On the Margins of Health Care Provision: Delivering at Home in Harare, Zimbabwe

ISSN 2349-7831
International Journal of Recent Research in Social Sciences and Humanities (IJRRSSH)
Vol. 2, Issue 2, pp: (28-39), Month: April 2015 - June 2015, Available at: www.paperpublications.org
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On The Margins of Health Care Provision:
Delivering at Home in Harare, Zimbabwe
Naume Zorodzai Choguya
Sociology Department, University of Zimbabwe, P.O. Box MP 167, Mt. Pleasant Harare
Abstract: This paper analyses the phenomenon of home deliveries by pregnant women in an urban setting in
Zimbabwe. It argues that, though home deliveries are commonly practiced in the rural areas, they have now found
their way into and are even proliferating in the urban areas. Social cultural values, religious belief and economic
status/resources determine women’s place of birth. Whilst government policies expounded through the Ministry of
Health (MoH) programs and policies denounce home deliveries, the frail health care system characterized by mass
exodus of qualified personnel, in availability of drugs and understaffing of healthcare centres do little to lure
pregnant women to deliver in hospitals. Furthermore, the high levels of poverty among the populace entail that
people cannot afford either public or private hospital services; and thus resort to home-based healthcare and
subsequently home deliveries. The paper explores the factors fuelling home deliveries and the challenges associated
with this practice in Harare, Zimbabwe.
Keywords: Home deliveries, policy, urban, urban poor, Zimbabwe.
1. INTRODUCTION AND BACKGROUND
The purpose of this paper is to highlight the reasons for home deliveries ( socio-cultural and economic dimensions home
deliveries) in Zimbabwe. Home birth remains a strong preference, and often the only option, for many women in low
income countries. The World Health Organization (1997) estimates that, 60% of births in the group of low income
countries occur outside a health facility. Literature shows that women who deliver at home are more likely to experience
perinatal mortality than those delivering in health institutions and there is an increased risk of neonatal infections and
hypothermia in home delivered especially preterm babies. These home deliveries are often conducted by untrained birth
attendants and sometimes in unsanitary conditions. These factors are known risk factors for perinatal mortality (Weeks
1995). Traditionally, deliveries occurred at home under the supervision of birth attendants or elderly women in the
community. However, in view of the global efforts to lower maternal mortality ratios in developing countries, it is argued
that one important aspect in efforts to reduce the health risks of mothers and children is to increase the proportion of
babies delivered under medical supervision.
In the medical literature, ―planned home birth‖ refers to delivery by qualified birth attendants in the home setting. These
births are planned during the prenatal course, when the women have met screening criteria for low perinatal risk. Standard
labor and delivery equipment and medications, access to hospitalization, are included in the delivery plan. Women can
only exercise the right to choose a birth place if they are offered a range of settings and have access to qualified providers
in each setting. Researchers have described the factors affecting women‘s choice of planned home birth and satisfaction
with home birth as the perceived differences in women‘s ability to control the environment and process of care. Women
describe an increased sense of safety at planned home births as facilitated by increased privacy, comfort, and
convenience; greater cultural and spiritual congruency; an improved power balance with medical providers; and the
ability to facilitate family involvement in a relaxed, peaceful atmosphere. They also appreciate the documented decrease

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in the rates of medical interventions care (Birthplace in England Collaborative Group, 2011; Janssen, Henderson, &
Vedam, 2009;).
However, most of the home deliveries in the developing countries do not follow this standard. The home deliveries in
Harare are occurring under the supervision of traditional birth attendants (TBAs). The TBA and her appropriate role in
Safe Motherhood Initiatives have been hotly debated for decades (Bergstr¨om & Goodburn, 2001; Sibley & Sipe, 2006;
Velimirovic & Velimirovic, 1978). Prior to the 1990s, international maternal child health policy focused on training TBAs
in practicing hygienic delivery methods and referring complications. The strategy was aimed at reducing maternal
infections and postpartum hemorrhage, the two leading causes of maternal mortality worldwide (Kruske & Barclay,
2004). In the 1990s, however, when arguably the TBA training strategy did not result in significant drops in maternal
mortality, international policy shifted to supporting initiatives encouraging deliveries with skilled birth attendants, defined
as health professionals who have been trained to proficiency in midwifery skills (Starrs, 1998). The effort to ensure skilled
attendance has taken many forms. In Nepal and Guatemala, existing traditional birth attendants are trained to employ
sterile technique (Freedman, 2007; Goldman, 2003). The Ministry of Health in Mozambique‘s has trained and deployed
non-physician surgical technicians to rural areas to perform obstetric surgeries in the event of complications during
childbirth (Freedman, 2007). In Afghanistan, an extensive competency-based midwifery training program has more than
doubled the midwifery workforce to date since 2002 (Currie, 2007). Malawi has begun to provide training in midwifery
skills to a proportion of its community health workers, known as District Health Officers (Fauveau, 2008). In Zimbabwe,
however, there has been a general disregard for TBAs and their practice and calls for institutional birthing under the
supervision of trained health professionals have been made. The country is defined by policy ambivalence regarding the
use of TBAs, despite having trained more than 15 000 TBAs under the Safe motherhood initiative. Policies and programs
have since then been designed disregarding TBAs and or their practice. In the decade since this policy shift, evidence
shows that achieving safe motherhood is not merely a question of having skilled attendants at birth, but also of the quality
of the services provided and access to emergency care (Van Lerberghe & De Brouwere, 2001; Bergstr¨om, 2001;
Buekens, 2001).The major underlying causes of maternal mortality are related to maternal health care (antenatal care,
supervised deliveries, and post natal care). In this paper home delivery refers to an attended (TBA, family and relatives) or
unattended child birth in a non-clinical setting.
2. METHODOLOGY AND SOURCES OF INFORMATION
To achieve that objective this paper utilizes three major sources of information. That is, a literature review, FGDs and
interviews held with key informants such as TBAs. The literature review concentrated on literature related to the
following five topics with a heavy bias towards the urban context:
 Zimbabwe women‗s experience and perspectives of access to maternal health services or any other assistance
 Linkages between gendered causes of maternal mortality and other women‗s health issues
 Implications of current health system characteristics for access to maternal health services
 Role of Traditional Births Attendants (TBAs) and other key actors at community level
 Evaluations of innovative community based interventions (Zimbabwe and elsewhere) to reduce maternal mortality.
Using the above criteria, over 100 articles and reports were reviewed which included peer reviewed publications,
organizational reports, case studies and other sources of information including media reports.
The Zimbabwean Context
The year 2007 marked the world‘s transition from a primarily rural sphere to a largely urban domain. Despite its status as
the world‘s least urbanized region, SSA currently has the fastest rate of urban growth in the world at between 3 and 4 %
per annum, with urban population in the region projected to increase from 37 % in 2011 to about 57 % by 2050 (UN
2012). Urban poverty as has been linked to substantial deterioration of key urban health and social indicators. The new
face of urban poverty has been linked to adverse SRH outcomes for the urban poor such as high rates of unwanted
pregnancies, higher fertility, sexually transmitted infections (STIs), and poor maternal and child health outcomes. There is

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need to take into cognizance the socio-environmental and economic conditions that heighten vulnerability to poor health
in urban contexts (Tipping et al 2005). Poverty, in particular, must be recognized as a key hindrance to sexual and
reproductive health in urban poor communities. In Sub-Saharan African (SSA) countries many child bearing women are
still being attended by TBAs and relatives at deliveries (Jamison et al., 2006; Crowe et al., 2012). Literature shows that
births without skilled personnel and without access to life-saving drugs are the commonest practice for millions of
mothers in the poorest countries where mortality rates and morbidity of the mothers are highest (Crowe et al., 2012;
WHO, 2012). In Zimbabwe, at least ten women die every day of pregnancy-related complications (ZDHS 2010/2011).
Moreover, 7-10 million women and girls the world over suffer severe or long lasting illnesses caused by pregnancy and
childbirth complications (WHO, 2012). The use of unskilled personnel (including TBAs) is argued to be among the
reasons for the high maternal and infant mortality rates in SSA. However, despite the expansion of interventions,
including construction of more health facilities close to the community, increased use of antenatal clinic, and increased
coverage of immunisation (MoH, 2003) the problem of home deliveries has persisted. ). A situational analysis study in
established that 28.8% of women delivered at home, 1.7% at the TBA‘s home and 0.3 % at Faith healer‘s home
(ZMPMS 2007 ) The proportion of home deliveries without a skilled birth attendant stood at 69 percent in 2009
(UNICEF, MoH 2010 Country Analysis Report). The institutional deliveries rate was 66%, which implies that 34% of
pregnant women deliver at home (World Bank 2013). This paper argues that rather than condemning the practice of home
deliveries there is need to understand the rationale and or factors fuelling the practice in order to develop meaningful
interventions for positive maternal health outcomes.
Zimbabwe is a land locked country in Southern Africa with ten administrative provinces. In 2007, out of the 12, 4 million
people, 47 per cent were urban and 53 per cent were rural (UNDP, 2008). In line with the Millennium Development
Goals, Zimbabwe is aimed at reducing by three-quarters, between 2000 and 2015, the maternal mortality ratio. The
indicators for monitoring progress are maternal mortality ratio and proportion of births attended by skilled health
personnel. Zimbabwe‘s progress report regarding the two indicators is appalling, characterized by a skyrocketing maternal
mortality ratio and a decline in skilled attendants at birth. Zimbabwe is one of the countries with the highest maternal
mortality ratios in the world. Health care in Zimbabwe has been categorized as pluralistic due to the existence of both
traditional and biomedical systems (Dahlin, 2002; Hansson, 1996; Mutambirwa, 1989). The country‘s health system is
dominated by the public sector, providing an estimated 65% of health care services in the country. Some facilities are
operated by municipalities and receive block grants from government. The Zimbabwean government claims that it has
done good work by reducing distance to healthcare facilities through the construction of healthcare facilities around the
country. The average distance to the nearest healthcare facility is between eight to ten kilometers (MHCWZ, 1999). .The
Access to Health Care Services Study of 2007 found that most communities live within a 5 km radius from their nearest
health facilities, whilst 23% live between 5 to 10 km and 17% are over 10 km from their nearest health centre (Makuto
2007). Generally, the Ministry of Health and Child Welfare has focused on Primary Health Care, with a strong emphasis
on community-based approaches, complemented by robust referral systems and facilities. In the 1980s and early 1990s
these health centres were adequately manned with a doctor to patient ratio of on average 1: 6000 in public institutions
Auret (1990). The 1980s showed a general improvement in most of the major health indicators and service utilization,
attributable to the expansion and improvements in the area of primary health care however, signs of deterioration were
evident in the 1990s. By the year 2000, Zimbabwe‘s well-organized public service delivery system fell into steady decline
toward near-collapse in 2008. The trends were a reversal of the gains made in the previous decade for example infant
mortality rate (IMR) rose from 77 and 53 per 1,000 live births in 1992 to 94 and 67 in 2009. The infant mortality rate had
decreased by 50 percent between 1980 and 1990, from 100/1,000 live births to 50/1,000 live births UNICEF (2010). On
the hand, maternal mortality increased dramatically from 283 per 100,000 live births in 1994 to 390 per 100,000 births in
1990 to 578 in 1999 to 830 in 2005/6 and 790 in 2008. This sharp rise in maternal mortality is largely explained by the
rapid spread of the HIV and AIDS epidemic. The Maternal & Perinatal Mortality Study of 2007 shows that the maternal
mortality was pegged at 725 per 100 000 live birth, with HIV&AIDS related deaths accounting for 25.5% of all maternal
deaths. Currently MMR has risen further to 960/100 000. The maternal mortality ratio estimate from the 2010/2011
ZDHS is 960 per 100,000 births, one of the highest in the world (World Bank, 2013). This rise in MMR is against the
backdrop of government commitment and intention to reduce MMR by three quarters by 2015

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Sources: World Bank 2011, 2013, Gonda 2012
FIGURE 1: MATERNAL MORTALITY TREND IN ZIMBABWE
Problem Tree of High Maternal Morbidity and Mortality in Zimbabwe: Source: Country Analysis of Zimbabwe
2010
390
450
670
830
790 787
960
MDG Target
98
0
200
400
600
800
1000
1200
1990 1995 2000 2005 2008 2010 2012 2015
Deathsper100000livebirths

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Factors Affecting Maternal Health in Zimbabwe:
Barriers against using reproductive and maternal health services include costs and distance to health facility, time,
poverty, quality of services, limited decision making power of women, lack of permission by their families to utilise the
health facilities as well as fear of side effects. These barriers are explored in detail below.
Availability of Resources, and Services Utilisation:
Focus on access constraints is one way of explaining barriers in the utilisation of health services. The commonly applied
measure of access to health care is availability of services, measured in terms of physical distance, travel time, availability
of transport, or even the nature of roads. However, the term quality care is multifaceted and value laden. Literature has
shown that what constitutes quality care differs for clients and health service providers. Findings by Galaa & Abu (1994)
show that the lay perception of quality care relates more to the attitude of health professionals in the care process than the
availability of institutional inputs and standards of care delivery. For health services clients, quality refers to their
reception by health professionals, rapport between clients and professionals, integrated care, conveniences, flexibility and
the extent to which clients are able to influence the treatment process. Health professionals however, view quality having
to do more with maintaining technical standards such as diagnostic and treatment regimes; professional skills
requirements; use of equipment including laboratory and x-ray services and supervision. Thus these differing views
interface in the clinical setting defining the health outcomes for many.
Whilst utilisation of health services is evidence that access is achieved, access cannot be equated with the use of services.
This is because, before a person can use or will use health services s/he must be aware of his/her condition, and feel it
warrants medical intervention, the appropriate services must be available (within reasonable time/distance); the services
must be acceptable he/she should have confidence in the technical competence and 'humanness' of the facility and the
providers; and the person should have the ability to obtain the services (money and or insurance). Each of these
prerequisites comprises a potential barrier to utilisation and it is the existence of these potential barriers that differentiates
the study of 'access' from that of 'utilisation'. It can therefore be argued that access to medical care is the function of two
sets of factors: characteristics of the health delivery system and the characteristics of the population at risk - its perceived
needs and morbidity, age distribution, sex, level of education and other background factors. Any of these factors can serve
as barrier to the utlisation of modem health care services. For Zimbabwean urban poor women, a mixture of these barriers
in varying degrees are intricately woven to present formidable barriers for maternal health services utilization.
3. QUALITY OF SERVICE & PATIENT MANAGEMENT
Post independent Zimbabwe has been embroiled in a protracted multifaceted crisis which has had detrimental effects for
social service provision in the country particulary health and education sectors. The country‘s health system has been in
decline since defined by a systematic decrease in coverage of most basic services and a rising maternal and child mortality
rate. Rural –urban disparities in acess to health care continue to grow. The increasing exodus of staff, high hospital fees,
and shortage of essential drugs have forced many more people to seek traditional health care sometimes with the
acceptance and encouragement of medical doctors (Chimhete, 2003; Mukumbura, 2000; Ncube, 2003) and to self-
medicate.
The government policy targets in 2007 were to achieve 80 per cent coverage of essential health personnel and to reduce
vacancy rates to 10 per cent (HSB, 2007). However, in 2009 physician and nurse density was no better than it had been in
2004, with an overall density of 12.3 health staff per 10,000. The WHO recommended levels are at least 25 doctors,
nurses and midwives per 10, 000 (GoZ, 2009). A massive internal and external brain and skills drain has led to a loss of
experienced, qualified health professionals from the public health sector in particular and the country at large. Some
institutions, particularly at district level, were found to be staffed by untrained or junior cadres (MoHCW, 2009; Makuto,
2007). With the proportion of home deliveries without a skilled birth attendant recorded to be 69 % in 2009, the target of
universal access to skilled attendance at delivery by t2015 is unlikely to be achieved. There is need for more effort and
investment towards strengthening the healthcare system and into scaling up coverage of maternity waiting homes as well
as putting in place predictable and enhanced health financing policies and mechanisms.
Attendance at antenatal care (ANC) was relatively high between 1994 and 2005 but antenatal care bookings and numbers
of women delivering at health facilities decreased by 30–50 per cent in 2005. This was attributed to shrinking incomes

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and increases in service fees (MoHCW, 2006, 2007). The share of women making four or more antenatal visits fell
between 1994 and 1999. There was a significant increase in assistance by skilled birth attendants between 1994 and 1999,
and a similarly significant decline between 1999 and 2005. By 2005, assisted deliveries were below the Millennium
Development Goal target of 80 per cent, although this level had nearly been attained in 1999 (Loewenson and Shamu,
2008). Whilst over 90% of pregnant women reportedly attend formal health facilities for antenatal care (Nhindiri et al,
1996), more than 30% of deliveries take place outside the formal system (WHO 2007, ZDHS 2005/6). The Zimbabwe
Demographic and Health Survey (ZDHS) (2006) results also showed a decline from 73% in 1999 to 69% in 2006 in
skilled attendance at delivery and in 2009 the Multiple Indicator Monitoring Survey in Zimbabwe (MIMS) reported a
further decline to 60%.
SOURCE: ZDHS, 2011
FIGURE 2: SKILLED ATTENDANCE AT BIRTH IN ZIMBABWE
Institutional deliveries also declined from 72% in 1999 to 68% in 2006 (ZDHS, 2006) and in 2009 MIMS reported a 7%
decline to 61%.
SOURCE: ZDHS, 2011
FIGURE 3: INSTITUTIONAL DELIVERIES IN ZIMBABWE
The 2007 Maternal And Perinatal Mortality Study found a number of barriers to access and uptake of maternal health
services, including delayed reporting, failure to recognise danger signs, high fees at district hospitals, first use of
traditional healers, service barriers (communication facilities, inadequate transport and communications, social barriers,
lack of drugs and skilled staff shortage) (GoZ MoHCW, 2009). Among mobile and vulnerable pregnant women only 58
73
69
60
66
0
10
20
30
40
50
60
70
80
1999 2006 2009 2011
Percentage(%)
PERIOD
72
68
61
65
54
56
58
60
62
64
66
68
70
72
74
1999 2006 2009 2011
Percentage(%)
PERIOD

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per cent reported being assisted by a skilled health worker (NEDICO, 2008). The most significant social differential for
coverage of maternal health services has consistently been mothers‘ education as well as wealth disparities.
In 2009, disruptions in communications and supplies were reported to have limited outreach activities and contributed to
adverse outcomes, particularly for maternity, acute and emergencies care (GoZ, 2009). The referral chain was reported to
be largely dysfunctional due to a critical shortage of ambulances at district level (GoZ MoHCW, 2010). These supply
constraints reportedly affected particular groups more. Women were more affected by numerous barriers, including
treatment fees, drug availability, transport and distance to facilities (CSO, Macro Int., 2007). A number of studies
identified that the decision to seek care is influenced by perceptions of physical accessibility, access to transport, distance,
insecure roads and inability to afford transport (Bartlett et al 2005). However, even where there is availability, there are
access barriers. Financial barriers were cited by 75 percent of women in the lowest income quintile compared to 35 per
cent in the highest income quintile (CSO; Macro Int., 2007). The low use of clinic services amongst some social groups
has been attributed in national planning to lack of knowledge, religious and cultural barriers, user fees and poor male
involvement (GoZ MoHCW, 2010). Generally, in Zimbabwe, women still have limited control over their sexuality and
reproductive rights. The challenge is to improve education for women and to reduce the gender inequity that prevents
women from making reproductive choices.
The Better Birth Initiative, a WHO strategy, specifically identifies continuous companionship during labor as a key,
evidence-based component of improving quality of care in low and middle-income countries (WHO, 2002). Despite a
large body of evidence supporting the benefits of continuous labor support, public hospital protocol in Zimbabwe and in
much of the developing world continue to isolate women during labor and delivery, a practice that has been described as a
violation of women‘s rights (d‘Oliveira, Diniz, & Schraiber, 2002). The preference for home birthing is influenced by the
fact that the woman in labour can get the much needed support from the spouse and family members present.
Additionally, the health professionals are accused of not giving the women the attention they need and do not have respect
for their clients. The set up of the maternity wards is further dehumanizing as everyone gets to see these women‘s naked
bodies.
4. POVERTY & THE COST FACTOR IN THE UTILIZATION OF SERVICES
The Economic Structural Adjustmnet Program (ESAP) and the post 2000 economic decline brought hardship for the poor
majority, with shortfalls in a range of basic needs and declining employment and income security. Poverty increased
between 1995 and 2003, both in terms of the food poverty line and the total consumption poverty line (Equinet 2011).
Total consumption poverty was higher in urban households than in rural households and in female-headed households
than in male-headed households (MPSLSW, 2006). Between 1990 and 2005, 56 per cent of people were living on under
US$1 a day and poverty tripled in Mashonaland Central (Harare), Bulawayo, Manicaland and Matabeleland South
(GoZ/UNICEF, 2007). Though poverty levels have not been measured in household surveys since 2005, the substantial
post 2000 economic problems, hyperinflation that eroded purchasing power and periodic droughts are reported to have
deepened poverty (Bracking and Sachikonye, 2006). There is evidence that urban poverty has increased for example the
2009 ZimVAC urban food security assessment found 33 per cent of the assessed households to be food insecure compared
to 24 per cent in November 2006, (ZIMVAC 2009). Evidence suggests that urban poverty may have risen since 2009 at a
time formal safety nets have not adequately addressed vulnerability. One assessment of ten select urban areas revealed a
Total Consumption Line poverty rate of 70% (ZimVac 2012).
The National Health Strategy 1997–2007 aimed at all households being less than 10 kms from a health centre. By 1997,
85 per cent of the population lived within 8 kms of a primary care facility (MoHCW, 2009). However, by 2003, 25 per
cent of all households and 30 per cent of the poorest households were further than 10 kms from facilities (MPSLSW,
2006). The population movements in the land redistribution exercise meant that more people moved into the previous
large-scale farming areas, characterized by distant health facilities. Nonetheless there was evidence of improving access
as reported use of facilities for illness rose from 62 to 71 per cent between 1994 and 2004 in both urban and rural areas.
However, in 2004, 23 per cent of those not visiting services when they needed to cited cost as the reason (CSO, 2006).
Use of private sector facilities was higher in urban than in rural areas in 1994 (with 25 percentage points difference) and
1999 (with 18 percentage points difference) but fell significantly by 2004 (to 9 percentage points difference) with cost a
barrier for urban users. The share of households more than 10 kms from a facility had reduced to 17 per cent by 2007,
although 40 per cent were still more than 5 kms away. However population movement, as a result of the agrarian reform

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programme and natural population growth, reduced geographic access in some parts of the country (MoHCW, 2009). In
2007, shortages of medicines, ambulances, water, electricity and sanitation at health institutions led to people using more
distant facilities, increasing household transport, medicine and fee costs (Makuto and James, 2007).
The cost of medical care is an important variable in determining the utilization of services. Until the introduction of user
fees, cost of health facilities was relatively small. The introduction of user charges for health services meant that some
people were automatically excluded by reasons of poverty and or unwillingness to pay. In 1980 free health care was
introduced for those on low incomes (below Z$150, equivalent to US$220). The policy position on user fees has been that
those who can afford to pay for services should do so but implementation of the principle has been mixed. Managing
exemption from fees has been difficult and costly, with some consequent injustices in who is exempted. In 1990,
emphasis was placed on fee collection. However, after evidence of high dropout rates from services, user fees in rural
primary care services were suspended in 1995. The National Health Strategy for Zimbabwe 1997–2007 targeted at free
treatment for the majority but stated that the policy of free health ‗creates a disincentive for people to join medical
insurance schemes‘. Poor people thus faced a variety of de facto cost barriers: the falling real value of the threshold for
free care; transport costs; private purchases of medicines due to drug stockouts; and poorly functioning exemption
schemes (MoHCW, 1999).
Though there are provisions for pregnant mothers, children under five years and adults over 65 years to be exempted from
fees, in 2008, 59 per cent of respondents were found to have been charged for health care services, especially in urban,
large-scale farming and mining areas. Of these, 36 per cent reported being unable to pay the fees (Makuto and James,
2007; Parl. of Zimbabwe, 2007). Private sector medical fees have risen sharply and government has not succeeded in
regulating them. User fee collection varies between and within the public and private institutions, depending on the level
of subsidies the facilities can secure from other sources. City clinics typically collect US$25 for a normal delivery while
central hospitals collect US$80 for a normal delivery and US$450 for a C-section. In the private facilities, the fees can
range from US$400-500 for a normal delivery and US$1050-$1400 for a C-section—costs that are prohibitive given
prevailing household poverty and low coverage by insurance schemes (World Bank 2013). The Maternal and Perinatal
Mortality Study of 2007 documented that among cases referred for childbirth complications, 14% of patients did not
follow through with the referral for financial reasons, despite the fact that professional care for complications during
pregnancy and childbirth is crucial in preventing maternal mortality.Thus a number of surveys such as the Maternal And
Perinatal Mortality Study (2007), the Health Services Study (2008) and the Assessment Of Primary Health Care In
Zimbabwe (2009) all report that communities considered user fees for services unaffordable. This contributed to reduced
access to services, especially for poor and vulnerable communities (MoHCW, 2009). User fees were the most commonly
mentioned reason for lack of access, especially for maternal health services (MoHCW, 2009). User charges are thus a
major deterrent to accessing health care, a major cause of delay in seeking treatment, and cause for many to turn to
traditional medicine and self-medication. Related to the issue of user charges were the issues of unofficial charges,
multiple payment points and inappropriate prescriptions (Martinez, 1992). These inflated the cost of treatment and further
aggravated the plight of the poor. The cost factor in health care is a crosscutting issue as the cost of health care to a patient
and family is not only the user charges, it also includes the access cost (transport, waiting time). The cost of health
services is a great inhibiting factor to health facility utilization.
Out of pocket expenses for MNCH care for Harare City: Source: Harare City Council: April 2013
Services City of Harare Government Central Hospitals Private Clinics/Hospitals
Antenatal care
$25
Seen at local Clinics
Delivery $80 $400-$500
C-Section Referred $450 $1050-$1400
Postnatal care $0.00 Referred to local clinics $20-$30

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5. CULTURAL BELIEFS AND GENDER RELATIONS
Culture and tradition have a significant influence on the decision to seek antenatal care. The challenge, therefore, is to
empower women through information,education communications (IEC) to enable them to make informed decisions
concerning their maternal and general health issues. Many families opt for the traditional birth attendant as their first line
of call for delivery services unless they believe labour is not normal. They just are familiar to and have trust in
homebirthing. Gendered barriers to education also have implications for health-related choices as the level of education is
considered to have an effect on people‗s capacity to make good health choices. Women and adolescent girls‘ choices and
ability to make choices in favor of their own health are jeopardized by the production and reproduction of gender
inequality at household and community level. For instance, health seeking decisions are generally made by men (Olesen
2005). Moreover, lack of male knowledge and understanding (with which to make decisions) is recognised as a significant
obstacle (Olesen et al 2005). Additionally, it is culturally unacceptable for women to receive midwifery/obstetrical care
from a man and this can explain partly why home births vastly outnumber those occurring in health facilities.
A woman's education and wealth are strong determinants of whether or not deliveries happen in institutions. A woman
can only exercise choice of birth site if she has unrestricted access to maternity providers in all settings. The odds of
delivery at a healthcare facility are 17.7 and 2.9 times higher among women who attained higher education and up to
secondary education respectively than among those who had no schooling at all both significant at the 1 percent level. The
odds of delivery at a healthcare facility amongst women who belong to the middle, richer and richest societies are 2, 2.5
and 6.4 times higher than amongst those women from the poorest family settings all at 1 percent level of significance
whilst the odds for women from the poor society utilising the same service are 1.3 times higher at the 5 percent
significance level. The odds for delivery at a healthcare facility are 3.5 times higher among women from urban areas than
among their rural counterparts at 1 percent level of significance. Women in polygamous households are 35 percent less
likely to deliver at a healthcare facility compared to those from non-polygamous households also at 1 percent significance
level. Women who cited distance as a big problem for getting to the nearest healthcare facility are 20 percent less likely to
give birth at health centers, significant at 10 percent level. The fact that a woman attended antenatal sessions has also
proved to be a significant determinant of delivery at health centers. The odds for delivery at a health centre are 2.1 times
higher among women who attended antenatal sessions than amongst women who did not get antenatal care at 1 percent
level of significance (Gregson et al 1999).
6. RELIGION
Religion is considered a significant constraint on demographic transition, and on fertility change, in particular, in a
number of historical and contemporary populations and this constraint can operate at a national level (Cleland and Wilson
1987; Grada and Walsh, 1995). In some instances, minority groups tend to maintain strict and sometimes separate
lifestyles, against backgrounds of widespread social, economic, and demographic change (Eaton and Mayer 1953;
Hostetler 1993). Commonly held beliefs and norms that could be religious or cultural, shape individuals perceptions of
their own health and the health services available. Religious and cultural beliefs have been found to be sources of
exclusion from maternal healthcare utilisation in Zimbabwe and Africa at large (Stephenson et al., 2006; ZDHS 2005/6)
Women from apostolic households and those that believe in traditional healing are less likely to make antenatal visits and
deliver healthcare facilities than women from other religious affiliations. Religious affiliation is thus a strong and
significant source of exclusion from antenatal care and delivery at healthcare facilities. The exclusion of women affiliated
to apostolic sects and traditional practice from antenatal care and delivery services has also been documented elsewhere.
In Zimbabwe, women affiliated to apostolic sects do not take medical services because they believe in faith healing and
they prefer traditional midwives. Traditionalists do not believe in modern day medicine and they prefer cleansing and
traditional herbs. Thus religious and cultural beliefs are a strong determinant of women‘s place of birth.
7. CONCLUSION
A link between poverty and maternal health has been clear for more than a century. Progress towards positive maternal
health outcomes will ultimately be dependent on strong health systems ensuring high coverage of midwifery services
supported by timely and competent hospital care, especially in the poorest countries in sub-Saharan Africa including
Zimbabwe. The persistent emphasis on global differences and strategies for maternal health has often entailed a neglect of

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biological, geographic, economic, and social differences in maternal mortality within populations. There is need to target
interventions towards the most vulnerable groups (mostly rural populations and the urban poor); understand local practice
and preferences. This in turn relies on the organisational and learning capacities of not just communities but also local
health providers and policy makers. Zimbabwe‘s health service infrastructure could support universal access, although
gaps need to be addressed in new resettlement areas. Improved uptake of services depends on overcoming shortages of
drugs, staff and other supplies, as well as barriers to uptake. These include charges for services and medicines, as well as
social factors Women are having babies at home because of religious beliefs, influence of family members, culture, fear
of hospital procedures and accessibility, affordability and user-friendliness of healthcare facilities. Zimbabwe has both
geographical and income level fee exemption policies. The policy of free care at clinic level has not been applied
uniformly. This together with informal charges, fees have raised cost barriers for poor households. The available
information consistently points to the role of social and cultural factors in women‗s choice and ability to choose access to
maternal health services. Gender inequality,
the low value put on women‗s health and men‗s accepted control of decisions over health service utilisation are among the
identified key problems. In addition, there are barriers related to costs and physical access, both of which have a gendered
dimension. All of these in turn influence decision-making and health seeking behaviour at household/community level.
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