Research Article

Factors contributing to low institutional deliveries in the district of

E Mugweni, MA Cur student MA Cur graduate, Department of Health Studies, University of South Africa VJ Ehlers, D Litt et Phil Professor, Department of Health Studies, University of South Africa JH Roos, D Litt et Phil Senior Lecturer, Department of Health Studies, University of South Africa

Keywords: Ante-natal care, home delivery, Abstract: Curationis 31(2): 5-13 institutional delivery, midwifery in The purpose of the study was to identify factors contributing to low institutional Zimbabwe, women’s health in Zimbabwe. deliveries in the Marondera District, Zimbabwe, among women who attended ante­ natal clinics, in order to enhance the number of institutional deliveries. A quantitative descriptive survey, gathering data by conducting structured interviews with 80 women, was used in this study. All 80 women attended ante-natal clinics but 40 delivered at home and 40 delivered at an institution.

The Health Belief Model (HBM) was used to contextualise the data. The research results indicated that factors that contributed to the low number of institutional deliveries included that women’s minimal expectations of cleanliness and non­ interference during labour and delivery could be met dtiring home deliveries; institutional deliveries’ costs included traveling expenses, losing family support and the inability to meet cultural expectations; women’s lack of knowledge about danger signs of pregnancy; and women’s negative perceptions of nurses working at the institution(s). The recommendations include reduced costs of institutional deliveries; allowing family members (especially the mother-in-law) to be present during institutional deliveries and to perform cultural rituals whenever possible. The nurses’ attitudes and competence levels should be addressed through in-service education sessions and sustained follow-up evaluations, including evaluations by pregnant women. Introduction and background information The health of women is an important contributing factor to the overall health of any Correspondence address: nation. The World Health Organization (WHO) ‘Maternal-Baby Package’ emphasises Prof VJ Ehlers that the key to safe motherhood is appropriately trained midwives (WHO, 1999:18). Department of Health Studies Safe motherhood is defined as the provision of high quality maternal health services PO Box 392 during pregnancy, delivery and in the postpartum period to ensure the health of the Unisa mother and infant (WHO, 2000:23). The four pillars of safe motherhood are cited as 0003 antenatal care (ANC), clean and safe assisted delivery, essential obstetric care and family planning (WHO, 1999:17). Tel: (012)429-67321(w) Fax: (012) 429-6688 (w) Zimbabwe’s Ministry of Health and Child Welfare (MOHCW, 2001:8) aims to reduce Cell: 084 587 3303 morbidity and mortality related to pregnancy and childbirth through providing E-mail: [email protected]

5 Curationis June 2008 enhanced access to ANC and safe perceptions, modifying factors and design assisted deliveries in hygienic variables affecting the likelihood of The study was a descriptive, quantitative environments. women’s actions to deliver their babies cross sectional survey using a structured either at home or at a health care interview schedule to collect data. With institution. The data obtained in this descriptive study the researchers Problem statement response to these questions will be used The primary health care (PHC) clinics in attempted to gain new information about to answer the second research question, the factors influencing booked ANC the Marondera District provide ANC namely: What recommendations can be services to pregnant women. However, women to opt for home rather than made to enhance women’s utilisation of safe assisted deliveries and essential institutional deliveries in the Marondera institutional delivery services in the obstetric care cannot be provided for District (Bums & Grove, 2001:268). The Marondera District? women opting for home deliveries, descriptive design involved describing because trained midwives and equipment and classifying factors influencing low are not available in women’s homes. Objectives numbers of institutional deliveries in this Proper care during labour and delivery The objectives guiding this study were district, in quantitative (numerical) forms constitutes an important prerequisites for to identify using descriptive statistics. It was a reducing morbidity and mortality risks for • individual perceptions (mostly cross-sectional survey because all the both mothers and babies (WHO, women’s perceptions of pregnant women attending ANC clinics 1999:27). This situation is particularly deliveries) and who delivered their babies, either at serious in Zimbabwe where 91% of the • modifying factors home or at an institution, during women attended ANC clinics (in the (demographic, socio- September 2003, comprised the Province of Zimbabwe), but psychological and structural population for this study. the institutional deliveries averaged 51 % factors) and (Mbizvo, Fawcus, Lindmark, & Nystrom, • variables affecting the Research setting 1993:371). likelihood that women would The study was carried out during choose institutional rather than September 2003 at one hospital in the The question that requires answers is home deliveries (amounting to Marondera District of Zimbabwe. The why women who attend ANC clinics in the perceived benefits expected PHC centre serves the needs of 33 317 the Marondera District continue to from institutional deliveries people (Mugweni, 2004:52). The rural deliver their babies at home, explaining counterbalanced by the health hospital had five registered general the disparity between the number of ANC expected costs). nurses and three midwives. bookings and institutional deliveries in The final objective of this study was to this district. use the data obtained to make Population and sample recommendations to increase the number The research population comprised all Purpose of the study of institutional deliveries, and reduce the women who attended ANC and who The main purpose of this study was to number of home deliveries, among delivered their babies either at home or identify factors influencing women’s women who attend ANC clinics in the at the hospital during September 2003. preferences for home deliveries rather Marondera District. The sample comprised 80 women who than institutional deliveries in the had utilised ANC services during 2002/3 Marondera District of Zimbabwe, to Assumptions and who delivered their babies during account for the low number of In terms of the HBM’s major components September 2003; 40 women who delivered institutional deliveries in this area. Based (Onega, 2000:271), the assumptions at home and 40 who delivered at the on the research results, recommendations underlying this study were that: hospital. This amounted to a retrospective study because it started will address women’s needs/preferences • individual perceptions of with women (who attended ANC clinics) so that the number of home deliveries women influenced their having delivered their babies either at could decrease and the number of decisions to deliver their babies home or at an institution during institutional deliveries among ANC at home rather than at a health September 2003 and then attempted to booked women could increase. care institution identify factors that influenced these Research questions • a number of modifying factors women’s decisions for their selected might have influenced women’s delivery venues. The research questions and objectives decisions as to their preferred are formulated according to the major place of delivery concepts of the Health Belief Model Sampling procedure • women’s perceived benefits of A list (census) of all post-natal women, (HBM), described by Onega (2000:271) institutional deliveries should who had used ANC services during 2002/ as individual perceptions, modifying outweigh the perceived costs 3, was available indicating which women factors and variables affecting the before they could take actions delivered their babies at home and which likelihood of initiating actions. to deliver their babies in health women did so at a health care institution. care institutions rather than to Separate lists were compiled for these two The major research question was: what opt for home deliveries. groups of women and a number was factors influence women who attend ANC assigned to each woman on each list. A clinics in the Marondera District to deliver table of random numbers (Bums & Grove, their babies at home? These factors were Research methodresearch 2001:760) was used to select 40 women then categorised according to individual

6 Curationis June 2008 from each list randomly. The 80 women • 4 - investigated the total of 80 women (each interviewer comprising the sample came from 33 affordability and accessibility of completed 40 structured interview villages in the Marondera District. maternity services (3 items) schedules) and no discrepancies were • 5 - identified cultural practices detected in their recorded responses. The Ethical considerations that could influence women’s first author and the statistician who coded and entered the data on the Epi Permission to conduct this study was choices of delivery venues (3 requested from and granted by the items) Info program could not distinguish between structured interview schedules Medical Research Council of Zimbabwe, • 6 - elicited information about the Provincial Medical Director of completed by the two interviewers. No respondents’ knowledge about Mashonaiand East Province, the District statistics were computed to verify this safe assisted deliveries (6 items). Council, the District Health Executive and observation. the Councillors of Wards 10-15 in the Marondera District. The research Validity and reliability of the Data collection procedures proposal was also accepted by the Ethics structured interview schedule The instrument was translated into and Research Committee of the Validity refers to the extent to which the Shona by a Shona-speaking researcher Department of Health Studies, University research instrument actually measures and the translations were checked and of South Africa. what it is supposed to measure, implying approved by a Shona-speaking teacher that it “reflects the abstract construct who taught English at Marondera’s Verbal consent was granted by each being examined” (Burns & Grove, secondary school. The interviews were participant after the purpose of the study 2001:814). In this study, face validity was conducted by two research assistants, had been explained. Subjects were based on the judgments of experts in the trained by the first author, who spoke informed that they had the right to refuse field of midwifery services (Polit & Shona fluently. The instrument was to participate, to withdraw from Hungler, 1999:255). The structured pretested by conducing interviews with participation at any stage and to refuse interview schedule’s items were derived six women who delivered their babies in to answer specific questions without from a literature review, and it was another district (three delivered at home suffering any ill effects whatsoever. No submitted to the midwives and registered and three delivered at an institution) remuneration was paid for participation nurses working at PHC clinics in the which did not participate in the actual and no expenses were incurred by Marondera District. The statistician and study. No changes were necessary as participants, as they were interviewed in two nurse researchers scrutinised the the women understood the questions. the privacy of their own homes. No instrument’s items. All the persons The interview schedules completed by names were written on any interview consulted, agreed that the interview the research assistants were evaluated schedules, but each name was crossed schedule’s items were relevant to factors by a Shona speaking researcher (the first out from the samples’ lists after each that could influence women’s choices to author of this article), and further training interview. The subjects were informed deliver their babies at home or at health was provided to the research assistants that the information would be used to care institutions. Two nurse researchers, about the dire necessity to complete the compile a research report but that no familiar with the Health Belief Model, structured interview schedule as fully as names would be disclosed. The agreed that the contents of the possible. interviewer’s contact details were participants’ answers could be supplied should a woman wish to ask categorised according to the major tenets The 80 interviews (lasting approximately questions at any stage. of this theory. 30 minutes each) were conducted by the two Shona speaking research assistants Research instrument Reliability refers to the degree o f over a period of 21 days, because women Face to face structured individual consistency or dependability with which had to be visited in 33 villages with poor an instrument measures the attribute it interviews were conducted to collect access roads. Every completed interview is designed to measure ” (Polit & Hungler, data. The structured interview schedule’s schedule was reviewed by the researcher 1999:653). A pre-test was done during items, based on information obtained and discussed with the research which six women, excluded from from a literature review, were both closed- assistant on the day of its completion. participation in the actual study, was and open-ended. The interview schedule done to determine the clarity of the items was not structured according to the major Data analysis and the consistency of the responses. tenets of the HBM to avoid creating Data analysis was done using the Epi Info No discrepancies between responses specific mindsets in the interviewees and/ Version 2002 Package. Descriptive obtained during the pre-test and the or research assistants. The instrument statistical methods were used to analyse actual data collection phase occurred. comprised the following sections: the data. Single table analyses were used No discrepancies were observed in the to determine the potential impact of the • 1 - requested biographic and interview schedules completed by the ANC information (7 items) factors influencing women to deliver their two interviewers. babies at home rather than at health care • 2 - focused on socio­ institutions. demographic data (7 items) Inter-rater reliability refers to “the degree • 3 - enquired about women’s of consistency between two raters who The Shona responses to the open-ended perceptions of Marondera are independently assigning ratings to a questions were recorded verbatim, District’s nurses rendering variable or attribute being investigated” translated into English by the first author, maternity services (12 items) (Polit & Hungler 1999:801). Two research and checked for consistency by a Shona- assistants independently interviewed a speaking English teacher from the local 7 Curationis June 2008 high school. These responses were Table 2 Number of ANC visits: home versus institutional deliveries grouped and analysed quantitatively. (n=68) Research results: data analyis and interpretation Number of ANC visits Home deliveries Institutional deliveries The results will be presented according 1 3 1 to the sections of the structured interview 2 9 2 schedule and thereafter discussed in terms of the major tenets of the HBM. 3 7 8 The biographic and ANC information of 4 6 4 the 80 interviewees will be presented initially so that the rest of the data can be 5 8 6 contextualised against this information. 6 4 10 Biographic and ANC information Out of a total of 80 respondents 40 (50%) delivered their babies at a health facility. Table 3 Parity of respondents (n=80) Respondents came from 33 villages.

Age Para 1 Para 2 Para 3 Para 4 Para 5 The modal age of respondents was 23, the youngest respondent was 16 and the Entire sample 26 26 14 6 8 oldest respondent was 38 years old. Home deliveries 10 13 6 3 8 ANC attendances Institutional deliveries 16 13 8 3 0 Table 2 indicates that the maximum number of ANC visits was 6 and the most frequent number (mode) of visits was 3, contrary to the recommended MOHCW Education levels (2001:27) ideal number of 6 visits. Marondera District Table 4 reveals that the level of education Concerning their perceptions/ had no statistically significant influence experiences with maternity services in the Socio-demographic factors on the chosen place of delivery. All the Marondera District respondents from In order to interpret women’s preferences women received some schooling and the both the home and institutional delivery for home versus institutional deliveries, majority acquired secondary education, groups, were dissatisfied with the: questions were asked about their marital as from the eighth year of schooling in status, educational levels and Zimbabwe. occupations. • Welcoming attitude of nursing Occupational status staff (85.0%). Marital status Poverty could limit the utilisation of • Patience of nursing staff The majority of the respondents (85.0%; health services (WHO 1999:14). (73.8%). n=68) were married, with no marked • Friendliness of nursing staff difference between those who chose No respondent was employed in the (72.5%). home versus institutional deliveries. formal economic sector, reflecting the • Talking to you in an scarcity of jobs in this rural area of understandable way (72.5%). Parity Zimbabwe, despite these women’s • Listening to you while you are Table 3 shows that only 16 (61.5%; n = educational accomplishments. talking (61.2%). 26) of the respondents with parity one delivered their babies at hospital, while Women’s perceptions of • Offering of a seat (57,5%). all respondents with parity five or more • Performance of physical delivered at home. maternity services in the examination (55%). • Taking of nursing history Table 1: Age of respondents: home versus institutional deliveries (53.8%). (n=80) • General information and explanation of procedures and examinations (52.5%) Age group No of home deliveries No of institutional deliveries • Specific information on danger signs and complications during 10-19 7 5 pregnancy (48.85%). 2029 25 30 • Specific information about pregnancy (47.5%) 30-39 8 5

8 Curationis June 2008 Table 4 Level of education: institutional versus home deliveries (n=80)

Place of delivery 1-7 years’ schooling 8-11 years’schooling 12-13 years’ schooling Total Home 6 32 2 40 Institutional 7 31 2 40 Total 13 63 4 80

institutions. (72.5%) Table 5 Occupational status of respondents (n=80) • No interference during delivery Cultural practices of the baby and placenta Occupation Frequency Percentage Table 6 shows that the (72.5%) majority of • Clean surface for delivery Self employed 6 7.5 respondents who (64.8%) Farm worker 2 2.5 delivered at home • Clean hands and body (63.8%) agreed with cultural • A clean environment (61.2%) Peasant farmer 49 61.2 practices. • Clean hands (61.2%) Unemployed 6 7.5 Others 17 21.7 The respondents who delivered at home gave Knowledge about danger signs of Total 80 100 the following reasons pregnancy in response to an open- The only conditions for which at least ended question: 60% (n=24 in each group) pregnant women would seek medical attention • The in-laws demanded that I Affordability/accessibility of were for vaginal bleeding and labour deliver at home maternity services in the pains that lasted for more than 12 hours. Marondera District • I had nobody to leave at home The majority of respondents who • I like delivering at home for Table 7 reveals that a traditional midwife delivered at home (60%; n=24) would continued care assisted most respondents, followed by have paid more than Z$500.00 for • The health facility is too far the women’s mothers while only one was transport to get to the health facility while assisted by her mother-in-law. In • Health staff members are rude. 37.5% (n=15) of those who delivered at response to an open-ended question, 19 the institutions paid this amount. This (23.8%) respondents experienced the suggests that many respondents who Knowledge about safe assisted following problems delivered at home might have lived deliveries • Abdominal pains and vaginal further away from the health facility than Both respondents who delivered at home bleeding and those who delivered at the health their counterparts. However, home Baby aspirated delivery services appeared to be more institution expressed that the following Backache expensive than institutional ones. As aspects of safe assisted deliveries were many as 92.5% (n=37) of the women who important to them: Child’s hand came first delivered at home paid Z$500 or more for • No interference during labour Mother could not pass urine these services compared to 15% (n=6) of (75%) Deep tear on the perineum their counterparts who delivered at • Clean cutting of the cord Dizziness Table 6 Cultural practice versus place of delivery

Cultural aspect Home deliveries (n=40) Institutional deliveries (n==40) Yes No Yes No n % n % n % n % * Masungiro 30 75 10 25 13 325 27 67.5 In-laws’ demands (to prove it is the son’s child) 24 60 16 40 14 35 26 65 In-laws’ demands (to fulfill cultural rituals) 25 62 15 37 4 10 36 90

* Musingiro is a Shona term denoting the cultural practice that a woman should deliver her first bom child at her parents’ home so that the family can provide support during delivery and in caring for the newborn baby.

9 Curationis June 2008 Table 7 Persons who assisted respondents who delivered at home pregnancy, as well as their negative (n=40) perceptions of the nurses might have influenced their decisions to deliver their babies at home rather than at an Person who assisted frequency percentage institution. Both groups of women indicated that they were dissatisfied with Traditional midwife 27 67.5 the nurses’ welcoming attitude (85.0%); Mother 10 25.0 patience (73.8%); friendliness (72.5%) and way of talking to the patients (72.5%). Mother-in law 1 15 Self 2 5.0 Modifying factors According to Onega (2000:271) Total 40 100 modifying factors include demographic, socio-psychological and structural • Excessive bleeding potential obstetric and neonatal factors influencing individual persons’ health-related decisions and actions. • Vaginal bleeding for three complications (WHO 1999:5). These months women exposed themselves and their babies to potential risks by opting for Demographic factors • Retained placenta home deliveries. Both these groups of There were no significant differences • Swollen breasts women fall into obstetric high risk groups between the women who delivered their and should have delivered at a health care babies at home compared to those who Research results institution, but preferred to do so at delivered at a health care institution home, probably based on their individual concerning their ages, marital-, discussed within the major perceptions of expecting no harm to occupational- or educational status. No tenets of the health belief themselves or to their babies, and woman was employed in the formal preferring no interference during the sector, 61.0% (n=49) were peasant farmers model (hbm) labour and delivery processes. This with limited incomes despite the fact that The research results will be presented perception might also have accounted for 83.75% (n=67) had completed 8-13 years’ according to the major tenets of the the finding that 22.5% (n=18) of the schooling. This high level of schooling HBM, namely individual perceptions, women commenced their ANC visits should enable these women to modifying factors and variables affecting during the first, 41.3% (n=33) during the understand the importance of the likelihood of initiating actions. second and 35.0% (n=28) during the third institutional deliveries, especially for trimester. Only 17.5% (n=14) of the those aged up to 19 as well as those aged Individual perceptions women attended the ANC clinic at least 35 or older, and for all primigravidas and Onega (2000:271) defines individual six times during their pregnancies, multigravidas. Table 1 indicates that 8 perceptions as a person’s beliefs about indicating that these women might not women in the 30-39 year age group his/her own susceptibility to disease, or have realised the importance of ANC reported home deliveries. Bennett and ill effects, and the seriousness with which visits and institutional deliveries. Among Brown (2001:214) remarked that older he/she views this perceived threat. the respondents who delivered at home, women are a high risk age group with Although all 80 (100%) women who 9 (22.5%) had only 2 ANC visits. WHO increased risks of perinatal mortality and participated in this study attended ANC (1999:6) recommends that women should post partum haemorrhage (PPH). These clinics, and 50.0% (n=40) of them begin ANC care during the first trimester, women should give birth at a health care delivered their babies at a health care before 16 weeks of pregnancy. The facility that can arrange transfer to an institution, 75.0% (n=30) wanted no respondents did not necessarily benefit institution equipped to deal with interference during the labour process from the ANC services provided in the potential obstetric complications and 72.5% (n=58) also wanted no area because out of the 80 women, only (WHO, 1999:5). interference during the delivery of the 22.5% (n=18) commenced their ANC baby and placenta. Based on these visits during their first trimester, while With their reported high levels of individual perceptions, home deliveries 41.3% (n=33) did so during the second education, Zimbabwe’s pregnant women appeared to be more acceptable than and 35.0% (n=28) during the third should be able to make informed choices institutional deliveries. trimester. In spite of the fact that all 80 concerning institutional versus home (100%) of the participants had attended deliveries, if the relevant information is Those eight women who delivered their ANC, they lacked knowledge about the provided at the ANC clinics. Table 2 fifth or subsequent baby did so at home danger signs of pregnancy, as 70.0% indicates that most pregnant women while 10 (out of 26) women delivered their (n=56) did not realise the importance of visited the ANC clinics only three times first babies at home. Women with parity seeking medical help for signs of potential during their pregnancies, limiting the one as well as those with parity five or eclampsia/pre-eclampsia. opportunities for receiving effective greater are at increased risk of maternal health education. and perinatal mortality and morbidity and These participating women’s individual should deliver their babies at sites with perceptions about non-interference and As many as 61.2% (n=49) of respondents referral and transfer facilities to a higher cleanliness during the labour and were peasant farmers (see table 5). Yields level health care institution better delivery processes, their lack of from peasant farming depend on rainfall equipped than PHC clinics to deal with knowledge about some danger signs of necessitating reliance on food aid from

10 Curationis June 2008 the government of Zimbabwe during placenta) should have delivered their The likelihood of initiating actions for droughts. Women facing potential food babies at a health care institution, and/ an institutional delivery (rather than a shortages might be unlikely to use or obtained obstetric help during and home delivery) institutional delivery services if these after delivery. These women’s minimal expectations for involve travel and other costs avoidable assistance during and after a delivery by opting for home deliveries. Those women who delivered their babies could be met at home as well as at an at an institution probably lived closer to institution. The total costs incurred by Socio-psychological variables the institution because their transport an institutional delivery outweighed In this study these variables implied costs were less than the estimated costs those of a home delivery. Therefore the cultural expectations, as reflected in table for women who delivered at home. conclusion, based on the HBM, could 6, indicating that more women who However, the cost for institutional be reached that: women’s expectations delivered their babies at home adhered deliveries were cheaper than home during delivery - minus greater costs of to cultural practices than those who deliveries, but institutional deliveries an institutional delivery = greater delivered at an institution. The involved additional costs of traveling, likelihood of a home delivery. acceptability of the maternity services finding child minders and getting were influenced negatively by the someone else to look after the woman’s home and fields, for those who were Limitations women’s perceptions that they might be The study was limited to one rural health peasant farmers. As all 80 participating unable to meet cultural expectations if center because it was the only health women attended ANC clinics, their babies are delivered at institutions, center offering maternity services at the institutional deliveries should have been family support would not be available and time of data collection (September 2003). accessible to all of them. their negative perceptions of the nurses The study was also limited to women working at these services (as discussed Variables affecting the likelihood of who had utilised ANC services and under “individual perceptions” in this delivered at home or at the health article). initiating actions institution in this area. Consequently the In terms of the HBM, minimal benefits research results cannot be generalised expected from institutional deliveries Structural variables affecting the to other areas in Zimbabwe, nor to MINUS the expected costs EQUALS the likelihood of action Zimbabwean women who did not attend The major structural variables that likelihood that women would deliver their ANC clinics. A random sample of 80 babies at an institution (rather than at affected the likelihood of the participating women had been selected. However, no women to deliver their babies at an home). inferential statistics were done to institution were their knowledge as well Minimal expected benefits extrapolate the results obtained from the as the affordability, accessibility and 80 participating women to the population acceptability of maternity services in the Both groups’ minimal expectations during of pregnant women in the Marondera Marondera District. labour and delivery included non­ district of Zimbabwe because the sample interference and cleanliness - which In both groups only 30.0% (n=12 in each size was small. group) would seek medical help for could also be met during home deliveries. The minimal expectations during an dizziness/blurred vision/generalised Only structured interviews were oedema, implying that as many as 70.0% institutional delivery include the effective conducted. More in-depth information could delay seeking medical help for monitoring of the labour process as well might have been obtained by conducting potential signs of eclampsia. The effective monitoring of the mother and individual and/or focus group interviews. severity of this situation is emphasised the baby after delivery, and timely referral No data were gathered from the nurses by reports that the majority of to higher level services should any to compare and contrast the data complication be suspected. The Zimbabwe’s obstetric deaths are due to obtained from the women. abortion-related complications and to perceived effectiveness of such severe pre-eclampsia/eclampsia monitoring could be compromised by (Mudokwenyu-Rawdon, 2001:16). women’s negative perceptions of nurses Conclusions Women’s lack of knowledge could have working at the institution. Individual perceptions that influenced been a structural variable influencing their women’s decisions to deliver their babies decisions not to deliver their babies at Expected costs at home included that they preferred health care institutions. All the problems The expected costs of an institutional cleanliness as well as no interference reportedly experienced by the delivery include traveling expenses, during labour and during the delivery of participants during and after home payment for the delivery, forfeiting family the baby and placenta. The interviewees deliveres (excluding backache and support during the delivery process, did not realise the potential dangers of swollen breasts) might involve obstetric non-adherence to cultural expectations, home deliveries, especially for emergencies with enhanced risks of and getting someone to take care of the primigra vidas and multigravidas, despite mortality and morbidity for both the home and children during the woman’s their high levels of education. ANC clinic mother and the baby. Women with these absence. Although home deliveries were attendances commenced late and were reported obstetric complications (severe reportedly more expensive than too few. abdominal pains, aspiration of baby, institutional deliveries, the additional child’s hand came first, mother could not costs of institutional deliveries might Cultural expectations, greater expenses pass urine, deep tear in the perineum, have made the latter option more incurred by institutional deliveries as well dizziness, excessive bleeding, vaginal expensive for these women with limited as the perceived negative attitudes of bleeding for three months, retained incomes. nurses, influenced women’s decisions

11 Curationis June 2008 to deliver their babies at home. The low signs of eclampsia/pre­ References minimal expectations of institutional eclampsia and the dire necessity BENNETT, VR & BROWN, LK 2001. deliveries (cleanliness and non­ to seek help timeously. Myles’ textbook for midwives. 13th interference), the perceived high costs • All pregnant women aged 19 or Edition Edinburgh: Churchill of institutional deliveries compared to younger, as well as those who Livingstone. home deliveries, and nurses’ perceived are 35 or older, should deliver at unfriendliness influenced these women health care institutions. BURNS, N & GROVE, SK 2001. The to opt for home deliveries. The number • At least six ANC visits should practice of nursing research: conduct, of institutional deliveries in the be encouraged and these critique and utilization. Philadelphia: WB Marondera District are unlikely to should commence during the Saunders. increase until these perceived first trimester of pregnancy shortcomings have been addressed. (prior to 16 weeks’ gestation). MBIZVO, MT; FAWCUS, S; • Health care institutions should LINDMARK, G & NYSTROM, L 1993. Recommendations provide facilities for cultural Operational factors of maternal mortality In order to enable more women in the practices during and after in Zimbabwe. Health Policy and Planning. Marondera District to deliver their babies delivery such as enabling the 8(4):369-378. at a health care institution, and enhance mother-in-law to be present the safety and wellbeing of pregnant during the birth, to fulfill cultural MINISTRY OF 11KALTI1 AND CHILD women and newborn babies, the rituals and to help care for the WELFARE 2001. Reproductive health following recommendations should be newborn baby. services: delivery guidelines. : heeded: • The possibility should be Government Printer. • ANC clinics should emphasise investigated to build self-care the advantages of institutional shelters for pregnant women MOHCW see MINISTRY OF HEALTH deliveries and assure pregnant near the hospital so that they AND CHILD WELFARE (of Zimbabwe) women that no unnecessary will not need to find expensive interference will occur during transport once the labour MUDOKWENYU-RAWDON, C 2001. labour nor during the delivery process started. Factors influencing pregnancy outcomes of the baby and placenta. • The charges levied for ANC in high-risk patients. Unpublished D Litt et Phil thesis. Pretoria: University of • Midwives’ preferences for visits and institutional deliveries South Africa. managing labour and delivery should be affordable for rural processes in the Marondera women. MUG WENI, E 2004. Factors contributing District of Zimbabwe should be to the disparity between antenatal investigated, and adjusted in Future studies should investigate the: bookings and institutional deliveries in accordance with pregnant • factors that influence women Marondera District. Unpublished MA women’s preferences for with high parity to deliver at Cur dissertation. Pretoria: University of cleanliness and no interference home South Africa. during these processes. Should • barriers to effective active interventions become communication between nurses ONEGA, LL 2000. Educational theories, necessary, midwives should and clients models and principles applied to inform the woman and her • quality of maternity services community and public health nursing in significant others and obtain rendered in the Marondera Stanhope, M & Lancaster, J 2000. permission prior to District. Community and public health nursing. 5th implementing any intervention, edition. St Louis: C V Mosby. if possible. Emergency “African women of reproductive age interventions should be have the highest death risk from PAUL, KB 1993. Maternal mortality in explained to the woman and her maternal causes o f any women in the Africa: 1980-1987. Social Science & significant others as soon as world. The lifetime chance of maternal Medicine. 37(6^:745-752. possible. Pregnant women death is 1:21 in Africa as compared to should be informed about their 1:54 in Asia, which ranks second... The POLIT, DF & HUNGLER , BP 1999 rights in this regard during their (African) continent accounts for 30% of Nursing research principles and ANC visits. all maternal deaths in the world as methods. 6th edition. Philadelphia: JB • Health education at ANC clinics against 18% o f births” (Paul 1993:745). Lippincott. should emphasise that all This situation remains unlikely to change primigravidas and all as long as large numbers of African STANHOPE, M & LANCASTER, J multigravidas (with the fifth or women opt for home deliveries. This 1992. Community health nursing subsequent pregnancy) should study identified some factors which process and practice for promoting deliver their babies at health could be addressed to enable more health. St Louis: CV Mosby. care institutions; and all women women to deliver their babies at a health who experienced previous care institution in the Marondera District WHO - see WORLD HEALTH obstetric problems. of Zimbabwe which could help to reduce ORGANIZATION. • Health education at ANC clinics maternal and infant mortality and should emphasise the danger morbidity figures in this area.

12 Curationis June 2008 WORLD HEALTH ORGANIZATION 2000. Safe motherhood: a newsletter of worldwide activity. Issue 28. Geneva.

WORLD HEALTH ORGANIZATION 1999. Reduction of maternal mortality: a joint WHO/UNFPA/UNICEF/ World Bank Statement. Geneva.

13 Curationis June 2008