Knowledge, Attitude and Practice (KAP) Analysis of Reproductive Maternal, Neonatal,

Child health and Nutrition (RMNCH-N) on the Copperbelt and Lusaka Provinces
Formative Research

Enhancing the Practice of Saving Life

UNICEF JULY, 2015

Lusaka, Zambia

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Table of Contents

Abbreviations ....................................................................................................................... vi

Executive Summary .............................................................................................................viii

METHODS ..................................................................................................................................................... ix

Research Key Findings ................................................................................................................................... ix

Recommendations ......................................................................................................................................... xii

Introduction ......................................................................................................................... 1

Background Literature......................................................................................................... 2

Adolescents......................................................................................................................................................4

Aim and Objectives of the Study .................................................................................................................... 7

Aim .......................................................................................................................................................................7

Specific Objectives ...............................................................................................................................................8

Research Questions .............................................................................................................................................8

Scope of the Research ...................................................................................................................................... 9

Methodology...................................................................................................................... 11

Sampling Procedure ......................................................................................................................................11

Selection of Adolescents ...............................................................................................................................12

Selection of Pregnant Women .....................................................................................................................12

Selection of Mothers to under five children ................................................................................................12

Selection of Male Parents .............................................................................................................................13

Selection of NHCs and Nutrition Groups ...................................................................................................13

Selection of other Community Members .................................................................................................... 13

Selection of Stakeholders ..............................................................................................................................13

Assessment of IEC Materials .......................................................................................................................13

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 Development of Data Collection tools ........................................................................................................13

Ethical Considerations..................................................................................................................................14

Field Test ....................................................................................................................................................... 14

Data Collection .............................................................................................................................................15

Quality Assurance Methods .........................................................................................................................15

Data Analysis ................................................................................................................................................15

Presentation of Key Findings ............................................................................................ 16

Knowledge, attitudes, beliefs and practices on RMNCH and nutritional issues....................................... 16

Knowledge and Practices .............................................................................................................................. 16

Contraceptive and Family Planning ................................................................................................................16

Antenatal Care...................................................................................................................................................18

Nutrition during pregnancy ..............................................................................................................................19

Deliveries ...........................................................................................................................................................21

Breastfeeding......................................................................................................................................................21

Teenage Pregnancies .........................................................................................................................................22

Postnatal complications ....................................................................................................................................23

HIV and pmtct ...................................................................................................................................................26

Factors impacting on the uptake of RMNCH and nutritional services ............................ 27

Factors affecting Family Planning ................................................................................................................ 27

Factors affecting ANC and Postnatal Services ............................................................................................ 30

Factors affecting Low Facility level Deliveries ........................................................................................... 32

Factors Affecting use of Mosquito nets and Good Sanitation and Hygine ................................................ 33

Factors Affecting LOW IMMUNIZATION ................................................................................................ 34

Role of health promotion in improving the uptake and delivery of services in RMNCH-
N? ....................................................................................................................................... 34

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Assessment of institutional capacity of health centers to implement health promotion
interventions ...................................................................................................................... 34

Assessing availability and usability of IEC materials on RMNCH-N ............................. 37

IEC Materials ................................................................................................................................................ 37

Assessing availability and usability of IEC materials on RMNCH-N ......................................................40

Sources of Information .....................................................................................................................................40

Sources of Information for Young People .......................................................................................................41

Language ............................................................................................................................................................42

Conclusions ....................................................................................................................... 43

Stakeholders Matrix mapping ........................................................................................... 45

Selected References ............................................................................................................ 57

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ABBREVIATIONS

ANC: Antenatal Care

CEDAW Convention on the Elimination of All Forms of Discrimination

against Women the Maputo plan of Action among and the

CARMMA Campaign for Accelerated Reduction of Maternal Mortality in

Zambia

EU European Union

FP: Family Planning

FANC Focused Antenatal Care

FGD Focus Group Discussion

HIV Human Immunodeficiency Virus

IEC Information Communication Education

IDI In-depth Interviews

IPTp Intermittent Preventive Treatment for Pregnant Women

ITN Insecticide Treated Nets

KAP Knowledge Attitudes and Beliefs

KII Key Informant Interview

MOH Ministry of Health

MCDMCH Ministry of Community Development Mother and Child Health

MDGi Millennium Development Goals Initiative

MDGs Millennium Development Goals

RMNCH&N Maternal, Neonatal, Child Health and Nutrition

LQAS Lot Quality Assurance Survey

SMAGs Safe Motherhood Action Groups

UNFPA United Nations Family Planning Agency

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UNICEF United Nations Children Emergency Fund

WHO World Health Organization

ZDHS Zambia Demographic Health Survey

ZNBC Zambia National Broadcasting Company

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EXECUTIVE SUMMARY

Zambia has recorded reductions in maternal and child deaths. Between 2001 and 2007, maternal
mortality reduced from 729 to 519 per 100,000 live births. In the same period, under five mortality
reduced from 168 to 119 per 1,000 live births. The MDG target set for MMR by 2015 in Zambia is a
reduction to 159. The factors that are associated with the high MMR in Zambia include challenges
to accessing services, 1st and 2nd delays, cultural beliefs and practices, poor referral system, transport
difficulties, and preference by some mothers to give birth at home. Poor antenatal coverage contributes
to high levels of maternal mortality.

In Zambia, the direct causes of maternal mortality include post-partum haemorrhage (34%), Sepsis
(13%), Obstructed Labour (8%), pregnancy Hypertensive disorders – eclampsia (5%), and Abortion
complications (4%). Indirect causes include Malaria (11%), HIV (10%) and others (17%). Chronic
Malnutrition and Anaemia, TB, respiratory diseases; as well as the non-communicable diseases, such
as cardiovascular disease (e.g. high blood pressure) and Diabetes are also contributing factors.
Successful interventions to reduce maternal mortality will need to focus on addressing both the direct
causes of maternal mortality, as well as the indirect causes.

Thirty four percent of all deaths among under-five children in Zambia occur in the post-neonatal
period and more than a half (53%) of neonates die within the first week of their life. Malaria is a major
cause of facility based under-five children deaths, followed by malnutrition, and pneumonia. Other
causes include neonatal disorders, diarrhea and anemia. AIDS related causes account for about eight
percent of deaths among children.

The situation has been further exacerbated by teenage pregnancy. Adolescent HIV prevalence ranges
from 3.6 per cent among boys to 5.7 per cent among girls in the country. High prevalence rates (15%-
22%) are reported among pregnant adolescents (15-19 years). Adolescents’ access and use of family
planning is the limited. Evidence shows that setting legal limits on age of marriage is likely to prevent
pregnancies in young adolescents, especially those from poor backgrounds.

This formative research was conducted to explore reasons for the low uptake of Reproductive
adolescent, Maternal, Neonatal, Child health and Nutrition (RMNCH-N) services. Specifically, the
aim of the research was to assess the Knowledge, Attitude and Practice (KAP) on RMNCH-N of users
and non-users of these services in six districts of the Copperbelt and Lusaka Provinces of Zambia
(Lusaka, Kafue, Ndola, Masaiti, Mufulira and Luangwa). Key indicators on RMNCH-N have already

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been documented by other studies1, however, due to methodological limitations to cover qualitative
reasoning for the identified indicators, this study undertook a dominantly qualitative approach.

METHODS

Qualitative methods were the dominant approach in this research and involved various methods that
included 51 FGDs with community members and groups, 25 Key Informant Interviews (KII), Desk
Review, and documentation of existing IEC materials in all the 16 selected health centers.

RESEARCH KEY FINDINGS

Findings clearly show that many community members are aware and appreciate the need for
RMNCH-N Services. They are aware of family planning methods, importance of delivery at the health
facility, effective breastfeeding, need to be aware of the danger signs of pregnancy and danger signs in
under-five children, healthy nutrition, and good practices that enhance the health of the mother and
the baby. However, cultural and traditional norms still persists in the communities throughout the
period prior to pregnancy, during pregnancy, nutrition, after delivery and during breastfeeding that
affect uptake of these services. Some of these practices put the health of the mother and child at risky.

The LQAS showed that generally women do not present themselves for ANC early. This in part is
due to long distances that pregnant women have to cover to get to the facility. Other than distance,
this research has established that women do not present themselves early mostly because they do not
want to share their status in the early periods with strangers, including health providers. This is
influenced by the belief that revealing a pregnancy in its early stages would lead the pregnancy to
disappear (being stolen).

Male involvement is limited in ANC and postnatal care which affects uptake. Men see their role as
one of providing material things, such as baby clothes. They are discouraged to escort their wives
because of long waiting times, negative perceptions of men who accompany their wives for ANC
(under female power). They also said that men should not go to the labour ward because the practice
is discouraged even by health service providers. In addition, some women and men perceive ANC as
a time when they are tested for HIV and other STIs. As such, some are afraid to present themselves
for fear of being tested.

Knowledge on some danger signs of pregnancy was scanty. Heavy bleeding, bleeding, swelling of
hands and feet and severe pain in the abdomen was the commonly mentioned danger sign. However,

1
These studies include: The Health Facility and Health Worker Baseline Assessment for Reproductive,
Maternal, Neonatal Child Health and Nutrition Services; LQAS Baseline Household Survey for
RMNCH and services; and Community Based Volunteers Skills Audit. In addition, desk review of
policy frameworks and programme mapping have also been undertaken as part of the baseline
assessment e.g. Assessment of the Regulatory Framework for Maternal, Newborn Child Health and
Nutrition (RMNCH&N) Services in Zambia.

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knowledge of the other danger signs were mentioned by less than half of the mothers interviewed. This
indicates that there is a need to continue educating mothers on the other danger signs.

Multiple reasons were identified for delayed breastfeeding. A significant number of mothers reported
squeezing out and discarding colostrum as it was thought to be dirty. When a mother had a still birth
previously, they have to wait until some rituals (using herbs) are performed leading to delays in feeding
the baby. Breastfeeding in public is discouraged because the baby may suffer from what is known as
‘icibele’ (diarrhea specific to infants). Mothers who are HIV positive are less likely to breastfeed their
babies exclusively for fear of transmitting the virus to their babies. This is against the policy which
encourages exclusive breastfeeding for HIV positive mothers for six months. Mixed feeding poses an
increased risk for HIV infection for babies.

Knowledge of contraceptives particularly short term and reversible contraceptive was high but limited
for the long term and irreversible contraceptives. Although the knowledge of contraceptives was
relatively high among the community members, the utilization was significantly very low.

The research results have shown that community misconception on family planning methods affect
uptake of these services. It was common among the respondents that family planning methods are
associated with negative outcomes such as, intermittent menstrual experiences, negative effects on
babies such as having a big head, watery vagina if one keeps using condoms, and myths that condoms
cause HIV. Family planning utilization is further hindered by the belief that use of family planning
pills and injectables lead to infertility, growth of beard, being thin, excessive periods for women,
excessive weight gain. Some major reasons for not accessing family planning services were opposition
from husbands

The use of traditional family planning was quite prominent among community members in the
selected research districts. Traditional beliefs of family planning include: wearing beads around a
woman’s waist, swallowing beads, drinking of munkoyo roots, seeds for dagga, inter alias. It is
important to engage with these beliefs and educate community members on myths and
misconceptions.

Young people were more aware of condoms than they were aware of other contraceptives. Access and
uptake of the contraceptives by the young people was very limited and is hindered by the lack of youth-
friendly centers and services coupled by the negative attitudes of service providers and adult.

When adults were asked what they thought about adolescents and family planning, they said that they
would not approve and would in fact report an adolescent or youth trying to access family planning
to his or her parents. Some felt that they would scold the ‘child’ because he or she is obviously not
following the norms.

On nutrition, the research findings revealed the need for women to focus on alternative meals that are
healthy both for the mother and the baby. Cultural beliefs still persist around nutrition. There are a
number of myths associated with certain foods. For example, eating eggs is associated with the baby
losing his or her hair. Beans is also discouraged because women may bleed a lot during delivery.

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Home deliveries were prominent among community members and the reasons cited included long
distances to the facilities, lack of adequate material utilities such as baby closes. In some cases,
pregnancies out of wedlock limit the woman’s presentation to the health facility because the father of
the child may be revealed at the time. Most of the women felt that there are no proper facilities at
clinics were they can deliver with dignity as the facilities are usually too small and the waiting time is
usually too long.

Unsafe practices seem to still take place in home deliveries such as the use of unsafe razor blades for
cutting the baby’s umbilical cord, as well as unavailability of gloves. Lack of birth preparedness is a
gap that is noticed in the discussions.

On postnatal and child care community members paid more attention to prenatal care than to post-
natal care. Mothers insisted on the importance but only went back to the clinic when the child was
not fine or was experiencing difficulties such as fever, or persistent coughing. Women are aware of
danger signs in the newborn. They, however, resort to traditional therapies for treatment. This delays
the taking of the child to the health center or clinic resulting in endangering the baby. It is imperative
that health promotion activities emphasize the importance of taking the baby to the health care center
for treatment when danger signs are noticed.

There are a number of IEC materials that are displayed in community clinics. These materials cover
a wide range of topics; HIV/AIDS, Malaria, Child health, Pregnancy, TB. Printing and display of
IEC materials is a common practice. There is very little evidence of a robust implementation campaign
in the communities within the selected districts. There appears no systematic and coherent thematic
campaigns in the clinics based on the mix of materials. This is only true of IEC materials. ANC,
SMAGs and community discussions are a preferred mode of sharing information.

Adolescents are a missing link in maternal, neonatal and child health. From family planning through
to pregnancy and delivery, young people face many obstacles and community sanctions. Young
people have challenges accessing family planning services. And when they get pregnant they
experience many obstacles in handling their pregnancies and subsequent childbirth. In most cases, the
children are raised by the parents or grandparents of the adolescents.

Communication and outreach are at the center of maternal, neonatal and child health interventions.
This report captured the type of IEC activities and materials in the selected health centers. Most health
centers that were visited had scanty IEC materials displayed. Some are placed in offices while others
are on the walls of clinics or health centers. In most health centers, the messaging is mixed as
evidenced in the content analysis of the presentation of the materials. Individuals responsible for IEC
materials are also ad hoc.

It is also concluded from research findings that many health centers have limited capacity to
implement health promotion intervention and this calls for effective collaboration with other key
stakeholders. Further the study has revealed that the community health workers and community
mobilisers have limited capacity too and need is eminent to strengthen their role in complimenting
facility interventions.

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RECOMMENDATIONS
1. The programme should consider constructing community shelters for pregnant women in the
project sites. This will contribute to increased number of pregnant women accessing ANC and
postnatal services.
2. Given the limited number of health providers, there is need to complement the available few
staff by strengthening the work of the SMAG members. The SMAGS can provide the extended
work-force in mobilizing community members for MCH services and comprehensively
educate the community on MCH, HIV and SRH.
3. There is a need to establish youth friendly SRH services for adolescents and young people in
order to increase knowledge and usage of SRH services. It is also recommended that the One
Stop service project develops an effective community to health facility referral system to
increase opportunities for adolescents to access services.
4. Community views on maternal, neonatal, child health and nutrition indicate that members of
most communities understand the need for family planning, antenatal care, are aware of some
danger signs of pregnancy, understand the need for good nutrition, the need to deliver at the
health facility with the assistance of a qualified health professional, the need to breastfeed the
baby within the first hour of delivery. There is however strong adherence to the cultural system
of the continuum from family planning through to childcare. It is important that any attempts
at improving the lives of the mother and baby continue to deconstruct cultural myths which
form a very strong layer of meaning within communities. This should be done through
community-level meetings, Posters, Radio and Television. The influence of religion is strong
in a number of communities. It is therefore important that church leaders are trained and used
as opinion drivers. In one health facility, they do not provide family planning because it is run
by a Christian organization. This is true of a number of health facilities in some rural areas
which are run by specific denominations.
5. Young people in most of the communities are sexually active. It is important to engage
communities in order to raise awareness about, and discuss sexuality of young people in the
public domain. While services are available to young people, community norms are strongly
against young people accessing these services. As a result, the services are accessed from shops
in the communities, especially in communities where there are no youth friendly services.
6. HIV and AIDS continues to be a problem in Zambia with a double digit prevalence of 13
percent. It is evidenced from the community level discussions that some individuals prefer
unprotected sex. This is evident in their sentiments preferring pills and injections over
condoms. Campaigns and programs aimed at raising awareness must use an integrated
approach where HIV/AIDS awareness remain a critical component of the messaging. For
example, ANC talks must incorporate education on HIV and dispel misconceptions.
7. MCDMCH has developed a Communications and Advocacy strategy on Maternal, Neonatal,
and Child Health. This strategy provides a platform on which findings in this report can be
used in developing key messages aimed at creating demand for the uptake of services as well
as change negative perceptions associated with RMNCH-N. It is equally important that the
strategy reinforces positive findings in order to strengthen resilient factors within the

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 communities. Moving forward a Communications and Advocacy strategy implementation
plan must be developed at district level using a multi-media approach.
8. The implementation of the strategy must be allocated to specific individuals who would be
responsible for monitoring health promotion activities. As things stand in the communities in
which the assessment took place, there is no specifically trained individuals who are
responsible for health promotion activities.
9. Community members proposed the need to enhance community level outreach activities
especially for men. They also suggested the implementation of recreational activities in the
communities especially for young people.
10. Strengthen coordination of key stakeholders in provision of RMNCH and Nutritional
information and services at community, district and national level. This also calls for a need
to strengthen an effective M&E system to track various RMNCH and nutritional intervention
and their effectiveness in yielding the anticipated results of the programme. The M&E system
should be participatory and engage community members at all levels of programme,
conceptualization, planning, learning and feedback
11. The programme should consider developing or working with other stakeholders to develop
appropriate IEC materials with uniform messaging on IEC materials for community members
to ensure they re-enforces BCC and intended information . These should be thoroughly piloted
for their relevancy appropriateness and suitability, to targeted audiences. The programme
should factor in measures of effective distribution both at facility and community level. There
should be a designated staff such as the Medical Information officer responsible for IEC
materials. Translation of the IEC matreials in local languages would be critical. The Project
should therefore focus on developing relevant education materials and develop various
participatory methods aimed at increasing understanding of RMNCH services for both adults
and young people.
12. Findings from the study support the idea of creating youth friendly centres at health facilities
or within the communities where young people can access the youth friendly services.
However, these will need the creation of community led management structures to ensure the
sustainability of these structures. The project should creatively engage the community to
ensure that the infrastructure is well looked after and that the services are provided.
13. Consideration of provision of on-site massive mobile RMNCH and nutritional services and
packages would address the needs of community members who are faced with the challenge
of long distances to health facilities
14. Long term consideration should focus or constructing more health centers providing RMNCH
and nutritional services which are as close to the client as possible. This should be coupled
with adequate capacity building and training of more health care providers in providing
RMNCH and nutritional services including non-judgmental SRH information to youths and
young people. Already existing health facilities require to be maintained with enough medical
equipment and expertise in order to ensure the safe delivery and increase the access to
RMNCH and nutritional services.
15. The programme need to consider engaging traditional and other community leaders to address
some of the cultural and traditional practices that hinder access of RMNCH and nutritional
services

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 16. Male involvement is critical in effective delivery of RMNCH and nutritional services in
Zambia and thus workable strategies of engaging men as critical partners should be explored.

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INTRODUCTION
The Government of Zambia, working with its partners, conducted a formative study and Knowledge,
Attitudes and Practice (KAP) analysis of Reproductive Adolescent, Maternal, Neonatal and Child
health and Nutritional (RMNCH-N) services in six (6) districts where the Ministry of Community
Development, Mother and Child Health (MCDMCH) is implementing the European Union (EU)
supported MDGi project. The project is aimed at accelerating progress towards maternal, newborn
and child morbidity and mortality reduction in Zambia for a period of 4 years (2013-2017). The aim
of the MDG Initiative is to contribute to the improvement of maternal, neonatal and child health and
nutrition in Zambia through increased utilization of quality health and nutrition services by vulnerable
women, adolescents and children in selected 11 rural and urban districts of Copperbelt and Lusaka
provinces.

The Initiative has five expected results addressing: 1) nutrition, 2) maternal, neonatal and child health
(RMNCH), 3) demand for RMNCH and nutrition services, 4) adolescent friendly health services and
5) strengthened institutional capacity. The “Expected Results 3 “which is a stand-alone
Communication for Development (C4D) area, focuses on “Increased knowledge and demand for
RMNCH care and services focusing on cultural, geographical, and financial barriers.”

This was a qualitative study which explored practices and attendant socio-cultural reasons that impact
on uptake of RMNCH-N services and adoption of safe and healthy behaviors in six of the 11 MDGi
districts. The six districts were selected based on low performance in the key indicators as documented
in the LQAS analysis. The process of selecting the districts was a consultative process with MCDMCH
and UNICEF Zambia. This study was motivated to complement other studies conducted under the
leadership of the Ministry of Community Development, Mother and Child Health (MCDMCH) in
partnership with UNICEF Zambia. These referenced studies include: The Health Facility and Health
Worker Baseline Assessment for Reproductive, Maternal, Neonatal Child Health and Nutrition
Services; LQAS Baseline Household Survey for RMNCH and services; and Community Based
Volunteers Skills Audit. In addition, desk review of policy frameworks and programme mapping have
also been undertaken as part of the baseline assessment e.g. Assessment of the Regulatory Framework
for Maternal, Newborn Child Health and Nutrition (RMNCH&N) Services in Zambia. However, the
enumerated studies have methodological limitations to capture in-depth Knowledge, Attitude and
Practice (KAP) data of the care givers, adolescent community (both service usurers and non-users)
hence this qualitative, in-depth assessment of the KAP. Furthermore, the current MDGi policy
analysis on RMNCH did not capture the health promotion policy frameworks to ascertain the
enabling environment or needs for advocacy gaps in C4D areas.

This report documents perceptions of mothers/caregivers, adolescents health workers and some
opinion leaders/gatekeepers on key behaviours, knowledge, social norms and other variables critical
to achieving the RMNCH and Nutritional behavioral outcomes. It covers the continuum of care, that
is, family planning through pregnancy, childbirth and the care of newborns. Nutrition is equally
central to the care of mother and child. While the subject of maternal and child health are high on the
public health agenda, adolescents and youths remain the missing link.

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BACKGROUND LITERATURE

Sub-Saharan Africa has the highest infant mortality rate and, at the same time, accounts for half of
the developing world’s maternal deaths (1 in every 100 births). It has also the lowest rate of
contraceptive use in the world (19%). Over four million unsafe abortions occur in Africa every year,
causing 30% of all maternal deaths in the continent translating into 90 lives of women lost every day.

Africa has a high burden of maternal mortality; one in every sixteen women face the risk of dying
due to pregnancy-related complications. With less than a year from the deadline for achieving the
Millennium Development Goals in 2015, the African continent, and Zambia, in particular, still face
great challenges in achieving MDGs 1a, 4 and 5 on women and children’s health. Overall progress
in improving health remains insufficient, especially in Sub-Saharan Africa where Maternal, Newborn
and Child Mortality rates remain the highest in the world. It is clear that the MDGs cannot be
achieved without accelerated and concerted efforts being channeled towards the reduction in
maternal, infant and child mortality, whose key indicators are linked to the MDGs.

The World Health Organisation (WHO) recommends that a pregnant woman without complications
should have at least 4 ANC visits.2 This is the updated approach called Focused Antenatal Care
(FANC) which emphasizes quality instead of quantity of visits. The emphasis on pregnant women
attending four ANC visits is that early detection of problems in pregnancy leads to more timely
treatment and referrals in case of complications. Women who do not receive antenatal care during
pregnancy are at higher risk of obstetric emergencies and adverse outcomes. According to the WHO3
(2013), the major causes of maternal deaths which could be prevented or treated if detected early are;
haemorrhage (25%), Sepsis (15%), abortions (13%), Eclampsia (13%), obstructed labour (7%), other
indirect causes (19%), other direct (8%). Thaddeus and Maine (1994) introduced the ‘three-delays
model’:

• Delay 1: Are women aware of the need for care and the danger signs of pregnancy?

• Delay 2: Are services in-accessible because they are not available, because of distance and/or
cost of services or do socio-cultural barriers prevent women from accessing services?

• Delay 3: Is the care received at the facility timely and effective?

Therefore, the reasons for low facility delivery, low antenatal attendance and, consequently,
pregnancy-related complications and maternal and neonatal deaths, include:

• Pregnancy and childbirth not considered special conditions requiring special care

2
http://www.who.int/gho/maternal_health/reproductive_health/antenatal_care_text/en/

3
http://www.who.int/evidence/sure/ZambiaReducingpostpartumhaemmorhage.pdf

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 • Prohibitive cultural or traditional practices and attendant social norms (Banda et al. 2007)

• Limited knowledge on importance of early ANC (Banda et al. 2012)

• Inadequate birth preparedness and complication readiness

• Transport challenges (Banda et al. 2007)

• Weak referral systems (reference)

• Inadequate community advocacy and community engagement for better maternal and child
health services

• lack of follow-up mechanisms to trace pregnant women who stop attending antenatal clinic

• Inadequate Mothers’ shelters/waiting rooms?

• Poor community support mechanism (Food banks and child care)

• Poor quality of health care (inadequate supplies, equipment and skills)

• Inadequate skilled HRH and negative attitude of health workers

• Low motivation of health workers

• Inadequate supportive supervision

In Zambia, the Maternal and Infant Mortality rates are a basic indicator of the social-economic status
of a country (ZDHS, 2013-2014). The recent results released by ZDHS indicate that, in Zambia, 398
maternal deaths occur per 100,000 live births. “For every 1,000 live births in Zambia, four women
(3.98) died during pregnancy, during childbirth, or within two months of childbirth.

Infant, neonatal and under- five mortality rates are at 45, 24, and 75 per 1,000 live births, respectively
(ZDHS, 2013-14). Despite the apparent decline from the preceding Demographic Health Surveys,
these mortality rates are still unacceptably high. The major causes of child mortality are malaria,
respiratory infections, diarrhea, malnutrition, and anaemia. What about pneumonia and measles?
Please check. HIV and AIDS continues to contribute to morbidity and mortality in pregnant women
and children.

Vaccinations are critical for the survival of children. In Zambia, about 68 percent of children age 12-
23 months were fully vaccinated (ZDHS, 2013-14). Specifically, 95 percent of children received the
BCG vaccination, 96 percent the first DPTHepB-Hib dose, 96 percent Polio 1, and eighty-five percent
of children received the measles vaccine. There is decrease for subsequent doses, with 86 percent of
children receiving the recommended three doses of DPT-HepB-Hib and 78 percent receiving all three
doses of polio vaccine. Only two percent of children received no vaccinations at all (ZDHS, 2013-14).

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Exclusive breastfeeding is recommended for children for the first six months of life. This was met for
73 percent of children. Evidence shows that complementary foods are often introduced early in
Zambia with 17 percent of children below 6 months consuming solid or semi-solid foods in addition
to breast milk (ZDHS, 2013-14). Findings from the LQAS indicate that most of the districts are still
underperforming in this regard. For example, exclusive breastfeeding is about 73% for Luanshya, 61%
for Masaiti, and Mufulira is at 70%. However, Chingola and Kitwe appear to be performing better at
86%. In a study in Mpongwe and Ndola districts, it was found that nulliparous women were 59
percent less likely to initiate ANC compared to multiparous women. It was also noted that those with
inadequate knowledge had a 2.2 odds of non-attendance to ANC. For unintended pregnancy, there
was an associated higher odds of starting late in both rural and urban settings, i.e. 4 times and 3 times
respectively (Banda, 2007). Perception of no benefits of early attendance is associated with a 4 times
likelihood of late attendance in urban districts. Women in rural settings are more likely to present
themselves late due to community norms (less value attached to ANC) whilst in urban areas there is
almost a 3 times higher likelihood due to cultural beliefs than misconceptions.

Antenatal care from a trained provider is important in order to monitor the pregnancy and reduce
morbidity and mortality risks for the mother and child during pregnancy and delivery. Ninety-six
percent consulted a skilled health provider (doctor, clinical officer, nurse, or midwife) at least once
for antenatal care for the most recent birth in the five-year period before the 2013-14 ZDHS survey.
Communities in rural areas have limited access to health care. It is currently estimated that in urban
areas approximately 99 percent of households are within 5 kilometers of a health facility, compared
to 50 percent in rural areas (UNICEF 2013). Sixty-four (64%) percent of births in Zambia were
delivered by a skilled health provider. The proportion of deliveries that took place in health facilities
was 67 percent.

Socio-cultural factors and structural arrangements (e.g. structural violence) compound families’
health care seeking behaviors such that many children are taken late to health facilities and pregnancy
is not given special care. For instance a woman who has just delivered observes certain cultural
sanctions. Knowledge and practices on infant and young child feeding practices are low. There
cultural practices such as a woman not revealing her pregnancy in its early states i.e. twelve weeks
because of the belief that it may disappear (Key Informants Interview).

ADOLESCENTS
Globally, there are more than one billion 10-19 year olds, 70% of whom live in developing nations.
The context for decision making regarding sexual and reproductive health is also rapidly evolving.
Adolescents report early sexual debut putting them at risk of early pregnancies and HIV. Adolescent
sexual activity , within or outside marriage can lead to negative reproductive health outcomes
including unplanned pregnancies, unwanted childbearing and abortions, as well as HIV and other
STIs. This is in addition to sexual cohesion experienced by adolescents (UNFPA, 2014).

The fact that some youths obtain some education, the logical assumption is that school based
interventions or programs are a logical choice for sexual and reproductive health intervention in
developing countries (Hindin and Fatusi, 2009). Youths and adolescents who get married are

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expected to bear children almost immediately compromising contraceptive use (Ibid.). “Unmet needs
for contraception, or non-use of methods despite the desire to limit births or delay them for a t least
two years, is high among unmarried adolescents in Sub-Saharan Africa” (Hindin, 2009). Most
adolescent pregnancies in Zambia are non-marital. This is because adolescents have unprotected sex
for various reasons, which include, seeking to prove fertility, have not considered contraception,
misinformed or limited knowledge on risk of pregnancy or STIs. Other reasons include transactional
and intergenerational sex. Adolescents in Zambia also believe that sex without a condom is more
enjoyable (U-Report, 2014). Evidence in some selected provinces in Zambia show that modern
contraception use among mothers of children 12-23 months is low (2.5% in Copperbelt; 0% in
Lusaka). This is also true for first ANC in the first trimester among adolescents (LQAS, 2014).

Innovative approaches such as the use of mobile text messaging, aside school-based programs are
being implemented to mitigate the impact of early sexual debut, unprotected sex, transactional sex,
unwanted pregnancies, early marriages, among others. For instance, the U-Report is an innovative
platform for young people to interact with specialized support on issues related to sexuality, and HIV
and AIDS (http://www.zambiaureport.org/home/).

Child marriage is widely acknowledged to a harmful socio-cultural practice. It permits sexual

exploitation and places a girl’s health at risk. In addition, children of adolescent mothers start life at
a disadvantage hence perpetuating a cycle of poverty and relative deprivation (Masikwa, et al. 2015).
It is recommended that consistent laws against child marriage may be associated with lower child
marriage rates among women who are most vulnerable to child marriage especially poor, uneducated
women usually living in rural areas (Ibid.)

Zambia has achieved a lot of successes in prioritizing Maternal and Child health and addressing HIV.
This can be seen by the number of national policy instruments and frameworks that the country has
developed. These include; Sixth National Development Plan, vision 2020,RMNCH strategic plan,
the sexual and reproductive and rights policy, the national health strategic plan, maternal, new-born
and child health communication strategy, termination of pregnant act and the. Besides, at
international and regional level Zambia is signatory to the Convention on the Elimination of All
Forms of Discrimination against Women (CEDAW), the Maputo plan of Action among and the
Campaign for Accelerated Reduction of Maternal Mortality in Zambia (CARMMA). The
Government has gone a step further in strengthening communities by setting up the SMAGS to
support pregnant women and educate them on pregnancy and delivery, newborn care related
knowledge and behaviours including the need to deliver at health facilities. In order to promote
access and utilization primary health care services including maternal and child health, Government
has abolished user fees in 2011.

Late antenatal care attendance remains high in both rural and urban districts indicating the need for
intensified and more focused utilization of resources aimed at increasing sensitization of the
importance of early attendance for high risk groups, such as women with unplanned pregnancies,
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inadequate knowledge about ANC, cultural beliefs and women who are multiparous (Isaac Banda,
Zambia Medical Journal, 2007).

Evidence shows progress as well as gaps in access and uptake of RMCHN-N services in Lusaka and
the Copperbelt provinces. Some of the gaps include; low client satisfaction of services in both
provinces, limited evidence on adolescent reproductive and maternal health, low indicators on CHW,
limited knowledge on ANC checks, women progressively (from first trimester to the fourth) stop
attending ANC, women are unable to recognize the danger signs of pregnancy and of the sick child
(LQAS, 2014). In some communities, women use African syntocinon to accelerate and augment
contractions in some cases leading to ruptures in the uterus and tragic loss of life mother and baby
(KII). This results in delayed presentation before a health facility and or delivery at home. This study
highlights the qualitative reasons for low uptake of services as well as understanding of issues related
to Maternal, Neonatal, Mother and Child Health including nutrition. Adolescent sexuality and
reproductive behavior is also documented.

Awareness of danger signs of a pregnancy delivery and during postpartum period can result in
mitigations against threats to the life of the mother and baby. The danger signs in pregnancy include
vaginal spotting or bleeding at any time, leaking of fluid from the vagina, unusual abdominal pain,
cramping, pelvic pressure, or persistent backache, persistent nausea and vomiting, especially in the
second and third trimester. The other danger signs in pregnancy are persistent headache or blurred
vision, marked swelling of the ankles and especially of hands and face, painful or burning urination,
foul-smelling vaginal discharge, chills or fever, feeling very tired, and decreased fetal movements in
the third trimester (Novak & Broom, 1999, MoH, 2005).

In Jordan, it was found that, overall, 84.8% of the women interviewed were not aware of danger signs
and symptoms of pregnancy complications. Education, current employment, husband's duration of
education, family size; and whether women were given information about danger signs and
symptoms—were associated with awareness in a binary analysis. When they checked the variables
against possible confounders, education level of study participants, their husbands' education level,
and receiving information about danger signs and symptoms were all associated with awareness
(P=0.02 for all associations). This was in a study to assess the level and determinants of awareness of
the danger signs and symptoms of pregnancy complication among pregnant Jordanian women aged
15 years and older (Okour, Abdelhakeem et al, 2011). It is noted that high levels of education are
positively associated with danger signs of pregnancy-it is not just pregnancy-it is also delivery and after
delivery. High levels of education are also associated with birth preparedness, for example, in Ethiopia
(Moran AC, et. Al. 2006, Mutiso SM, Qureshi Z, Kinuthia J. 2008).

It is recommended that mothers protect themselves and their babies against mosquitoes to prevent
malaria. However, the LQAS indicates that only 8% of households with children 0-59 months had

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their homes sprayed. There is also low ownership and utilization of ITNs (33% and 23% respectively).
The proportion of children of children 0- 59 months who slept under an ITN a day preceding the
survey is also very low. While there has been investment in distribution of mosquito nets in Sub-
Saharan African, Zambia included, use of mosquito nets by pregnant women has been low (Baume
CA, Marin MC, 2007).

Health communication campaigns globally are used in developing countries to provide information
about health services and encourage healthy behaviours. They are also used to change cultural and
social norms and attitudes, and assist people achieve better health outcomes through the use of
essential health services. Campaigns have been used to combat the HIV/AIDS (Bertrand et al
2006; Cohen, Wu and Farley 2004; Singhal and Rogers 2003; UNAIDS 1999), promote family
planning and encourage smaller family sizes (Bertrand and Kincaid 1996; Montgomery and Casterline
1996; Piotrow et al 1997; Rogers 1995). Printing and display of IEC materials is a common practice.

In Zambia, the ministry of Community Development Mother and Child Health and the Ministry of
Health have also adopted the use of IEC as a communication strategy to encourage the uptake of
maternal, neonatal and child health services. To this effect, a Communication and Advocacy Strategy
for Reproductive Health, Maternal Newborn, Child Health and Nutrition has been developed. The
purpose of this strategy is to guide communication activities that are implemented at national,
provincial, district and community levels. The strategy is aimed at equipping service providers with
tools and approaches to provide locally designed, appropriate and relevant information on
communication (p.iv). The strategy encourages the use of mass media viz. radio and television, films
on DVDs/monitors/screens, newspapers and information packets, posters, calendars, comic books,
booklets/leaflets, books, signs, banners, billboards (15-16). This report documents findings from a
qualitative investigation of IEC materials related to maternal, neonatal, and child health and nutrition.

With reference to the foregoing, this report documents community views of reproductive health,
maternal newborn, and child health and nutrition. It also documents adolescent sexual and
reproductive health services. Practices on the continuum of reproduction from pregnancy through
to childbirth, child health and surrounding practices are explored for the deeper cultural reasons.

AIM AND OBJECTIVES OF THE STUDY

AIM

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To assess the Knowledge, Attitude and Practice (KAP) on Reproductive adolescent, Maternal,
Neonatal, Child health and Nutrition (RMNCH-N) of users and non-users of these services in Six
districts of the Copperbelt and Lusaka Provinces of Zambia

SPECIFIC OBJECTIVES

1. Assess levels of knowledge, attitudes, beliefs and practices on RMNCH and nutritional issues
2. Explore community-level factors impacting on the uptake of RMNCH and nutritional services
3. Assess individual, household and community-level barriers to accessing RMNCH-services in
targeted communities
4. Determine the role health promotion can play to improve the uptake and delivery of services
in RMNCH-N
5. Determine institutional capacity of the selected health centers to implement health promotion
interventions
6. Categorise available Information, Education and Communication materials on RMNCH-N
and their source in the selected districts
7. Undertake channel analysis for effective messaging in the MDGi districts
8. Undertake a mapping of key informants and influencers of RMNCH-N issuers for caregivers
(users and non-users of services) adolescent (10-19 years) and communities in the MDGi
districts.

RESEARCH QUESTIONS

Some of the survey questions are:

1. What is the level of knowledge, attitudes, beliefs and practices on RMNCH and nutritional
issues? (What are the narratives accompanying the KAP that explain the reasoning?)
2. What and why are the community-level factors impacting on the uptake of RMNCH and
nutritional services? (Explore community level discourse on RMNCH and Nutrition)
3. Why are household barriers still existing in accessing RMNCH and Nutrition services in
targeted communities? (Qualitative narratives also explored deeper meanings to the
challenges)

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 4. How can health promotion be used to improve the uptake and delivery of services in RMNCH-
N?
5. What are the available Information, Education and Communication materials and their
sources on RMNCH-N in the selected districts?
6. Who are the key informants and influencers of RMNCH-N issues for caregivers (users and
non-users of services) adolescents (10-19 years) and communities in the MDGi districts?

SCOPE OF THE RESEARCH

This research focused on the following expected results:

1. Nutrition

2. Maternal, neonatal, and child health (RMCNH)

3. Demand for RMNCH and nutritional services focusing on Communications for

Development (Increased knowledge and demand for RMNCH care and services addressing
socio-cultural, geographical, structural and financial barriers.

4. Adolescent friendly health services, and

5. Assessment of IEC materials related to RMCNH-N at district level and the attendant
process of implementation (The purpose of which is to assess the available IEC materials
and their thematic focus).

The following were the expected deliverables of the research:

1. Undertaking formative research and KAP analysis by collecting primary data on social
cultural, religious beliefs, social norms, community-level factors, perceptions and how this
informs practice on identified RMNCH issues including social norms;

2. Mapping out causal links of barriers such as social cultural norms, values, beliefs, decision-
making, and power relations, geo-physical, economic, political, and structural violence. This
was documented from both and etic and emic perspective;

3. Undertake a desk review of existing policies on health promotion and practice, life-skills
development , community participation, and recommend Communications for
Development on all its four constructs in selected RMNCH outcome areas of the MDGi
Project;

4. Profile key informants on sources of information and influencers on RMNCH on primary,

secondary and tertiary levels for the caregivers targeting both users and non-users of services
in the MDGi project sites. This is important because resulting interventions need to be based
on specific targets and their profiles.

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 5. Following result no. 4, undertake channel analysis for the segmented audiences. This is
critical for essential and effective targeting of interventions;

6. Assess available Information, Education and Communication materials on RMNCH-N.

This assessment focused on content, strategic design, source and intended effect on
audiences; and, Write up reports and briefs specific to districts

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METHODOLOGY

Qualitative methods were the dominant approach in this research and involved various methods that
included 51 FGDs with community members, 25 Key Informant Interviews (KII) and documentation
of existing IEC materials in all the 16 selected district health centers. Details of the number of
interviews conducted by type are shown in the table below:

Table 1: Number of FGDs and KII Conducted by district

Rufunsa Kafue Masaiti Ndola Mufulira Lusaka

Adolescent FGD (above 15 1 1 1 1 1 1
years)

Adolescent FGD (10-15 1 2 2 2 2 2

years)
Women FGD 1 2 2 2 2 2
Male FGD 1 2 2 2 2 2
Nutrition Groups FGD 1 1 1 1 1 1
SMAGS FGD 1 1 1 1 1 1
KII 5 3 4 5 3 5
I.E.C Checklist 2 2 3 3 2 3
Total 13 14 16 17 14 17

SAMPLING PROCEDURE
This section describes how the different respondents were selected. Inclusion and exclusion
criteria of respondents is also provided. It should be noted that a multi-staged sampling procedure
was followed in this study. This involved selection of the MDGi district followed by selection of
health facilities. Thereafter groups and individuals were selected to be part of the study as detailed
below. It is to be noted that when data saturation was not reached during these interviews, theoretical
sampling was adopted to further appreciate the issue.

Stage 1: Selection of Districts

A total of six districts were purposively selected by the Government of the Republic of Zambia’s
representatives from MCDMCH in partnership with UNICEF. The districts were selected out of
11 operational areas of the project based on rural/urban criteria.

Stage 2: Selection of health facilities

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The selection of health facilities was done purposively based on performance of the facilities on
RMNCH&N indicators. Those health centers identified in the LQAS study as “low performing"
were included in this study. A total of 39 health facilities were identified as low performing in the
LQAS of which two were not on the list of the 2012 Facility Census and another 2 were Health
Posts without location details i.e. whether rural or urban. This meant selecting facilities from a
total of 35 facilities. In order to maximize coverage, 16 facilities were selected taking into
consideration a combination of rural and urban location. This represented 46% of the total number
of facilities. The 2012 Health Facility Census was used to classify the clinic as either rural or
urban.

A complete list of the facilities of the selected facilities is provided in Annex 1

Stage 3: Selection of Respondents

The main target groups for this study were health facility staff, adolescents, community members,
groups linked to the health facility such as SMAGs, NHCs, nutrition groups and community leaders
who were interviewed as key informants. The selection methods for these target groups is provided
in the sections below.

SELECTION OF ADOLESCENTS
In each catchment population, adolescents were selected from the individuals that have had access to
the clinic and those that have not had access. Additionally, adolescents were selected from available
youth clubs and youth friendly corners. In summary, the following individuals were included in FGDs
with adolescents

• Those that have attended or not attended any services at the facility
• Adolescents from youth clubs and/or youth friendly centers

A combination of these groups were included in each FGD. Adolescents were interviewed in separate
groups of age 10-15 and those aged 15-19. The 10-15 age group has been included because evidence
suggests that intervening with this age group has more benefits in terms of reducing teenage
pregnancies later on in life.

SELECTION OF PREGNANT WOMEN

Women attending antenatal or maternal-related services from the health facility were interviewed at
the clinic. ANC and Under-5 clinics were used to conveniently select women to be interviewed. A
minimum of 10 women were interviewed at each facility.

SELECTION OF MOTHERS TO UNDER FIVE CHILDREN

In the 6 districts, women attending under five clinics and accessing post natal services were
included in the study. Focus group discussions were held with these women. One FGD was

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held at each of the health facilities with these women. Some questions exploring women
practices related to nutrition were also be explored in the FGDs.

SELECTION OF MALE PARENTS

Male parents to participate in FGDs were selected using purposive methods. SMAGs and NHCs
helped to identify 8-10 male parents with children under the age of five. These were included in the
FGDs.

SELECTION OF NHCS AND NUTRITION GROUPS

In each of the health facilities selected, NHCs/SMAGs and nutritional groups are available as part
of the extended health care providers. These were interviewed as separate groups.

SELECTION OF OTHER COMMUNITY MEMBERS

The study also targeted communities in the selected 6 districts. A community was defined as
geographic location within the selected district, which falls within health centers’ catchment areas.
For rural districts, communities in this case are equivalent to a village (an area under the headship
of a village headperson) while in urban areas, this was equivalent to a ward. From each community,
leaders such as headmen, ward leaders, were interviewed when present. However, it was difficult to
get traditional leaders.

SELECTION OF STAKEHOLDERS
Other than community members, stakeholders working in the RMNCH&N were also interviewed.
These included at least five NGOs/CBOs working in the district, as well as government structures
such as DHMT and other health facility staff.

ASSESSMENT OF IEC MATERIALS

A rapid assessment of IEC materials was done through a careful analysis of available materials at
the facility level. A content analysis of the existing IEC materials was done. The analysis focused on
target audience, thematic focus, positioning of the materials, and visual codes used.

DEVELOPMENT OF DATA COLLECTION TOOLS

The tools that were used included FGD guides, Key Informant guides, and checklists for literature
review.

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ETHICAL CONSIDERATIONS
Prior to commencement, the research was reviewed by the research ethics committee. Our
understanding of human research ethics rested on three fundamental principles that are considered
the foundation of all regulations or guidelines governing research ethics. These principles are: Respect
for persons, Beneficence and Justice.

These principles are considered universal, transcending geographic, cultural, economic, legal, and
political boundaries. They are also appropriate when dealing with vulnerable populations such as
children and women.

Research procedures must never harm study participants, physically or psychologically. This means
that a thorough understanding of the circumstances of the participants was critical prior to conducting
the interviews. In order to put ethics into practice, the assessment was subjected to ethical review
under ERES Converge. The proposal, after amendments was approved for research.

Confidentiality and anonymity: Research participants was assured of confidentiality and anonymity.
This means that no names or any label that could be used to identity participants. The names of the
participants were not be recorded anywhere, instead codes were used to identify participants.

Informed participation/consent: Participants were informed on the nature and purpose of this study.
Their willingness to participate was sought. Participants who accept to take part in the study were also
be informed of their willingness to withdraw, without giving reasons, any time. They were also
required to sign a consent form as an indication of their freedom to participate (refer to information
sheet and consent forms).

Minors: Special attention was paid to minors. Since this study included the age category of 10-15 year
olds, it is important that special care be taken in consideration of their rights. Parental or guardian
permission is gotten prior to engaging the children in the process of recruitment for focus group
discussions. Once parents and or guardians have assented on behalf of the children, the researchers
additionally explained to the children the nature and purpose of the study. The language used was be
appropriately tailored to these young people.

FIELD TEST
Since it is a requirement that a study pilot be conducted in an environment similar to those obtaining
in the study areas, a pilot took place in Lusaka’s Kalingalinga clinic. The training and the pilot
were held back-to-back whilst the knowledge acquired by the candidates is still fresh on their minds.
The pilot was meant to expose the field teams to the expectation of the actual field work
concerning the following: selecting specific respondent roles and responsibilities of each individual
member of the team; collecting adequate data for each type data collection instruments so that each

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step is fully supervised, challenges and opportunities to the successful collection of good quality data
are identified were identified.

DATA COLLECTION
Data collection was conducted after the pilot test with teams going to all districts as scheduled for a
period of two months between April and June 2015.

QUALITY ASSURANCE METHODS

To ensure that data of very high quality is collected during the assessment, the field team was recruited
on the basis of previous field work experience. Each team had a supervisor who assigned daily tasks
to research assistants and ensure that study protocols are adhered to. The supervisor also checked for
compliance every day after field work.

DATA ANALYSIS
Data were analysed using thematic adapting a constant comparison method to come up with common
themes. Deviant cases were also explored in addition to the emerging themes.

The results of this report are being presented in line with the following themes:

1. Knowledge, attitudes, beliefs and practices on RMNCH and nutritional issues

2. Factors Impacting Uptake of RMNCH and nutritional services
3. Barriers and Facilitators to accessing RMNCH-services
4. Health Promotion can play to improve the uptake and delivery of services in RMNCH-N
5. Available Information, Education and Communication materials on RMNCH-N and their
source in the selected districts
6. Channels of Communication for effective messaging in the MDGi districts
7. Key informants and influencers of RMNCH-N issuers for caregivers (users and non-users of
services) adolescent (10-19 years) and communities in the MDGi districts.
For organizational convenience, the continuum of pre-pregnancy, pregnancy, child-birth, post-natal
and child care are adopted for a continuous narrative. All selected themes will be discussed in this line
to answer the research questions:

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PRESENTATION OF KEY FINDINGS

KNOWLEDGE, ATTITUDES, BELIEFS AND PRACTICES ON RMNCH AND

NUTRITIONAL ISSUES

This section highlights the knowledge, attitudes, beliefs and practices of community members on
RMNCH and nutrition in the targeted districts. The community members are categorized as Adults
(male/female), Adolescents and young people, Community Mobilisers and Service Providers.

KNOWLEDGE AND PRACTICES

Previous studies have shown that low knowledge is associated with low uptake of RMNCH services
in Zambia. In this study an attempt was made to assess the level of knowledge and practices among
community members on RMNCH-R and explore reasons for the low uptake.

CONTRACEPTIVE AND FAMILY PLANNING

Participants were asked to mention contraceptives that they are aware of in their communities. It is
clear from the findings that there is high level of knowledge among community members on
contraceptives. Knowledge of preventing pregnancy is almost universal; the majority of women that
participated in the study knew at least one method of how to prevent an unwanted pregnancy. The
most common method cited is the use of injectable contraception. More Young people were able to
mention a condom as a contraceptive than the adult counterparts. Other methods mentioned by
especially adult discussants included the natural family planning method, breastfeeding and the
temperature methods. The knowledge of long lasting and reversible contraception was however very
low.

“…People love those medicines. Even the people you have seen here today, they have come for the injections. Even
us we encourage them. Whenever we go into the villages we tell them it is important to be on family planning to
allow the child to grow. We tell them it is not healthy to be having children every year. That is why you see so
many here today.” Service Provider at Twapia Clinic
During FGDs participants also mentioned traditional contraceptives. These included drinking
concentrated tea, wearing some beads around the waste, going to the traditional healers to suspend
reproduction among others. Adult’s participants in all the districts were more knowledgeable of the
contraceptives compared to adolescent and young people.

“Well some women in this community also use traditional family planning, for instance there is one where you
wear in the waist and if it cuts then the fertility goes. So for one to conceive again they have to untie where they
tied from”.

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Other traditional family planning methods include roots and seeds that are swallowed or worn to
prevent pregnancies:
“Others also use traditional family planning like you get a certain plant that bears fruits and swallow the seeds of
the same plant (insele zambanje). For instance if you swallow five seeds that means you will not conceive in the
next five years.”

While others use eating seeds of selected plants, wearing beads around the waist, and drinking Munkoyo roots,
etc.
Although knowledge on condoms was significant on condom as a contraceptive, usability of it was
very limited for both adults and young people. More For married adults they did not feel a need for it
as they were married. Very few participants indicated using condoms with their regular partners even
in cases where one had more than one sexual partner.

“It is culturally unaccepted for me to use a condom with my husband. In fact if ‘I’ as a woman suggests to use a
condom then I my husband will think am now misbehaving elsewhere with another man” Mufulira FGD woman
participant

In discussions with mothers, injectable contraception was said to be preferred because it does not
require remembering on daily basis as compared to pills. It was mentioned that, it is difficult to take
pills because you often forget.

“Personally I think the family planning that can help us women in this community is the injections, there you can
choose which one you want if it’s for three months or five years it’s up to you the person. If I say the pill is better
most women forget to take pill and they conceive and they start saying no pills don’t work.” Chikumbi Female
FGD participant

On the part of the young people access to contraceptives is still a challenge, coupled with stigmatizing
attitudes of the service providers which hinders utilization.

“these contraceptives especially the pills and condoms are found everywhere but we feel shy to get them. We are not
happy the way they give these condoms at the clinic at least if they introduce a group that can be conducted by our
fellow youths it would be better and we can be feeling free to access these services.” Young Female participant in
Mufulira

“When you go to get these services you find that the person who is there knows your parents or just the people
around the clinic can see you going there and they may tell your parents that they saw me going to get family
planning services and am in trouble with my parents.” Young Female Participant in Ndola

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ANTENATAL CARE
Antenatal care is essential to maternal, newborn and child health. This is because during ANC, health
care workers can help detect any possible complications both to the mother and to the baby and
provide prompt treatment where necessary. During ANC, sexually transmitted infections can be
diagnosed and treated, presumptive treatment of malaria is provided and mothers learn about birth
preparedness and receive information on child care.

During the assessment, use of antenatal care services by mothers was measured. Various variables
were considered including the number of times the mothers went for antenatal care, how old was the
pregnancy when the mother decided to go for first antenatal care, the type of services they received
during antenatal care and a comparison of level of education and access to antenatal care.

Men and women showed knowledge of ANC as important and insisted on the need for expectant
mothers to attend for the full term. Others felt that ANC is an opportunity to check for malaria
infections, HIV or STIs and other health issues. All groups affirmed the importance of ANC for the
health of the child and emphasized the benefits of attending ANC for the good of both the child and
mother. For example, SMAGs emphasized the need to attend ANC in order for the mother and the
baby to be monitored during pregnancy:

“Well what I know about antenatal is that, it’s the time pregnant women go and register at the clinic for checkups
until they give birth. Making sure that [the] she finishes all the visits at the clinic.”

“What we know as men is that when a woman is pregnant, she has to come to the hospital to be scrutinized in her
health. Check her HIV, STI and other health issues. And if she is pregnant or not, if this is true- she should be
registered so that she will be on continuance check from the clinic. If she is pregnant, she is registered.” (Twapia
Clinic).

“If the woman doesn’t go to ANC, she may discover that the baby is not growing well, or maybe the child is dead
in the womb. They also have to make sure the blood of the woman is okay, and there are no diseases.” (SMAGs,
Chiawa)

“The benefits are many. At the clinic they will be able to detect the pregnancy, check if the baby is healthy, and
whether the baby is getting the proper food while in the womb.“ (FDG)

The study found that many people in the selected community are aware of the need for family
planning, delivery at the health facility, need to be aware of the danger signs of pregnancy, healthy
nutrition, and good practices that enhance the health of the mother and the baby. While most of the
respondents were happy with the services provided at health facilities, some of them felt that the

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negative attitude of staff members remains an obstacle to presenting themselves before the health
facility.

Mothers were asked about postnatal danger signs that warrant to see a medical personnel if noticed
during pregnancy and after delivery. Heavy bleeding, bleeding, swelling of hands and feet and severe
pain in the abdomen was the commonly mentioned danger sign. However, knowledge of the other
danger signs were mentioned by less than half of the mother interviewed. This indicates that there is
a need to continue educating mothers on the other danger signs.

Other danger signs mentioned included: watery discharge from the vagina, swollen legs and hands,
severe headaches, and stomach pains. Malaria was also highlighted as a danger sign to pregnancy:

“From 3 months onwards, if she begins to bleed it is very serious. She must be rushed to the hospital. Others
experience swelling of legs. That is dangerous. Others it is non-stop headache. All these are dangerous conditions”
Woman participant in Chawama FGD.
“…… and there is also what we call matrice where the vagina is closed by a piece of meat. So when a
woman sees such dangers she is supposed to rush to the clinic for medical checkup” Kanyma SMAG
member
“Malaria is a danger sign hence a pregnant woman has to sleep under a mosquito net to protect herself and the
unborn baby from malaria.”
“The other danger signs of a pregnant women are that if she is bleeding, vomiting, fitting and if the legs and hands
are getting swollen.”

Women groups in all the districts assessed displayed more knowledge about danger signs compared
to men. Adolescent did not display good knowledge of danger signs of pregnancy. In case of noting
danger signs women reported that they would seek medical assistance from healthcare providers.
However, young people would depend on their parents and grandparents. Respondents only took
their children to the healthcare centers after trying to treat the child at home. It is noted that women
insist on trying to treat the problem at home prior to seeking professional care. In the case of fever,
they are more likely to take malaria tablets i.e. Fansidar before consulting medical practitioners. There
is no clear distinction made between bleeding before delivery and bleeding after delivery.

NUTRITION DURING PREGNANCY

Cravings during pregnancy are noted as one of the natural occurrences that women experience during
pregnancy hence missing out on important diets that are critical for a healthy pregnancy. But there are
cultural beliefs about the effect of some of these foods on pregnancy hence expectant mothers are not
allowed to eat, for example, Lusale, beans, or sugar. For Lusale, it is believed that women will have a
lot of water during delivery. For beans they say the women would bleed a lot. As for sugar, the belief
is that the baby will be born with a lot of rush:
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“A pregnant woman may have challenges in terms of nutrition because she tends to be choosy or have cravings
hence missing out the types of foods she supposed to be eating as a pregnant woman.”

“Traditional can also make a woman not to have the right foods that she is supposed to be eating. For instance
when a woman is pregnant she is not allowed to eat beans because she will have a lot of blood when giving birth
hence she will lose a lot of it blood.”

There is also a belief that eating eggs during pregnancy may lead the child not having hair. “Others
say that women are not allowed to eat eggs because the baby might be born without hair.” Men noted that “The
woman has to feed well because all the food going into the mother is beneficial to the baby” (Men FGD). Pork
is not good for a pregnant woman because of the association of the prolonged delivery of piglets which
is likely to be transferred to a woman’s experience:
“They used to stop them from eating eggs saying the child will be bald; don’t eat pork because you will take long
to deliver or the child will be snorting like a pig; they said the pig suffers a long time before delivering so the woman
would also suffer for a long time in labor.”

“A pregnant woman was not allowed to eat a bird called “kambasa” because a baby will be born with a head like
kambasa and also a pregnant woman was not allowed to eat eggs concurrently because a baby would born with a
bald head”.

“A pregnant woman was not allowed to eat (Imfuko) because a baby would born with upper teeth and that baby
would be called (ichinkula) meaning a child who cannot be controlled or corrected.”
“Pregnant women should not eat delele (okra) because okra does not have vitamins the vitamins are destroyed by
the soda that is added to it.”

Some respondents on the other hand recognized the need for expectant mothers to eat healthy foods.
For example, men in some of the communities, recommended that:
“Pregnant women need to be eating vegetables, eggs and fruits”.

“Some pregnant women tend to be selective when it comes to food they eat for example some women refuse to eat
meat, and kapenta
“The person who is pregnant is not supposed to eat liver because during delivering the blood can be too much.”
“Pregnant women are supposed to be eating a lot of vegetables and fruits especially vegetables like katapa (cassava
leaves) so that she has enough blood for both her and the unborn baby in her body.”

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DELIVERIES
The study also assessed some confounding reasons for home deliveries and established that the major
reason for home deliveries is long distances to health facilities followed by lack of privacy at the
facilities and wanting to deliver at home because of traditional beliefs. Participants were also able to
point out the dangers of delivering at home which included much pain, and bleeding i

Some participants shared incidences of home deliveries, which resulted in maternal deaths in their
communities. One of the Facility in Charge of Mupapa clinic explained that the maternal fatality
related to delivery that occurred in the last one year was as a result of excessive bleeding. A woman
gave birth at home and she started bleeding, by the time they reached the clinic it was too late. The
major reason given for home deliveries especially in rural districts such as Masaiti and Rufunsa was
long distances to health facilities. Some respondents indicated that they have to walk for more than 5
hours to reach the health facility where they also have to wait for many hours before they could be
attended to. A significant number of respondents cited the unfriendly attitudes of the service providers
as reason for delivering at home.

BREASTFEEDING
Mothers sometimes prefer to squeeze out the first milk and not feed it to the baby because of its
appearance. It is believed that the first milk can make the baby sick. There are other factors that may
delay the feeding of the baby within the first hour of delivery such as rituals being performed in the
event that a mother has experienced the death of a child before. Breastfeeding in public is also
discouraged because
“…because of a contagious diarrheal disease called Ichibele. This disease can be transmitted from one baby to
another if a woman is breastfeeding at the same time with another woman whose baby has charms.”
“The other practice is that may negatively affect the breastfeeding of the baby is that one where the first milk is
squeezed out and not given to the baby. Here at the clinic we are taught that the first milk is very healthy to the
baby in fact it is the healthiest milk of them all.”

“Yes, it is also believed that if the woman had a child who died while he or she was breastfeeding she is not supposed
to breastfeed the newly born baby until some rituals are done that’s when she can breastfeed that baby. They say
that if she breastfeeds the new baby without the rituals being done that baby will die as well or won’t be growing
healthy.”
“If the baby vomits on the breast they stop breastfeeding the baby.” (16-19 year olds)
“If you breastfeed the baby in public and there is another person who is breastfeeding the baby will get sick what
they call ichibele.”

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There are a number of reasons why a child may not be breastfed in the first hour of his or her birth.
Some of the reasons include mothers experiencing pain and the belief that the yellowish milk can make
the child sick:
“Most women would not breastfeed the baby in the first hour because their breasts pain so much.”
“They don’t breastfeed in the first hour because they believe that the baby is not supposed to drink it because the
child will get sick of the same yellowish substance that comes out in the first hour.”
Some men expressed ignorance on breastfeeding because, they said, “usually what happens is that the woman is
taken to the house of her mother where she is taken care of until after may be after 3 weeks. Everything happens at
her parent’s home, so we don’t know as men.”
Breastfeeding is important for the growth of the newborn baby. Breastfeeding in the first hour is critical
as the newborn receives good nutrition. Mothers understand the importance of breastfeeding.
However, there are some practices that prevent mothers from practicing what they know as important.
These include the belief that the first milk is dirty and makes the baby sick; when a woman has had a
miscarriage or has previously experienced the death of her child, she is less likely to breastfeed until
some rituals are performed. In some cases, mothers are not likely to breastfeed in public because of a
phenomenon known as icibele. HIV positive mothers do not breastfeed to prevent transmitting the
virus to the newborn. Some practices that women implement during breastfeeding, especially for the
first time, includes washing the nipples as well as applying saliva to the nipples.

TEENAGE PREGNANCIES

Adolescents and young people between the ages of 15 - 19 were asked what the causes of teenage
pregnancy are and how to prevent teenage pregnancy.

Almost a third of adolescents attributed teenage pregnancy to starting sex early. The other major
reason cited was the desire for money and material things such as phones which is consistent with
poverty as the reason why teenage girls are getting pregnant.

From the discussions, boys appeared to blame the girls for teenage pregnancy. Frequently, boys
complained about girls exposing their bodies through the way they dress. Boys complained about
miniskirts, tights trousers and low cut jeans that reveal underwear.

“The way girls dress these days, they expose their bodies anyhow, doing that they attract us boys to propose them
and engage in casual sex hence we impregnate them…..Girls of nowadays likes boys a lot and when a girl shows
that she likes you, we agree to have sex with them. In my view that is why there is a lot of teenage pregnancy.”
FGD Participant, Ndola

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In similar discussions with adolescents and young people in Masaiti, they felt that peer pressure and
lack of recreational facilities are some of the causes of teenage pregnancies.

“As you may have seen for yourself, here there a lot of drinking places and no recreational facilities to keep young
people away from risky behaviour such drinking and sex. We need community groups for youths and youth centers
to keep us busy” FGD participant in Masaiti

Boys also attributed teenage pregnancy to lack of self-control among boys. Adolescent boys said that
they have sexual desire. “It is just being part of a man. You have this desire and you approach the girl.
If she agrees you have sex with them.” Said another participant.

Girls on the other hand mainly cited poverty, lack of family support, lack of IEC materials on
sexuality, abuse from boys and men, and the lack of condom use by boys as major cause of teenage
pregnancy.

“The adult men and even boy force girls to have sex even when they don’t want to. The problem is with the boys,
they just want to have sex with you even when you don’t want. When you ask them to use a condom, they refuse.
” Female participant in Mfulira

“Boys and even some adult men also like abusing us. You don’t want to have sex, but they just force you to have
sex. So you get pregnant” said another girl. The other frequently mentioned reason is girls wanting money. “Girls
like money these days. So they have sex with older men to get some money to buy food at home and other things
they want.

The lack of access to SRH services such as contraceptives for young people was yet another reason
cited for teenage pregnancies in all the districts by young people.

“I think the problem is that we cannot not get condoms easily from the health facility as adults and service providers
would shout at us, so most of young people who cannot abstain end up having sex live and the end up with
pregnancies”

On the other hand parents blamed young people for early pregnancies. Local terminologies such as
‘Tabomfya fye’=they are just promiscuous, and maule=they are prostitutes were common used to
blame adolescents and young people for early sex and teenage pregnancies. Other adults felt that early
sexual debut is the major reason. “You the problem that I can point at is that once a young person
tastes sex for the first time, they become uncontrollable ‘Mintasondwa=Once you taste it, you will
never stop’. They can even listern to their parents.

“these children you can get tired of teaching, they don’t listen if they just go outside the yard you can’t touch them.”
Parent in Rufunsa

POSTNATAL COMPLICATIONS

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Postnatal care is very important for both the mother and the baby. Most postnatal deaths occur shortly
after birth. WHO recommends that mothers should attend postnatal care within 24 hours of birth, 3
days after birth, 7-14 days after birth and six weeks after birth.4

During the assessment it was found that almost all mothers that delivered within the health facility
were provided with postnatal care within 24 hours of birth. Most women were discharged within a
day after giving birth from the health facility.

However, very few returned to the health facility within 3 days after birth for postnatal care services.
The majority, returned to the health facility 7 days after birth.

Distance to health facilities was cited as the major reason why mothers failed to return to the health
facility three days after delivery.

“It is difficult to walk back to the health facility shortly after giving birth. At least after some days, you have
recovered a bit to take a long walk again.”

The other reason is that mothers were comfortable to stay at home if both the mother and the baby do
not show any danger signs that would warrant going back to the health center shortly after birth.

“If the baby is ok and the mother is ok, there is no need to go back to the health facility immediately. You can at
least rest a bit.” Said one participant.

Mothers were asked about postnatal danger signs that warrant to see a medical personnel if noticed.

Heavy bleeding was the commonly mentioned danger sign. Knowledge of the other danger signs was
significantly low among the participants.

The assessment also show that some negative cultural practices are performed when a child is just
born which may put the health the child at risky of many infections. For instance for births that are
attended to traditional Birth Attendants and community health workers, the umbilical cord of a child
is cut and the baby washed. It is apparent that in some cases, where parents are not ready for delivery
the umbilical cord may be cut using anything that is available including razor or string:
“When the child is born the cord is cut and the mother first cleans herself and the baby is cleaned and then breastfed.
The people who attend to them are those who went to help her deliver, the TBAs (Traditional Birth Attendants).”

“Yes we do have Traditional Birth Attendants who teaches the mothers after delivery how to keep and feed the
baby also tell them about the importance of immunization.”

4
http://apps.who.int/iris/bitstream/10665/97603/1/9789241506649_eng.pdf

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“They cut the umbilical cord using a string but they don’t care if what they are using is right or wrong.”

Rituals Performed on New Baby

They first give the baby some water with herbs, then massage the mother with herbs
before breastfeeding. Yes there are some traditions that these women follow in the
community like getting goat skin and mixing it with herbs and apply on both the mother
and child but these practices are discouraged because they cause infections.

The child has to be received into the bedroom through some rituals. Typical practices may include
smearing the baby with semen and passing him/her over fire. It is believed that if this ritual is not
performed, then the child may suffer severe chest pains and may cough blood:
When the child is just two days or so after birth, they would chew herbs together with salt and spew
the concoction on the baby’s body including in the mouth. This is meant to protect the baby.
“When a baby is born the woman has to sleep with the spouse, if this is not practiced the baby will have unfinished
cough.”

“A mother doesn’t have to sleep with another man besides the husband and also a mother doesn’t have to cook
until she is given traditional medicine to prevent ichifuba chamankowesha (unclean cough).”

“There’s a practice called ukukosha umwana meaning making the baby strong where a newly born baby is smeared
with sperms on the chest and the back after sexual intercourse.”

Childbirth is treated with caution. There are also practices that must happen when the child is born.
All these practices are meant to protect the child from getting sick. Some practices may actually be
harmful to the health of the baby.
Parents narrated the dangers to the health of their child. They noted that when the child experiences
high temperature or is coughing or has related problems then they practice self-medication. Parents
also stated that the diseases that are a danger to the health of their baby include: pneumonia, malaria,
problems in breathing, yellowish eyes, and severe diarrhea. It is noteworthy that mothers firstly attend
to treat the baby at home prior to reverting to the health facility. Experienced mothers are more likely
to keep the child at home compared to nulliparous mothers:
“The dangers of the child’s health is when the temperature is high, if the child stops breastfeeding and also if the
baby starts to fit.”

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“The other danger signs are that if the child starts to cough, have difficulties in the breathing, has yellow eyes and
has stomach problems. What I do when I see these signs I quickly rush the child to the clinic, but there are others
who take their children to which doctors and others just buy panado pa kantemba (kiosk) and give the child.”

It is noteworthy that no group discussed essential baby care practices such as keeping the baby
warm nor bathing the baby in the first 24 hours. Medical attention for the child is only sought
when all efforts prove ineffective at home.

Women, for instance in Chikumbi, stated that a cough, malaria, diarrhea, low blood, high temperature
and continuous crying are dangers to the health of the child:
“The dangers to child health can be that if a child has a cough, malaria, diarrhea and low blood.”

“Also if the baby’s temperature is high it’s also in dangers the Childs’ health and if the baby is crying a lot.”

“The baby can die from measles if that child has not been immunized by it (measles) or can die from polio.

“The baby can also die if the body temperature is too high, can die from diarrhea and also vomiting.”

HIV AND PMTCT

In this study, knowledge on HIV was also accessed as it relates to maternal health. Although the
knowledge on HIV transmission was almost universal in all the districts and across all participants,
myths still persists especially among the young people. This is substantiated by the fact that some of
the participants still believe HIV can be transmitted through a mosquito bite, and casual kissing. The
extract below is from one of the participants and was echoed by others in almost all the districts

“For me, if a mosquito bites an HIV positive person and then bites you who is not. Then you can get HIV because
it is transmitting the infected blood. This is why we need to use the mosquito nets”

“The reason why HIV can be transmitted through kissing is because of the way some of us as young people kiss.
Some of the young ones kiss like they are sucking and in the process opens up gums of the partner and thus you
can get HIV” Male participant from Mupapa FGD in Masaiti

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With regards breastfeeding, there is mixed information among community members particularly as it
relates to PMTCT. A significant number of women and men interviewed did not understand why
women living with HIV should exclusively breastfeed. Others feared that a child can get HIV if a
woman breastfeeds the child if a woman is HIV positive even if she is on ART.

“I don’t understand how a child would not get HIV from HIV positive pregnant woman, as far as I know, a child
can bit the titi of the mother and can get HIV, so am confused about this exclusive breastfeeding thing…” pregnant
woman at Fiwale Health Facility

Some mothers believe that when one is HIV positive then they should not breastfeed the baby for fear
of transmitting the virus, for instance the group of 16-19 year olds said:
“Maybe if the mother is HIV positive and the baby is HIV negative they are not supposed to breastfeed the baby.”

Although a significant number of participants believed that use of condoms can prevent HIV, some
misconception on correct usage still exists. For instance some participants, both adults and young
people believe that to maximize protection, it is better to use more than one condom. Similarly very
few respondents were able to explain correct use of female condoms. Both women and men still believe
that a female condom need to be worn for many hours before the sexual act, others believe the
chemicals in it can cause a woman to have cancer.

FACTORS IMPACTING ON THE UPTAKE OF RMNCH AND NUTRITIONAL

SERVICES

The assessment findings show that a number of factors influence the uptake of RMNC and nutritional
services in the targeted study districts. The study findings reveal varied confounding factors that hinder
uptake of RMNCH and nutritional services. These factors range from Cultural/Tradition, social and
economic and RMNCH and nutritional service provision on the other hand which are eminent in the
project sites. This section presents findings on this aspect:

A lot of myths and harmful cultural practices still persist in targeted communities that in turn affect
the uptake of RMNCH and nutritional services. These factors affect the women during with regards
Family Planning, ANC, Postnatal, and during breastfeeding and nutrition

FACTORS AFFECTING FAMILY PLANNING

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Misconceptions: The research results have shown that community misconception on family planning
methods affect uptake of these services. It was common among the respondents that family planning
methods are associated with negative outcomes such as, intermittent menstrual experiences, negative
effects on babies such as having a big head, watery vagina if one keeps using condoms, and myths that
condoms cause HIV. Men stated, for instance, in Twapia, that traditional methods of family planning
are better because they do not have side effects, such as obesity, high blood pressure, and becoming
very thin. For others, injections result in infertility:

“Others say that if you take the pill for a long time it will affect the baby by having a big head. Well others say if
you keep using condoms the girl will have watery vagina and its condoms that give HIV.”

“For others they say that the injection for three months makes the woman infertile and that the pills if you take
them for a long time you can have a clot that results to cancer.”

“What make us unhappy about the family planning are the side effects that come with them because service
providers don’t do anything about them. Some of the effects are losing weight and loss of appetite.”

Associated with misconception on contraceptives and family planning is gender based violence. Some
of the respondents attributed some cases of gender-based violence to family planning usage:

Some men felt that, some men who are ignorant about family planning, end up being violent to their
wives who access these services. The result is that women access such services secretly and do not
divulge the information to their spouses for fear of intimate partner violence:
“I know for sure that it is women mostly who come here for family planning. Certain cases result in in GBV. It is
mostly because men are ignorant about family planning which makes it a source of gender based violence.”

Other misconceptions included perceptions that chemicals contained in both male and female
condoms cause cancer.

Lack of youth friendly services for young people: The major reason for low uptake of contraceptives
among sexually active young people as informed by the study included lack of youth friendly centers
where these services could be offered in a non-judgmental manner, negative attitudes of services
providers, adult negative attitude towards young people accessing the services and the lack of self-
confidence among the young people themselves.

In all the health facilities assessed, there were no youth friendly services to accommodate adolescents
and young people. If an adolescent wants to access services they have to queue up together with the
adults. The majority of service providers interviewed in facilities explained that this is mainly because
they are understaffed and besides they need resources if they are to establish youth friendly centers.
They do not have time to create youth friendly services as this would take them away from the general
public. The other reasons was that although the clinics has Community Based Distributors and
NHCs/SMAGS for family planning services, they do not have trained young people that can provide
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peer to peer services to fellow adolescents and youths. There is a need therefore to develop youth
friendly services to increase access and utilization of reproductive health services by young people.
Provision of family planning services for both adults and young people at the same center hin hinders
adolescents from accessing services as a result of self and community stigma.

Negative attitudes against adolescent sexuality let alone pregnancies hinders uptake of
contraceptives. Some respondents strongly condemned young people accessing family planning
services. Some of those opposed were from the SMAGS.

“You find that when you go to get the condoms, the nurses would even be shouting on top of her voice to the others
that ‘hey give me the keys to where we keep the condoms I give this boy he wants some’, so you feel shy such that
everyone knows what you have gone to do at the clinic and they start thinking otherwise. So we are not happy.”
Young Male Participant in Masaiti

Availability and Access to Family Planning Services: Family Planning services are accessed at the
clinic or health centers from health service providers. Some of the family planning methods such as
condoms are also accessed from communities i.e. from shops within the community and the chemists.
They also get from traditional healers. It is noteworthy, for example, that community members in
Kafue said that family planning services are readily available any time one wishes to access them.
However, community members felt that the distribution of family planning devices in the communities
was mismanaged as people were given, for example, pills without explanation:

“A long time ago we would also access the family planning services in the community but now we no
longer have such services because the people who were responsible for this would just give the
contraceptives without even explaining how to use them.” (FDG).

SMAGS were named by some community members as sources for family planning services in the
community. The SMAGS also go round in communities to educate the communities about
reproductive health and family planning. But they are mainly known for assisting pregnant women
take care of their pregnancies as well as during delivery:

“We receive SRH services from the clinic and also in the community through the SMAGS” “Yes they have
SMAGs they help during and after delivery. They help them for the coming baby and how to take care of the baby
when it is born.” (FDG).

Sometimes preferred methods of family planning methods are not available. For instance in Masaiti,
SMAGs said:

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“Sometimes Sexual reproductive services are not available in our communities and also in our health
facilities you’d find that a woman is looking for Depo-Provera and it is not available.” This may be a
result of stock outs.

Community members also identify a number of obstacles to accessing services. These included, lack
of information, beliefs that if they access these services then they will develop cancer. Others are
prevented from accessing family planning services by their husbands.

In Twapia, for instance, men believe that their wives access family planning services in secret and they
also leave their cards at the health facility so that their husbands would not find out. Women, in some
cases, do not reveal to their husbands that they are accessing family planning services. Others are on
family planning without the consent of their husbands. Distance also came up as a major obstacle to
accessing family planning services.

“People also access these reproductive services in the communities, the Community Based Distributors are the ones
who give us the family planning in the villages. But before they give you they teach us about the types of family
planning and how to use them. These Community Based Distributors just give pills and condoms they do not give
injections they say that if you want injections you have to go and access them at the clinic.”

FACTORS AFFECTING ANC AND POSTNATAL SERVICES

Male Involvement: The role of men for ANC and Post natal services is an important support to
pregnant women especially in a society where structures are predominantly male dominated.
However findings show that ANC and postnatal is dominantly held as a woman’s responsibility while
social norms around male involvement discourage men from accompanying their wives to the health
center. The role of the men is reduced to material provisions.

Some women who participated in the study reported that some men escort them to ANC during the
first visit.
“Men escort us for antenatal if we are coming for the first time of that pregnancy.” Chiawa FGD
This is because, in most health facilities, it is mandatory for men to accompany their partners for the
first visit. Respondents confirmed that they do not attend to women who do not come to the hospital
with their partners. Community discussants noted the importance of educating men on family
planning and the necessity of accompanying their partners during ANC and postnatal visits.
Women groups felt that men need to show love and care to their wives and children by getting
everything they need during pregnancy. This, accordingly to the narratives, means that men are able
to provide material needs when women are due to deliver.

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Men also agreed that they do not accompany their wives to ANC and postnatal because husbands are
usually busy earning support for the family. They stated that they find it difficult to get permission
from work.
“Men are also denied permission at work.” (Kanyama).
Men despite not accompanying their wives narrated the benefits of going for ANC.
Men showed that their role is one of facilitating the delivery of the baby by making sure that new
clothes are bought, including all necessary utilities. They also said that these are signs to a wife that
they care. Men also stated that they prepare for the delivery of the baby in advance. They depend on
being told when the delivery is likely to take place by their partners. This means that social expectation
dictates part of the role men play in caring for their expecting partners.
Inadequate Preparations for the new born: Some of the respondents attributed the low uptake of ANC
to lack of good cloths required for the new-born.
“Good clothes for the mother and baby are an indicator of care and a loving spouse. If these are not
available, the woman is less likely to go and deliver at the health facility for fear that others may
perceive her marriage as unloving”
“You buy baby clothes because the wife gets upset/depressed if she doesn’t see any baby clothes.”
This finding shows the need for senstisation of expecting parents in birth planning. SMAGS also
agreed on the material obligation that the men have towards their wives: “You had to prepare what was
required. There are many things. Money, napkins, blankets. When you notice the days are coming closer you have
to prepare.” It is important to note that most groups reported that lack of proper clothing, which meant
new clothes for the baby, resulted in some women choosing to deliver at home. Was that all that came
out for birth preparedness and complication readiness? There is nothing on having money, transport
beforehand, knowing when and where to go to in case of complications etc. so that the woman can be
immediately taken to the health facility in case of complications. Also knowledge about danger signs
is not mentioned.

Long waiting time is also cited as a reason for men’s failure to accompany their wives for ANC and
postnatal. “It takes too long before your wife is seen, and you could be here the whole day. It means
the following time you won’t go there, and then the wife will not be seen” (Men FDG).
Others admitted that the clinic adds a condition, saying, “if your husband is not there we won’t attend to
you.”

Long waiting times, lack of material goods, men are busy earning for the family, denied
permission at work, a man who accompanies partner to the clinic is perceived as
overprotective of the partner or others are considers as being controlled by their wives.

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No waiting shelters: One of the prominent reasons cited by the respondents for low ANC and
Postnatal services was the lack of waiting shelters to accommodate both pregnant women and their
partners. Most of the facilities assessed did not have designated waiting shelters. Men complained that
even if they may want to accompany their partners, the available structures can only accommodate
the women, thus they feel left out.

Incestuous relationships: Some opinion leaders felt that there are some practices such as incestuous
relationships that make people hide pregnancies within their families as a result do not present
themselves early before health care professionals. Early marriages also cause delays for pregnant girls
to present themselves before a health facility for fear of prosecution. As a result, these cases are handled
away from the watchful eyes of the healthcare professionals in some communities:
“Incestuous marriages. Pregnancies are concealed and the clinic does not get to know, so the pregnancy does not
develop well. Second, early marriages. Early marriages means that the girls do not appear at the clinic for ANC
because they are afraid. They just handle everything at home. The girls are hidden in the gardens until they
deliver.” (Chiawa KII).

Long distances to Health Facilities was a prominent reason for low ANC and Postnatal attendance. Mothers failed
to return to the follow-up ANC and postnatal services due to long distances. In some instances such Chikumbi,
Rufunsa and other rural facilities, clients have to walk distance as far as 30 – 40Km to reach the facility.

FACTORS AFFECTING LOW FACILITY LEVEL DELIVERIES

Community members attribute home deliveries to a number of factors. These include, lack of transport
and long distance. Respondents did not report preparing for transport as part of birth preparedness.
But there are also reported perceptions of poverty such as not having good and new baby clothes as a
reason for mothers shying away from health facilities. Community members hide pregnancies if they
are considered illegitimate. Such pregnancies may include those suspected of resulting from incestuous
relationships or from married men. Experienced mothers are less likely to present themselves to the
health facility because they feel competent to handle a birth:
“Others it’s because they are used giving birth from home and they are over confident that they can manage to
deliver on their own since they have been doing it all along.”

“For others it’s due to lack of transport. You find that the woman goes into labour but she doesn’t have money for
transport so in the end she delivers from home.”

Also due to long distance, some people cover a lot of kilometers just to get to the nearest health center
so they feel lazy to walk and they decide to give birth from home. Men, like women, identified the
dangers of home deliveries. Men stated that when a woman delivers at home, there may be

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complications or the child may get sick. In other places, it is believed that incestuous pregnancies are
hidden and as such become a danger to the baby:
“There is too much incest. They prefer to go into the bush so that they lose the baby. If they go to the hospital the
baby will survive and the people will see that the baby resembles another person.”

“Sometimes women relax and delay to go to the clinic even when they know that they are about to deliver.”

Distance is a major obstacle as well as not having new clothes for the baby. Home deliveries are
normally supported by traditional birth attendants or a grandmother. However, when the child is born,
she or he is immediately taken to the clinic or health center in order to obtain a birth certificate. Also
when the midwife is male some women may refuse to go to the health facility. In other instances,
women who had not been attending ANC are less likely to present themselves to the health facility for
lack of knowledge on their due date. Other women prefer to give birth at home where they are given
traditional medicines to speed up labour and the delivery process:
“Immediately the baby is born, it is taken to the clinic so that the child can have a birth certificate.”

If the midwife is male, some young people felt that that causes others to shun the health center:
Others are just used giving birth from home, they believe giving birth from home is better than from the clinic
because at home they are given some traditional medicines to speed up the process.

Factors Affecting Breastfeeding and Good nutrition

For instance, breastfeeding in the first hour is challenged by the belief that the first milk will make the
baby sick. There is also a belief certain cultural practices must take precedence before feeding the baby
which delay putting the baby to the breast in the first hour of delivery.

FACTORS AFFECTING USE OF MOSQUITO NETS AND GOOD SANITATION

AND HYGINE

Limited Resources: Mothers acknowledged the importance of sleeping under a mosquito net. They
also acknowledged the importance of using clean water but felt constrained by the unavailability of
the resource in which case they resorted to using shallow wells or rivers. Washing of hands in the
critical moments is noted but respondents felt that the reasons for failure to wash hands are various,
including: laziness, forgetfulness, perceived cleanliness of the environment. Some of them said that
they do not touch the faeces.

33 | P a g e
FACTORS AFFECTING LOW IMMUNIZATION

There are a number of obstacles that parents face in taking their children for immunization. These
include religious beliefs, distance, and, in some cases, laziness. Some parents said that they themselves
were never immunized and are still alive today. Some churches tell people not go for immunization.
Others felt that immunization itself causes babies to get sick. Others who have not had their children
immunized are likely to feel secure that even the other babies would not be prone to diseases despite
not being immunized:
“Obstacles that the women face in taking their children for immunization is just being lazy and also distance. You
find that a woman has to cover a lot of kilometers just to take the baby for immunization so they feel lazy and
wonder how much distance they are going to cover.”
“Others its religious beliefs. There are some churches that tell their members not to take their children for
immunization but instead just believe in prayers.”
“Our elders say that they never took us for immunization and we just grew up well so they see no point of us taking
the children for immunization and they also that it’s these immunization that makes our children to get sick.”
“Some will not have their children immunized because they believe that it’s this same immunization that makes
the child get sick.”

ROLE OF HEALTH PROMOTION IN IMPROVING THE UPTAKE AND

DELIVERY OF SERVICES IN RMNCH-N?

Health promotion can play a critical role in creating demand for services. Findings from the
communities indicate that community level factors impact strongly on knowledge, attitudes and
beliefs in the communities. Social norms also play a significant role in shaping community ethos. It
is noteworthy that for young people, community leaders, parents, health service providers’ attitudes
affect young people’s uptake of services.
It was noted in the discussions that SMAGS in particular featured dominantly as a source of
information on family planning, pregnancy and delivery. Community mobilisers are a desired channel
for creating awareness in the communities.
The Communication and Advocacy strategy for maternal, neonatal, Child Health and Nutrition
provides an opportunity for creating demand for services. Findings in this report would provide the
narratives and rationale for developing health promotion messages specifically tailored to encourage
positive practices. The messages would also help in deconstructing myths and misconceptions
prevalent on the identified themes.

ASSESSMENT OF INSTITUTIONAL CAPACITY OF HEALTH CENTERS TO

IMPLEMENT HEALTH PROMOTION INTERVENTIONS

34 | P a g e
This section focuses on institutional capacities of visited health facilities during the assessment to
implement health promotion interventions for RMNCH and nutrition. The findings are general and
common among the health centers visited. On Average, and excluding some district hospitals visited,
each health center had on average Opened 5 members of staff, 3 nurses, and one Environmental
Health Technician. These are would be complimented by 3 - 5 classified daily employs that included
a guard. These members of staff provide health care services to a catchment population of about
ranging from about 6,000 to 9,326 of which the majority are women. The population ratio to a
qualified health care worker was as high as 1 : 1,800 people. Common services that are related to
RMNCH included the following

Family planning services:

Family planning methods available were Depo-provera and Oralcon F (an oral contraception). The
clinics would also provide implants and IUD in rare cases and one to two service provider, (1 male
nurse and 1 female nurse) would be trained to insert and remove Norplant (Jadelle) and IUD (Copper
–T). The implants and IUD were not very popular in the community. But also the constraint of having
only two staff makes them to be the less preferred choice among women at the centers. During
discussions the assessment team sought to establish whether centers experiences commodity stock out
for family planning. It was established that the family planning commodities are rarely out of stock.
But there cases when family planning pills run out in stock from district pharmacies. During the
assessment on some health centers Oralcon F was out of stock and this is because it was out of stock
at the district pharmacy.

Antenatal Care:

In some of the health centers visited such as Kanyama health center clinic, health care workers have
made significant efforts to integrate various reproductive health and HIV services during ANC. When
a woman reports for antenatal clinic they test for HIV; provide PMTCT, starting with educating the
mother on the importance of preventing HIV transmission to babies; the clinic provides PMTCT drugs
to mothers as well. STI screening using Rapid Plasma Reagin (RPR) tests and provides malaria
prophylaxis by giving Fansidar an anti-malaria drug. Mothers are also monitored for Anaemia (HB
test), they are dewormed and they receive classes on Birth planning, dangers of pregnancy, and how
to give birth each time there is an ANC class.

Maternity Waiting House

35 | P a g e
A significant number of health facilities visited, particularly those in rural districts, such as Masaiti,
Kafue rural and Rufunsa do not have formal maternity waiting shelters. So mothers from far away
villages would have to wait for their turn outside the facility or squat in nearby houses a few days
before delivery.

Deliveries

A number of facilities visited in the assessment are designated delivery centers and have just a room
used for deliveries. There are no labour wards. So a woman is discharged upon delivery. If there are
complications, the most common one being postpartum hemorrhage, they refer the cases referral
hospitals, which are very distant away from these centers.

There no adequate beds in most of the delivery rooms. In many centers there is lack of privacy in these
rooms as they are just close to treatment rooms or even the reception areas.

Due to the lack of privacy many women prefer to deliver at home rather than at the health facility.
The only people that are more likely to deliver at the health facility are those that come from far, those
from nearby say everyone will hear them delivering so they deliver at home and they just come to the
clinic after delivery.

Postnatal Care

Almost all centers visited in the assessment also provides postnatal care. This includes checking the
health of both the mother and the baby and they continue to monitor the baby’s growth until the child
reaches five years old. Under-five clinics take place are also conducted. During the clinics
immunization is provided to children as and when they fall due.

Youth friendly services

There are no youth friendly services at almost all the facilities assessed as such adolescents that want
to access reproductive health services receive it together with the adults as such services are shunned
by many adolescents and young people.

Working with community mobilisers

36 | P a g e
Due to limited number of service providers for RMNCH and nutrition, community health workers
compliment the available health workers in promoting health. In assessment an attempt was made to
establish the working relationship and capacity of community mobilisers in promoting health

It is clear from findings that there is very little community involvement in MCH activities at
community level. For instance the only very few community members interviewed from selected
health facilities reported that they have been involved in in RMNCH and nutritional activities in
their communities except during immunization and child health weeks. This was also validated
through FGDs with NHCs and SMAG

Only a few participants in the FGD felt that community leaders are participating in health promotion
at community level. Further it is clear from the discussions with community members that a lot need
to be done to disseminate more RMNCH and nutrition information and working closely with
communities and NHCS and SMAGs can play a critical role. Very few participants felt Community
health workers are sharing RMNCH and nutritional information at community gatherings

Community members feel that the NHCs and SMAGS are regarded as less active at community level
in mobilizing communities for RMNCH services and there is need to strengthen their capacity in this
regard.

Further discussions with SMAGs and NHC reveal a number of challenges they face which need to be
addressed if they are to be effective in complimenting government efforts in promoting health, these
are as follows:

• Lack of motivation as they do voluntary work

• Lack of skills and capacity in budget tracking and performance monitoring

• Challenges working with some DHMTs.

• Lack of transport to cover longer distances and conduct follow ups to clients

• Not recognized by visitors to the clinic because they are not formally recognized by facility staff.

• Youth’s don’t even know in the first place that they are supposed to monitor the health providers in
the facility.

ASSESSING AVAILABILITY AND USABILITY OF IEC MATERIALS ON

RMNCH-N

IEC MATERIALS

37 | P a g e
Most of the IEC materials that are posted in the health facilities are posters. They are mainly displayed
on the walls of the facilities. A few are placed on, for instance, lockers in offices. Themes covered
include: Nutrition, Family planning, Hygiene, danger signs of pregnancy, breast cancer, Couples
VCT, HIV/AIDS, Sanitation (hand washing), TB, signs of pregnancy. There appears to be no
consistency on the individuals responsible for IEC materials in the selected institutions. In some
places, the Sister in Charge was responsible. In others, a person in charge of MCH, Clinical Officers,
Volunteer from NGO, and the CDE.
Chawama

Information Education and Communication Assessment Tool

Health Facility Type of material (Poster, Positioning of Thematic Officer
Leaflet, fact sheet-Name it the IEC material Focus of the Responsible for
and take photo) Material the material
(Nutrition,
FP, other)
1. Poster Wall Couples
VCT
2. Poster Danger Signs
of Pregnancy
3. Poster Pregnancy
and Birth
4. Poster Breast
Cancer
Poster Breastfeeding

Butondo

Information Education and Communication Assessment Tool

Health Facility Type of material (Poster, Positioning of Thematic Officer
Leaflet, fact sheet-Name it the IEC material Focus of the Responsible for
and take photo) Material the material
(Nutrition,
FP, other)
1. Poster Wall – OPD Breastfeeding Sr. In-Charge
2. Poster Wall Passage Maternal CDE
Care
3. Poster Wall MCH Post natal

38 | P a g e
 care
4. Fact Sheet Office Locker Maternal MCH
Care
Fact Sheet Cupboard Child Birth

Province: Lusaka

District: Rufunsa

Health Facility Type of material Position of the Thematic focus of Officer

IEC material the material responsible for
the material
Luangwa bridge poster Clinic front wall immunization Nurse in
charge
poster Screening room HIV test Nurse in
wall charge

Province: Lusaka

District: Rufunsa

Health Facility Type of material Position of the Thematic focus of Officer

IEC material the material responsible for
the material
Mpanshya mission poster Wall Successful Nurse in
breastfeeding charge
poster Wall 3 simple ways to Nurse in
prevent malaria charge
poster Wall Growth of a child nurse in charge

Health promotion can play a critical role in creating demand for services. Findings from the
communities indicate that community level factors impact strongly on knowledge, attitudes and
beliefs in the communities. Social norms also play a significant role in shaping community ethos. It

39 | P a g e
is noteworthy that for young people, community leaders, parents, health service providers’ attitudes
affect young people’s uptake of services.
It was noted in the discussions that SMAGS in particular featured dominantly as a source of
information on family planning, pregnancy and delivery. Community mobilisers are a desired channel
for creating awareness in the communities.
The Communication and Advocacy strategy for maternal, neonatal, Child Health and Nutrition
provides an opportunity for creating demand for services. Findings in this report would provide the
narratives and rationale for developing health promotion messages specifically tailored to encourage
positive practices. The messages would also help in deconstructing myths and misconceptions
prevalent on the identified themes.

ASSESSING AVAILABILITY AND USABILITY OF IEC MATERIALS ON RMNCH-N

SOURCES OF INFORMATION
Community members reported a number of channels as sources of information on RMNCH-N. The
clinic is a major source of information. Almost all groups identified the clinic as their source of
information. The other sources of information about FP, Pregnancy and the health of the baby
included, TBAs, SMAGS, Television and Radio as well as pamphlets. Some respondents said that
they were given pamphlets when they cannot read:
“The information about the pregnancy we get from here at the clinic, TBA, friends and also community health
workers.”
“We also get such information from the radios and televisions.”
“They learn from their parents and here at the clinic during antenatal care”.
“through outreach by going door to door in the communities, but I think if we were to give out the brochures it
would be the best so that those who did not have the time to listen to the door to door teaching can have time to
read what they missed out.” (SMAGs)

Men noted the following sources of information, but also stated that information is not enough:
We learn when we go to ANC
Sometimes we learn from a friend who went there and he shares with us
Even our grandparents teach us about these matters
Radio and television also help
We need more organized information instead of listening to each other

40 | P a g e
The best way to communicate (reach) women in most community is foot soldiering, television, radio,
print media i.e. newspapers, posters, and facility-based discussions with clients:
“There is a need for the health center to come up with community groups to educate the people in the community.”
“Well in the community people have the challenge of accessing the information because of long distance so people
feel lazy to walk long distances.”
“I think groups should be formed that will be going round in the community to teach all those who feel lazy to
come and access these services.”

Community leaders and opinion leaders also recommended that the government needs to come up
with specific radio or TV programs to do with reproductive health and Newspapers for those who
work in offices. They also felt that Posters also would be useful.
It is important that information is laid out in a language that is friendly to selected audiences. A multi-
media approach would be most effective. Some respondents described being given materials to read
when they are illiterate:
“Personally the challenge that I face is that when I need information and then they give me a book to read or a
pamphlet and I can’t read. Meaning I have to find someone to read for me and explain.”

SOURCES OF INFORMATION FOR YOUNG PEOPLE

Youths get information from several sources. Some of the sources included, the clinic, schools,
friends and radio stations. Other communities had youth friendly corners but others did not and
young people suggested that these should be introduced in the community health centers:

From the clinic, they have a youth friendly corner at the clinic.
“We get this information from the clinics, from our friends, from schools and also from the radio
stations.”
“Through the clinic but they should involve our fellow youths by having a youth friendly corner.”
“Sometimes our parents teach us about sexuality but it’s just us the children we like experiments.
Experimenting what our parents or teachers at school teach us.”
“My parents are not open to us the children to talk about sexuality so they call other people to

41 | P a g e
 come and talk to us about such.”

LANGUAGE
The language used in most IEC materials is English. These may not be adequate especially in rural
communities. For example, one respondent reported being given materials on the care of pregnancy
in English which she is unable to read. On the spot check of available materials revealed that most of
the materials are in English and none were in a local language.
Effective messaging in the MDGi districts should focus on use of community-based media such as
theatre, discussion groups, sessions run by traditional leaders, ANC sessions. Community groups
such as SMAGS, Nutrition Groups, etc. may also be used as vehicles for effective Communication.

Community Radio programs provide an opportunity to raise awareness on the highlighted thematic
areas. Opinion leaders such as headmen, chiefs, medical practitioners, priests, pastors, elders, among
others, in communities are looked upon as important mediators in message placement.

A multimedia mix will be an important resource in creating demand for RMNCH-N services in
the communities. The Communications and Advocacy Strategy for Maternal, Neonatal, Child
Health and Nutrition developed by the MCDMCH is an important resource for creating demand.

42 | P a g e
CONCLUSIONS

Findings clearly show that many community members people in the selected community are aware of
the need for family planning, delivery at the health facility, effective breastfeeding, need to be aware
of the danger signs of pregnancy and danger signs in under-five children, healthy nutrition, and good
practices that enhance the health of the mother and the baby. However high levels of knowledge on
the above does not necessarily resonate with the RMNCH and nutritional practices which are to a
significant level influenced by cultural and traditional norms some of which would put the health of
the mother and child at risky.

The research has also established that there are a number of significant factors that influence uptake
of RMNCH and nutritional services in the targeted communities and facilities. One of the major factor
is the long distances to the health centers particularly in rural districts, coupled with poverty to enable
pregnant women and mothers to provide for alternative transport to walking. Long distances to health
facilities is further worsened by inadequate staff capacity at health centers to respond to RMNCH and
nutritional needs of the clients and as such clients have to wait for long hours before they could be
attended to by a service provider. This has in turn affected the quality of the RMNCH and nutritional
services.

Male involvement in RMNCH and nutritional programme is yet another hindrance to uptake of the
services. RMNCH and Nutrition is dominantly held as a woman’s responsibility while social norms
around male involvement discourage men from accompanying their wives to the health center. The
role of the men is reduced to material provisions. In addition the finding show the limited involvement
of community leaders, especially traditional leaders and other gate keepers are not involved in
RMNCH and nutritional interventions and in addressing some harmful cultural practices that hinders
uptake. Findings show that unavailability of some of the services such as family planning services
caused by some stock outs is yet another challenge for uptake of the services.

In all facilities assessed, there is limited or no youth friendly RMNCH and nutritional services and
where these services exists, uptake by young people including, adolescent mothers and young people
living with HIV is hindered by the negative, and stigmatizing attitudes of service providers that hinder
young people to access the services.

Limited appropriate and relevant IEC materials to compliment the clinical aspects of the RMNCH
and nutritional intervention.

It is also concluded from research findings that many health centers have limited capacity to
implement health promotion intervention and this calls for effective collaboration with other key
stakeholders. Further the study has revealed that the community health workers and community

43 | P a g e
mobilisers have limited capacity too and need is eminent to strengthen their role in complimenting
facility interventions.

44 | P a g e
 STAKEHOLDERS MATRIX MAPPING

Partner Program Focus Interventions Target Districts Health

/Activities Facilities/
Intervention
areas
MCDMCH RMNCH and • Development of policies National Community
nutritional service strategies and guidelines and ditrict
provision • Ensure implementation level
of programmes
• Monitoring and
evaluation of
programmes
• Capacity building of
personnel
• Operational research
Coordination of technical
working groups
MGCD National strategy Sensitisation of stakeholders Nationwide
for reducing HIV
and AIDS
amongst women
and girls in
Zambia
Women for Sexual Sensitisation, advocacy, Lundazi, Petauke, Work with
Change Reproductive community mobilisaton for Chongwe, communities
Health Rights for participation in SMAGs, Kalomo, Choma, and health
rural women male involvement in SRH, Sinazongwe, facilities in our
work with traditional leasers Mazabuka, operation
in changing negative Kaoma, Senanga, areas
attitudes and practices Mumbwa and
Kapiri.
MoYS SRH for out of • Skills building National level National
school youths • Training wide/Commu
Entrepreneurship nities
skills
Ministry of Food and • Development of
National
Agriculture nutrition security policies strategies
and guidelines

45 | P a g e
 • Ensure
implementation of
programmes
• Monitoring and
evaluation of
programmes
• Capacity building of
personnel
• Operational research
• Coordination of
technical working
groups
MOH – HIV Unit HTC • Development of policies All districts and District
HBC strategies and guidelines provinces Hospital
STI • Ensure implementation
MC of programmes
• Monitoring and
evaluation of
programmes
• Capacity building of
personnel
• Operational research
• Coordination of
technical working groups
NAC • Adults • HIV policy coordination In all districts in None directly
• Youths and programming Zambia
• Women • Funding
• Men • Monitoring and
• Adolescents Evaluation

MOH- (DPHR) • SRH • Policy development Countrywide Countrywide

o Male • HR training and support
o Femal • Guidelines development
e • Monitoring and
o Youth evaluation
• FP • TSS
• SRH-HIV • Coordination
integration at
service
delivery level
• HIV services

46 | P a g e
CSO
Population Build social, • Create safe spaces for
Lusaka Lusaka:
Council- health and girls 10-19
Kapiri
Chawama
Adolescent Girls economic assets • Provide health and
Kabwe
Kamwala
Empowerment for vulnerable lifeskills education
Mumbwa
Chipata
Program (AGEP) girls 10-19 in and financial
Shibuyunji
Chazanga
Zambia to lead to: education
Ndola Kapiri:
- Increased • Provide health
Kitwe
Mulungus
educational vouchers to selected
Masaiti hi
attainment participants for SRH
Solwezi
Luanshim
- Delayed and wellness services ba
marriage at public and private
Kakulu
- Fewer providers and
Chibwe
unwanted • Train health Kabwe:
pregnancies providers in AFHS at
Makululu
- less HIV/STI contracted public
Katondo
infection, and and private health
Mahatma
- increased centers with the aim Ghandi
income of: Memorial
generation • Providing adolescent Mumbwa:
girls access to quality
Myooye
health services
Lwili
• Breaking some of the
Chiwena
psychological Shibuyunji:
barriers for
Kapyanga
adolescent girls to Ndola:
access health
Chipuluku
services su

Twapia
• Provide personal

Mushili
savings accounts to

Kaloko
selected participants
Kitwe:
to:

Kawama
• Help build girls

Kwacha
savings culture at a

Bulangililo
young age

Ipuskilo
• Instill positive
Masaiti:
money management

Masaiti
• Promote economic
Boma
assets

Masaiti
• Allow girls to Council
provide for
Chinondo
themselves, manage
Kambowa
47 | P a g e
 emergencies, and
Chondwe
help them make safe,
Mutaba
health related Solwezi:
decisions
Kapijimpa
• Conduct four year nga
longitudinal study to
Luamala
evaluate AGEP:
Mitukutuk
• Annual observation u
for 4 yrs, 2 yrs post-
Kamiseng
program a
• Impact outcomes:
age at first sex,
marriage, birth,
grade attainment,
HIV, STI
• Bio-marker data
collection at baseline
for HIV testing,
Endline for HIV, STI
testing (ages 15-19)
SAfAIDS SRHR, Maternal • Training of teachers, Have reached 68 At least 3
and Child Health, guardians, pupils districts of Zambia health
(key target through school but currently facilities and 3
populations: dialogues on CSE working in: communities
women and and SRHR and 3 schools
adolescences and • IEC material Kabwe, Kapiri in selected
young development, Mposhi, Kabwe, districts
people)HIV including toolkits Chongwe, Lusaka,
prevention for • Establishing the Mazabuka,
young people, referral network and Livingstone
focusing on Low color coded referral
and Inconsistence cards
use of condoms, • Training of Service
VMMC, MCP Providers and
and PMTCT Parliamentarians of
SRHR and also
referral system
• Establishing Mobile
service centers for
youth friendly
services through

48 | P a g e
 community and
youn4real clubs
• Community
Advocacy and
Community
Mobilisation through
door to door and
outreach activities
for increased
demand
• Involving Traditional
Leaders through
community
dialogues and
involving men as
protectors
• National advocacy
through national
dialogues, policy
briefs, position
papers
ZISSP Family planning, • Support to development Luangwa, 134 Rural
sexual and of policies, strategies, Chongwe, Mbala, Health
reproductive tools and training Mpika, Nakonde, Centres found
health for manuals for adolescent Chilubi, Mkushi, in all 27
adolescents and health Serenje, Kapiri- districts.
youth support to • Capacity building for mposhi, Mansa,
selected 27 health providers and peer Chienge,
districts educators in Adolescent Nchelenge,
health Masaiti, Luanshya,
• Support coordination Lufwanyama,
mechanism (ADH Solwezi,
TWG) Mwinilunga,
• Support TSS and PA Zambezi, Kalabo,
activities at National and Shangombo,
Provincial levels Lukulu, Kalomo,
Gwembe,
Sinazongwe,
Lundazi, Nyimba
and Mambwe
NGOCC • Support to member Districts where
organisations with some NGOCC

49 | P a g e
 Reducing gender projects on HIV and member
inequalities in AIDS and maternal organisations with
access to health health through grants programmes in
services • Gender Budgeting( HIV/AIDS and
analysis of national maternal health
budget from a gender operate:
perspective with a focus
on health, social Lusaka, Rufunsa,
protection, agriculture Chongwe,
and education, Mufumbwe,
submission and Kasempa,
advocacy for increases Solwezi, Kapiri
funding to the sectors Mposhi, Kabwe,
above, budget tracking Chibombo,
from a gender Mkushi,
perspective) Mumbwa,
• Participation in SAGs, Milenge, Mansa,
PDDCs and DDCCs by Kasama,
NGOCC members Mpulungu,
• Capacity building for Mporokoso,
member organisations Nakonde, Isoka,
Mpika, Chama

GNC SRHS MCH embedded in the All nursing schools 52 nursing

AYFS curriculum for all students and Colleges programmes
SRHR-HIV are utilizing
the curriculae
ZWARSM 10 Health
• Respectful
centres where
maternity care Capacity building for health Luwingu,
ever the
• SRHR-HIV providers, communities and Chongwe, Solwezi,
activity will
integrated SMAGs Lusaka, Kafue
take place
services
Alliance Zambia Improved sexual • Sub-granting to 2 Chipata, Choma 6 Rural Health
and reproductive Partners to implement an centres in 2
health outcomes SRH/HIV pro-youth districts
for young people programme in schools Chipata:
aged 10-24 and health centres. Mnukwa rural
through • Supporting the increased health centre,
integrated utilisation of SRH/HIV Namuseche
SRH/HIV and services by young boys

50 | P a g e
 rights approaches and girls at health rural health
including centres. centre
adolescent and • Adopting gender Kamulaza
youth friendly sensitive protective rural health
health services. mechanisms. centre,
Jerusalem
rural health
centre
Choma:
Batoka health
centre,
Shampande
clinic
Bwafwano Sexual &
Training of Peer Educators
Chibombo
Chazanga
Integrated Reproductive
Life Skills Training
Chongwe
Chibefwe
Services Health for
Sexual & Reproductive
Lusaka
Chipata
Organization Adolescents Health Education
Mkushi
Kayoshya

Community Awareness
Masansa
Campaigns on SRH
Mungule

Establishment of SRH
Ngwerere
Clubs
Nkumbi

Peer Health Counseling

HIV Testing

Screening & Management
of STIS

Family Planning Services

Condom Promotion &
Distribution

Safe Motherhood Activities

Capacity Building for
Traditional Birth
Attendants

Maternal & Child Health
Services
Adolescent &
Establishment of Child
Chibombo
Chazanga
Youth Friendly Rights Clubs
Chongwe
Chibefwe
Services
Life Skills Training
Lusaka
Chipata

Peer Counseling
Mkushi
Kayoshya

Pediatric ART Counseling
Masansa

Say & Play Therapy
Mungule

Safe from Harm Activities
Ngwerere

Nkumbi

51 | P a g e

Sports & Recreation for
Community Health
HIV Services
Home Based/Voluntary
Chibombo
Chazanga
Counseling & Testing
Chongwe
Chibefwe

ART Services
Lusaka
Chipata

Treatment of OIs
Mkushi
Kayoshya

PMTCT
Masansa

Home Based Care
Mungule

Psychosocial Support
Ngwerere

Nutrition Counseling
Nkumbi

Establishment of Support
Groups for PLHIV

Capacity Building for
Community Volunteers

Pediatric ART Counseling

Economic Strengthening
activities for PLHIV

Laboratory Services
(Hematology & Chemistry
Analysis)

Treatment Adherence
Support and Counseling

HIV/TB Co-infection
interventions

Diagnostic Counseling &
Testing Services

Condom Promotion &
Distribution

Zambia HIV and Sexual Campaign for and lobby National and sub- Policy-makers
Disability Reproductive government to mainstream national and
HIV/AIDS Health for and integrate disability issues government programme
Human Rights persons with in the policies, strategies, institutions and implementers
Programme disabilities programmes. implementing in 5 provinces
(ZAMDHARP) organisations in
Luapula, Eastern,
Lusaka,
Copperbelt,
Southern provinces
MAMAZ • •

52 | P a g e
 Save the • Comprehensi • Collaborative National and sub- Policy makers,
Children ve sexuality partnerships with CBOs national community
education and government members
• HIV/AIDS
PPAZ • Reproductive • Family planning, National and sub- Policy makers,
health sexuality education national community
members
ZINGO • HIV/AIDS • Assist religious Network of FBO Policy makers
• Reproductive communities to become organizations and faith
Health more involved in based
HIV/AIDS prevention organizations
and impact mitigation.
Marie Stops • Reproductive • Provide sexual and Selected districts
health reproductive health
services such as
abortions, circumcision
and FP
CHAZ • Reproductive •
health
• HIV and
AIDS
• Malaria
ARHA • HIV and • Life skills training Lukulu,Kalabo,m Lukulu
(adolescents AIDS • Peer education training ongu,kaoma
reproductive prevention • Mobile and static sesheke senanga Lubosi rural
health advocates intervention, services health center
) mitigation • VHCT,STI (HP)
care and • Condom distribution Simakumba
support both male and female rural health
• Sexual and • Support and strengthen center
reproductive youth friendly corners Namayula
health rural health
• Run health resource
information. center
center
• Life skills Lubosi district
• Household intervention
hospital
• School based
(HAC)
interventions
ARHA SRH
• Support and train
Information
Community action
resource
teams
Center (YFC)
Mongu

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 Mongu Urban
Clinic
Prisons clinic
Limulunga
Rural Health
Center
Liyoyelo
Clinic
ARHA SRH
Information
resource
Center (YFC)
Ikwichi Rural
Health Center
Kalabo
Winela Clinic
Liyoyelo
Clinic
Kalabo
District
Hospital
ARHA SRH
Information
resource
Center (YFC)

UNFPA Maternal health; • Demand Generation National In process of

Sexual for Ad/Youth selecting target
Reproductive Friendly SRH-HIV Target districts: facilities in
Health and HIV Services districts
(key target • CSE: Technical North Western
populations: support for in-school Province: Zambezi
women and CSE (in support to , Chavuma,
young people) existing UNESCO/ (Solwezi)
UNICEF support); Luapula
and support towards Province: Samfya,
development and Milenge, (Mansa)
Operationalisation Western Province:
out of school CSE Kaoma, Lukulu,
framework (radio, Kalabo (Mongu)
H4+ districts:
Chama, CHadzi,
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 conversations, Serenje, Kalabo
alangizi) and Lukulu
Family Planning • Strengthening youth
and Improved friendly service
sexual and delivery (at national
reproductive and district levels):
health outcomes • Support towards
for young people interventions to end
aged 10-35 child marriage
through (national); and
integrated community led in In process of
SRH/HIV and target districts selecting target
Youth Vision rights approaches • Build health; social facilities in
including and economic assets National Wide, districts
adolescent and of vulnerable girls, Lusaka, Choma,
youth friendly within the context of Kafue, Mazubuka
health services. broader district

Young Women
Leadership Academy
Mobile Health System
(SMS Family Planning
Services
Condom Promotion &
Distribution
Training of Peer
Educators
Life Skills Training
Sexual & Reproductive
Health Education
Community Awareness
Campaigns on SRH
Establishment of SRH
Clubs
Peer Health Counseling
Support to development
of policies, strategies,
tools and training
manuals for adolescent
health

55 | P a g e
 Capacity building for
health providers and peer
educators in Adolescent
health
Bilateral Partners
UNICEF
UNDP
EU
UNAIDS
PEPFAR
USAID
Global Fund

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SELECTED REFERENCES

1. CSO, Zambia Demographic Health Survey 2013-2014 (Preliminary Results)

2. CSH, Saving Mothers, Giving life (SMGL) Operations Research Study: An
Assessment of the Implementation, Acceptability, Usability, and Usefulness of the
Birth Plans in Four SMGL Districts. 2013
3. CSH, Final Formative Research Report: Nutrition Behaviours among Households in
Zambia- A Maternal and Child Health Study to Explore Factors related to Nutrition
and Prevention of Childhood Illness, 2013.
4. CSH, Drivers of Modern Contraceptives Use, Antenatal Care, Place of Delivery, and
Use of Pospartum and Neonatal Services in Selected Areas of Zambia, 2012.
5. UNICEF, Innovative Approaches to Maternal and Newborn Health, 2013
6. UNFPA, A Study of Factors Associated with Maternal Mortality in Zambia, 1998
7. Nsemukila, B. Assessment of the Regulatory Framework for Maternal, Newborn
Child Health and Nutrition Services in Zambia
8. Mondoloka, A. Mapping of RMNCH and Nutrition Programs/Projects in Lusaka and
Copperbelt Provinces, 2014
9. Mondoloka, A. Profiles of the Eleven (11) Selected Districts for the MDGi Program
for Accelerating Progress towards Maternal, Neonatal and Child Morbidity/Mortality
Reduction in Zambia, 2014.
10. Mondoloka, A. Register of RMNCH and N Programmes and Projects of Relevance
to the MDGi Programme for Accelerating Progress towards Maternal, Neonatal and
Child Morbidity/Mortality Reduction in Zambia, 2014.
11. Vargas William and Colin BEckworth, LQAS Household Survey Zambia 2014 – A
Baseline Survey for the Millennium Development Goal (MDG) Acceleration
Initiative in 11 Districts of Lusaka and Copperbelt Provinces, 2014.
12. Thaddeus and Maine, Adolescent Sexual and Reproductive Health inDeveloping
13. Countries: An Overview of Trends and Intervention International Perspectives on
Sexual and Reproductive Health, 2009.
14. U-Report, http://www.zambiaureport.org/home/. Year accessed, 2014
15. World Health Organisation, Trends in Maternal Mortality: 1990-2013. Estimates by
WHO, UNICEF, UNFPA, The World Bank and the United Nations Population
Division
16. Awareness of danger signs and symptoms of pregnancy complication among women
in Jordan Okour, Abdelhakeem et al. International Journal of Gynecology and
Obstetrics , Volume 118 , Issue 1 , 11 - 14

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 17. Hiluf M, Fantahun M. Birth Preparedness and Complication Readiness among women in Adigrat town,
north Ethiopia. Ethiopian Journal of Health Development. 2007;22(1):14–20.
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preparedness for maternal health: findings from Koupela District, Burkina Faso. J
Health Popul Nutr. 2006;24(4):489–497.[PMC free article] [PubMed]
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clients. East Afr Med J.2008;85(6):275–283. [PubMed]
20. Hailu M, Gebremariam A, Alemseged F, Deribe K. Birth Preparedness and
Complication Readiness among Pregnant Women in Southern Ethiopia. PLoS
One. 2011;6(6):e21432.. [PMC free article][PubMed]
21. World Health Organization. Mother-Baby Package: Implementing safe
motherhood in countries. Practical guide WHO/FHE/MSM/94.11. Geneva:
World Health Organization; 1994.
22. Pembe AB, Urassa DP, Carlstedt A, Lindmark G, Nystrom L, Darj E. Rural
Tanzanian women's awareness of danger signs of obstetric complications. BMC
Pregnancy Childbirth. 2009;9:12. doi: 10.1186/1471-2393-9-12. [PMC free
article] [PubMed] [Cross Ref]
23. Davidson, M. R, Ladewig, P.A. W, & London, M. L. (2008). Clinical Handbook for
Old’s Maternal-Newborn Nursing and Women’s Health across the Lifespan. 8th
edition. Pearson Education Inc., Upper Saddle River, New Jersey 07458
24. Baume CA, Marin MC: Intra-household mosquito net use in Ethiopia, Ghana, Mali, Nigeria,
Senegal, and Zambia: are nets being used? Who in the household uses them? Am J Trop Med
Hyg 2007, 77:963-971. PubMed Abstract | Publisher Full Text

25. Allen K, Larissa J, Alice R, Gorette N, James N, Lynn A. Barriers to male

involvement in contraceptive uptake and reproductive health services: a qualitative
study of men and women’s perceptions in two rural districts in Uganda. Reprod
Health [Online]. 2014. Available from: http://www.reproductive-health-
journal.com/content/ [Accessed January 10, 2014].
26. Meka A, Okwara EC, Meka AO. Contraception among bankers in an urban
community in Lagos State, Nigeria. Pan Afr Med J. 2013; 14:80.
27. Gebremariam A, Addissie A. Intention to use long acting and permanent
contraceptive methods and factors affecting it among married women in Adigrat
town, Tigray, Northern Ethiopia. Reprod Health. 2014 Mar 16;11(1):24.
28. Paschal Awingura Apanga, Matthew Ayamba Adam. Factors influencing the
uptake of family planning services in the Talensi District, Ghana. The Pan African
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29. Adongo Philip Baba, Tabongo Philip TN, Azongo Thomas B, Phillips james F,
Stone Allison, Sheff Mallory C. A comparative qualitative study of misconceptions

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30. Lagro M, Liche A, Mumba T, Ntebeka R, van Roosmalen J. Postpartum care
attendance at a rural district hospital in Zambia. Trop Doct. 2006;36(4):205-8
31. Mary Katepa-Bwalya1*, Victor Mukonka2, Chipepo Kankasa3, Freddie Masaninga1,
Olusegun Babaniyi1 and Seter Siziya, Infants and young children feeding practices
and nutritional status in two districts of Zambia. International Breastfeeding Journal: 2015

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 List of Health facilities selected for the study

Facility Type

Lusaka Chawama Urban

Kanyama Urban

Matero Main Urban

Rufunsa Mumpansha Rural

Luangwa Bridge HP Rural

Kafue Kambale Rural

Chiawa HP Rural

Masaiti Chikumbi Rural

Mupapa Health Center Rural

Fiwale Rural Health Centre Rural

Ndola Kaniki Health Centre Urban

Dola Hill Health Centre Urban

Twapia Healt Centre Rural

Ndeke Health Centre Urban

Mufulira kamuchanga clinic Urban

Butondo Urban

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