Determinants of Home Delivery by Antenatal Care-Booked Women in Seke District, Mashonaland East Province

Abstract

Maternal and neonatal mortality remain public health challenges in Sub-Saharan African countries including Zimbabwe. Antenatal care, skilled birth attendance and postnatal care are key strategies that have been put in place to reduce maternal and neonatal preventable deaths. Impressive ANC uptake rates are now the norm globally but it is the discrepancy between ANC uptake and skilled birth attendance which is of concern. In Mashonaland East province this discrepancy was noted to be increasing between 2017 and 2020 with Seke District consistently being the highest contributor to the home delivery by ANC-booked women rate. The district was also noted to be having an increasing home delivery rate during that same period. This study therefore sought to explore the determinants of home delivery by ANC-booked women in Seke district. A mixed concurrent quantitative-dominant study was carried out using a case-control study design which was complemented by in-depth interviewing of key informants. 115 case/control pairs were conveniently recruited from women who delivered either at home or in health institutions between 2017 and 2021, after ANC uptake. The two hospitals in the district as well as Epworth Polyclinic were purposively selected, while seven of the remaining fifteen health facilities were randomly selected, to give a total of ten participant recruitment facilities out of the eighteen health facilities in the district. Eight health workers were also purposively selected to participate as key informants. Interviewer administered questionnaires and key informant interview guides were used to collect data. Quantitative data was analysed using Epi-info 7 while quantitative data was analysed thematically and triangulated with quantitative findings. Having less than 4 ANC visits (AOR 5.2; 95% CI: 2.44-11.2; p<0.001), having an unplanned pregnancy (AOR 2.7; 95% CI: 1.27-5.51; p=0.009) and having a parity of 4 and above (AOR 3.9; 95% CI: 1.90-8.30; p<0.001) were the independent factors associated with participants being more likely to deliver at home after utilising ANC services. Having a gestational age of less than 16 weeks at the first ANC visit (AOR 0.4; 95% CI: 0.20-0.90; p=0.028) was an independent protective factor associated with participants being less likely to deliver at home after ANC uptake. The study also found that there was a statistically significant difference in knowledge levels between those who delivered at home after utilising ANC services, and those who delivered at health institutions (p<0.010) with the latter generally being superior in terms of knowledge levels. Qualitative results also complemented quantitative findings as themes of client lack of knowledge, low risk perception and feeling experienced with regards to childbirth emerged during analysis. Other important themes which emerged were the issue of high delivery fees, lack of tolerance of harmless traditional practices at health institutions, lack of resources at health institutions as well as shortage of healthcare staff observed during ANC by clients. The determinants of home delivery by ANC-booked women are interrelated and highlight that the quality and quantity of ANC visits play a crucial role in the choice of place of delivery that women ultimately make. Quality of care during ANC should thus be optimised as ANC is the point of contact for acquiring knowledge and having confidence and the right attitude nurtured to promote use of health facilities for delivery.