One hundred and ninety-three (193) people took part in the study, through eleven (11) focus group discussions (FGDs), seven-teen (17) in-depth informant interviews (IDIIs), and three (3) community meetings (see Table 2 for a break-down).
Table 2: Study participants
|
Category
|
Rural participants
|
Peri-urban
|
Urban
|
Total no. of participants
|
Age ranges
|
Educational level
|
Marital status
|
|
FGDS
|
|
Pregnant women
|
14
|
8
|
12
|
34
|
17-38
|
22 Secondary school.
10 Primary school.
2 none
|
26 married;
8, not married
|
|
WOCBA
|
20
|
-
|
15
|
35
|
19- 37
|
27 Secondary school.
5 Primary school.
2 none
|
23 married;
6 widowed;
1 single;
5 divorced
|
|
Elderly women
|
17
|
-
|
7
|
24
|
53-65
|
11 Secondary school.
9 Primary school.
4 none
|
15 married;
3 single;
6 widowed
|
|
Spouses
|
-
|
-
|
8
|
8
|
23-65
|
8 Secondary school
|
8 married
|
|
KEY INFORMANTS
|
|
Health staff
|
5
|
4
|
1
|
10
|
28- 51
|
10 Secondary school
|
8 married;
2 single
|
|
Transporters
|
-
|
1
|
-
|
1
|
42
|
Secondary school
|
1 married
|
|
Pregnant women
|
3
|
-
|
-
|
3
|
23-29
|
Secondary school
|
3 married
|
|
WOCBA
|
-
|
1
|
1
|
2
|
25-36
|
Secondary school
|
1 married;
1 divorced
|
|
Spouses
|
-
|
-
|
1
|
1
|
43
|
Secondary school
|
1 married
|
|
PARTICIPATORY LEARNING APPROACHES (PLA)
|
|
Community members
|
74
|
-
|
-
|
74
|
27-64
|
57 Secondary school.
12 Primary school.
5 none
|
51 married;
19 widowed;
4 single
|
|
Total no. of participants
|
193
|
The participants' ages ranged from 17 to 65, with over two-thirds having attained secondary level education. Tertiary education was not prioritised in both the urban and rural settings because of the lack of opportunities that have been further compounded by the economic downturn in the country. The major sources of income were mining, both formal and artisanal. Incomes ranged between USD $20–250 per month, and there were no significant differences in the salaries between the urban and the rural dwellers. Participants in the urban area lived within a radius of 5km to the health facilities, while two-thirds in the rural areas lived within 10 km and a third living as far as 40km.
The PLA methods resulted in 3 key themes: (a) factors influencing the choice of transport, (b) telecommunication and network systems, (c) community perceptions of the feasibility of the RoadMApp. Table 1 presents the major themes and associated sub-themes.
Table 1: Themes, sub-themes, and codes resulting from the data analysis
|
Superordinate Theme
|
Sub-theme
|
Codes
|
|
1. Factors influencing the choice of transport
|
Quality of transport
|
· Affordability
· Transport network
· Safety of the transport
· Waiting for time travel
· Cost of travel
· Ambulance system
· Waiting mothers' shelters
|
|
2. Telecommunication and network systems
|
Network coverage
|
· Mobile phone ownership
|
|
3. Community perceptions of the feasibility of the RoadMApp
|
Positive perceptions of the intervention
|
· Reducing maternal delays
· Travel for referrals
· Lower travel costs
|
|
Wicked problems (economically difficult problems)
|
· Poor economy
· Poor road infrastructure
|
Theme 1: Factors influencing the choice of transport
Participants defined factors influencing the choice of transport as the affordability, transport network, safety of the transport, waiting for time travel, cost of travel, ambulance system, and waiting mothers' shelters.
Sub-theme 1.1: Affordability
Cheaper modes of transport were available in urban areas. These included the government-subsidized Zimbabwe Urban Passenger Corporation (ZUPCO) buses. Some pregnant women shared rides in Honda Fit vehicles, which carried 6-8 passengers (instead of the standard capacity of 4) and commuter buses, which took 18 passengers (instead of 14). The women preferred these commuters and Honda Fit taxis because of availability and shorter waiting time. The cheaper buses also had challenges of long waiting times and overloading. The following excerpt sums up the women's experiences on the use of public transport:
"ZUPCO is cheap but very hot (because of overloading). Passengers, drivers, and conductors seem not to understand or empathize with pregnant women. Even if I am pregnant, they expect me to stand. Sometimes when the bus is full, and they can leave you behind. However, smaller vehicles do not take time to load, but their design is not 'pregnant woman-friendly.' The poor road terrain even makes things worse," (An urban pregnant woman within the age range of 22-26).
Sub-theme 1.2: The transport network
Urban areas have an established road-network as compared to Kwekwe rural. The major roads in the urban and peri-urban areas were tarred, while the minor roads are dusty with gravel and potholes. Some peri-urban places were hard to access, and most vehicle owners were reluctant to use those routes because of probable damage to their vehicles. These hard-to-access areas negatively affect the waiting time, possibly leading to home births or born before arrival, as shown in the following comment:
"You wait for hours before they pick you as transporters would prefer to ferry people from areas where roads are good. I experienced labour pains at 9.00 am and immediately called the transporter who came 5 hours later. I could have given birth at home," (An urban postpartum woman within the age range of 18- 24).
Subtheme 1.2.1: Communities preference of transport options
Community meetings discussions showed a preference for locally available transporters arguing that there was a reduction of waiting time as prearrangements would have been made. Local transporters knew the road network and the accessibility of roads during different seasons. Participants said commercial transporters to be unreliable, as when the need arose, they would be elsewhere doing business. They were also reportedly charging exorbitant fees. A community member said:
"Our people can navigate their way to the health facilities using the worst of roads, and they show a human face in that they are prepared to get the woman to the health facility irrespective of the wear and tear of their cars," (Female FGD participant, age range 35-40)
To make the RoadMApp workable, spouses suggested having a list of drivers to choose from and standardised costs.
Sub-theme 1.2.2: Safety of the transport
Despite the availability of public transport in urban areas, most pregnant women mentioned the safety and unaffordability of public transport, especially for routine visits to health facilities. This saw pregnant women within the 5-10km range walking to the clinic/hospital. Pregnant women who walked would leave home at around 0400hrs to catch the queue at the clinic/hospital (that opened at 0700hrs). In rural areas, the most common mode of transport is animal-driven carts (scotch carts) that are accident-prone. Sometimes, women in labour walk long distances to access the road network to get transportation. The situation is worse in the rural areas where pregnant women reportedly walk more than 20kms.
Women both urban and rural do not feel safe to catch a ride in a car whose driver is unknown, as they had heard of criminals who were prowling most places taking advantage of unavailability or poor lighting. One older woman said:
"It is dangerous to board a vehicle from an unknown driver as we have heard reports of people being murdered by unknown assailants," (FGD participant, age range 55-60).
Walking any distance during labour could be problematic in the day and worsened at night. The following excerpt summarizes the ordeal of a woman who went into labour at night:
"I called our local transporter when my daughter got into labour, and he told me he had other errands to do, and he would only be available after 3hrs. That would have been a serious delay as the labour pain had intensified. I asked her siblings to accompany her. They walked in the dark for 2 hours before they got transport to the health facility. They could have been robbed, or she could have delivered in the forest," (An elderly woman within the age range 55-60).
To safeguard pregnant women, community meetings suggested a creation of a list of all eligible drivers, a community resource that would be shared with women during their antenatal classes (ANC). The older women and some men raised concerns about the cultural appropriateness of allowing men to transport women who were not their wives to the health facility. An elderly woman reiterated:
"We have heard stories of pregnant women being abused en-route to the health facilities," (Participant age range 55-60).
The men gave suggestions to the team for the male spouse or relative to accompany the woman to the health facility.
Sub-theme 1.3: Cost of travel to clinics
Vehicle owners/drivers were reportedly charging high prices because they took advantage of clients who would be (a) panicking, (b) desperate, and, (c) with an acute need of transport, especially during the night. The remotest village had the highest cost of hiring a car during an emergency, with some women asked to pay an equivalent of USD$100 (Z$1,000) for a distance of 20km. The amount they paid was equivalent to fares for distances of 230km. To justify excessive charges, a transport provider revealed that transporting pregnant women was risky as the drivers lacked skills of handling emergencies that could occur on the way to the health facilities. One transporter commented:
"Seeing a woman delivering is not anything that a male would want to witness. By ferrying a woman in labour to the clinic, you put yourself at risk", (Male transporter within age range 33-40).
Communities throughout the District requested for a standardised model of pricing by transporters to avoid discrepancies and overcharging. They also recommended basic emergency care training and the provision of essential medical supplies for dedicated transport operators as a way of bridging the gap where there were no ambulances.
Sub-theme 1.4: Ambulance system
Ambulances that were based at the District or General hospitals were only called in cases of emergency for both urban and rural women. The ambulances whose standard charges were the equivalent of USD$3 were overwhelmed and often delayed. The delays were further compounded by the rampant fuel shortages in the country. Ambulance drivers were said to demand only cash for their services, yet cash was not easily accessible because of the economic crisis in the country. A health worker commented on the complexity of issues about ambulance availability:
"We only have one ambulance for all clinics. Imagine if there are complications at the same time. The ambulance is not for emergencies only. We also use it for duties like the collection of drugs from other health facilities", (A key informant from one of the rural clinics, age range 30-35).
Local authority officials attributed the inefficiency of the ambulance system to an increase in the population, with some citing that on a single day, they could receive a maximum of 10 calls for one ambulance. The desperation for transport led to the usage of fire brigades for emergency transportation of women to the health facilities. Because of the unreliability of the ambulance services, some urban and peri-urban residents with medical aid cover used private ambulances. There were no private ambulance services in rural areas, as most of the population did not have any form of health insurance. A single ambulance in rural communities could cover a radius of over 200km in rough terrain, and pregnant had to be transported by scotch carts or wheelbarrows to accessible places.
The unavailability of cash was worse in rural areas. Some community members highlighted that ambulance drivers demanded payment in kind (e.g., goats or chickens). The communities suggested the use of electronic mobile fund transfers for the success of the RoadMApp initiative.
Sub-theme 1.5: Waiting mothers' shelter
The non-availability of mothers' shelters at some rural clinics/hospitals presented a need for readily available transport systems for a referral to the next level of care, which in most cases were in urban areas that were very far from the women's homes. The length of stay affected the women as they did not have a social support system. Some women were absconding referrals and opting for risky home deliveries. A health care worker commented:
"Rural women are reluctant to be referred to the next level of care because of lack of accommodation and support, particularly in urban settings," (Female Key informant within the age range 40-45).
Theme 2: Telecommunications and network infrastructure
The telecommunications network providers have tried to ensure that most areas in Zimbabwe have network coverage. The RoadMApp intervention will heavily rely on the network accessibility and hence the importance of understanding the network patterns in the study areas.
Sub-theme 2.1: Network coverage
Participants reported network coverage to be good in urban areas where all telecommunication service providers had a substantial number of base stations. However, network challenges were experienced when there were intermittent electricity supplies, a common occurrence in Zimbabwe. The farther away rural communities were from the urban areas, the weaker the network. Despite the low network coverage in most rural settings, voice calls and messages could still be received, but there was poor Internet connectivity. The communities knew the best spots to pick up signals for communication. However, this was a challenge for nurses who had to disrupt their duties to connect to networks. One participant said:
"At this place, we have serious network challenges, and it becomes difficult when our wives need emergency help. Sometimes one has to go up a tree to access the network," (Rural male participant age range 28-35).
The community suggested that the RoadMApp application should have a communication system that did not rely much on the Internet and which could use the simplest mobile phones to benefit all communities. They suggested the adoption of platforms used by local mobile money wallet operators such as Econet, Netone, and Telecel, which can be accessed by punching a set of preprogrammed numbers.
Sub-theme 2.2: Mobile phone ownership
Discussions revealed that most people in urban settings owned mobile phones, but this was not always the case in rural areas. Failure to possess a phone in the rural areas was because of the low-income levels and unavailability of electricity. Owning a phone meant that one had to have solar charging equipment. The reduced network availability in most rural areas caused communities to rely less on mobile phones and mobile banking applications. People in rural areas were reluctant to use mobile money transactions, yet it was the only medium of exchange. Those without mobile phones requested help from friends or family members. The rural participants mentioned that community members were always willing to share their phones in cases of emergencies.
Theme 3: Community perceptions about RoadMApp
The participants perceived introducing the RoadMApp intervention as a strategic way of reducing pregnant women's woes of delays in accessing transport and reaching health care facilities in remote rural communities. Unlike the urban areas, the catchments of some clinics or hospitals in the rural areas were as far as 40 km because of the spatial distribution of settlements, landscapes, and rivers in between. There were also cases where pregnant women in urban areas accessed health centres far from their homes because of different socio-cultural and economic realities. For example, referrals for primigravida and multiparous women and travelling to access scans or a caesarean section specialist. The cost of these regular check-ups was costly. Hence, the women were advocating for shared rides, which would cut on the waiting time and provide social support. Consideration of the community needs by the RoadMApp mHealth would increase the chances of its acceptability.
Sub-theme 3.1 Community perceptions of challenges of RoadMApp,
Although communities appreciated the need for BPCR, there were some obstacles. For example, the issue of obstetric emergencies among women who were not booked for antenatal care (ANC). Women who booked late were reportedly aware of pregnancy preparation, but this awareness did not translate to preparedness because of financial constraints. Communities had limited sources of income to enable savings (due to low/unstable incomes and no sources of livelihood) and volatile costs of transport (because of macroeconomic issues). The community argued that RoadMApp would be adversely affected by the lack of savings for pregnancy. One community participant had the following to say:
"There could be cases where a woman is alerted to report to the health facility, but she might not raise money for transportation. We are all aware that irrespective of the nonuser fees for maternal health care, pregnant women are still delaying in accessing health care," (Rural woman of childbearing age range 26-31).
The lack of maternal savings also affected women who booked early. The women regarded adequate savings as a panacea to generate money to pay for transport and out-of-pocket payments (OOPs). Hence, communities expected the RoadMApp intervention to handle mobile savings and bridge the gap between service providers who did not accept mobile money. In this way, the intervention would act as a health savings scheme targeting financially excluded communities. The savings were expcted to grow into investments to enable access to other services (food, medications) at the health facilities.
Sub-theme 3.2: Poor economy
Discussions revealed that the economic downturn was taking a toll on pregnant women, as most of them had become household breadwinners. Partners were often migratory labourers, leaving pregnant women to fend for their families (with the help of neighbours and relatives). Most husbands were artisanal miners from other districts or miners working underground and inaccessible during emergencies. A participant reflects this in the expert below:
"Most of these women's husbands are illegal miners, and they go underground when they are needed the most," (Female participant, age range 40-45).
We can consider the economy a "wicked problem" (a significant societal or cultural problem that the communities, researchers, and the study cannot solve). Across all interviews, participants strongly felt that the RoadMApp intervention would be successful if there were funding attached to it. There were concerns about whether the response had enough funds to withstand the rapid hyperinflation, considering that participants would make savings in the local currency. Some even suggested that the World Bank initiative, which had introduced free maternity services, could be extended to the RoadMApp intervention.
Sub-theme 3.3: Poor road infrastructure
Another wicked problem cited by the participants was the inadequate or non-existent road infrastructure, which poses a challenge to the RoadMApp intervention. The poor road network makes most rural areas inaccessible. Women experiencing labour or complication signs cannot reach health facilities on time. Discussions during the community engagement suggested that the RoadMApp initiative should also budget for the rehabilitation of roads, particularly in the rural areas. One male participant asked:
"We hope fixing roads is one of your plans if this noble initiative is to succeed, " (Male spouse, age range 35-40).