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

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.