Maternity care in Zambia : With special reference to social support

Abstract: The Zambian woman starts childbearing early and gives birth to an average of 5.9 children during her reproductive period. The already high levels of maternal deaths are increasing in Zambia. Only 43 per cent of the women deliver with the assistance of a skilled attendant. Maternity care is in focus in this thesis because of the crucial impact it may have on childbearing women and their newborns' health. The aim of this thesis is to describe prevalent maternity care routines during normal childbirth in Zambian maternities and the views of staff, newly delivered mothers and social support women (relatives, friends) on providing extra social support to labouring women. The aim is also to measure the effects of extra social support to primiparous women during labour, on labour outcome and mothers' early childbirth and breastfeeding experiences. A cross-sectional study, including primi- and multiparous women (n=84), health staff (n=40), and social support women (n=36) were carried out at the University Teaching Hospital (UTH) in Lusaka, at two Urban Health Centres in Lusaka, and at eight district hospitals in the Southern Province of Zambia. A Randomised Control Trial was performed at UTH and 299 healthy primigravidae women attending antenatal care were randomised to routine labour and delivery care (Group I) or offered to have extra social support during labour by a female companion, social support person (Group II) or a doula (Group 111). Observations, semi-structured interviews and questionnaires, record reviews and field notes were used to collect data. It was found that the maternity routines were not evidence-based and culturally appropriate. Labouring women were confined to bed during the whole labour and delivery period. Food and drinks were withheld, and no gowns to maintain women's privacy were provided. Foetal monitoring was inconsistent and the partograph was either not used or partly lacking. All women were delivered in a lithotomy position and there was lack of support for early motheribaby contact, prevention of hypothermia in the babies and early initiation of breastfeeding. None of the women were allowed to have any companion present during labour (Paper I). Newly delivered mothers expressed a desire for having a supporting person present during labour to provide emotional and practical support. Those who were not in favour of the idea gave reasons such as relatives would interfere with the care provided. Health care staff cited hospital policy and administration of traditional medicine as reasons for not allowing a social support person to stay with a labouring woman (Paper II). The majority of the social support women accompanying pregnant women to maternity units were aware of ongoing Zambian traditional childbirth practices and beliefs. Half of them considered themselves as traditional birth assistants (mbusas). They advised the pregnant women on the use of traditional medicine and sexual relations during pregnancy. One third of the social support women were in favour of the idea to give extra social support to labouring women in Zambian maternity units (Paper III). About 40 per cent of the primigravidae were adolescents (14-19 years of age) who had significantly less education than the older age groups (p=0.000). In total, 68 per cent were unemployed with inadequate living facilities and financial resources. The majority (78 %) had never used a family planning method and the main sources of information on sexual issues were friends and mass media. Sixty-three per cent made their first antenatal visit during the second trimester, and 22 per cent of the teenagers attended the antenatal clinic during the third trimester. Most of the women reported that they had a social support person, assisting them at home during the antenatal period and that a relative would escort them to a maternity unit, when labour commenced (Paper IV). There were significantly more use of analgesia (p=0.033), caesarean sections (p=0.010), and episiotomies (p=0.008) in the control group. Significantly, more mothers in the intervention groups perceived that they coped well with labour (p=0.000). There was no difference in labour outcome, whether a doula or a social support person (SSP) supported a labouring woman. There was no difference found in the groups regarding time of first breastfeeding after birth in the labour ward (Paper V). Significantly more mothers in the supported groups stated that their labour had been very easy (p=0.02) and more mothers in the supported groups had enjoyed their birth experience. All the mothers had had their infants 'skin-to-skin' contact with them, shortly after birth. More mothers in the supported groups reported that they were going to have enough milk for their babies (p=0.01). There were misconceptions about the value of colostrum and about one fourth of the mothers had had no or poor assistance from the staff regarding breastfeeding. Fifty-five per cent of the fathers (Groups I-III) had not seen their newborns before the mother and baby were discharged from the maternity unit (Paper VI). Implications for practice: Physiological, psychosocial, and cultural aspects including preparation for parenthood should be included in the plan of maternity care. Midwives should reorient their practices to evidence based and culturally appropriate care. Social support, including fathers of the newborn, should be encouraged in the practice of midwifery in Zambia.