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

BACKGROUND: A shortage of skilled birth attendants and low quality of care in health facilities along with unattended home deliveries contribute to the high maternal and neonatal mortality in sub Saharan Africa. Identifying and addressing context-specific reasons for not delivering at health care facilities could increase births assisted by skilled attendants who, if required, can provide life-saving interventions. METHODS: We conducted 22 in-depth interviews (IDIs) with midwives at three health facilities in peri-urban communities and 24 semi-structured surveys with mothers in two areas served by health facilities with the highest number of reported home deliveries in Lusaka, Zambia. Both IDIs and surveys were audio-recorded, transcribed and coded to identify themes around delivery and birthing experience. RESULTS: We found that most women preferred institutional deliveries to home deliveries, but were unable to utilize these services due to inability to recognize labour symptoms or lack of resources. Midwives speculated that women used herbal concoctions to reduce the duration of delivery with the result that women either did not present in time or endangered themselves and the baby with powerful contractions and precipitous labour. Respondents suggested that disrespectful and abusive maternity care dissuaded some women from delivering at health facilities. However, some midwives viewed such tactics as necessary to ensure women followed instructions and successfully delivered live babies. CONCLUSION: Difference in beliefs and birthing practices between midwives and mothers suggest the need for open dialogue to co-design appropriate interventions to increase facility usage. Further examination of the pharmaceutical properties and safety of herbal concoctions being used to shorten labour are required. Measures to reduce the economic burden of care seeking within this environment, increase respectful and patient-centred care, and improve the quality of midwifery could increase institutional deliveries.

The impact of home-installed growth charts and small-quantity lipid-based nutrient supplements (SQ-LNS) on child growth in Zambia: a four-arm parallel open-label cluster randomised controlled trial.

BACKGROUND: Childhood stunting remains common in many low-income settings and is associated with increased morbidity and mortality, as well as impaired child development. METHODS: The main objective of the study was to assess whether home-installed growth charts as well as small-quantity lipid-based nutrient supplements (SQ-LNS) can reduce growth faltering among infants. All caregivers of infants between 2 and 10 months of age at baseline, and at least 6 months old at the beginning of the interventions, in 282 randomly selected enumeration areas in Choma, Mansa and Lusaka districts in Zambia were invited to participate in the study. Cluster randomisation was stratified by district. A software-generated random number draw was used to assign clusters to one of four arms: (1) no intervention (control); (2) home installation of a wall chart that contained a growth monitoring tool along with key messages on infant and young child feeding and nutrition (growth charts only); (3) 30 sachets of SQ-LNS delivered each month (SQ-LNS only) or (4) growth charts+SQ LNS. The primary outcomes were children's height-for-age z-score (HAZ) and stunting (HAZ <-2) after 18 months of intervention. Secondary outcomes were haemoglobin (Hb), anaemia (Hb<110.0 g/L), weight-for-height, weight-for-age z-score (WAZ), underweight (WAZ<-2) and child development measured by the Global Scales of Early Development (GSED). Outcomes were analysed intention to treat using adjusted linear and logistic regression models and compared each of the three interventions to the control group. Assessors and analysts were blinded to the treatment-blinding of participating families was not possible. RESULTS: A total of 2291 caregiver-child dyads across the 282 study clusters were included in the study. 70 clusters (557 dyads) were assigned to the control group, 70 clusters (643 dyads) to growth charts only, 71 clusters (525 dyads) to SQ-LNS and 71 clusters (566 dyads) to SQ-LNS and growth charts. SQ-LNS improved HAZ by 0.21 SD (95% CI 0.06 to 0.36) and reduced the odds of stunting by 37% (adjusted OR, aOR 0.63, 95% CI (0.46 to 0.87)). No HAZ or stunting impacts were found in the growth charts only or growth charts+SQ LNS arms. SQ-LNS only improved WAZ (mean difference, MD 0.17, 95% CI (0.05 to 0.28). No impacts on WAZ were seen for growth charts and the combined intervention. Child development was higher in the growth charts only (MD 0.18, 95% CI (0.01 to 0.35)) and SQ-LNS only arms (MD 0.28, 95% CI (0.09 to 0.46). SQ-LNS improved average haemoglobin levels (MD 2.9 g/L (0.2, 5.5). The combined intervention did not have an impact on WAZ, Hb or GSED but reduced the odds of anaemia (aOR 0.72, 95% CI (0.53 to 0.97)). No adverse events were reported. INTERPRETATION: SQ-LNS appears to be effective in reducing growth faltering as well as improving anaemia and child development. Growth charts also show the potential to reduce anaemia and improve child development but do not seem as effective in addressing growth faltering. Further research is needed to better understand reduced effectiveness when both interventions are combined. TRIAL REGISTRATION NUMBER: NCT051204272.