Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

BACKGROUND: Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. METHOD: A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. RESULTS: A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). CONCLUSIONS: Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

'Born before arrival': user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia.

BACKGROUND: Maternal mortality remains high in sub-Saharan Africa. Health facility intra-partum strategies with skilled birth attendance have been shown to be most effective to address maternal mortality. In Zambia, the health policy for pregnant women is to have facility childbirth, but less than half of the women utilize the facilities for delivery. 'Born before arrival' (BBA) describes childbirth that occurs outside health facility. With the aim to increase our understanding of trust in facility birth care we explored how users and providers perceived the low utilization of health facilities during childbirth. METHODS: A qualitative study was conducted in Kapiri Mposhi, Zambia. Focus group discussions with antenatal clinic and outpatient department attendees were conducted in 2008 as part of the Response to Accountable priority setting and Trust in health systems project, (REACT). In-depth interviews conducted with women who delivered at home, their husbands, community leaders, traditional birth attendants, and midwives were added in 2011. Information was collected on perceptions and experiences of home and health facility childbirth, and reasons for not utilizing a facility at delivery. Data were analysed by inductive content analysis. RESULTS: Perspectives of users and providers were grouped under themes that included experiences related to promotion of facility childbirth, responsiveness of health care providers, and giving birth at home. Trust and quality of care were important when individuals seek facility childbirth. Safety, privacy and confidentiality encouraged facility childbirth. Poor attitudes of health providers, long distances and lack of transport to facilities, costs to buy delivery kits, and cultural ideals that local herbs speed up labour and women should exhibit endurance at childbirth discouraged facility childbirth. CONCLUSION: Trust and perceived quality of care were important and influenced health care seeking at childbirth. Interventions that include both the demand and supply sides of services with prioritizing needs of the community could substantially improve trust and utilization of facilities at childbirth, and accelerate efforts to achieve MDG5.

Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey.

BACKGROUND: Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia. METHODS: A population-based survey was conducted in 2007 as part of the 'REsponse to ACcountable priority setting for Trust in health systems' (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban-rural residence. RESULTS: There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi. CONCLUSION: Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.