‘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. Electronic supplementary material The online version of this article (doi:10.1186/1471-2393-14-323) contains supplementary material, which is available to authorized users.


Outpatients (men and women separately)
General care Introduction: We would like to learn about your perceptions of the health services. We would particularly like to know if the health services at the health facilities you know are trusted among people, and if they are perceived to be accessible and of good quality. * How are the official health services in this area? OR What is your experiences with… * What health service / health facility /-ies do you trust more / less? -Dispensary, health centre, hospital, local healing (government-voluntary agency?) -Probe: why? Examples? (such as , good relationship with provider, information, respect, privacy, previous experience) -Probe: (1) "With which kind of illnesses do you go to which services (traditional healer, public services, private providers)? (2) "Why: drug availability, previous experience, cost, attitude of provider, peer/social pressure, trust?" -What should change for you to trust the dispensary / health centre / hospital more? * What is your experience regarding the availability of drugs / medicine? -At the dispensary, health centre, hospital, local healers? * What is your experience with the conduct of the health providers (courtesy, confidentiality, privacy, respect)?
-At the dispensary, health centre, hospital, local healers? -Differing categories of providers? (nurse assistants, nurses, physicians, healers) -In what way could health providers modify their conduct to improve your confidence in them / your respect for them?

Malaria
Introduction: Malaria is a major cause of illness and death. We would like to ask about your experience with preventive and treatment options.
* What measures do people in this area take to prevent malaria infection? * Do you have experience with mosquito nets / mosquito nets treated with insecticide (ITN)? -Have you heard about / seen the ITN nets? -How easy / difficult is it to get these nets? -Why are you using / not using an ITN net? * What is the availability of drugs for malaria treatment?
-At the dispensary, health centre, hospital, local healing?
HIV Introduction: Many people are also infected with HIV. We would like to ask about the preventive and treatment options in this area.

Adolescents/youth aged 18-24
Introduction: We would like to learn about young people's perceptions of the health services. We would particularly like to know if the health services at the health facilities you know are trusted among young people, and if they are perceived to be accessible and of good quality.
General care * How are the official health services in this area? OR What is your experiences with… * What health service / health facility /-ies do you trust more / less? -Dispensary, health centre, hospital, local healing ( -If a family member became HIV infected, would it be better to keep it a secret? * How easy is it for someone infected with HIV to get access to treatment? -Perceptions about the treatment options? * What can a person who suspects that he / she has been infected with a sexually transmitted infection do? -Where do most people go for treatment of STI's (dispensary, health centre, hospital, local healers?) -Availability of drugs for treating STI's? -Perceptions of STI treatment services?
Thank you very much for your time!