In order to address the goal of this paper, a phenomenological qualitative design which incorporated in-depth interviews (IDIs) and key informant interviews (KIIs) were used. This provided a detailed understanding of the women’s experiences and perceptions concerning the enablers and obstacles on the utilisation of waiting mothers’ shelters in rural Zimbabwe. Women who had used the waiting mothers’ shelter since 2015 were engaged through (IDIs) as the healthcare professionals were also engaged through (KIIs).
The central unit of analysis for this article was women who have used the waiting mothers’ shelter at Bonda Mission Hospital since 2015. This time frame is significant due to the government mandate that all hospitals in rural Zimbabwe should have a waiting mothers’ shelter under the Maternal and Neo Natal Health Road map 2007-2015 policy (MoHCC 2016, United Nations Population Fund [UNPF] 2016). Expectant mothers who participated in this research were from different age groups (18-45) and geographical areas regardless of class and marital status in Mawadza village. The age groups 18-45 were dominant because 18 years is the legal age for consent in Zimbabwe and 45 was the furthest that participants consented to participate in the study.
In addition, KIIs in this study were doctors, nurses and midwives. Two representatives were chosen from each category of KIIs but midwives had four representatives to capture the narratives of those trained by the (MoHCC) and those who had gone through the training of Zimbabwe Traditional Healer’s Association [ZINATHA]. Two representatives provided broader experiences from those on the ground and those involved in supervisory tasks.
Data Collection Procedure
The data collection process in this study was from between June and November 2019 in Mawadza village in Mutasa District in Manicaland, Zimbabwe. Mawadza village falls under Mutasa Rural District Council [MRDC] in Manicaland province. The province is estimated to have a population of 1,755,000 according to the (ZIMSTAT 2012: 213). Manicaland Province is subdivided into six districts, namely, Mutare, Chipinge, Chimanimani, Buhera, Makoni and Mutasa. Mutasa district is located thirty kilometres from, Mutare which is the provincial capital city (Musuka et al., 2021).
Bonda Mission Hospital is a mission hospital run by the Anglican Church. This hospital is the largest in Mutasa district with a threshold that goes beyond Mutasa district. In addition, Bonda Mission Hospital remains the only option for villagers in Mawadza, which is the case study area for this research. The hospital is an Anglican Mission hospital that has an associated school of Nursing and Midwifery. Bonda Mission has 50 nurses and ten doctors (Musuka et al., 2021). The waiting mothers’ shelter is located within the hospital premises and there are houses where expectant mothers await delivery. As part of the amenities at the shelter, there are two houses, Blair toilets and water tanks to ensure access to clean water. One of the houses accommodates those who are awaiting labour and the other accommodates those receiving postpartum care after childbirth.
A total of 23 interviews (IDIS and KIIs) were conducted which lasted for approximately 60- 80 minutes each. The interviews were conducted in the Manyika dialect, the local language used by the people in the Mawadza community. The data collected from the interviews were audio-recorded by the author and then transcribed and translated to English afterward. The author is Zimbabwean by birth, descent and she is female. She speaks Shona, particularly ChiManyika dialect, the predominant variety used by people in Mawadza community. This study was about women and was carried out by a woman to implement what Oakley (1975; 1980; 1988) advocated for (study of women by other women) to eradicate gender biases in sociological childbirth studies. The author also resides in Mutare, the Manicaland provincial capital, about 50 kilometres from the case study research area. She has a strong command and knowledge of culture and childbirth issues in the case study area.
Qualitative data from the IDIs and KIIs were entered into an excel matrix. These data were then analysed both deductively and inductively, coding both according to a framework that was based on the IDI and KIIs topic guide, but also with an iterative approach to emerging themes. These data were then analysed thematically for patterns, trends, and outliers to explore.
The study got ethical approval from the MoHCC Manicaland Provincial offices. This research methodology was considered to be of no physical risk and minimal psychological risk to participants and the data was anonymised during the writing process to ensure confidentiality.
The section analyses the women’s experience on enablers and obstacles to utilising waiting mothers’ shelters at Bonda Mission Hospital. It looks at the social processes associated with these experiences from the narratives and nuances of the women themselves.
Need to Access Skilled Birth Attendants
The need to access skilled birth attendants has encouraged expectant mothers to use the waiting mothers’ shelter at Bonda Mission Hospital. The necessity to use the waiting mothers’ shelter varies with the medical conditions of the expectant mothers, birth experiences and complications, among other factors. Most expectant mothers interviewed agreed that they needed the shelter because they were safe in the hands of healthcare workers who had experience in handling pregnancies. Participant (i) stated that:
I always want to await labour in the shelter because it gives me access to nurses and doctors whenever I need them. Right now, the country is going through strikes, but we have midwives on duty and they constantly teach us how to do the correct thing with our pregnancies. I think that is very important to me as a mother.
In agreement with Participant (i), Participant (ii) stated that:
I am an HIV-positive pregnant mother and my condition requires me to give birth at a hospital to save my new-born child from getting infected. Therefore, I need qualified health care workers to assist me during delivery; so, waiting for delivery in the shelter is important.
Postpartum care received in the shelter has also been a major driving force for women to utilise the waiting mothers’ shelter. The fear of post-delivery haemorrhage, which usually results in the death of new mothers in this area, has driven mothers to use the shelter for proper assessment before they are discharged out of the facility.
KI 1, who is a doctor, had this to say:
Up to 98% of the mothers who use the shelter do not suffer from post-delivery haemorrhage, and the last recorded case in this hospital was handled well with proper medication to stop the new mother’s profuse bleeding. Other common conditions are Yellow fever and Jaundice among newborn babies. This requires extra check-ups and care and when mothers experience this, they realise they need to await labour in the shelter in order to receive comprehensive postpartum care.
Narratives presented by the participants show that there is a growing dependency on the waiting mothers’ shelter among facility users due to the services offered and this has been supported by some of the by-laws in the community that support the use of the mothers’ shelter. The existence of these by-laws has also facilitated the increased utilisation of the waiting mothers’ shelter.
Criminalisation of Home Births in Surrounding Villages
The communities, through by-laws, have criminalised homebirths.Chiefs and village heads penalise families who give birth at home. All participants acknowledged that when one gives birth at home, the family pays a fee to the chief they can obtain a letter to the hospital acknowledging a new birth in his village book. This letter serves as proof of delivery so that the newborn can be put on an immunisation plan and, later on, be eligible for registration in the registry department for issuance of a birth certificate. Participants noted that without the letter from the chief, one could not register one’s newborn baby; hence, the baby will not have a birth certificate or national identity or any other documentation.
KI 2 further remarked that:
The MoHCC has not totally disqualified but does not categorically encourage home births, especially in this Zimbabwean context, and mostly in our rural communities. Community by-laws then act as a social control mechanism to support the use of formal maternal health care facilities by rural women so as to reduce maternal mortality, especially during or soon after delivery. These by-laws have been useful in encouraging expectant mothers to attend prenatal care at the hospital and come to the waiting mothers’ shelter to await delivery.
Although the aforementioned factors have been push factors for women to use the waiting mothers’ shelter, participants noted other challenges that still deter them from using the waiting mothers’ shelter at Bonda Mission Hospital.
Inadequate Knowledge about the Waiting Mothers’ Shelter
Inadequate knowledge about the waiting mothers’ shelter is one of the reasons why some women choose not to await labour in the waiting mothers’ shelter. The inadequate knowledge is also gendered as men are reported not to know its operations, usefulness, and benefits of using the waiting mothers’ shelter in the prenatal and postpartum stages. Expectant mothers know of the benefits of awaiting labour at the shelter through their experience in this facility. There is not enough awareness about the actual activities that occur in this facility. Participant (iii) articulated that:
I only had to know this when I came here. Back in our villages we think coming to the shelter is for weak expectant mothers who want to be relaxing for two weeks before giving birth. I think we used to think so because we did not get enough information about the shelters.
Inadequate knowledge of the activities that occur in the shelter and the benefits that women have by awaiting labour is a deterrence to the utilisation of this shelter. In addition, the fact that men also have inadequate knowledge of the shelter especially its purpose and functions has further deterred women from using the shelter since they lack ultimate decision making power to leave their houses for some time as they await labour.
Matrix 1: Enablers and Obstacles to the Utilisation of Waiting Mothers’ Shelters
• Criminalisation of Home Births
• Need to access skilled health workers
• Need to prevent complications
• Women’s low decision-making power to use the shelter.
• Domestic expectations and Gender Roles
• Lack of privacy in the shelter
• Economic challenges
• Long Distances to the Shelter and Lack of Effective Transportation System
Women’s Lack of Decision-Making Power to Use the Shelter
The participants depend on their husbands’ authority to use the shelter. For those who do not have husbands, a male member of the family’s authority is needed before going to the shelter. Expectant mothers indicated their interest to await labour in the shelter but they are sometimes not allowed by their husbands. Some participants noted that they awaited labour in the shelter for their first pregnancies only but were not allowed by their husbands to do the same for the second time and some for the third time even. Participant (iv) narrated that:
My husband did not want me to keep on going to the shelter after my first pregnancy. He kept on explaining to me that there was no need to spend resources using the shelter every time I fall pregnant as it was going to be difficult for him to fund for that.
Key informants noted that most women come to the shelter with their husbands’ authority because they do not have the decision-making power to come to the shelter without the husband’s consent. This is because husbands usually face challenges in taking care of the families when their wives are away.
Family Expectations and Gender Roles
Expectant mothers also highlighted that they have family commitments that require their ongoing presence at their homesteads. In this culture, women (mothers) are responsible for a number of tasks such as household chores and child-rearing, apart from child bearing. The fathers usually do not want to let go of their wives to go to the shelter for they do not want to be burdened by household chores and child rearing duties. Most men prefer that the expectant mother’s pregnancy be monitored at home in order to avoid house hold chores since they will be committed with manual labour to provide for their families. Participant (v) noted that:
I have so many commitments at home that require my attention as a mother. I have other young children who still need my care. I ended up taking them to my mother for proper care when I am away. I also have a field that is not being tilled at the moment because the people who assist me cannot come when I am not there. Coming to the shelter disrupts the normal way of life but there is no option because we need to save the babies’ lives and our lives too.
Family commitments are a notable reason why women are not utilising the waiting mothers’ shelter. In Mawadza community gender roles according to the societal beliefs, women are expected and required to be in the private sphere (the home). The involvement of women in household chores is influenced by the societal culture. Gender roles have gone to the extent of influencing the childbirth process in Mawadza rural community.
The Increasing Involvement of Men in the Hospital Childbirth Process
The childbirth process at Bonda Mission Hospital increasingly involves men. Contrary to that, the birth process in this area has traditionally been handled by women (female midwives) both in hospital deliveries and home births. Over the years, there have been a considerable number of men joining the field of gynaecology, obstetrics and generally being trained to be midwives at Bonda Mission Hospital. The increase in the number of men joining this field has also gone along with the fluidity of most gender roles in contemporary societies. In maternal health, specifically, in Zimbabwe, this has been influenced by the growing medicalisation of the birth process and the need for more skilled birth attendants; hence men end up joining, if not dominating the sphere. Participant (vi) noted that:
I am not comfortable with male midwives in the shelter; they make me so shy, and it’s against our culture to expose our bodies to males – regardless of the help they could be offering. The males are even rude. They keep on telling us to be professional because they would be at work and not there for jokes.
The increasing involvement of men in hospitalised birth is an area of major concern from the narratives of a significant population of the participants. A closer analysis shows that the concerns of the women arise from their cultural beliefs and the respect of the women’s reproductive system and genitals more specifically in this culture. The dismantling of this tradition results in women not being comfortable giving birth in the hospital and resorting to the perceived dignified home birth surrounded by women.
The Relationship between Expectant Mothers and Health Care Workers in the Shelter
Overall, participants highlighted many reasons influencing their decision to either use or not use the waiting mothers’ shelter to await delivery. Expectant mothers indicated that healthcare workers often mistreat or demean them during their antenatal visits and their stay in the waiting mothers’ shelter. Additionally, health workers agreed that expectant mothers often do not receive the care they deserve due to staff shortages owing to the current economic hardships. None of the TBAs interviewed listed the relationship between expectant mothers and health care providers as the reason why expectant mothers do not await delivery in the waiting mothers’ shelter. It had been a barrier for most expectant mothers, and a reason why they think their peers do not use the waiting mothers’ shelter. Participant (vii) noted:
The treatment we get in this shelter is harsh at times. The midwives usually shout at us and they do not care how we feel after they shout at us. I would like to see in this shelter that, when an expectant mother comes into the shelter, she should be treated with respect and dignity like any other human being. They should treat us like their daughters, not shout at and beat us … So, I would love to see the midwives welcoming and treating us well.
Expectant mothers stressed that their mistreatment by the health care providers amounted to what they believed was a misuse of their authority. Expectant mothers stated that they felt helpless in these situations as they rely on these professionals for care. Furthermore, since most of the expectant/new mothers were of lower socio-economic status, they feared speaking up or were unsure what to say in those situations.
Health care workers admitted that it was often difficult to maintain positive attitudes throughout the day due to staff shortages, with the current economic hardships being faced in Zimbabwe. The health care professionals noted that the patient load is often greatest at these facilities than at the primary and secondary levels. In addition to staff shortages, health workers confirmed that expectant mothers were mistreated or shouted at when they presented late for care or did not follow simple instructions. KI 4 stated that:
I think much of it is the personal attitude; it could also be related to the long shift we are taking these days. At the moment, we are not short-staffed in theory but in practice, people show up for work for a few hours and then disappear because nurses and doctors are on strike nationwide. You may find that one doctor could be having one shift that he is doing; he has one shift and another shift and another shift, and they are tired. (Furthermore), you are telling this expectant mother (what is wrong), and she does not understand you, and the expectant mother is doing something else and then you yell on top of your voice.
The participants have noted that the situation in the shelter has been worsened by a lack of respect and lack of privacy in this facility. This is an area that they possibly would like to see improve.
Economic Challenges, Long Distances and Lack of Proper Transport System
Furthermore, among the reasons women do not use the waiting mothers’ shelter up to the level it is supposed to be used, are the long distances that exist between the expectant mothers’ homes and Bonda Mission Hospital, lack of proper transportation to the health care facility and a poor road network. Participants indicated that they use donkeys, bicycles and motorbikes as transport to the hospital for prenatal care before they are due for their waiting period in the shelter. This has posed challenges to them because it is difficult to use a bicycle until one reaches the hospital with the state of the road network. Hiring a car or a motorbike is expensive for most expectant mothers. Participant (viii) stated that:
I was given a bicycle to use by my husband, but, it’s not efficient because the terrain is not flat before I reach the hospital using the shortcut.
Economic challenges have worsened the long distances. When the expectant mother is due to go to the shelter, she is required to bring provisions such as a notebook, firewood, food, pots, blankets, buckets, toiletries, including detergents to clean the toilets, latex gloves, cotton wool, candles, razor blades, shaving cream, and presentable clothing – preferably nightwear. These provisions are usually required to be utilised by the expectant mothers during their stay in the shelter.
Due to economic challenges expectant mothers fail to provide all these requirements to be eligible to await labour in the waiting mothers’ shelter. Participant (viiii) articulated that:
It is very hard in this economy to have all the provisions needed to stay in the shelter. At the end of the day, when you realise you do not have enough, you will just resort to giving birth at home
The challenges of providing one’s consumables while awaiting labour in a waiting mothers’ shelter are common in Mawadza village. Complications of pregnancy and childbirth can pose severe risks to the health of expectant mothers, especially in resource-poor rural settings. These result in some not meeting the required standards, so they resort to non-use of the facilities. Intervention from governments and other stakeholders to assist with provisions such as food and sanitary wear is vital to encourage those without access to these also to use the waiting mothers’ shelters.