The quality of maternal health service provision is one of the indicators of a vibrant health system. Over the years, the utilization of maternal health services in the city of Harare had gradually declined. This study aimed to establish the determinants of utilization of maternal health care services among maternity clients in the HWSWD.
Approximately, half of the world’s population is under 25years and the young women in this age group are twice more likely to die in childbirth when compared to women over 25 years . This study showed that the majority of the respondents were in the 19 to 24 and were 59% times more likely to utilize the maternal health care services than those above 25years. A similar study conducted in Kenya and Bangladesh also revealed that younger women were more likely to utilize skilled birth attendance and maternal health care than older women [19, 20]. This is a good indication revealing that more young women are proactive towards ensuring a healthy mother and a healthy infant post-delivery.
Mothers who had fewer than two children (most likely young) were also more likely to utilize maternal health care services when compared to those who had more than two children. This was consistent with other studies which also found that maternal health care utilization was significantly associated with birth order of less than or equal to two [21- 23]. With increasing parity, mothers become more confident due to the cumulative experience of childbirth and they missed ANC and PNC visits which were detrimental to their health as well as the health of the developing or newly born baby. Many women in this study opted to visit the facility for the first booking after the recommended first trimester. This result was similar to those of an Indian study where most of the pregnancy registrations were done between 16 and 24 weeks . Late registration can result in mothers missing fundamental health education opportunities.
Cultural background, norms, and beliefs can potentially influence one’s decision to seek health care services or not. Apostolic faith which constitutes 33% of the Zimbabwean population is linked to the diminished use of modern health services due to their doctrine, teaching, and regulations . In this study women from the apostolic sects were less likely to use the maternal health services. This may be due to a common belief among the congregants that prophets from these sects can be able to diagnose and address the health problems faced by both the mother and the developing baby. This can lead to complications since most of these women often seek services late. Cultural beliefs, women’s autonomy, economic conditions, physical and financial accessibility are a major predictor of utilization of health services .
The use of health services can be hampered by the distance to be traveled by women to seek maternal health services [27, 28]. Shorter distance to the health facility was significantly associated with the utilization of services due to reduced costs of traveling to the clinic or hospital. Transport problems were viewed as a strong determinant of the utilization of health services in HWSWD and this finding complied with findings from another previous study . Women from the slums surrounding the district faced a challenge of poor road networks and long distances since these areas are remote and lack development. This results in delays especially if the mother is faced with imminent labor and delivery issues at night.
Families with better income status are more likely to utilize maternal health services [23, 24, 27]. In the Shona culture, the husband/male partner is perceived as the provider for the family and our study found out that a husband/male partner’s monthly salary of more than $100 and those who were formally employed was associated with improved utilization of maternal health services. Although the maternal services offered at the facilities are ‘free’, many related expenses such as transport to the clinic, CT-scan, and consumables used during delivery are dependent on out of pocket payments from the mothers. Formally employed husbands/partners are more likely to have health insurance which enhances access to health services. Poverty is associated with non-use of health services in India . Consequently, pregnant and nursing mothers who cannot afford these expenses are bound to have difficulties in seeking health care services.
Even when services are readily available, women’s decision making power has a major impact on the ability of mothers to seek health services . Thus, women who earn a stipend or salary are more likely to seek health services. However, this study noted that women who earned less than $100 a month were more likely to use maternal health services than their counterparts who earned more. Due to stringent long working hours in Zimbabwe, those who earn more may have little time to visit the facility on the recommended days. This was confirmed by participants (mainly case) who reported that they failed to book in time and meet the recommended appointments because they were at work.
Skilled birth attendance during labor and delivery is only possible if the referral system is active, the health system is adequately equipped and sufficient health care workers are well trained and motivated . These two interventions are instrumental in reducing maternal and infant mortality and morbidity. However, health systems in low resource settings are usually grossly underfunded and women services received by the mothers are of poor quality. Women attending facilities for maternal services in HWSWD endure long waiting hours in the queues due to a shortage of staff. Thus, it was no surprise that some women ended up seeking services from private institutions. Literature also reviewed that poor services in the public health sector led to women seeking ANC services from private doctors .
Maternal education is a strong predictor of the utilization of maternal health services and this was supported by studies in Ethiopia and Bangladesh [23, 32]. Conversely, the current study did not find a significant difference in the utilization of services and maternal education status. The majority of the mothers (97%) had gone beyond the primary school level hence we assumed they understood the importance of utilizing the services.
Pregnant women who sought permission to visit health facilities from their spouses were less likely to utilize maternal health services compared to those who did not. This shows that a woman’s autonomy is vital in the utilization of maternal health services. In a study conducted in Burkina Faso, it was noted that to increase utilization of maternal health services, the empowerment of women and exemption of user fees/cost-sharing could help improve access . The need to seek permission contributed to the three delays in seeking health services which increases the risks of severe complications or maternal death. A study conducted in Ethiopia found out that more than half of the respondents reported that the decision to seek obstetric care was made by the husband/partner .
In most countries in the African region, women are still vulnerable to common and preventable causes of maternal morbidity and mortality like postpartum hemorrhage and sepsis. This is mainly due to a lack of access to maternal health care because of user fees. In Nigeria, the introduction of user fees has been widely implemented in government health programs as a means of alleviating pressure on constrained budgets as demands for services increase . However, many sub-Saharan African countries have introduced “free” maternity services in a bid to eliminate poverty as an important barrier to maternal health service access and utilization . Our study revealed that maternal health services in this urban setting were not entirely free since women were made to pay $25 at initial booking.
Surprisingly, almost three quarters of both the cases and controls reported that they preferred to be attended by a male nurse during all the three episodes of maternal visits. This finding is strange and difficult to interpret since women are known to be more caring than men. Mothers in this study perceived male nurses as kindness and empathetic when compared to female nurses who were perceived as brusque and cynical. Health worker’s attitude of disrespect and abuse of women during institutional delivery services can be a barrier to the utilization of maternity care services. A similar study revealed superior respectful maternity care performance of male providers over female providers . Another study in South Africa cited that female nurses ‘deployed violence against patients in their work’ . The female nurses mainly did this to create a social distance and assert their professional identity.
Satisfaction with the service provided by clinicians at the health facility during pregnancy was significantly associated with the utilization of maternal health care. Pregnant women who were satisfied with the service provided were more likely to utilize maternal health care services than those who were not. The process of care dominates the determinants of maternal satisfaction in developing countries. In a study to determine client satisfaction with delivery care service in Southwest Ethiopia, client satisfaction was seen to play a significant role in increasing utilization of institution-based delivery and thus reducing maternal morbidity and mortality mostly through focusing on women-friendly care in hospitals .
Our study found out that women who had unplanned pregnancies were less likely to utilize maternal health services. Two studies in east Africa also found out that women who had unplanned pregnancies were two times more likely to book for ANC late compared to women who had planned to have a baby [40, 41]. This may be attributed to the late diagnosis of the pregnancy thus, the woman may be shy visit the clinic and register the pregnancy especially in cases where the pregnant mother is very young, dependent, and not married.
The utilization of maternal health care services is influenced by many individual, household and system-based factors. The factors constitute health beliefs and personal characteristics of the users, social structure, availability, quality and cost of services. Inequity in the use of health care services is also an important element affecting maternal and child survival. High standards of maternal health care utilization are the only measure towards safe motherhood.