BackgroundLuapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women’s and community’s needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces.MethodsA cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata.ResultsWomen who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women’s decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain.ConclusionsWomen and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women’s needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable.Electronic supplementary materialThe online version of this article (10.1186/s12884-017-1649-1) contains supplementary material, which is available to authorized users.
The individual impacts of several components of family planning service quality on contraceptive use have been studied, but the influence of a composite measure synthesizing these components has not been often investigated. We (1) develop a composite score for family planning service quality based on health facility data from Burkina Faso, Ethiopia, Kenya and Uganda and (2) examine the influence of structural quality on contraceptive practice in these four countries. We used nationally representative cross-sectional survey data of health facilities and women of reproductive age. First, we constructed quality scores for facilities using principal component analysis to integrate 18 variables. Second, we linked women to their closest facility using geo-coordinates. Third, we estimated multivariable logistic regression models to calculate women’s odds ratios for modern contraceptive use adjusting for facilities’ quality and other factors. In Burkina Faso, Ethiopia and Uganda, the odds of using a modern method of contraception was greater if the nearest facility provided high- or medium-quality services compared with low quality in the univariable model. After controlling for possible confounders, the adjusted odds ratios were significant for high quality (aOR: 3.12, P value: 0.005) and medium quality (aOR: 2.57, P value: 0.009) in Ethiopia and in the hypothesized direction but not statistically significant in Uganda or Burkina Faso, and in the opposite direction in Kenya. A process quality measure—having been visited by a community health worker—was statistically significantly associated with modern contraceptive use in three of the four countries (Burkina Faso aOR: 2.18, P value: 0.000; Ethiopia aOR: 1.78, P value: 0.000; Uganda aOR: 1.96, P value: 0.012). These results suggest that service quality in public facilities may be less relevant to contraceptive use in environments where the universe and reach of providers changes actively. Programs promoting contraception therefore need to consider quality within facility types and their service environments.
The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not prohibitive to accessing care.
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