Normative Beliefs and Values Shape Mother’s Care Seeking Behaviours for Skilled Birth Attendance (Sba) During Birthing in Africa: A Scoping Review Protocol

Background: Skilled birth attendance (SBA) during delivery has been associated with improved maternal health outcome. However, low utilisation of SBA during childbirth has continued in many developing countries including Zambia. An understanding of the beliefs and values and how mothers are inuenced by relational normative motivations is critical in understanding some “hidden” barriers and facilitators to utilisation of SBA in health facilities. Methods: A scoping review of normative beliefs and values shaping care seeking behaviours for Skilled Birth Attendance by mothers in Africa will be conducted. Google scholar, PubMed, EBSCOhost, SCOPUS, Embase and WEB of Science will be searched for articles that meet the eligibility criteria. The primary search will include peer-reviewed articles. Further searches will be made on Research gate, including grey literature from university websites for dissertations and theses. We will also search reference lists for relevant articles and studies. Keyword searches will be used to identify articles. Two independent reviewers will begin screening for eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. During title and abstract screening, duplicates will be removed. Study selection will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, and the Mixed Method Appraisal Tool will determine the quality of included studies. Content analysis will be used to present the narrative Discussion: Understanding how individual mother’s health seeking behaviours for SBA and those close to them are inuenced by their beliefs and values is critical to informing health systems on the possible “hidden” barriers and facilitators to utilisation of SBA in public health facilities. The review will complement evidence base on normative beliefs and values shaping care seeking behaviours for Skilled Birth Attendance by mothers in Africa.

relevant articles and studies. Keyword searches will be used to identify articles. Two independent reviewers will begin screening for eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. During title and abstract screening, duplicates will be removed. Study selection will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, and the Mixed Method Appraisal Tool will determine the quality of included studies. Content analysis will be used to present the narrative Discussion: Understanding how individual mother's health seeking behaviours for SBA and those close to them are in uenced by their beliefs and values is critical to informing health systems on the possible "hidden" barriers and facilitators to utilisation of SBA in public health facilities. The review will complement evidence base on normative beliefs and values shaping care seeking behaviours for Skilled Birth Attendance by mothers in Africa.

Background
Maternal and infant mortality and morbidity in developing countries in large part could be averted if all women successfully utilised care from skilled birth attendants for childbirth [1]. Utilisation and access to quality facility-based services by skilled birth attendants (SBAs) during pregnancy, delivery and postdelivery has been associated with improved maternal health outcomes [1,2]. However, low utilisation of care by SBAs during childbirth has continued in many developing countries, including Zambia.
Existing evidence revealsthat individual and contextual factors, including health system factors, in uence mothers' care seeking behaviours for skilled birth attendance in health facilities duringchildbirth [3,4].
Health system factors that hinder care seeking for childbirth have been reported to include limited availability of healthcare workers, lack of equipment and supplies [5,6], and the attitude [7]and practices of health care workers,such as disrespectful and abusive care [8]. Individual level factors,such as the mother's age [9], marital status [10], level of education,economic status of the household [11,12], andcultural and religious beliefs [13][14][15][16] have also been reported as negative predictors to care seeking behaviours of mothers.The location of services available is another important contextual factor hindering utilisation of SBA for childbirth from the health facilities [17].
Some studies have reported that although some mothers are willing to seek care for childbirth [18] and would prefer to give birth in a health centre witha skilled health care provider [19], their perceptions and understanding ofthe care provided by skilled birth attendants during child birth [20,21]in uences their intention and decision to seek care for childbirth. This becomes one of the contributing factors to the existing disparities to access and utilisation of care from SBAs during childbirth.
The growing need for health systems to ensure better maternal and infanthealth outcomes for populations requires continued exploration of possible hidden barriers using diverse approaches that inform policy. An understanding of the beliefs and values and how individual mothers are in uenced by relational normative motivations is critical to informing public health policy on the such "hidden" barriers and facilitators to utilisation of SBA in public health facilities inZambia. Down and colleagues (2018) argue that the care of mothers during childbirth should be designed to ful l women's personal and sociocultural beliefs and expectations [22]. Therefore, studies focusing on mothers' normative values and beliefs and how these shape their decisions to seek care froma skilled birth attendant during childbirth need to be explored.
Normative ethics is concerned with the individual's view of what is morally right and wrong [23]. However, the extent of the evidenceon mothers' normative values and beliefs and how these values may be shaping their decisions and motivation to access care by a skilled birth attendant is limited. Therefore, we aim to map and document existing literature on normative beliefs and values that shape care seeking behaviours for SBA ofmothers in Africa. We hope that the ndings from this review will highlight gaps in the existing literature and form a basis for re ning research questions for future interventions.

Search Strategy
A systematic search, selection, and synthesis of existing literature will be used through a scoping review methodology in order to answer the research question. Scoping reviews are a comprehensive and rigorous method aimed at rapidly mapping key concepts underpinning a research area. The review will be guided by the Arksey and O'Malley [24] framework which entails identi cation of the research question, identi cation of relevant studies, selection of studies, charting the data, and collating, summarising, and reporting the results. We will also appraise the quality of the included studies as recommended by Levac et al [25].

Identifying the research question
Our research question is: What is the evidence of normative beliefs and values that shape care seeking behaviours for SBA by mothers in Africa?
We have used the Population-Concept-Context (PCC) approach recommended by the Joanna Briggs Institute for scoping reviews [26] to construct a clear and meaningful research question for a scoping review ( from university websites for dissertations and theses. We will also search reference lists for relevant articles and studies. Review articles will be excluded. Medical Subject Headings (MeSH) terms that will be included during the search for relevant articlesare:perception, expectation, experience, mothers, women, normative belief, culture, value, norm, tradition, utilization, utilisation, uptake, maternity, delivery, childbirth, sub-Sahara, Africa developing and low-and middle-income country.We will also useBoolean terms, ANDand OR to separate the keywords. Thesearch strategy will be adapted foreach database. For each search conducted, we will documentin detail the date of search, the search engine, and the number ofpublications retrieved.

Pilot Study
A pilot search was conducted in PUBMed and google scholar to determine the feasibility of the research question and search terms using a scoping review method. A preliminary search of articles was done on 28 th April and the output of the pilot search is shown on Table 2. Selection of studies Identi cation ofappropriate and relevant articles will be guided by selection criteria.

Inclusion criteria
To be included, articles will have to meet the following characteristics:

Evidence on beliefs and values surroundingchildbirth
Evidence on perceptions towards facility delivery or skilled health care providers

Articles published between 2000 and March 2020
Articles in English Exclusion criteria We will exclude the following articles;

Studies not in English
Studies with no evidence of mother's values, beliefs, or norms surroundingchildbirth Studies not focused on childbirth or delivery services

Studies not freely available in full text
All the articles retrieved from the databases will be screened for eligibility through the following stages. In the rst stage, the principle investigator (PI) will screen the all the titles for eligibility, and articles that meet the eligibility criteria will be exported to endnote, a referencing software (version 7) used to store and organize citation information. All the titles that are not eligible will be excluded and all the duplicates deleted. In the second stage, the PI and a trained reviewer will independently (in parallel) screen the abstracts from the retrieved titles to include only eligible articles. In the last stage, the PI and another reviewer shall read through the full articles for eligibility. At every stage, any differences in the outputs will be resolved through a discussion and if needed a decision will be derived by inviting athird screener. The Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines [27] will be used to report the screening process. (See Fig 1).
Charting the data A data extraction form will be used that includes the following variables: author(s) and date of publication, country of publication, aims or purpose of the study, study design, key ndings, and conclusion or recommendations. The charting form will be pre-testedby the reviewers on ve to ten randomly selected studies to determine consistency [28]. This will be done by ensuring that the reviewers independently conduct a trial data extraction and later discuss as a team to ensure that the approach is in line with the objective. To improve the applicability, consistency,and quality of the chart, a continued review through an iterative process, which involves reading and re-reading the summaries, will be ensured. This process will entail continuous editing of the extraction formthroughout the duration of the study.
Collating, summarising, and reporting the results All studies that meet the inclusion criteria will be analysed using both descriptive quantitative summaries(including gures) and qualitative thematic content analysis. Data relating to the beliefs and values of mothers or women and their social networks, in regards to childbirth by skilled health care providers in Africa,will be coded using NVivo version 12 (ref?). Emerging themes will be identi ed, coded, and categorised into major themes. The resulting themes will then be synthesised, summarised, and discussed in relation to the objective of the study and its implications onethicalpractice, policy, and future research.

Quality appraisal
To determine the methodological quality of the studies to be included, we will use the mixed method appraisal tool (MMAT) version 2018 [29]. The MMAT tool will help us determine the quality of the studies by examining the aptness of the aim of the study and the adequacy of the methodology, study design, participant recruitment, data collection, data analysis, presentation of ndings, and authors' discussions and conclusions. A scoring matrix in the MMAT tool will be used to independently appraise the quality of the studies,and the results from the scoring will be used to determine the overall quality of the article.

Discussion
Efforts to identify drivers to non-use of SBA among women should consider different and additional dimensions including normative and ethical inquiry [30][31][32]. Understanding the beliefs and values of mothers and others close to them, and how individual mothers are in uenced by these beliefs and values, is critical to informing public health systems on the possible "hidden" barriers and facilitators to utilisation of SBA in public health facilities. The ndings from this review may inform public health and clinical practice,and guide the design of strategiesthat respond to the beliefs and values of mothers, in efforts to achieveUniversal Health Coverage for maternal health care interventions in developing countries.
This scoping review may have limitations worth noting. Firstly, the basic characteristic to scoping review methodology lacks additional quality assessment or critical appraisal of included articles, which will limit our ability to identify evidence gaps. Secondly,the exclusion of non-English studies from the review due to a lack of capacity to screen articles not available in Englishmay limit the generalizability of the ndings to non-English populations.
This scoping review will be critical to uncover thebreadth and extent of research that exists in eld. The ndings of the review may be of interest to researchers by highlighting research gaps that may need further investigation.Further, implementers and policymakers involved in interventions aimed at improving SBA may be informed by the evidence from the review. Finally, the review of ndings from studies in Africa will be of interest to informing health systems on some demand side barriersand facilitators to utilisation of SBA in public health facilities.