Experiences of Facility-Based Delivery Services among Women of Reproductive Age in Unguja Island’ Zanzibar: A Qualitative Study

Research Article

J Fam Med. 2018; 5(4): 1149.

Experiences of Facility-Based Delivery Services among Women of Reproductive Age in Unguja Island’ Zanzibar: A Qualitative Study

Sigalla GN1’2’ Bakar RR1’3* and Manongi RN1

¹Institute of Public Health’ Kilimanjaro Christian Medical University College’ Moshi’ Tanzania

²Department of Health’ Evangelical Lutheran Church in Tanzania’ Arusha’ Tanzania

³School of Health and Medical Sciences’ State University of Zanzibar (SUZA)’ Tanzania

*Corresponding author: Bakar RR’ School of Health and Medical Sciences’ State University of Zanzibar (SUZA)’ P.O. Box 1898’ Zanzibar’ Tanzania; Tel: +255- 777457234; Email: [email protected]

Received: August 22’ 2018; Accepted: September 19’ 2018; Published: September 26’ 2018


Background: Progress towards the 2030 targets for ending preventable maternal and newborn deaths dependents on the quality of care during delivery period. Zanzibar’ as in the context of low-income countries’ contributes to high maternal mortality due to obstetric complications. Considering that maternal deaths occurs in a world where 80% of all births are attended by a skilled health attendant’ there is a need for further exploration on the way services are delivered in the healthcare facilities in order to inform on the implementation strategy for universal coverage for health-facility delivery.

Methods: Descriptive exploratory study was conducted using a qualitative approach to explore experiences of facility-based delivery services among women of reproductive age in Zanzibar. Ten focused group discussions were carried out from the community. Data were analysed using thematic analysis approach.

Results: The study found that women's experience encountered during delivery in health facilities varied widely; from very satisfies to the most challenging delivery experiences. Important to women were the level of customer care they received’ space and privacy assigned to them’ confidentiality and availability and use of essential medical equipments and supplies required for maternal and neonatal care services in these healthcare facilities during delivery. Based on their perceived level of satisfaction for services they received’ clients were the most important influencers on the facility based delivery seeking behavior to other pregnant women in the community.

Conclusions: Healthcare facility services need to be improved by providing equipment and supplies in order to increase women’s satisfaction on the services received during facility deliveries for pregnant women. Furthermore’ the attitude of healthcare providers to their clients should be positive during the provision of delivery services as this will encourage more women in facility deliveries.

Keywords: Experiences; Challenges; Facility-delivery services; Unguja Island; Zanzibar


Improving maternal and newborn health has been an important global priority to avert maternal and/or newborn morbidity and mortality [1–3]. Approximately 830 preventable maternal deaths happen every day in the world due to pregnancy and childbirth with 99% of them occurring in developing countries [4]. The situation is serious in Zanzibar whereby 307 deaths are estimated to occur in every 100’000 live births [5]. In order to end these preventable maternal deaths’ a call to successfully implement the Sustainable Development Goals (SDGs) has been made’ with a target of reducing global maternal mortality to less than 70 deaths per 100’000 live births by 2030 [6]. Today’ the deaths are still occurring in a world where approximately 80% of all births are attended by a skilled health attendant [7]. Considering the main emphasis of SDGs is on universal access to delivery services in health facilities and that the deliveries are assisted by a trained healthcare provider [8]’ there is a need for further exploration on the way services are delivered in the healthcare facilities in order to inform on the implementation strategy for universal coverage for health-facility delivery.

Zanzibar has made efforts to increase births at healthcare facilities. However’ the goal may not be realized if women do not consider giving birth at a healthcare facility as a “positive experience” based on their previous experiences for services they have received [7]. A fulfilling experience on women’s delivery services is mainly a result of quality of services received which in Zanzibar’ as in the context of Sub-Saharan countries’ is a huge challenge [9–11]. Little evidence exists about women’s opinions on the quality of delivery services (demand side) they receive at healthcare facilities. However’ the general quality of basic maternal care at Zanzibar’s health facilities (supply side) have been reported to be a challenge [11’12]. Fakih et al. assessed the status of maternal and newborn health services in 79 out of 224 health facilities in Zanzibar and reported a huge shortage of staff’ compounded by few facilities capable to provide basic and comprehensive emergency obstetric and neonatal care (EmONC) [12]. Quality of services is poor in primary healthcare facilities’ which are the majority and assist about 40% of all deliveries [11]. The performance of the health sector in Zanzibar remains unsatisfactory even though geographical coverage of the health facilities is considered equitably distributed to all regions and districts’ and easily accessible to 95% of the population [13]. Blending the evidences for both demand and supply sides that influence facility-based deliveries is important in understanding a holistic nature of the challenges facing the health system in Zanzibar; further adding to the literature on the women’s experiences in using healthcare facilities for delivery.

Progress towards the 2030 SDG targets for ending preventable maternal and newborn deaths depends on improvement of quality of care during birth such that the care is responsive to clients’ demand. There is limited documented evidence’ if any’ of women's experiences on maternal healthcare services at health facilities in Unguja Island. Understanding women’s perceptions on the services delivered through exploration of their experiences in care is important in strengthening national health systems which are key in achieving universal health coverage. Such experiences are crucial in addressing specific health system bottlenecks that negatively influence the health-seeking behavior of women during pregnancy’ labour and birth [1]. The study aimed to explore women's experiences on facilitybased delivery services among women of reproductive age in Unguja Island’ Zanzibar.

Materials and Methods


The study was conducted in Unguja Island’ Zanzibar between March and April 2016. Unguja Island is one of the two Islands in Zanzibar; the other being Pemba. The islands are situated off the eastern coast of Tanzania Mainland with an area of 2’654 sq. km. Unguja Island covers an area of about 1’464 sq.km. [14]. It has three administrative regions’ which are further subdivided into six districts; North A’ North B’ West’ Urban’ Central and South. Each district is further subdivided into smaller administrative units known as “Shehias” [15].

According to the 2012 Census’ the total population of Unguja was 896’721’ mostly concentrated in the Zanzibar Urban and West districts [16]. Zanzibar has the overall fertility rate of 5.1 children per woman [17]. In 2012’ it was estimated that Zanzibar had 339’007 women of childbearing age (15 - 49 years) [16].

Study design

This study employed descriptive exploratory design using qualitative approach.

Sampling and Study participants

Three districts (Urban’ West’ and North B districts) out of six’ were purposively selected because they are highly populated with good coverage of the facilities providing maternal and newborn healthcare services [5]. Simple random sampling was used to select ten shehias from the selected districts. With the assistance of local government leaders and community health workers in the ten shehias’ the research team identified all women of childbearing age (15-49 years) who had delivered at healthcare facilities in the past years prior to data collection. These were eligible for the focus group discussions (FGDs). Women were identified by using a record book from the shehia's office which has a list of all shehia's residents. From each shehia’ 10-12 women were purposively recruited for the study. With the help of local leaders’ the research team identified the venue and suitable time for the meetings. A prior meeting was arranged to meet the selected women so as to provide information about the study’ why they have been selected’ and how the results will be used.

Data collection

Ten FGDs were conducted using an interview guide with semistructured questions. The guide was in Swahili language. The guide comprised of two main question areas: 1) experiences of women at healthcare facilities during delivery 2) challenges of facility-based delivery services.

Before beginning the discussions’ all study participants were informed about the aim and importance of the study. All FGDs were recorded using digital voice recorders. Participants were asked for their consent to be recorded. Verbal consent was requested from all the participants and confidentiality was assured by excluding their names as identification in the collected information. Each FGD lasted for about 45 to 60 minutes and was moderated by the principal investigator (PI) and a note taker; a nurse with experience in qualitative research.

Data analysis

All FGDs were transcribed and translated into English’ and were analyzed using thematic analysis approach. The discussion scripts were read several times to get familiar with the context of the data. After familiarization’ a preliminary coding structure was agreed upon by two coders and a codebook was created and additional codes which emerged during coding process were added concurrently following consensus by both coders. Saturation was achieved when no more codes emerged from the data. The PI always checked for accuracy during the coding process to ensure that the meaning of units’ codes and categories was congruent to emerging patterns. Discrepancies were resolved and agreed upon through discussion until consensus was reached. After completion of the coding process’ major issues were highlighted’ appropriate themes searched for categorization and the emerging themes were defined and named.

Ethical consideration

This study was approved by the Kilimanjaro Christian Medical University College Research and Ethical Review Committee (certificate number 677). Approval to conduct the study was also granted by the Zanzibar Medical Research Council. Permission to involve the community was sought from the respective shehia leaders. A verbal consent was requested from each study participant whereby a consent form was given to each participant to sign to confirm her willingness to participate in the study.


Social demographic characteristics of the study participants

A total of one hundred and eight women of childbearing age from the three districts participated in the study. The mean age was 29 years (range’ 19-46 years). More than one-third (42%) of the study participants were in the age range of 25-34 years. Majority (92%) of the women were married and about 82% had completed secondary education. Nearly two-thirds (66%) were multiparous’ and 79% were housewives. Only few study participants (10%) were employed in the formal sector. Farming was the main source of livelihood of most of the participants though reported by less than a quarter (11%) of the study participants (Table 1).

Citation:Sigalla GN, Bakar RR and Manongi RN. Experiences of Facility-Based Delivery Services among Women of Reproductive Age in Unguja Island, Zanzibar: A Qualitative Study. J Fam Med. 2018; 5(4): 1149.