Social Science and Medicine: How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia

1 January, 2019

Happy New Year to all HIFA-Zambia and HIFA members. Thanks to John Eyers (HIFA Literature Search volunteer) here is an interesting new paper from the journal Social Science and Medicine. Fulltext here:

CITATION: How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework.

Social Science and Medicine. 220 (pp 312-321), 2019. Date of Publication: January 2019. Kaiser J.L.; Fong R.M.; Hamer D.H.; Biemba G.; Ngoma T.; Tusing B.; Scott N.A.


To reduce maternal mortality, countries must continue to seek ways to increase access to skilled care during pregnancy and delivery. In Zambia, while antenatal attendance is high, many barriers exist that prevent women from delivering with a skilled health provider. This study explores how the individuals closest to a pregnant woman in rural Zambia can influence a woman's decision to seek and her ability to access timely maternity care. At four rural health centers, a free listing (n = 167) exercise was conducted with mothers, fathers, and community elders. Focus group discussions (FGD) (n = 135) were conducted with mothers, fathers, mothers-in-law, and community health workers (CHWs) to triangulate findings. We analyzed the FGD data against a framework that overlaid the Three Delays Framework and the Social Ecological Model. Respondents cited husbands, female relatives, and CHWs as the most important influencers during a woman's maternity period. Husbands have responsibilities to procure resources, especially baby clothes, and provide the ultimate permission for a woman to attend ANC or deliver at a facility. Female relatives escort the woman to the facility, assist during her wait, provide emotional support, assist the nurse during delivery, and care for the woman after delivery. CHWs educate the woman during pregnancy about the importance of facility delivery. No specific individual has the role of assisting with the woman's household responsibilities or identifying transport to the health facility. When husbands, female relatives, or CHWs do not fulfill their roles, this presents a barrier to a woman deciding to deliver at the health facility (Delay 1) or reaching a health facility (Delay 2). An intervention to help women better plan for acquiring the needed resources and identifying the individuals to escort her and those to perform her household responsibilities could help to reduce these barriers to accessing timely maternal care.

The highlights of thispaper are:

- First use of the Three Delays Framework combined with the Social Ecological Model.

- Free listing and focus group discussions conducted with communities in rural Zambia.

- Husbands, female relatives, CHWs influence a woman's access to maternity care.

- Unfulfilled roles are barriers to women seeking and delivering at a health facility.

- Birth preparedness intervention utilizing CHWs could reduce the interpersonal barriers.

Comment (NPW): Thinking more generally, I wonder if perceived and actual 'roles and responsibilities' are adequately represented and defined - at all levels of the health system and across all areas of health care. if people's roles and responsibilities are better understood, it should make it easier to address barriers and drivers and thereby promote better health outcomes.

Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: /