title: Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study.
abstract: BACKGROUND
  Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women's preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia.
  
  
  METHODS
  We conducted ten focus group discussions (n = 100) with women of reproductive age (15-45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored.
  
  
  RESULTS
  Our findings show that women's lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them.
  
  
  CONCLUSIONS
  Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.
authors.affiliation: Ministry of Health, Monze District Medical Office, P.O. Box 660144, Monze, Zambia. Cephas.Sialubanje@maastrichtuniversity.nl.|Department of Work and Social Psychology, Maastricht University, P.O. Box 616, , 6200MD, Maastricht, The Netherlands. Cephas.Sialubanje@maastrichtuniversity.nl.
authors.forename: Cephas
authors.initials: C
authors.lastname: Sialubanje
authors.affiliation: Department of Work and Social Psychology, Maastricht University, P.O. Box 616, , 6200MD, Maastricht, The Netherlands. karlijn.massar@maastrichtuniversity.nl.
authors.forename: Karlijn
authors.initials: K
authors.lastname: Massar
authors.affiliation: Zambia Centre for Applied Health Research and Development, P.O. Box 30910, Lusaka, Zambia. dhamer@bu.edu.|Centre for Global Health and Development Boston University, Crosstown 3rd floor, 801 Massachusetts Avenue, Boston, MA, 02118, USA. dhamer@bu.edu.|Department of International Health, Boston University School of Public Health, Crosstown 3rd floor, 801 Massachusetts Avenue, Boston, MA, 02118, USA. dhamer@bu.edu.
authors.forename: Davidson H
authors.initials: DH
authors.lastname: Hamer
authors.affiliation: Department of Work and Social Psychology, Maastricht University, P.O. Box 616, , 6200MD, Maastricht, The Netherlands. r.ruiter@maastrichtuniversity.nl.
authors.forename: Robert A C
authors.initials: RA
authors.lastname: Ruiter
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D003657:Decision Making; D003858:Dependency, Psychological; D005260:Female; D017144:Focus Groups; D005843:Geography; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006700:Home Childbirth / Q000523:psychology* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D008880:Midwifery / Q000706:statistics & numerical data*; D026684:Personal Autonomy; D011247:Pregnancy; D036301:Qualitative Research; D012424:Rural Population; D066262:Social Norms; D012959:Socioeconomic Factors; D018454:Spouses / Q000523:psychology; D055815:Young Adult; D015024:Zambia