity could have occurred if the non-MWH group lost motivation or became
resentfully demoralized after baseline assessment. Further prospective studies are needed to
evaluate maternal-newborn delivery outcomes for cases referred from health facilities with and
without a MWH for CEmONC.
Regarding newborn delivery outcomes, while there were slight statistically significant
differences in Apgar score among MWH and non-MWH users, they were not present when
188
controlling for distance, age, gravida, and parity. Moreover, there is likely significant inter-
observer variability in the 5 minute Apgar score documented in the maternity delivery register. It
is important to recognize the limitations of the Apgar score, which includes subjective
components, as an expression of the newborn’s physiologic condition at one point in time
(Committee on Obstetric Practice American Academy of Pediatrics‐Committee on Fetus and
Newborn, 2015). The Apgar score provides a convenient method for reporting the status of the
newborn infant immediately after birth, and quantifies clinical signs of neonatal distress, such as
cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or
gasping respirations (Watterberg et al., 2015); however, researchers have found large variations
in the distribution of Apgar scores, likely due to national scoring practices, making the Apgar
score an unsuitable indicator for benchmarking newborn health across countries (Siddiqui,
2017). It would be helpful to have reference materials with standard definitions and guidelines
for calculating the Apgar score and identifying maternal-newborn delivery outcomes at the
district CEmONC facility.
Furthermore, no clear guidelines or protocols were in place at the hospital for diagnosing
or documenting most maternal-newborn delivery outcomes. The quality of documentation in the
delivery register likely varied by the person entering the data. Students training in the district
hospital were often the ones entering information into the delivery register. While there were few
cases with incomplete documentation, under-reporting of delivery outcomes in the delivery
register is a potential limitation. Lack of electricity, understaffing, operating at over-capacity,
and competing demands for the attention of nurses and midwives make data entry difficult or
under-prioritized and, therefore, may have caused gaps in the register. Every provider was
responsible for identifying complications, thus creating potential for not recognizing or recording
189
complications or conditions requiring special attention. Finally, because data about actual use of
MWHs by case and referrals that occurred to other CEmONC facilities were unavailable, no
inferences about causality or correlation between maternal-newborn delivery outcomes and a
woman’s use of MWH could be made.
Conclusion
By examining maternal-newborn delivery outcomes for cases referred from five facilities
with MWHs and five without MWHs to a single district hospital, this study found that, among all
referrals across the ten facilities, more came from facilities with a MWH than from those without
MWHs. Although there was no significant difference in maternal or newborn outcomes, and lack
of pertinent data precluded an assessment of MWH utilization, the use of MWHs likely allowed
for early access and rapid recognition of prolonged labor at a BEmONC facility, offering a
probable referral source to CEmONC in rural Zambia. Recognition of prolonged labor at a
BEmONC facility with a MWH likely led to crucial referrals to CEmONC at the district hospital
for management, which in turn could argue for the effectiveness of MWHs as a potentially
lifesaving intervention to improve maternal-newborn delivery outcomes in rural Zambia.
This study is the first case series that we are aware of to focus on the impact of referrals
from facilities with MWHs on maternal-newborn delivery outcomes in a low-resource setting. It
is innovative, timely, and important because it provides vital new knowledge on the association
of referral from facilities with MWHs and maternal-newborn delivery outcomes. Among all
women referred to a district hospital from facilities with and without MWHs, we found that
referrals were more likely to come from facilities with MWHs. This finding is significant as we
enter the post-2015 era of sustainable development with a goal to reduce the inequities of
preventable death by reaching all women and newborns.
190
More research is needed to compare the long-term impact of MWHs on newborn delivery
outcomes and health in communities. Additional investigation of maternal-newborn outcomes
comparing documented MWH use and referral to CEmONC facilities in urban settings is
justified to understand the potential wide-ranging impact of MWH use. Meanwhile, the
potentially lifesaving effects of findings from the case series on maternal-newborn delivery
outcomes at a district referral hospital could ultimately be used to influence public health policies
regarding the access and use of MWHs in Zambia and other low-resource countries.
191
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CHAPTER 6
Summary
Newborn morbidity and mortality remain a serious global health challenge in low- and
middle-income countries (LMICs). Targeting the time around birth with proven high-impact
interventions and quality care for small and sick newborns may prevent up to 80 percent of
newborn deaths (UNICEF, 2018). Maternity waiting homes (MWHs) offer a way to provide
better perinatal obstetric care (Kelly et al., 2006; Lori, Wadsworth, Munro & Rominski, 2013) by
targeting the high-risk period before birth. By addressing distance to the health facility and
transportation barriers, MWHs could increase the use of skilled birth attendants, thereby
reducing newborn morbidity and mortality in rural, low resource areas of Zambia (Lori et al.,
2016). In addition, the expanded purpose of many MWHs is to increase newborn health
knowledge for mothers utilizing them. Also, by bringing women closer to a health facility so
they can deliver with a skilled attendant, MWHs may improve maternal-newborn outcomes.
To catalyze action in lowering maternal and newborn mortality, the United Nations
Member States launched the Sustainable Development Goals (SDGs), mobilizing efforts to end
all forms of poverty, fight inequalities, and tackle climate change while ensuring that no one is
left behind (United Nations, 2018). The third SDG is to ensure healthy lives and promote well-
being for all, at all ages. To reach SDG targets, newborns and their mothers need access to good
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health care through programs such as Saving Mothers, Giving Life (SMGL) and important life-
saving interventions such as maternity waiting homes (MWHs). Fortunately, nurses are in a
unique position to accelerate the reduction of newborn mortality in low resource settings. The
research summarized here explored MWH use as part of an ecological systems approach to
reduce newborn morbidity and mortality ratio targets set by the United Nations to meet the SDGs
goals.
Historically, the focus of research studies evaluating MWHs has been on maternal
outcomes (Buser & Lori, 2016; Figa'-Talamanca, 1996; Kelly et al., 2006; Lori, Wadsworth,
Munro & Rominski, 2013). Although perinatal and newborn health is mentioned in a limited
number of articles (Chandramohan, Cutts & Millard, 1995; Lori, Munro et al, 2013; Tumwine &
Dungare, 1996; van Lonkhuijzen, Stegeman, Nyirongo, & van Roosmalen, 2003), results are
unclear, with only fragmentary understanding of newborn outcomes at MWHs (Buser & Lori,
2016).
Given the dearth of evidence, the relevant and critical overarching goal of this
dissertation was to explore and describe the cultural practices, knowledge, and beliefs of
essential newborn care and health-seeking in the context of MWHs and the SMGL initiative in
rural Zambia. Guided by the Ecological Systems Theory (Bronfenbrenner, 1977, 1979, 1989,
1994), this goal was met through three distinct studies. Study 1 addressed the gap in knowledge
by using focus groups to describe the knowledge and beliefs of newborn care and illness from
the perspective of rural Zambian women, community members, and health workers. Also, in
order to identify traditional and professional newborn care practices in rural Zambia, the first
study examined the social and cultural factors that influence ways women seek newborn care.
Study 2 explored the association between MWH use and maternal-newborn health and delivery
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outcomes, using a quasi-experimental approach to assess maternal knowledge of newborn care
and care-seeking for users and non-users of MWHs referred to a district hospital for delivery.
Study 3 examined the characteristics of those referred from facilities with and without MWHs,
using a sample of all women with complications who were referred from ten lower-level
BEmONC facilities and arrived at the higher-level CEmONC district referral hospital. Medical
record data for the analysis was extracted from delivery registers located in the one district
referral hospital.
Broadly, findings from the three studies highlight and support the maternal-newborn dyad
duality faced by women as they navigate the complex interplay between cultural newborn care
practices and evidence-based “Essential newborn care” (ENC) of the health system (Figure 6.1).
As seen in the three studies, rural Zambians understand the importance of seeking pregnancy
care at the health facility for delivery and know about ENC according to World Health
Organization (WHO) (2017) guidelines. However, women don’t always act on what they know
about the benefits of ENC and maternal-newborn health-seeking. Multiple factors influence
adherence to traditional newborn protective rituals and avoidance of maternal-newborn health-
seeking at an established facility, including the influence of husbands and grandmothers over
health decision making, desire to preserve dignity at health facilities, financial constraints, and
geographic barriers.
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Figure 6.1 The maternal-newborn dyad duality
Implications for Practice
Numerous implications for nursing practice emerged from this ecological systems
approach, which explored the impact of MWH use on maternal-newborn health and delivery
outcomes in rural Zambia. Professional and community health workers should be supported to
continue work in promoting maternal-child health in rural Zambia. Nurses and midwives can
promote the maintenance of cultural beliefs that benefit or at the very least do no harm to the
mother-newborn dyad (microsystem) while encouraging the reframing of potentially detrimental
practices. Professional and community health workers can incorporate the potential for harmful
effects from traditional protective rituals, such as the use of herbal medicine to speed labor or
apply to the umbilical cord, into the mother-newborn health education messages. Regarding
familial roles in the health decision making-process, nurses and midwives have a duty to foster
those that promote the health of the mother-newborn dyad. Concerning the preservation of
dignity (exosystem) theme, there is an obvious need for nurses and midwives to promote privacy
and modify clinic spaces to allow women to feel more comfortable with seeking care.
Furthermore, it is important for nurses and midwives to reinforce the importance of partner
testing for sexually transmitted infections (STIs) during routine antenatal care (ANC) despite the
issue of shame.
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It is encouraging that nurses and midwives are identifying maternal-newborn health
problems early and referring appropriately. However, findings from Study 3 raised questions
about the potential for wide variation in classification of labor complications, conditions
requiring special attention, and subjective remarks regarding stability of maternal-newborn dyad
by nurses and midwives at the district referral hospital. Results highlight the urgency of targeting
younger, primigravida women for education by nurses and midwives in rural health facilities to
improve maternal “Essential Newborn Care” knowledge in Zambia. Younger women need more
education by nurses, midwives, and community health workers about timing of PNC visits,
newborn health problems and danger signs, exclusive breastfeeding, umbilical cord care, and
newborn skin care.
Theoretical Framework
The relevance of the operationalized Ecological Systems Theory to the three studies in
this dissertation is shown in Figure 6.2. Based on our operationalization of the grand Ecological
Systems Theory for maternal-newborn health and MWH use in three studies in this dissertation,
we conclude that it can be applied globally. This further validates the theory, especially since our
studies were the first that we know of to apply it to healthcare in rural Eastern and Luapula
provinces of Zambia. The Ecological Systems Theory was modified for maternal-newborn health
and MWH use with the maternal-newborn dyad representing the microsystem, family and
community members the mesosystem, healthcare organization the exosystem, culture the
macrosystem, and health policy the chronosystem.
In Study 1, individual maternal-newborn dyad factors associated with newborn care in
rural Zambia in the microsystem included demographic characteristics and maternal
understanding of essential newborn care. In the mesosystem, a strong sense of family &
203
community to protect the newborn was evident. Themes at the level of culture (macrosystem)
and healthcare system (exosystem) were uncovered supporting the identification of traditional
and professional newborn care practices in rural Zambia.
When the Ecological Systems Theory was operationalized in Study 2, factors at the
individual maternal-newborn dyad (microsystem) level that influenced maternal “Essential
Newborn Care” knowledge included age and gravida. At the public health policy (chronosystem)
level, factors influencing outcomes in the study included national and local government agency
support for maternal-newborn health, including district-wide participation in the SMGL program.
Zambian Ministry of Health promotion of and funding for maternal-newborn health and MWH
use in Lundazi district also influenced study outcomes at the chronosystem level.
In Study 3, the case series, maternal-newborn delivery outcomes were likely influenced
by environmental factors consistent with the operationalized Ecological Systems Theory,
including the individual maternal-newborn dyad (microsystem), healthcare organization
(exosystem), and public health policy (chronosystem). Microsystem factors playing an important
role in delivery outcomes for the maternal-newborn dyad included self-care during pregnancy,
family, and social roles. Healthcare organization (exosystem) factors that could influence the
individual maternal-newborn dyad delivery outcomes included potential differences in how
nurses and midwives are educated and trained to recognize maternal and newborn complications.
Maternal-newborn delivery outcome variables could have been affected by public health policy
chronosystem factors, such as the implementation of the SMGL program and active health
education of community health workers (SMAGs) in all study sites and likely influenced the
health-seeking behavior for pregnant women.
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Figure 6.2 Relevance of operationalized Ecological Systems Theory to three studies in dissertation (adapted from Berger, 2007;
Stranger, 2011)
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Strengths
Although development of further research is needed, findings presented here shed light
on newborn care practices and health-seeking behavior, maternal knowledge of newborn care,
and maternal-newborn delivery outcomes in rural Zambia. The inclusivity of the operationalized
Ecological Systems Theory that views an individual maternal-newborn dyad within the context of
nested hierarchical systems makes the operationalization of Bronfenbrenner’s work ideal for
global community health research. This dissertation is innovative because it is the first to focus
on the association between maternal-newborn health and delivery outcomes and MWH use in a
low-resource setting, and has the potential to inform future research, practice, and policy.
The research presented here partially fills the gap in knowledge about the outcomes of
newborns born to mothers with access to MWHs. The use of different types of methods in data
collection across the three studies and the inclusion of diverse focus group participants
strengthens the validity of the findings of the dissertation. An essential strength of Study 1 is that
it adds to the literature about cultural values, beliefs, and practices of rural Zambians related to
newborn care and illness that influence maternal-newborn health. Study 2 is the first to assess
maternal knowledge of newborn care and care-seeking in relation to MWH and SMGL
interventions in rural Zambia. Study 3 is timely and important because it provides vital, new
knowledge on the impact of referral from facilities with and without MWHs on maternal-
newborn delivery outcomes.
Limitations
Several limitations in this dissertation are worth mentioning. Since all studies were
conducted in rural districts in Zambia, results cannot be generalized to other districts in Zambia
or to the broader population. Also, findings of the three studies do not reflect changes over time.
206
Furthermore, an inherent power differential existed between participants and researcher, as well
as potential for bias by cultural brokers/interpreters/researcher. To address these limitations, the
principal investigator situated herself within the local context, was mindful of power dynamics,
and cultivated cultural humility through a process of reflection to challenge her own cultural
biases.
The researcher’s ability to understand fine distinctions in meaning may be limited by the
use of local languages by the participants and by the lack of elaboration on a topic in the focus
groups and maternal knowledge surveys due to low literacy levels. Cultural brokers, fluent in
both local languages and English, mitigated this potential limitation, and provided assistance in
deciphering the cultural meaning of mother-newborn care phenomena while interpreting audio-
recordings, responses on the Maternal Knowledge of Newborn Care Questionnaire, and verbatim
transcriptions of focus groups.
Because the data were collected retrospectively, Study 3 was limited by the existing
variables in the maternal delivery database. Without data about MWH use by participants or
referrals that occurred outside the district hospital, no inferences about causality or correlation
between maternal-newborn delivery outcomes and MWH use could be made. Healthcare
organization (exosystem) factors present in the operationalized Ecological Systems Theory could
have influenced the individual maternal-newborn dyad (microsystem) delivery outcomes. Since
no clear guidelines were available, documentation may have varied widely in classification of
labor complications, conditions requiring special attention, and subjective remarks regarding
stability of maternal-newborn dyad by nurses and midwives at the district referral hospital.
207
Future Directions
In combination, the three studies highlight that rural Zambian women, community
members, and health workers have an understanding of newborn care according to WHO
guidelines (2017). As shown in Studies 1 and 2 in this dissertation, rural Zambians understand
the importance of ANC, delivering at the health facility, and dangers signs prompting health-
seeking for newborns. Clearly, on-going community health sensitization programs such as
SMGL and the presence of community health workers from the SMAGs are reaching far corners
of rural districts to increase knowledge at the grass roots level. These programs should be
continued and expanded to reach regions not yet covered.
Given the understanding of essential newborn care expressed by rural Zambians, we can
conclude that lack of knowledge about maternal-newborn health in rural communities is not the
biggest barrier to decreasing high rates of newborn morbidity and mortality. In rural Zambia,
knowledge of newborn and pregnancy care does not directly translate into maternal-newborn
health seeking. Other factors, such as adherence to traditional newborn care practices,
transportation, distance, and financial barriers influence whether a woman makes timely
decisions to seek maternal-newborn health services. Also, women often rely on their husbands
for financial support and, without money, face difficulty in covering the cost of travel to the
facility or of supplies for newborns after delivery, such as baby blankets and clothing. Study 1
revealed the maternal-newborn dyad duality experienced by women as they are pushed and
pulled between fulfilling competing cultural and health system responsibilities. More research is
needed to explore this maternal duality to better understand how nurses and midwives can meet
the psychosocial needs of this population.
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Research exploring the push-pull felt by mothers navigating cultural practices and health
system regulations has the potential to inform future interventions aimed at improving newborn
care. To foster confidentiality, individual interviews with women could be considered for a
follow-up study, since participants might be reluctant to express maternal duality in the open
forum of a focus group. To further explore the concept of maternal duality in rural Zambia, a
mixed-methods approach could be used in these interviews to explore perceived cultural
responsibilities and to collect data using a validated instrument measuring understanding of
ENC. A more rigorous rating of responses on the questionnaire with a scale to assess each
maternal “Essential Newborn Care” outcome on the Maternal Knowledge of Newborn Care
Questionnaire is needed. The tool should be further tested in future research to demonstrate
adequate reliability and validity.
Husbands, grandmothers/mothers-in-law, and community members all influence a
woman’s decision-making about maternal-newborn health seeking. Longstanding gender norms
and stereotypes persist in the patriarchal social systems and attitudes of rural Zambians, which
contributes to unequal power relationships for women in their families and communities. This
power differential often leads to imbalanced influence over maternal health-seeking decisions by
opinion-leading husbands and grandmothers/mothers-in-law. Community health policies aimed
at increasing use of maternal-newborn health services, such as MWHs, need to consider the
expanded network of people who influence a woman’s decisions, including her family and the
broader community. A targeted exploration of the family’s sense to protect the newborn is
warranted to understand whether it would be helpful to recommend policies in Zambia that
would increase involvement by husbands and grandmothers in routine professional maternal-
newborn health care. Additional research should investigate the roles of husbands, grandmothers,
209
and community members, and to explore their understanding of the benefits of their involvement
in pregnancy and postpartum maternal-newborn care.
Unfortunately, discrimination against women continues to take place in male-dominated
rural Zambian agricultural households. Further contributing to unequal power over maternal-
newborn health decision-making for women are the high rates of early marriage and child
bearing in rural Zambia demonstrated in the sociodemographic characteristics in all three studies
included in this dissertation. Moreover, gender-based violence is prevalent in Zambia. According
to the Zambian Demographic and Health Survey (DHS) (2014), 43% of all women aged 15-49
years of age experience intimate partner physical and/or sexual violence at least once in their
lifetime, with 27% of women experiencing violence in the last 12 months. Research programs
aimed at increasing the participation of husbands in routine maternal-newborn health and ANC
that incorporates principles to prevent gender-based violence would be useful for exploring how
to mitigate power imbalances and help husbands understand the benefits for women and the
entire family when they access care during pregnancy and after delivery.
Future studies are needed to compare the long-term impact of MWHs on newborn
delivery outcomes and health in communities. Additional case series investigation of maternal-
newborn delivery outcomes comparing CEmONC facilities associated with and without MWHs
in urban settings is justified to understand the potential wide-ranging impact of MWH use.
Evaluation of MWH use in urban settings should incorporate a pre- and post- assessment of
maternal “Essential Newborn Care” knowledge into the study design to identify any trends
associated with MWH use.
Finally, moving forward, it will be important to study the long-term sustainability of
MWHs. The financial and logistical support of the international non-governmental organization
210
(NGO) partner in constructing the MWHs in these studies ended in late 2018. While measures
were put in place to ensure community ownership and responsibility for operating the MWHs,
the sustainability of the intervention after resources from an NGO are no longer available needs
to be evaluated. Follow-up studies should evaluate the impact and functioning of MWHs
operating under community ownership to further understanding of the long-term sustainability
and cost-effectiveness of MWHs as an intervention to improve maternal-newborn health and
delivery outcomes.
Career goals and plans
My eventual goal as a PhD-prepared nurse scientist is to contribute positively to the
discipline of global child health by performing innovative and impactful scientific research and
teaching in a robust academic setting. I am also interested in teaching and mentoring the next
generation of scholars. I envision myself working as an independent research scientist,
conducting studies that evaluate community-based models of care for improved newborn and
child health across the globe.
I am passionate about contributing to a reduction of newborn morbidity and mortality in
low- and middle-income countries. I intend to use the research from this dissertation as a
platform to generate new knowledge and explore innovative ways of promoting newborn and
child health worldwide. My immediate next research steps will be to study as a Fogarty Global
Health Fellow. As a postdoctoral fellow, I plan to conduct a qualitative needs assessment via
individual interviews and focus groups to explore interest in and viability of MWHs as an
intervention to reduce maternal-newborn mortality in an urban low-resource setting. Most
MWHs are located in rural areas such as the ones included in this dissertation. Recent health
policy changes recommend a shift away from rural delivery facilities towards larger urban
211
facilities for better maternal-newborn outcomes (Kruk et al., 2018; Montagu et al., 2017).
However, there is an exceptionally wide gap in knowledge about the interest in and viability of
MWH use in an urban environment. The research will be innovative and timely as we enter the
post-2015 era of sustainable development with a goal to reduce the inequities of preventable
deaths by reaching all women and newborns. Results of the research will aid in understanding
whether resources could be mobilized to establish MWHs in urban Kumasi, Ghana. This
exploratory project could be adapted and implemented in other urban settings throughout sub-
Saharan Africa, such as Lusaka, the capital of Zambia. The proposed project will reduce the gap
in knowledge about interest and support for urban MWHs as health policy shifts toward
encouraging women to deliver in larger-volume facilities.
The results of the individual interviews and focus groups have the potential to provide
pilot data for future grant submissions after the postdoctoral fellowship. If themes elicited from
individual interviews indicate that community stakeholders and key decision makers are
interested in mobilizing resources to establish MWHs, and themes from focus groups indicate
that women of childbearing age and family members deem MWHs a viable intervention to
reduce maternal-newborn mortality, I will use results of this initial needs assessment as a
platform from which to build future grant applications.
Conclusions
This three-study dissertation explored the cultural practices, knowledge, and beliefs of
newborn care and health-seeking in rural Zambia. Taken together, results of the three studies
support the notion that MWH and SMGL interventions can benefit the maternal-newborn dyad.
The recommendations presented here can be used to develop interventions to increase use of
MWHs and continue SMGL maternal-newborn health services to improve pregnancy and
212
newborn outcomes in rural Zambia. The operationalized Ecological System Theory exhibited its
usefulness as a guide for the research included in this dissertation.
To summarize, Study 1 highlighted the need to pay attention to the maternal duality
experienced by women pulled between fulfilling cultural and health system responsibilities.
Study 2 demonstrated that both MWH users and non-users in the rural district were
knowledgeable about ENC; however, younger age and primigravida were significantly
associated with lower maternal “Essential Newborn Care” knowledge. Findings can be used to
inform future interventions aimed at improving maternal-newborn care and evaluating the long-
term sustainability of MWHs. In Study 3, more referrals came from facilities with a MWH than
from those without MWHs. Referral from facilities with MWHs and recognition of prolonged
labor at a BEmONC facility likely led to crucial referral for labor management to CEmONC at
the district hospital, in turn bolstering support for the effectiveness of MWHs and SMGL
programs as potentially lifesaving interventions to improve maternal-newborn delivery outcomes
in rural Zambia.
213
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Appendix A
Consent for Focus Group Study
General Information about Research
The University of Michigan in the United States and Africare-Zambia are leading a research
study. We want to find out about experiences, beliefs, and customs about seeking care for
mothers and babies. You are being asked to be in this study because you are a valued member of
the community and speak English and/or Bemba or Tumbuka.
Background and Purpose for this study
In 2013– 014, the University of Michigan and Africare/Zambia completed an evaluation on the
need for and support of maternity waiting homes located next to rural health facilities in Zambia.
We learned that existing maternity homes, were often small, poorly constructed, lacked basic
amenities and, thus, often were not used. Based on the knowledge gained from that evaluation,
we designed a model for a high-quality maternity home we call the Zambian Maternity Homes.
One part of that model is to engage the community in behaviors that may increase health-seeking
behaviors around childbirth and newborn care.
The reason for this study is to learn more about experiences, beliefs, and customs that may
influence seeking care for mothers and babies.
Study Procedures
You can choose to be in this study or not. Your decision is voluntary and does not affect your
role in the community in any way. If you decide to participate, you will meet with a group of
other community members. We will ask for your opinion about how you and your community
get information and make decisions about seeking healthcare. There will be one group meeting
with 8-12 other community members and that will last for approximately 60-90 minutes. We will
ask for your ideas about how the community might do things differently. We will make voice
tapes of the group meeting to make sure that we have a record of everyone’s ideas. We will not
use names on the tapes or when we type them out. If you do not want to be recorded you cannot
participate in the research.
We will also ask you some questions before the group meets; it will take about 5 to 10 minutes
for those questions. We will not write your name on any interview forms.
Snacks will be provided during the session.
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Possible Risks and Discomforts
Participating in the interview and being in the group is not likely to cause you any harm.
Whatever you say will be private and confidential. We will ask everyone in the group not to talk
outside of the group about anything that we discuss in the group. This way whatever you say in
group will also be private. We don’t think anything we talk about will upset you, but if it does
you can leave at any time with no problem to you. If this does happen, we will give you names
of people you can talk at the Health Center who can help you get over being upset. Participation
is up to you.
Possible Benefits
You will not get special treatment or rewards for being in the group, but we do hope that being in
the group and sharing your ideas might help us understand more about how health care is
managed in your community. Sometimes people tell us they feel good about helping make
things better for others.
Alternatives to Participation
You do not have to participate in the group if you don’t want to. If you do not want to be in the
group, it will not affect your role in the community in any way.
Confidentiality
We will keep what you say private as best we can. We will ask everyone in the group not to talk
outside of the group about anything that we discuss in the group. This way whatever you say
will be private. We will not talk about you being in the group outside the research team. We will
keep all information on a computer that is password protected. No one will be able to see it
except the research team. You will not be named in any reports. Our records may be reviewed to
make sure we are doing the research correctly (ERES Converge Institutional Review Board in
Zambia and/or the University of Michigan Institutional Review Board in the United States).
Compensation
You will not be paid to be in the study. Snacks will be served during the discussion to thank you
for your time.
Additional Cost
It will not cost you anything to be in the study, except for your time.
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Voluntary Participation and Right to Leave the Research
You can choose to be in the study or not be in the study, it is up to you. If you choose not to be
in the study, there will be no problem for you now or in the future. You can leave the study at
any time without any problem to you now or in the future. Being in the study or not being in the
study does not affect your role in the community in any way.
Termination of Participation by the Researcher
We will not ask you to leave the study unless you are too upset to continue.
Contacts for Additional Information
If you have questions or concerns about the research, please contact the Co-Investigator / Project
Director, Gertrude Musonda at:
Africare-Zambia
Flat A, Plot 2407, Off MBX Twin Palm Road
Ibex Hill, Box 33921
Lusaka, Zambia
Tel: =260 977476766 or Email: gmusonda@africare.org
Your Rights as a Participant
If you have questions about your rights as a research participant, or wish to obtain information,
ask questions or discuss any concerns about this study with someone other than the researcher(s),
please contact the University of Michigan Health Sciences and Behavioral Sciences Institutional
Review Board, 540 E. Liberty St. Ste. 202, Ann Arbor, MI 48104-2210. For international calls
from Zambia to the US, 00+1+734-936-0933 or email: irbhsbs@umich.edu. Please note the time
in Michigan is 6 hours earlier than in Zambia.
This research has been reviewed and approved by the ERES Converge, 33 Joseph Mwilwa Road,
Rhodes Park, Lusaka, Zambia. If you have any questions about your rights as a research
participant you can contact the ERES CONVERGE IRB, between the hours of 8am -5pm
through the landline +260 0955 155633/4 or email: eresconverge@yahoo.co.uk
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VOLUNTEER AGREEMENT
The above document describing the benefits, risks and procedures for the project title The
Evaluation of Zambian Maternity Homes (ZaMs) Project in Mansa and Lundazi Districts
has been read and explained to me. I have been given an opportunity to have any questions about
the evaluation research answered to my satisfaction. I agree to participate as a volunteer.
___________________ _____________________________________________
Date Name and signature or mark of volunteer
If volunteers cannot read the form themselves, a witness must sign here:
I was present while the benefits, risks and procedures were read to the volunteer. All questions
were answered and the volunteer has agreed to take part in the evaluation research.
________________ ____________________________________________
Date Name and signature of witness
I certify that the nature and purpose, the potential benefits, and possible risks associated with
participating in this evaluation research have been explained to the above individual.
________________ ____________________________________________
Date Name and Signature of Person Who Obtained
228
Appendix B
Oral Script for Nurse In-Charge/Village Chief Announcement to Village
Zambian researchers from Africare working with the University of Michigan in the US are
coming to the village on __________; they will be here for part of the day (time will be
included). They are interested in learning more about your experiences, beliefs, and behaviors
that influence health decisions and actions. They want to talk to woman who have babies that are
less than 1-year-old. They also want to speak to adults 18 years or older who are community
members, community health workers/TBAs, or healthcare staff.
They will talk to people for 90-minutes in groups and for 10 –minutes in individual interviews.
You do not have to talk to them and you will not have a problem if you don’t. They will make a
voice recording of the discussions and interviews. Everything will be confidential. They will
not use names on the recordings. If you do not want to be recorded you may choose to not be in
the study. There will be snacks given during the discussions.”
They will be here on ___________________. You are invited to come if you are interested and
eligible.
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Appendix C
Focus Group Interview Guide
Date: __________________________________________
Facilitator: ______________________________________
Note taker: _____________________________________
District: ________________________________________
Community/Health Center: ________________________
Number in attendance (not including Africare staff):_______________________________
Type of Group (check one):
o Women with infants under one year
o Community members
o Health workers
Now we are ready to get started with the focus group. I will be the moderator today. This is
_____________ and s/he will be taking notes and keeping us “on time”. We will be meeting for
about 90 minutes. We are going to use a tape recorder so we do not forget the important things
you tell us. Is that OK?
You have been invited to join a focus group with community members. This focus group is an
interview, conducted by a trained moderator from Africare. The interview is conducted in a
natural way, much like a discussion. In the focus group, people are free to give their views and
opinions to the questions that the moderator asks.
Two organizations – Africare and the University of Michigan—have joined together to learn
more about our community; they want to better understand our experiences, beliefs, and
traditions about seeking care. I am here to ask you questions about health issues, especially for
pregnancy, delivery, and newborns. Before we begin, I thought we should introduce ourselves.
Let me begin. My name is _______ and I work for Africare.
I want to remind you that your comments are the research team only to learn more about the
community and nothing you say will not be shared with others.
START THE TAPE RECORDER HERE!
AFTER YOU TURN ON THE TAPE RECORDERS, BE SURE TO STATE: THE DATE,
YOUR NAME, THE DISTRICT, THE COMMUNITY/HEALTH CENTER AND THE
TYPE OF GROUP (e.g. Women with infants, Community members, or Health workers).
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YOU ARE READY TO ASK THE QUESTIONS.
First, I’d like to learn a little about your customs, traditions and community.
1) What do you think are the major health problems in your community?
Probe:
o Do you know any women that have died while giving birth or in the few days
after?
o How many women have died while giving birth in your community?
i. Tell me what people in the community did when the mother died.
ii. Tell me what you saw.
iii. Tell me what happened.
iv. Tell me what helped.
v. What caused the mother to die?
2) Tell me about the information health workers provide about pregnancy or childbirth.
o What do you think about the information health workers provide about caring for
newborns?
3) Tell me about the information your family or friends provided about pregnancy and
childbirth?
o What do you think about the information your family or friends provided about
caring for newborns?
4) Now, I’d like to ask about the customs and traditions in your community for pregnant
women, women giving birth, newborns and the few days after delivery.
Probe:
o Who is usually present during labor? What does this person do for the mother while
she is in labor?
o Who is usually present at the delivery? What does this person do for the mother
during the delivery?
o Is there a different person to tend to the newborn than the person tending to the
mother? Who is that person?
o What are the common things you do for the mother and the baby immediately after
birth? In the following week?
o What are the common things you do for the baby immediately after birth?
o How long does the woman stay at (identified facility) after having a baby?
5) Who do you go to for answers, guidance, and advice if you have a problem or question
about pregnancy, childbirth or newborns?
Probe:
o How do they influence the decisions you make about your health and the health of
your baby?
o How do you (women in your community) get the resources you need to change
things that involve your health?
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o How do you (women in your community) get the resources you need to change
things that involve the health of your baby?
o What health information do you want (need)?
6) Have you heard about some women delivering at home?
Probes:
o Why would a woman choose to deliver at home?
o Who decides where she will deliver?
o What might make it easier for a woman to use a facility for birth?
7) In the past 6 months, have you participated in a meeting or gathering around pregnancy,
childbirth, or newborn care?
Probes:
o Tell me more about that.
o Have you ever been involved in organizing a meeting or gathering to provide
information to your community?
o What types of groups or meetings would you like to see in your community?
o What would help you to take care of your newborn?
8) Next I’d like to ask you a few things about caring for a newborn baby. Tell me some
things you or the midwife does right after a baby is born—in the first day.
Probes:
o Do new mothers or midwives do anything special to keep a baby warm right after
it is born?
o In your communities, when does a newborn baby get the first bath? How often do
you bathe a newborn?
9) Tell me about caring for the newborn cord.
Probes:
o Do you have the resources to care for the cord in the way you were taught?
o If you don’t have the resources, what can you do?
10) Now I’d like to talk to you about breastfeeding. Tell me how long a mother usually
breastfeeds after her baby is born in your community.
Probes:
o How are mothers supported to breastfeed?
o When does breastfeeding start?
o Do mothers give colostrum to the baby?
o Do some mothers have problems with breastfeeding?
o If a woman has difficulty with breastfeeding, what can she do?
o When are other foods besides breast milk usually introduced?
11) Tell me about taking babies to the clinic for “routine” care.
Probes:
o Do mothers have their baby immunized? Why or why not?
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o Does the newborn currently receive health care? If so, where do they receive
health care?
12) Tell me about taking babies to the clinic for “sick’ care.
Probes:
o Tell me what you do if the baby has a cough.
o Tell me what causes the baby to have a cough.
o What do you know about pneumonia?
o Tell me what you do if the baby has a fever.
o Tell me what causes the baby to have a fever.
o Tell me what you do if the baby has diarrhea.
o Tell me what causes the baby to have a diarrhea.
13) Have you ever heard about or seen a very sick baby or a baby that died?
Probes:
o Tell me what people did.
o Tell me what you saw.
o Tell me what happened.
o Tell me what helped.
o Did the baby get better?
o What caused the baby to be sick (or die)?
14) Tell me some things mothers can do to keep their baby healthy.
Probes:
o Do you have the resources to do these things?
o Is there any problem to do these things?
15) Are any of the problems or issues we just talked about new to anyone?
233
Appendix D
Codebook for focus groups
Theme 1: Essential newborn care
newborn care and care-seeking according to Pregnancy, Childbirth, Postpartum and
Newborn Care/Essential Newborn Care guidelines
o state importance of attending ANC, facility deliver, PNC
o able to identify maternal-newborn danger signs during delivery and postpartum
eclampsia & eclampsia
described by participants as “fitting/pressure/being swollen”
postpartum hemorrhage
described by participants as “too much blood”
management of anemia
described by participants as “not enough blood/lack of blood”
PMTCT, HIV exclusive breastfeeding for 6 months
discuss/obtain prophylaxis medication during ANC/PNC visits
early initiation and exclusive breastfeeding
initiate within one hour of birth
frequent feedings
breastfeed exclusively for months
newborn & infant feeding
avoid complementary foods in newborn
initiate complementary foods at 6 months
malaria in pregnancy
use mosquito net
take malaria prophylaxis medication
interventions to improve preterm birth
manage stress
avoid heavy lifting
limit hours worked in field
post-partum family planning
discuss/obtain during ANC/PNC visits
umbilical cord care
only clean water, no bandage
kangaroo care
maximize skin-to-skin contact
skin/thermal care
use blankets/hats to keep baby warm
prompt drying and covering
only clean water with gentle soap, no need for herbs/Vaseline/etc.
delaying of first bath
ideally wait for 24 hours after birth
hygiene practices
safe food handling to prevent diarrhea
234
clean home environment
wash hands after using toilet
wash hands before breastfeeding
Theme 2: Traditional newborn protective rituals
cultural care of the umbilical cord
o use of traditional herbs/rat feces
o belief that newborn will be barren if cord falls between legs
o belief that cord must be buried under special tree or harm will come to family
cultural prevention of cough and pneumonia
o spread sperm on newborns to prevent cough
o newborn breathing of smoke will prevent
early introduction of traditional porridge
o dietary belief that early introduction of porridge with traditional herbs at 1-2
months will protect newborn from disease
Theme 3: Strong sense of family & community to protect the newborn
husband
o belief that intercourse with anyone except wife will cause death to newborn
o belief that sperm is harmful to fetus/newborn
mother-in-law/mother/grandmother
o belief that use of traditional medicine will speed up delivery
community members
o belief that if single people touch or see newborn the baby will die or be infertile
Theme 4: Preservation of dignity
lack of privacy
o shame of being seen naked by male providers
o small clinic & delivery wards
embarrassed to make noise during delivery
Partner’s fear of HIV/STI testing
o desire by men not to be tested for STIs
235
Appendix E
Delivery Register Instructions, Zambian Ministry of Health
236
237
Appendix F
Delivery Register Data Collection Tool
Data Source: Delivery register at Lundazi District Hospital
Data Collector: PhD Student and/or Zambian Research Assistant
Frequency: Daily
Population: All post-partum women at Lundazi District Hospital from Lundazi District
Data Collector: _________________________ Today’s Date: __________________________
1. Location of delivery:
ZaMS SITES
LUSUNTHA
MWASELUNDAZI
NKHANGA
NYANGWE
ZUMWANDA
NON-MWH COMPARISON
SITES
CHIKOMENI
KAMSANO
KAPICHILA
LUKWIZIZI
PHIKAMALAZA
CEmONC
LUNDAZI DISTRICT HOSPITAL
OTHER
(SPECIFY)_________________________________
2. Date of admission (column b): _________________
3. Name of Mother’s village (column e): _________________
4. Origin Code (column e): Circle one response
1= within 12km, within catchment area
2= more than 12 km, within catchment area
3= within district but outside catchment area
4= from outside district
Maternal History
5. Age of Mother (column g): _________________
6. Number of pregnancies (gravida) (column h): _________________
238
7. Number of births (parity) (column i): _________________
8. Conditions Requiring Special Attention (column k)
___________________________________________________________________________
___________________________________________________________________________
9. Date of Delivery (column s): ________________ (DD/MM/YYYY)
10. Mode of delivery (MOD) (column u): Circle one response
1= Spontaneous Vaginal Delivery (SVD)
2= Caesarean Section (CS)
3= Breech (BRE)
4= Assisted
Mother Delivery Outcome
14. Labor Complications (column ab):
______________________________________________________________________________
____________________________________________________________________________
Newborn Outcome (If multiple birth, please answer the following for each newborn)
15. Condition of Baby 1 (column ad): Circle one response
A (alive) NO =0
YES=1
D (dead) NO =0
YES=1
16. APGAR score (column ae): (@ 5 minutes ) ____________
17. Birth weight (column af): (in gm) ____________
19. Breastfeeding within 1 hour? NO =0 YES=1
239
2nd newborn
15b. Condition of Baby (column ac): Circle one response
A (alive) NO =0
YES=1
D (dead) NO =0
YES=1
16b. APGAR score (column ad): (@ 5 minutes ) ____________
17b. Birth weight (column ae): (in gm) ____________
19b. Breastfeeding within 1 hour? NO =0 YES=1
3rd Newborn
15c. Condition of Baby (column ac): Circle one response
A (alive) NO =0
YES=1
D (dead) NO =0
YES=1
16c. APGAR score (column ad): (@ 5 minutes ) ____________
17c. Birth weight (column ae): (in gm) ____________
19c. Breastfeeding within 1 hour? NO =0 YES=1
20. Remarks (column am): (write an intervention or relevant information with regard to labor and
delivery
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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APPENDIX G
Oral Script for Nurse or Research Assistant Announcement to Women at Lundazi District
Hospital and CEmONC MWH
The following is the script to be read to potential participants who are interested in participating
in the study and are requesting additional information. The PI and research assistant/translator
will use this script.
“Because you are pregnant or have recently delivered a baby, you are being invited to participate
in a study. This study is done by myself, Julie Buser, a doctoral student at the University of
Michigan. I am interested in understanding newborn health and knowledge of newborn care.”
“If you agree to participate in this study, you will be asked to have 1 interview with myself and a
Zambian research assistant who is acting as a translator for me in this study. These interviews
will be conducted at a time and location of your choice and will be in your choice of Tumbuka or
English language. The interviews will be conducted in a private place in the maternity waiting
home (Mother’s Shelter) in Tumbuka or English.”
“If you agree to participate in this study, your name and identity will not be revealed or
associated with anything you say or do in this study. You are in no way obligated to participate
in this study and you may withdraw your participation at any time. Your name will not appear on
these notes. Participation in this study has no effect on the services or care you receive from the
clinic or hospital.”
241
APPENDIX H
Information Sheet, Address of Ethical Issues & Informed Consent
for Quasi-Experimental Study
Title: Maternity Waiting Home Use and Newborn Outcomes in Lundazi, Zambia
Researcher: Julie M. Buser, MS, CPNP-PC, RN, PhD Student
General Information about Research
The University of Michigan in the United States is conducting a research study. We want to help
women in Zambia have safer births and healthier babies. We want to find out about newborn
care and the maternity waiting homes (MWHs) in your district. You are being asked to be in this
study because you are a valued member of the district and are pregnant or recently delivered a
baby. If you agree, you will participate in an individual interview and survey with a researcher.
We will ask about demographic information and ask for your opinion about newborn health and
knowledge of newborn care. The interview is expected to last about 45 minutes. Snacks and a
juice drink will be provided after the discussion.
Possible Risks and Discomforts
Participating in the study is not likely to cause you any harm. We will ask everyone participating
in the study not to talk about anything that we discuss. This way whatever you say will be
private. We don’t think anything we talk about will upset you, but if it does you can leave at any
time with no problem to you. If this does happen, we will refer you to the health center if you
are distressed. Participating in the study or not participating in the study is up to you. If you do
not want to participate in the study, it will not affect your role in the community or at the hospital
in any way.
Possible Benefits
You will not get special treatment and there will be no direct benefits to you for participating in
the study.
Confidentiality
We will keep what you say private as best we can. Researchers will not discuss what happens in
our discussion outside the research team. We will keep all information on a computer that is
password protected. No one will be able to see it except the research team. The survey form will
not ask for individually identifiable information. You will not be named in any reports. Our
records may be reviewed to make sure we are doing the research correctly (ERES Converge
Institutional Review Board in Zambia and/or the University of Michigan Institutional Review
Board in the United States).
Compensation
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You will not be paid to be in the study. Snacks a juice drink will be provided after the discussion
to thank you for your time.
Additional Cost
It will not cost you anything to be in the study, except for your time.
Voluntary Participation and Right to Leave the Research
You can choose to be in the study or not be in the study, it is up to you. If you choose not to be
in the study, there will be no problem for you now or in the future. You can leave the study at
any time without any problem to you now or in the future. Being in the study or not being in the
study does not affect your role in the district or at the hospital in any way.
Termination of Participation by the Researcher
We will not ask you to leave the study unless you are too upset to continue.
Contacts for Additional Information
If you have questions or concerns about the research, please contact the researcher, Julie Buser at
+ 260 972612613
Your Rights as a Participant
If you have questions about your rights as a research participant, or wish to obtain information,
ask questions or discuss any concerns about this study with someone other than the researcher(s),
please contact the University of Michigan Health Sciences and Behavioral Sciences Institutional
Review Board, 540 E. Liberty St. Ste. 202, Ann Arbor, MI 48104-2210. For international calls
from Zambia to the US, 00+1+734-936-0933] or email: irbhsbs@umich.edu. Please note the
time in Michigan is 6 hours earlier than in Zambia.
This research has been reviewed and approved by the ERES Converge Institutional Review
Board in Lusaka, Zambia. If you have any questions about your rights as a research participant,
you can contact ERES CONVERGE IRB, 33 Joseph Mwilwa Road Rhodes Park
LUSAKA. Tel: 0955 155633/4. Email: eresconverge@yahoo.co.uk
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VOLUNTEER AGREEMENT
The above document describing the benefits, risks and procedures for the project title Maternity
Waiting Home Use and Newborn Outcomes in Lundazi, Zambia has been read and explained
to me. I have been given an opportunity to have any questions about the evaluation research
answered to my satisfaction. I agree to participate as a volunteer.
If volunteers cannot read the form themselves, a witness must sign here:
I was present while the benefits, risks and procedures were read to the volunteer. All questions
were answered and the volunteer has agreed to take part in the evaluation research.
________________ ____________________________________________
Date Name and signature of witness
I certify that the nature and purpose, the potential benefits, and possible risks associated with
participating in this evaluation research have been explained to the above individual.
________________ ____________________________________________
Date Name and Signature of Person Who Obtained Oral Consent
244
APPENDIX I
Maternal Knowledge of Newborn Care Questionnaire
Data Source: Maternal interview
Data Collector: PhD Student and/or Zambian Research Assistant
Frequency: Daily
Population: All women staying at Lundazi District Hospital Mothers Shelter and all post-partum
women referred to Lundazi District Hospital from MWH intervention and non-MWH control
sites.
Data Collector: ____________________________ Today’s Date: ______________________
1. How old were you at your last
birthday?
Age in years |___|___|
2. How many years of school have
you completed?
None
Lower Primary (1-4)
Upper Primary (5-7)
Junior Secondary (8-9)
Senior Secondary (10-12)
Tertiary
3. Are you now single, married,
living together, separated,
divorced, or widowed?
Single
Married
Living Together
Separated or Divorced
Widowed
4. How many times have you been
pregnant?
_____________
5. How many live births have you
had?
_____________
6. How many stillbirths have you
had?
_____________
7. How many living children do
you have?
_____________
8. Did you plan to deliver at Lundazi District Hospital?
YES
NO
9. Were you referred to Lundazi District Hospital?
YES
NO
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10. IF YES, where were you referred from?
MWH Sites
Lusuntha
Mwaselundazi
Nkhanga
Nyangwe
Zumwanda
Non-MWH Sites
Chikomeni
Kamsano
Kapichila
Lukwizizi
Phikamalaza
CEmONC MWH
Lundazi District Hospital
11. IF YES, why were you referred?
RECORD ALL REASONS MENTIONED
The doctor/nurse told me I had to
I was bleeding
The baby was stuck
I was in labor pain for a long time
The baby was not in the right position
I have HIV, syphilis, or other sexually
transmitted infections
Distance
High blood pressure
I needed a caesarian section (C-section)
I had a fever
My womb was leaking fluid
There were problems with the baby
Wait to deliver
No midwife available at clinic
Don’t know
Other
(Specify)_____________________________
12. Did you stay at a Mothers Shelter before delivery?
YES
NO
13. IF YES, which one?
MWH Sites
Lusuntha
Mwaselundazi
Nkhanga
Nyangwe
Zumwanda
Non-MWH Sites
Chikomeni
Kamsano
Kapichila
Lukwizizi
Phikamalaza
CEmONC MWH
Lundazi District Hospital
Other (Specify)____________________________
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14. Did someone tell you to stay at the Mothers Shelter?
YES
NO
15. IF YES, who told you to stay at the Mothers Shelter?
Nurse
Midwife
TBA
SMAG
Traditional Healer
Family Member
Don’t Know
Other (Specify)_______________________
16. IF YES, what was the reason you were told to stay at the Mothers Shelter?
RECORD ALL REASONS MENTIONED
The doctor/nurse told me I had to
I was bleeding
The baby was stuck
I was in labor pain for a long time
The baby was not in the right position
I have HIV, syphilis, or other sexually
transmitted infection
Distance
I needed a caesarian section (C-section)
I had a fever
My womb was leaking fluid
There were problems with the baby
Wait to deliver
No midwife available at clinic
Don’t know
Other (Specify)_______________________
17. Did you attend any health talks at the Mothers Shelter?
YES
NO
18. IF YES, what were the health talks about?
RECORD ALL HEALTH TALKS MENTIONED
Danger signs for mother, labor, recognition and early signs and postpartum care
Nutrition and exercise during pregnancy
Good sanitation and hygiene to prevent diarrheal diseases
Post-partum family planning
Malaria in pregnancy
Danger signs for neonatal and well-baby care
Early initiation and exclusive breastfeeding
Post-partum family planning
Infant and young child feeding practices
Immunizations
STDs, HIV and AIDS
Gender Based Violence
Don’t know
Other (Specify)___________________________________________________________
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19. IF YES, who gave the health talks?
Nurse
Midwife
TBA
SMAG
Traditional Healer
Family Member
Don’t Know
Other (Specify)_______________________
20. Did you attend antenatal care (ANC)?
YES
NO
21. IF YES, how many ANC visits did you attend?
1
2
3
4
Don’t know
Other
(Specify)_____________________________
22. During antenatal care, did a healthcare provider talk with you about newborn problems you
should watch for?
YES
NO
DON’T KNOW
23. Tell me what health problems in your newborn would make you want to take your baby to
the clinic. (ASK QUESTION AND WAIT FOR RESPONSE WITHOUT PROMPTING)
RECORD ALL PROBLEMS MENTIONED
Seizures
No movements or weak cry
Weak suckling or feeding
Breathing difficulties or rapid breathing
Fever
Shivering
Diarrhea
Excessive crying
Redness/Discharge around the umbilical cord
Eyes swollen and red with pus
No urination/stool
Cough
Other (Specify)______________________
None/Don’t Know
24. Apart from ANC visits, did you receive newborn information from anyone else during your
pregnancy?
YES
NO
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25. IF YES, who gave you the information?
Nurse
Midwife
TBA
SMAG
Traditional Healer
Family Member
Don’t Know
Other (Specify)_______________________
26. When did you learn about health problems in your newborn that would make you want to
take your baby to the clinic?
During my stay at the mothers shelter
From midwife during ANC
In community from a SMAG
At home from a family member
Don’t Know
Other (Specify)_______________________
27. Tell me about how you will care for your baby’s umbilical cord when you get home.
RECORD ALL APPLICATIONS MENTIONED
Breastmilk
Plain Water
Soap (Lifebuoy)
Traditional Herbs
Don’t Know
Other (Specify)______________________
___________
28. Have you ever heard the term “Kangaroo Care”, or skin-to-skin care, for the baby to keep
them warm?
YES
NO
29. IF YES, tell me what you know about “Kangaroo Care”, or skin-to-skin care, for the baby to
keep them warm.
RECORD ALL ITEMS MENTIONED
Baby naked against your skin
Baby wears a hat
Promotes bonding and/or Attachment
Helps promote increased milk production
and/or Breastfeeding success
Don’t Know
Other (Specify) ________________________
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30. How will you care for your baby’s skin when you get home?
RECORD ALL APPLICATIONS MENTIONED
Petroleum Jelly
Commercial Baby Lotion
Cooking Oil
Breastmilk
Traditional Herbs
Glycerin
Don’t Know
Other (Specify) ________________________
31. Tell me what you know about exclusive breastfeeding.
RECORD ALL ITEMS MENTIONED
Only give breastmilk for 6 months
No other liquids or solids are given
Good nutrition
Breastmilk
Promotes optimal growth
Protects baby from diarrhea and/or infection
Don’t Know
Other (Specify) ________________________
32. How long do you plan to breastfeed?
____________________________
33. When do you plan to give your baby complementary foods?
____________________________
34. Sometimes newborns get diarrheal diseases. Tell me what you know about good sanitation
and hygiene to prevent diarrheal diseases. RECORD ALL ITEMS MENTIONED
Exclusively breastfeed
Wash hands before and after eating
Wash hands before and after using
toilet
Maintain hygienic environment
Don’t Know
Other (Specify) ________________________
35. Who told you about good sanitation and hygiene to prevent diarrheal diseases?
Nurse
Midwife
TBA
SMAG
Traditional Healer
Family Member
Don’t Know
Other (Specify)_______________________
36. When will you take your baby for the first check-up?
_____________________________
