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Health Systems Response to Routine
Maternal and Child Health Service

Delivery Amidst COVID 19 Pandemic at
Kanyama 1st Level Hospital Lusaka
District 3rd Edition Tandwa Syakayuwa
And Regina Chansa (Cavendish
University
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British Journal of Healthcare and Medical Research - Vol. 9, No. 3
Publication Date: June, 25, 2022
DOI:10.14738/jbemi.93.12263.
Syakayuwa, T., & Chansa, R. (2022). Health Systems Response to Routine Maternal and Child Health Service Delivery Amidst COVID
-19 Pandemic at Kanyama 1st Level Hospital - Lusaka District. British Journal of Healthcare and Medical Research, 9(3). 1-58.
Health Systems Response to Routine Maternal and Child Health

Service Delivery Amidst COVID -19 Pandemic at Kanyama 1st
Level Hospital - Lusaka District
Tandwa Syakayuwa
Cavendish University Zambia, Lusaka, Zambia
Regina Chansa
Cavendish University Zambia, Lusaka, Zambia
ABSTRACT
Aim: To ascertaining the health systems response to routine maternal and child
health services amidst the COVID -19 pandemic at Kanyama 1st Level Hospital –
Lusaka, Zambia. Method: A qualitative research study was conducted on Antenatal
Clinic and Post Natal Clinic mothers as targets; Community Health Workers, Health
Care Workers, and policy makers as key informants, utilizing five (5) Focused group
discussion to reach saturation. Data was collected using topic guides and analyzed
manually by transcribing and coding it. Sample size for participants were selected
using simple random sampling on ANC/ PNC mothers, while the three categories of
key informants were purposefully selected. The indirect effects of COVID-19
pandemic framework which mirrors the WHO six building blocks adopted from the
Global Health Life Saving Tools was used to analyze the health system’s readiness
amidst the COVID-19 pandemic at Kanyama 1st Level Hospital – Lusaka, Zambia.
Results: Findings were that the facility had challenges with regards to health
workforce, supplies and equipment, which ultimately affected quality provision of
maternal health services as outreach services were disrupted. Although the health
facility responded well in providing alternative schedule to cope with the influx of
mothers at the center from the closed outreach posts, the epidemic preparedness
in responding to the epidemic was not up to the expected standards. Later,
reduction in PNC and ANC attendance was noted, and home deliveries and deaths
suddenly increased. The HCW, CHWs also had challenges ranging from lack of
psychosocial support / Personal Protection Equipments, and inadequate training.
In addition, frontline workers had inadequate knowledge on triaging a Covid-19
suspected pregnant mothers. Also findings such as lack of tracking system for follow
up on mothers who missed appointments due to fear of contracting COVID -19; and
essential drug stock out was noted during the pandemic. Monitoring and evaluation
system was in place but irregular and not in tandem with prompt feedback that was
required. On the other hand, the study results also revealed one positive aspect of
ANC/PNC mothers having knowledge on the importance of maternal services
despite fears for COVID – 19 , facility delivery, signs and symptoms of COVID -19
infections and preventive measures. However, the end users expressed myths on
the transmission of the virus and the testing process. Conclusion: the research
revealed lack of epidemic preparedness at Kanyama 1st level hospital that would
allow the continuation of maternal and child health services amidst the COVID-19
outbreak. The facility had needed a timely and comprehensive health system
Services for Science and Education – United Kingdom

British Journal of Healthcare and Medical Research (BJHMR) Vol 9, Issue 3, June - 2022
response to the epidemic that is elaborate and specific to respond to all specifics of
the health system in relation to maternal services verses COVID -19 which would
have been the answer to this call.
Key words: Health Systems* Response *Epidemic* Health Services *Antenatal Clinic &
Post Natal Clinic*
INTRODUCTION
Health systems across the world are challenged by the Novel Coronavirus Disease COVID -19
pandemic which has no exception, for country, color, status, or race. When health systems are
overwhelmed and people fail to access needed services, both direct mortality from COVID -19
and indirect mortality from preventable and treatable conditions increase dramatically (iWHO,
2020). In some countries, rapidly increasing demand for care of people with COVID-19 is
compounded by fear, misinformation, and limitations on the movement of people and supplies
disrupting the delivery of health care for all people.
Reductions in access to and utilization of essential maternal and child health (MCH) services
during epidemics translate into important increases in the number of women and new-born
who suffer complications or die during pregnancy, childbirth, and the postnatal period
(iiRoberton et. al. 2020). MCH promotes attendance of 1st ANC at 12 weeks and or I trimester,
completion of 4 ANC+, health facility delivery , breastfeeding within the 1st hour of birth and
access to PNC services within the 42 days of puerperium i.e. (critical immediate care in the first
hour following delivery within the labour ward , 6 hours in the postnatal ward, of transition
and home recuperation and 6 weeks following delivery) therefore, essential to sustain all these
services even during pandemics like COVID-19.
Researchers at the Guttmacher Institute note that even a 10% decline in service coverage
during pregnancy could result in an additional 28,000 maternal deaths and 168,000 new-born
deaths and millions of unintended pregnancies as family planning services face disruptions. In
addition, interruption of routine immunization services poses a major risk for secondary
outbreaks of vaccine preventable diseases (VPD) (iiiRiley, et al. 2020).
In the same vein, health seeking behaviors for essential services is equally affected as such
outbreaks bring along fear and anxieties among the general populace including the Health Care
Workers ( iv WHO, 2020). With restrictions on travel and gatherings, health facilities
with limited infection prevention supplies and unreliable infection control practices,
and disrupted outreach and community health workers routines threaten to exacerbate limited
access to care and negatively impact women and children’s health (vGlobal Health, 2020). This
requires undivided attention for health systems response to ensure non disruption of routine
essential services.
The COVID -19 pandemic is claiming lives across the globe and causing disruption to the
delivery of primary health care services including essential services affecting the most
vulnerable groups like women and children. While the Novel Coronavirus Disease (COVID -19)
will increase mortality due to the virus, it is also likely to increase maternal and neonatal
mortality indirectly. A critical concern is the interruption of routine maternal and childhood
Services for Science and Education – United Kingdom 2

Syakayuwa, T., & Chansa, R. (2022). Health Systems Response to Routine Maternal and Child Health Service Delivery Amidst COVID -19 Pandemic
at Kanyama 1st Level Hospital - Lusaka District. British Journal of Healthcare and Medical Research, 9(3). 1-58.
immunization services that need to be sustained while addressing the direct effects of the
pandemic (viClara M, (2020).
There is need to sustain the standard maternal and child health services as recommended by
the MOH-Zambia (2018) in the ANC guidelines for a positive pregnancy experience. The
integrated ANC package comprises of a mix of known effective interventions that are linked to
other services in order to safeguard and prioritize the health and wellbeing of the pregnant
person and growing foetus. Facility level operationalization of the integrated ANC package
requires scaling up of eight (8) key areas of ANC service delivery. These include: - 1. ANC service
provision; 2. Community engagement; 3. Organization of ANC services; 4. Essential practices in
ANC; 5. Ailment Prevention; 6. Nutrition; 7. Complication management; and 8. ANC monitoring
and evaluation systems. Each ANC contact comprises of three key elements:
(i) Health Information: Provision of relevant and timely ANC information ,(ii)Medical
Assessment: Implementation of effective clinical practices (including interventions and tests)
(iii)Intra-personal Support: Provision of psychosocial and emotional support Health system
strengthening interventions, such as staff training, and improving equipment, transport,
supplies, etc. to support the home visits (At least one home visit should be conducted during
the pregnancy).(iv)Group spaces to hold meetings (Offering women a range of opportunities
for communication and support, so that their individual preferences and circumstances can be
catered for) (v) Resources, e.g. additional community volunteers, transport and budget for
material, for community MCH outreach activities(vi)Incorporate ANC outreach into existing
community outreach programmes (e.g. Child health) (vii) A minimum of eight (8) ANC contacts
are recommended throughout the pregnancy period. This allows for an active engagement
between the pregnant woman and health care provider and facilitates increased maternal and
fetal monitoring and assessments to support a healthy pregnancy and early detection of
problems.
In Sub Saharan Africa which includes mostly low- and middle-income countries, the impact of
containment and preparedness policies on maternal and child health could be more
pronounced following the COVID -19 outbreak. Even before the emergence of COVID -19, high-
quality and timely maternal and child healthcare services were inadequately and or
unavailable, inaccessible, or unaffordable for millions of women (viiClara M, (2020).
In response to the pandemic, the World Health Organization (WHO) declared COVID -19 as a
global public health emergency of international concern (PHEIC) on 30 January 2020. For
example, experience from the Ebola and HIV / AIDS outbreak shows that essential services
were disrupted that included logistics and distribution of healthcare workers to sustain
continuity of essential services that including maternal and child health services. For example,
the 2014 Ebola outbreak in West Africa recorded a decline of service utilization by 27% and
inpatient care by 44%. This was as a result in disruption of essential routine services that also
includes maternal and child health services. During the Ebola epidemic in West Africa in 2014–
2016, the use of reproductive and maternal healthcare services plummeted so much that
maternal and neonatal deaths and stillbirths indirectly caused by the epidemic outnumbered
direct Ebola-related deaths. Women were unable to access family planning, completed fewer
antenatal care visits, and were more likely to give birth at home. Some of these women stopped
going to facilities due to fear of infection and increased physical and financial barriers. Others
URL: http://dx.doi.org/10.14738/jbemi.93.12263
3
were denied care if they were suspected of having Ebola as many facilities were not equipped
to provide maternal healthcare to infected women. (viiiEmanuel et al. 2020).
Zambia, being part of the Sub – Saharan Africa is among the middle-income countries and has
the highest fertility rate in Africa with an average fertility rate of 6 children and approximately
2,062 births per day. In 2018, the maternal mortality rate was 183 deaths per 100,000 live
births. To date, only 68 percent of children in Zambia are fully immunized (ixUnited Nations,
2020). Therefore, continuity of essential service delivery amidst the COVID -19 pandemic is
critical in mitigating the risk of system collapse in provision of essential services such as routine
maternal and child health services.
Figure Error! No text of specified style in document.-1.1: Location of study area. (Extract google
map of Lusaka from www.googlemaps.com)
In this vein, like most Countries, Zambia health system has negatively been impacted due to the
COVID -19 pandemic following the escalating cases of COVID -19 Zambia is recording each day
with a positivity rate at about 12% per day bringing the current cases as of August 30th standing
at 12,025, of which over 100 are healthcare workers infected, with about 95 COVID -19 deaths
and 192 COVID -19 related deaths (xMOH, 2020). This has fostered re-organization of health
systems to effectively respond to the problem. As such, Zambia has adopted the WHO
guidelines, which included partial lockdown, scaling up screening centers, setting up public
health teams to respond to alerts, securing quarantine centers and follow ups through contact
tracing to ensure effective detection and timely management (xiWHO, 2020). Furthermore, by
May 2020, the Government through the Ministry of Health, and its cooperating partners put in
place the “General Guidance on Provision of Essential Services Amidst the Pandemic''.

This move is important to sustain the gains the country has made in achieving preventable
maternal and child morbidity and mortality and many other preventable diseases as the impact
of COVID -19 can easily erode some of these hard-won gains (xiiMOH, 2020). It is thus imperative
that the Ministry of Health continue to make strides to ensure continuity of essential services
to maintain the gains achieved this far by putting in place a functional and resilient health-care
delivery system that meets the needs of vulnerable groups including women and children under
5 years.
The study was undertaken at Kanyama level one hospital located in the West of Lusaka
province. The facility has a catchment area of over 500,000 inhabitants and it is one of the
highest populated settlements in Zambia. As a referral hospital, it is the only 1st level hospital
in Zambia that records high birth rates of over 20 deliveries in a day. The facility has
approximately 32,032, women of childbearing age (18-49 yrs.), Expected Pregnancy: 7,863,
Expected Deliveries: 7,571 and Expected Live Births: 7,280 (xiiixivMOH, 2018).
MCH is particularly concerning because of the actual situation in Kanyama is highly populated
and there is a mismatched between the number of people and the available health services: a
lot of women still deliver at home without skilled health personnel (doctors, nurses and
midwives) or in crowded clinics not well equipped, putting into risk their own lives and of the
newborns.
With increasing numbers of the COVID -19 cases, there was urgent need to understand the
influence of COVID -19 on delivery of routine maternal and child services including access and
utilization, how the health system has responded to continue provision of essential maternal
and child health services amidst the pandemic require proper documentation for effective scale
up of best practices for the present and future outbreaks.
Statement of the problem

Zambia like many other countries may not have been spared by the impact of COVID -19 on
provision, access and utilization of essential services affecting the most vulnerable groups in
society such as mothers and children. Therefore, disruption in routine provision of critical
lifesaving services such as routine Antenatal Care (ANC) and Postnatal Care (PNC), Child
immunizations, nutrition and family planning services may have huge effects on these
populations (WHO, 2020). This spotlight on continuation of essential routine services
highlights the importance of routine maternal and child health systems response and calls to
question the preparedness of health systems in the country (xvDarmstadt et al, 2005). Since
some services such as ANC, PNC and immunization have limited virtual options, therefore, even
amidst the pandemic delivery of these services should continue to be prioritized as lives of
mothers and children depend on these services. In order to have a component of generalization
of the results, Kanyama 1st level Hospital was chosen as the study area because first of all it’s a
referral hospital. Secondly because of its huge population to the extent that they deliver in
crowded clinics, not well equipped, and waist still some even deliver at home without skilled
health personnel (doctors, nurses and midwives), putting at risk their own lives and of the
newborns. The health facility records over 20 deliveries per 24 hours approximately 32,032,
women of childbearing age (18-49 yrs.), Expected Pregnancy: 7,863, Expected Deliveries:
7,571 and Expected Live Births: 7,280 (MOH, 2020).
5
It is thus important that all pregnant women attend the recommended 4 ANC plus sessions for
a health pregnancy, have access to family planning upon delivery and her child be fully
immunized by the end of the first birthday even amidst the pandemic. However, disruption of
such essential services may lead to losing millions of mothers and children to preventable and
treatable diseases and conditions and not necessarily the pandemic (Clara M, (2020)
It is for this reason that the researcher undertook this study to explore and measure the urgent
need to understand how the health systems have responded to effectively, efficiently, and
equitable sustain routine service delivery of maternal and child health services informed by
evidence from the end user’s experience. This research is thus important as from experience
most of the research being undertaken on COVID -19 are focusing on epidemiology and clinical
trials and not necessarily the impact of and sustainability of essential routine services of MCH
on the vulnerable groups amidst COVID - 19.
Significance of the study

Although some countries have reported evidence on health systems response in sustaining
delivery of essential maternal and child health services, In Zambia, documentation is limited to
the MOH general guidance on continuity of essential services amidst the COVID -19 pandemic
with limited documentation focusing on practical health systems response on continuation of
essential routine maternal and child health services.
Furthermore, the general guidelines are limited to outlining what should be done with limited
documentation on how it should be done. Health systems practical tools to guide how service
delivery for routine maternal and child health services should continue to meet the needs of the
end user are not available and or not well documented in the MOH general guidance on
provision of essential services amidst the COVID -19. However, the WHO guidelines on
maintaining essential health services: operational guidance for the COVID -19 context has
described how these services should continue to be provided. It was thus important to
understand to what extent has Zambia operationalized this guidance, what are the best
practices and what gaps exist and what can be done to bridge the gaps, in addition to
understanding health seeking behaviors catalysts by fears, anxieties, myths and misconception
surrounding the pandemic.
Therefore, findings from the study will enhance evidence -based planning, redesigning, and
developing responsive strategies to guide practical delivery of routine maternal and child
health services for the Ministry of Health and its Cooperating Partners amidst pandemics. The
findings will inform the current and future epidemics too, hence averting preventable
morbidity and mortality during pandemics.
Conceptual Framework
The Framework for indirect effects of COVID -19 Pandemic adopted from the Global Health Live
Saving Tools was utilized to hypothesize inquiry on how the health systems have responded in
continuation of delivery of essential routine maternal and child health services amidst the
COVID -19 pandemic. One catchy thing about this framework is that it mirrors well with the
WHO six building blocks framework that describes the main pillars for a functional health
system. These Framework for the indirect effects of COVID -19 Pandemic includes the following
six key areas: (i) Availability of health workforce, (ii) supplies and equipment, (iii) provision of
health services, (iv) demand, (v) access, and (vi) utilization of health services. The framework
outlines the linkage of essential functions of a health system that factors access, coverage,
utilization, and quality service provision. As described in figure 1 below:
Figure 1.2: Framework for indirect effects of the pandemic
It is a known fact that a resilient health system is a prerequisite for reduction in disease burden
including maternal and child health morbidity and mortality. This requires re-organization of
health systems to effectively respond to the problem at hand (xviWHO, 2007). Suffice to mention
that in developing countries like Zambia, health systems are fragile and require a responsive
strategy to sustain provision of essential services that mostly affect the most vulnerable like
women and children. Health systems are vulnerable to external pressure as well which may
affect functionality to the extent of complete collapse if no practical evidence-based
interventions are put in place beyond the general guidelines (xviiFridell et. al. 2019).
In line with the framework above, the researcher wanted to establish how the health systems
has responded in continuation of provision of essential MCH services amidst the COVID-19
pandemics with focus on:
Availability of health workforce

Kanyama 1st level hospital has lot of women, has approximately 32,032 in the childbearing age
(18-49 yrs.); of which 7,863 are expected Pregnancy: 7,571 are expected Deliveries: and
Expected Live Births of about 7,280 (DHIS, 2020). Although the women are expected to deliver
from the health facility, most of them still deliver in their homes without skilled health
personnel health personnel (doctors, nurses and midwives) to be in attendance. As a referral
hospital, it is the only 1st level hospital in Zambia that records high birth rates of over 20
deliveries in 24 hours. A facility with such a high rate of births operates at 50% of its workforce
7
according to the Ministry of Health. How can it continue to effectively deliver essential services
of MCH to the expected standards if not overstretching the 50% of its work force beyond its
capacity with the coming in of thee Covid 19 pandemic demanding its full attention?
Supplies and equipment

The facility has a catchment population of over 500,000 inhabitants and it is one of the highest
populated settlements in Zambia. With reference to the number of birth per 24 hours above,
other women who deliver in homes, in other crowded clinics not well stocked with medical
supplies, not well equipped necessary equipment and with inadequate essential supplies such
as ferrous, folic acids, Fansidar and, BP machines may be risking their own lives and of the
newborns.
It can thus be concluded that Health systems can only function well with availability of health
workforce, adequate supplies, and equipment. This will make public health facilities provide
health services even amidst COVID-19 and other pandemics.
Provision of Health Services (Access)

Access to MNCH services is cardinal to save the lives of mothers and children. During
pandemics, a lot of myths and misconception are fueled and may inhibit access to MNCH
services. As such, increasing access points that should be brought to as close to the community
as possible through outreach services. It was imperative to understand what strategies were
put in place to scale up access for MNCH services.
Provision of Health Services (Demand Creation)

To sustain championing of essential services such as MCH services amidst pandemics. It is
important to put in place demand creation initiatives for effective health promotion. Effective
communication is vital to overrule myths and misconception that may impede uptake of health
services. This initiative should be tailored to the needs of the community and be sensitive
culture and social demands. A mix media approach is important to facilitate effective
communication. Other countries such as Sierra Leone and Bangladesh scaled up daily COVID -
19 situation update through TV with specific message on IPC, immunization, nutrition, and child
care; Development of communication materials for immunization and MNCH service utilization
during COVID; Utilization of traditional methods of communication–IPC by community level
health care provider, milking on immunization day at outreach vaccination center, increase in
call centers and number of doctors voluntarily providing hot lines for counselling services.
What then has the facility put in place to scale up demand creation of MNCH services even
during the COVID-19 pandemic?
Utilization of health services

Scaling up maternal and child health services utilization amidst pandemics, old (that still hold
value to the pandemic, and new measures should be put in place to sustain demand and access
to essential health services. This is imperative to override reduced coverage of health
interventions that may ultimately lead to increased maternal and child mortality if not tackled
well. It is thus imperative to continue MCH service provision amidst pandemics as women who
will remain healthy during pregnancy and after birth are more likely to stay healthy later in life
and have better birth outcomes, influencing infancy, childhood, and adulthood normal growth
(xviiiWHO, 2017).
Thus, there was a need to investigate and establish practical interventions that the health
systems in the country have put in place to withstand pressure amidst the pandemic and most
importantly continuation in the provision of routine antenatal care (ANC), a service which has
limited options for virtual implementation as an alternative.
General Objectives
To explore the health system response to routine maternal and child health services amidst the
COVID -19 pandemic at Kanyama 1st Level Hospital
Specific Objectives
a) To establish awareness of COVID-19 practices among mothers accessing ANC and PNC
b) To understand health seeking behaviors for routine ANC and PNC services in the wake of
COVID -19.
c) To identify mitigating factors put in place to ensure continuation of routine Maternal and
Child health services following the COVID -19 pandemic
Research Questions
a) Are the ANC/PNC mothers aware of the COVID -19 practices?
b) What are the health seeking behaviours’ for ANC and PNC mothers for service utilization
amidst the COVID -19 pandemic at Kanyama 1st level Hospital?
Operational Definition of Terms

Maternal Health: refers to antenatal care (ANC) given to women during pregnancy with the
overall aim of ensuring good health for both the mother and the unborn child.
Child Health: refers to fully adherence of ANC services for good health of the unborn child up
to postpartum period
Health Services: refers to routine ANC and child health service provision in the postpartum
period routine ANC and child health services within the postpartum period.
Health Systems: organizations, institutions and resources devoted to improving and
sustaining routine ANC and child health services within the postpartum period.
Access: refers to availability of routine maternal and child health services amidst the COVID -
19 pandemic with supporting health workface, supplies and equipment.
Utilization: refers demand and access to routine maternal and child health services even
amidst the pandemic.
Knowledge: refers to the mother’s awareness of importance and availability of routine
maternal and child health services amidst the COVID -19 pandemic. It further refers to mother’s
awareness on COVID -19 transmission and prevention.
LITERATURE REVIEW
Health seeking behaviors for ANC and PNC mothers for service utilization amidst the
COVID -19 pandemic at Kanyama 1st level Hospital?
Health behavior includes all behaviors associated with establishing and maintaining a healthy
physical and mental state (WHO, 1995). Health seeking behaviors are important for mothers
and their children to access timely health services support and treatment. However, there are
many factors that influence an individual to practice early seeking behaviors. These include but
are not limited to socio demographic characteristics discussed in the previous section in
9
addition to one’s knowledge and attitude. This section will thus discuss the health seeking
behaviors for routine ANC associated with knowledge, attitude, and practice.
Knowledge, Attitude, and practice towards using routine ANC services

They say knowledge is power; it enables individuals to make informed decisions about their
health. Globally, studies have shown that women who have the knowledge about the
importance of ANC, their early seeking behaviors and completion of ANC visits is higher
compared to women who have less knowledge about the importance of ANC services. A study
conducted in South Asia (xixPatel, et al. (2016), “on knowledge and practices of antenatal care
among pregnant women attending antenatal clinic at a Tertiary Care Hospital of Pune,
Maharashtr xx a”, revealed that about 58% women had adequate knowledge regarding ANC.
However, 100% of women had a positive attitude towards ANC. Around 70%, women were
practicing adequately, and variables such as education and SES had a significant association
with practices about ANC. Overall, the still higher proportion of (41.9%) of pregnant women
has inadequate knowledge, and about one-third of study participants have poorly practiced
ANC care. Their knowledge on certain aspects of ANC were still poor, especially regarding the
importance of early antenatal check-up, health screening and complications related to diabetes
and hypertension in pregnancy.
In Malaysia, (Asia) a study on “Knowledge, Attitude and Practice on Antenatal care among orang
Asli women in Jempol, Negeri Sembilan” was conducted. It was discovered that pregnant
women’s level of knowledge of the importance of ANC, screening tests, and complications of
diabetes and hypertension during pregnancy was poor and this affected their health seeking
behaviors (xxiRosalia and Muhamad, 2011).
Utilization
Studies conducted across the sub-Saharan Africa (xxiiOkedo, et al. 2019) involving 74 studies in
a report titled “Determinants of antenatal care utilization in sub-Saharan Africa: a systematic
review “, revealed the following, with regards to attitude and perception, Women who
considered pregnancy a risky event were more likely to use ANC than those who considered it
risk free. Women who had a good attitude towards maternal health were twice more likely to
attend ANC compared with those with a poor attitude.
Another compounding factor affecting access and utilization of ANC services is distance. Many
studies have shown that distance of more than 5 KMs limits pregnant women access to health
facilities. The WHO recommends that in every 5 KMs there should be a health facility. However,
many countries especially those in developing countries do not meet those recommended
standards. For example, (xxiiiYamashita and Kunkel, 2010) a study conducted in the United
States “The association between heart disease mortality and geographic access to hospitals:
County level comparisons in Ohio, USA”. The study, like many studies, has revealed that general
health care utilization for every kind of service is affected by distance from those services. For
example, in developed countries like the USA, there was a decay effect of the distance on the
health care service utilization, i.e., as the distance increases from the healthcare facilities;
utilization of services was reduced.
In developing countries, including Zambia, in a book written in Geneva “’ Opportunities for

Africa’s new-born; Practical data, policy, and programmatic support for new-born care in
Africa’’. Points out that ANC health promotion has continued to educate women on birth
planning, emergency transportation is one of the significant components of birth planning.
Governments have tried to introduce community ambulances that are managed by the local
communities to bridge the transport gap especially among women who require access to
obstetric care. Studies from Pakistan have found that access to obstetric care depends upon the
transportation system and physical distance between the villages and the centers. The study
further revealed that with huge expenditures and passage of twenty-two years, only 33% of the
rural Pakistani population is living within 5 kilometers (xxivWHO et al. 2010).
xxvShaikh and Hatcher, et al (2005) in a study conducted in Pakistan ‘’Health seeking behaviors
and health service utilization in Pakistan: challenging the policy makers’’. The study revealed
that distance has even been found as a hindrance in seeking care especially in the case of women
who lacks autonomy and needs somebody to accompany her, as a result, the factor of distance
gets strongly adhered to other factors such as the availability of transport, the total cost of travel
and women’s restricted mobility. Therefore, there is a strong association between distance to
the health facility and utilization of services. Long distance to antenatal clinics limits pregnant
women access to health facilities.
However, ( xxvi Nyambe et al. 2015) in a study on factors associated with late antenatal care
booking: population-based observations from the 2007 Zambia demographic and health
survey. The study found that distance is not among barriers women faced in accessing health
care, it was expected that distance to health facilities would be significant, but contrary to that,
distance was insignificant at both univariate and adjusted logistic regression analysis. What
appeared to be significant were women who had problems in getting money for treatment and
women who were concerned that there might be no drugs at the facility. Women who had no
problems getting money for treatment were 36 percent less likely to book for ANC late. Those
women who thought non-availability of drugs at the health facility was not a big problem were
1.26 times more likely to book late.
A study carried out in New Zealand titled “Barriers to early initiation of antenatal care in a
multi-ethnic sample in South Auckland, New Zealand”. The studies revealed that distance was
found not to be among barriers women faced in accessing health care, it was expected that
distance to health facilities would be significant, but contrary to that, distance was insignificant
at both univariate and adjusted logistic regression analysis. What appeared to be significant
were women who had problems in getting money for treatment and women who were
concerned that there might be no drugs at the facility. Women who had no problems getting
money for treatment were 36 percent less likely to book for ANC late. Those women who
thought non-availability of drugs at the health facility was not a big problem were 1.26 times
more likely to book late. The study thus concludes that Late booking for antenatal care in the
Counties Manukau District Health Board area (South Auckland) is associated with
sociodemographic factors, social deprivation, and inadequate social support (xxviiCorbett and
Chelimo, 2014)
11
Mitigating factors public health facilities put into place to ensure continuation of routine
MCH services following the COVID -19 pandemic
Mitigating factors are dependent on the six building blocks of the health care systems
framework that describes the main pillars for a functional health system; and or the six-key
area, namely: Availability of health workforce, supplies and equipment, provision of health
services, demand, access, and utilization of health services. This will outline the linkage of
essential functions of a health system that factors access, coverage, utilization, and quality
Health Systems Strengthening: Availability of Health Workforce, Supplies, Logistics

xxviii AED et al. (2010) in a handbook completed with efforts from various organizations
including the United Nations bodies in Geneva ‘’Opportunities for Africa’s New-born’. The
report indicated that a new analysis conducted suggests that if 90 percent of women received
ANC, up to 14 percent, 160,000 more new-born lives could be saved in Africa compared with
other components of maternal, new-born, and child health (MNCH) packages such as childbirth
and postnatal care, the additional lives saved is fewer. This is partly because ANC already has
relatively high coverage and saves many lives already, so the gap between current coverage and
full coverage is smaller. However, the benefits of ANC are greater than mortality reduction
alone, and given the relatively low cost of ANC, this package is among the most cost effective of
any public health package.
Furthermore, ( xxix Roberton et al. 2020) A global modelling analysis study conducted in the
United States on “Early estimates of the indirect effects of the COVID -19 pandemic on maternal
and child mortality in low-income and middle-income countries: a modelling study’’. The study
reviews that, due to the pandemic, there is a reduced availability of health workers, supplies,
and equipment, while simultaneously a higher demand for health services. This disruption
heightens risks, leading to a potential increase in maternal mortality of 8 to 39 percent and in
child mortality of 10 to 45 percent. Within six months, the world could see up to an additional
57,000 maternal and 1.2 million child deaths.
A study conducted in Northern Ghana on ‘’exploring the Determinants of Antenatal Care

Services Uptake: A Qualitative Study among Women in a Rural Community in Northern Ghana’’.
He argues that a similar pattern is expected with COVID -19 if health systems response does not
put in place timely measures to overcome service provision. It is evident that the pandemic and
the response to the pandemic are affecting both the provision and utilization of reproductive,
maternal, new-born, and child health (RMNCH) services. Amid the pandemic, health workers,
equipment, and facilities have been reassigned to address the influx of patients with COVID -19
(xxxTi-enkawol, et al., 2019).
In an article titled; “Reasons for late presentation for antenatal care, healthcare providers’
perspective” in Gauteng, South Africa, the study revealed that Health infrastructure and system
failures such as limited dedicated spaces for confidential counselling, shortages of equipment
and drugs, and large patient to healthcare provider ratios are important deterrents for patients
and causes of frustrations for both pregnant women and healthcare providers. Healthcare
providers expressed their acute need for additional personnel, especially counsellors during
night shifts, to cope with the many required tasks. Healthcare workers admitted that women
endured long waiting times and were sometimes turned away because of limited staff to see to

all patients. In some cases, clinics imposed daily quotas and turned away women who came
after the quota was reached (Jinga, et. Al., 2019).xxxi
The “UN Appeal '' states that, Zambia is of no exception to this impact, the health system is also
expected to come under severe stress with human resource, essential health commodities and
supplies being diverted to support COVID -19 response. In addition to countries directing
frontline health care workers to respond to COVID -19 pandemic, like many countries, Zambia
has seen an increase in the number of healthcare workers infected by the COVID -19 virus
resulting in shortage of essential frontline healthcare workers. As part of infection control
measures, Health Care Workers must go through quarantine for a period of not less than two
weeks (xxxiiUnited Nations, 2020).
Suffice to mention that even before the COVID -19, Zambia had a smaller number of Health Care
workers required to meet the patient to Health Care Worker ratio. This has resonated in
impacting the availability of essential health service delivery, especially health services for
pregnant women and new-born that cannot be delayed or shifted to other settings.
UNICEF in the WHO COVID -19 guidelines competed in Geneva on ‘’maintaining essential health
services: operational guidance for the COVID -19 context’’. argues that many countries face
health workforce challenges, including shortages, maldistribution and misalignment between
population health needs and health worker competencies. Additional factors may limit the
availability of health workers to deliver essential services during the pandemic, including the
redistribution of staff to treat increasing numbers of patients with COVID -19 and the loss of
staff who may be quarantined, infected, or required to care for friends and family. The
combination of increased workload and a reduced number of health workers is expected to
severely strain the capacity to maintain essential services, and it will particularly impact
women, who make up most of the health workforce. These predictable challenges should be
offset through a combination of strategies, including recruitment, repurposing within the limits
of training and skills, redistributing roles among health workers, while keeping health workers
safe and providing mental health and psychosocial support.
Service Delivery
A study conducted in West Africa on ‘’Mortality, morbidity and health-seeking behavior during
the Ebola epidemic 2014–2015 in Monrovia results from a mobile phone survey’’. The study
reveals that during the time of the Ebola outbreak in West Africa, Poor health seeking behaviors
for conditions other than the epidemic from public health facilities has also been reported. Low
utilization of services by the general population lead to under-diagnosis and no treatment of
diseases, thus leading to complications and higher disease (xxxiiiKuehne, et. al. 2015).
The xxxiv World Health Organization COVID -19 guidelines completed in Geneva in 2020
‘’Maintaining essential health services: operational guidance for the COVID -19 context’’ states
that, it is a known fact that among the general populace, the ongoing COVID -19 pandemic is
inducing fear and anxieties, which may be influencing health seeking behaviors and service
delivery even for essential regular maternal and child health services. Due to an increase in the
number of health care workers being infected with the virus, this has induced fear that hospitals
and health care workers are agents of the virus, this may affect utilization and demand for
essential services.
13
Factors associated with limited access to routine ANC during the COVID -19 pandemic
In the Maternal and New-born Health Disparities Report issued by (xxxvUNICEF, 2018) reviews
that several researchers who conducted research in Africa including Zambia indicate that
demographic characteristics play a role in access and utilization of ANC services and that
inequity in ANC persists. The report indicates that the better educated the mother is, the more
likely she will receive critical maternal health services and higher percentage of deliveries
having a skilled birth attendant relative to the mother’s level of education. This equally applies
to other variables such as age, marital status, occupation, and socio-economic status.
Furthermore, a study conducted in South Asia (Maharashtra) by ( xxxviPatel, et. al. 2016) “A
study on knowledge and practices of antenatal care among pregnant women attending
antenatal clinic at a Tertiary Care Hospital of Pune, Maharashtra”, it was found that almost all
the variables such as age, education, occupation, marital status, parity, type of family, and
socioeconomic status (SES) had a significant association with awareness about ANC.
In another study conducted in Cambodia on “Sociodemographic characteristics associated with

the utilization of maternal health services in Cambodia”. The study revealed that important
demographic, socioeconomic and geographic disparities were observed in the utilization of
ANC. Urban residency, having better educational status, white collar job, access to electronic
media showed positive association, whereas higher parity (having > 2 children) and unwanted
pregnancy showed negative association with the use of maternal healthcare services. Having at
least four ANC visits was associated with significantly increased higher odds of using health
facility delivery and postnatal care (xxxviiZhou, et. al. 2020).
A global analysis report “A Review of Progress in Maternal Health in Eastern Europe and Central
Asia’’ revealed that; in many countries (including Albania, Bulgaria, Georgia, Kazakhstan,
Kyrgyzstan, Romania, Tajikistan and Turkey) there are variations in antenatal care and
attended deliveries due to rural locations, education, age and/or socio-economic status. Roma
women tend to have lower access and usage in all relevant countries included in this review
(xxxviiiUNFPA, 2009).
A study conducted in Africa , in the maternal and newborn disparities report further revealed
that most of the countries in sub Saharan African present a similar picture, for example in 81
percent of mothers with a secondary or higher education made at least four ANC visits,
compared to only 64 percent of mothers with no education, Only 30 percent of deliveries among
mothers with no education had a skilled attendant at birth, compared to 56 percent of deliveries
among mothers with primary education and 83 percent of deliveries among mothers with a
secondary or higher education ( UNICEF, 2018).
Furthermore, studies conducted across the sub-Saharan Africa complied by (xxxixOkedo, et. al.
2019) involving 74 studies in a report titled “Determinants of antenatal care utilization in sub-
Saharan Africa: a systematic review “, revealed the following, in 19 studies, the relationship
between maternal education and overall uptake of ANC was reported. The lack of formal
education and lower educational levels were predictors of poor ANC use among women in these
studies. However, another study was conducted in Nigeria. “Socioeconomic factors contributing
to exclusion of women from maternal health benefit in Abuja, Nigeria”, found that more

educated women were less likely to use ANC from skilled medical providers (xlOyewale and
Mavundia, 2013).
The maternal and new-born disparities report (UNICEF, 2018) indicated that in the Central
Africa Republic only 26% of mothers in the poorest households have 4 Antenatal Care visits
compared to 62% of mothers in the richest households. In Ethiopia, only 2% of deliveries in the
poorest households had a skilled attendant at birth, compared to 46% of deliveries in the
richest households. In Malawi, 83% of deliveries in the poorest households have a skilled
attendant at birth compared to 95% of deliveries in the richest households. While in another
study (Okedo, et. al. 2019) involving 74 studies in a report titled “Determinants of antenatal
care utilization in sub-Saharan Africa: a systematic review. The results indicated that there was
a higher odd of inadequacy in ANC visits among women who engaged in sales/business,
agriculture, skilled manual, and other jobs when compared with women who currently do not
work.
The picture is quite similar as of Zambia. in the maternal and new-born disparities report
(UNICEF, 2018) argues that in Zambia, the better educated the mother is, the more likely she
will receive critical maternal health services. For example, by mother’s education, only 46
percent of deliveries among mothers with no education had a skilled attendant at birth,
compared to 57 percent of deliveries among mothers with primary education and 96 percent
of deliveries among mothers with a higher education. In terms of income, only 45 percent of
deliveries in the poorest households had a skilled attendant at birth, compared to 94 percent of
deliveries among the richest households, 20 percent of new-born in the richest households
receive PNC within 2 days after birth.
xli Tarekegn, et al, (2014) in a study conducted in Ethiopia “Antenatal care and women's
decision-making power as determinants of institutional delivery in rural area of Western
Ethiopia “, concluded that a variety of predisposing, enabling and need factors affect ANC
utilization in sub-Saharan Africa. Intersectoral collaboration to promote female education and
empowerment, improve geographical access and strengthened implementation of ANC policies
with active community participation are recommended.
Summary
The Literature has revealed the importance of mothers accessing and utilizing ANC services
even amidst pandemics like COVID -19. These are life saving strategies and the lives of mothers
and children depend on them. Available literature has shown low utilization of ANC services
even before the COVID -19 pandemic. It is of no doubt that Women and their families need more
support to appreciate and understand the benefits of accessing and utilizing routine ANC
services even amidst outbreaks. Literature has also discussed the need for health systems
response to continue providing these essential services amidst the pandemic. This is important
to ensure that the gains attained on maternal and child health programs this far are not eroded
due to the pandemic. If health systems are not organized effectively and efficiently to sustain
provision of these essential services, many mothers and children may die from preventable
diseases. However, critics have also revealed that most goals and targets set up are over
ambiguous and governments fall to fulfill them, hence, they remain to be mere
pronouncements.
15
Therefore, the need for a responsive health system that ensures both the supply and demand
side cannot be overemphasized. However, to what extent has countries like Zambia adopted
these recommendations to ensure non disruption of essential services like ANC and PNC
including lessons learnt are yet to be well documented. Influence of COVID -19 on health
seeking behaviour for regular maternal health services and socio-demographics are not well
understood. These and many more factors related to health systems (HS) response in
continuation of essential maternal and child health services such as availability of health
workforce, supplies and equipment, service delivery (finances, technology) that trigger
demand, access, and utilization of health services was the focus of this research.
METHODOLOGY
Research Design
Qualitative research methods were used to ascertain Health Systems Response to Routine
Maternal and Child Health Service Delivery amidst the Covid-19 Pandemic; and to determine
any changes in the supply and demand of the MNCH services in line with the WHO six building
blocks. Data was collected using topic guides and analyzed manually by transcribing and coding
it. Sample size for participants were selected using simple random sampling on ANC/ PNC,
while the three categories of key informants were purposefully selected. The indirect effects of
COVID-19 pandemic framework which mirrors the WHO six building blocks adopted from the
Global Health Life Saving Tools was used to analyze the health system’s readiness amidst the
COVID-19 pandemic.
Study Area
The study took place at Kanyama 1st Level Hospital in Lusaka District located – West of Lusaka
Province. The Hospital offers services to a population approximately over 500, 000 and it is one
of the highest populated settlements in Zambia. As a referral hospital, it is the only 1st level
hospital in Zambia that records high birth rates of over 20 deliveries in a day. The facility has
approximately 32,032, women of childbearing age (15 to 49 yrs.). According to the 2020
Demographic Health Information Services the expected pregnancy was 7, 863. The expected
deliveries were 7,571 and the expected Live Births were 7, 280 (DHIS, 2020).
Study / target Population

The study population were mothers in the childbearing age between (18 – 49 years) and
pregnant. While the target population were mothers between the age 18 to 49 years who are
pregnant and in their 3rd trimester, not in labour but delivered and or in their postpartum
period; from which our sample size was drawn to get the views of the end users. The study also
targeted the service providers which included the frontline health care workers working at
Kanyama 1st level hospital in the MCH department specifically working in the antenatal care
clinic, labor ward (as they monitor the post-natal mother in the first hour after delivery) and
the post-natal clinic (midwives and nurses attending to the 6 days and 6 weeks post delivered
women and their babies) and other key informants at community level and as well as at MoH
provincial and central level working on maternal and child health programs. The sample size
for this research was as follows: 16 ANC/PNC mothers, 8 frontline health care workers, 8
community health workers and 4 central policy makers as key informants. The total is 36
participants were involved in the interview and exposed to FGD.

Sample selection
The study employed a qualitative approach and qualitative data was collected using focus group
discussions. In total there were five FGD conducted; two with the mothers (PNC and ANC) and
one from each category of the Frontline Health Care Workers, Community Health Care Workers
and Policy Makers as key informants as detailed below:
a) FGDs with ANC/PNC Mothers
The researcher sampled 16 mothers from the ANC and PNC registers using a simple random
sampling to give an equal chance of all mothers to be selected into the sample, and categories
such as age, and educational status were factored to have a representative sample at the
recruitment/screening stage. The 16 mothers were considered for Focused Group Discussion
(FGD) as follows:
Mothers aged between 18 to 49 years (Pregnant and or lactating – in the postpartum period)
were targeted using a simple random draw; and eight (8) mothers were picked to represent the
two categories of the FGD as follows: (i) One FGD with pregnant mothers in the 3rd to 4th
trimesters (ii) One FGD with mothers in the postpartum period to investigate health seeking
behaviors.
FGDs with Frontline Health Care Workers, Policy Makers and Community Health
Workers as second focus group discussion for eight (8) health care workers from the MCH
department at Kanyama 1st level hospital from the ANC Clinic, Labor ward and Postnatal Clinic.
The third FGD was for key informants from CHWs eight (8) working at MCH based in Kanyama
linking the community and the health facility for MCH activities ; and fourth were (4) Policy
makers interviews involving provincial and central level MoH staffs who were purposefully
selected to identify mitigating factors put in place to ensure continuation of routine MCH
services as follows in line with the WHO six blocks as follows: (i) Key informant interviews
involving provincial level and central level MoH staff who are policy makers ( 4 staff ) (ii) One
b) FGDs with frontline health care workers from the MCH department at Kanyama 1st level
hospital from the ANC Clinic, Labor ward and Postnatal Clinic (8 staff). (iii) One key informant
FGDs with community health workers based in Kanyama working on MCH activities (8 CHWs).
The community health workers were included in the study as they are a link between the
community and the health facility, as such, it was cardinal to include their experiences and
views on continuation of provision of essential services amidst the COVID-19 pandemic. These
hold registers in the community and help in following ups on mothers who miss appointments
because of sickness and report to the health facility so that the mothers can be fetched or
referred. The MOH general guidance on provision of essential services amidst the COVID-19
pandemic clearly stipulates that community level is an integral platform for primary health care
and is key to the delivery of services and thus the reason for inclusion to get the first had
information at community level (these are the eyes for HCW and Policy makers).
CHW are also needed for essential public health functions, and to the engagement and
empowerment of communities in relation to their health. As there is need to Leverage and
strengthen the community platform as an integral part of primary health care to ensure an
effective COVID-19 response such as engaging with community stakeholders to identify and
address barriers to access caused by stay-at-home policies, concerns about risk of infection in
health facilities and other factors.
17
The FGD with frontline health care workers and the key informant’s interviews covered the six
(6) health systems building blocks namely service delivery, finance, health workforce,
governance and leadership, information and medicines, suppliers, vaccines, and technologies.
The methods were chosen because it reduces the challenge of time and finances needed to carry
out the research. Therefore, the sampling frame for mothers was drawn from all women of
childbearing age at Kanyama 1st level hospital (15 to 49yrs.) and for the frontline health care
workers the sampling frame was the staff register working in the MCH department.
Inclusion criteria
The sample included women of childbearing age and mothers who met the following criterion:
Are Were residents of Kanyama compound, were present at the time of interview and have been
selected, provided consented to be in the study; pregnant in the 3rd to 4th trimester and or
lactating mothers in the postpartum period ; frontline health care workers working at Kanyama
1st level hospital in the MCH department, health management personnel at provincial and
national level, and community health workers based in Kanyama engaged in working on MCH
activities.
Exclusion criteria
Mentally retarded, terminally ill and cannot speak, Pregnant women in their 1st and 2nd
trimester (because of timeline), women experiencing labor pains and cannot speak and those
who didn’t have non consented to participate in the study. Pregnant or lactating mothers aged
17 years and below.
Pilot Study
In this study, the pilot study was conducted at Chipata 1st Level Hospital within Lusaka District.
The hospital was chosen because it has similar characteristics to the research settings that have
been included in the study. The pilot study constituted 10% of the sample size from each of the
categories. The pilot study helped to correct errors within the data collection tools. Among the
items corrected was to shorten the number of questions in the topic guides, include missing
questions and correct the flow of the questions.
Dissemination of Findings
The researcher will disseminate the study findings by submitting copies of the report to the
following:
● The Medical Library at Cavendish University Zambia
● National Health Research Authority
● Ministry of Health Headquarters
● Lusaka Provincial Health Office
● Lusaka District Medical Office
● Kanyama MCH department
The researcher will also utilize available avenues for wider dissemination such as conferences
and workshops

Ethical and Cultural Consideration

● Ethics clearance was obtained from the Local Research Ethics Committee, ERES-
Converge). Written permission to conduct the study was obtained from the Lusaka
provincial health office and this was presented to authorities at the study site.
● Consent: the research objectives and purpose will be explained in full to the study
participants and or respondents. Verbal and written informed consent were obtained
from all individuals willing to participate. For participants who declined to participate they
were reassured that no privileges will be denied to them. Equally those who consented
were not remunerated.
● Confidentiality and anonymity were maintained, and respondents interviewed in a secure
space to ensure privacy. All subjects who participated in the investigation were assigned
a unique study identification number by the research team and no personal identification
details were collected. After each interview session / FGD session the investigator put all
recordings in a computer with password protected and the data collection tools in a secure
place only accessed by the research team.
● Risks and benefits for subjects
This investigation possessed minimal risk to participants. The primary benefit of the study is
indirect in that data collected will help improve and guide efforts to understand opportunities
and gaps in maintaining service delivery of essential routine maternal and child health services
amidst the pandemics:
• Prevention of COVID -19 infection among the research team and respondents
• In line with the MoH standards, the research team were trained in IPC procedures
(standard, contact, and droplet precautions). These procedures included proper hand
hygiene, and the correct use of surgical masks.
• All study team members including the participants were provided with adequate
personal protective equipment and hand hygiene supplies to protect themselves while
interacting.
• Vehicles at most had only four passengers so that at least one-meter distance can be
maintained, the research team were encouraged to drive with open windows.
• There were no sick team members, but plans were to appropriately triage and strictly
prohibited from participating in data collection.
• Interaction was strict to maintaining social distance space of 1 meter and
participants/respondents who did not have face masks were provided with one.
• The meeting space had open windows for easy air circulation and were possible done in
an open-air space that has adequate privacy.
Data analysis
Data analysis was done manually. At data analysis stage, transcribing was conducted at two
stages that included the third-party reviewers. Data Analysis flow that was employed included:
Audio recording, audio decoding, transcribing, cleaning of data, thematic extraction and the
narrative analysis of the ‘stories’ using an inductive (data-driven) format of data, to allow the
data to speak for itself and then get a conjecture meaning out of it. Transcript drafting and final
write up. Below is the detailed steps undertaken: Step 1: researcher listened to all the
recordings to make sense of the whole information and jotted ideas. Step 2: The researcher
selected what the recordings were all about.
19
Step 3: A list is made of all the themes were clustered together. Step 4: Merging of themes and
codes were done. Step 5: Wording description of themes were done and aligned to objectives
as the main thematic areas. Step 6: The researcher made the final decision and created codes
Step 7: The Researcher proceeded to coded data analysis Step 8: The researcher recodes
existing material if necessary (xliiDe Vos, 1998: 343-344). (The researcher used this step for
code cleaning and aunthentification). And finally, transcription was done using a verbatim
approach. This was done so as to even capture the emotions of the speaker, as depicted in the
speech. (xliiiCreswell 2020) notes that verbatim transcription is where you type every single
word/sound uttered by every participant in an audio recording. For example, this can include
all kinds of non-verbal nods like “um, uh, mm hmm” and filler words like “like, you know, kind
of” etc. along with all repeated words and sentences.
RESARCH FINDINGS
Participant Information for ANC and PNC Mothers
To determine the socio-demographic factors of respondents; the Eight (8) antenatal and Eight
(8) postnatal mothers were interviewed using a screening tool at the recruitment stage to get
an in-depth understanding of the characteristics of the respondents. The ANC mothers’
education level was at (75% six (6) had attended secondary school, while the rest had attended
primary school. Their partners were at fifthly percent (4) for both secondary and primary
school attainment. The PNC mothers was 50% (4) apiece primary and secondary education,
while that of their partners was a combined at 75% (6) who had attained secondary and
university education, while 25% (2) had done primary education.
In order to identify mitigating factors, put in place to ensure continuation of routine Maternal
and Child health services following the COVID -19 pandemic at Kanyama 1st level Hospital, the
key informants (policy makers), health care workers, community health workers and ANC and
PNC mothers were interviewed using the focus group discussions; and the following were the
themes that come up.
Awareness of COVID-19 practices among mothers accessing ANC and PNC services
Knowledge about COVID -19 (symptoms, transmission, and prevention)
Antenatal and postnatal mothers were able to state the signs and symptoms of COVID -19 that
included headache, flu, feverish, high body temperature, body aches, chest pains, failing to
breath, coughing. Most insightful were the views by R2. A 32-year-old female said that the signs
and symptoms of COVID -19 included ‘having Flu, feeling weak and having body pains.’ Two of
the PNC respondents even confessed having flu, headache, and fever during the FGDs. “What I
know, and I have heard about Covid -19 is that it is a serious disease, and it has killed many people.
So, those who are healthy we need to take care, put on a mask, use sanitizer, and follow everything
health professionals are telling us. I also have a headache, flu, and fever”. R4.
COVID -19 transmission and prevention

The mothers had a misconception that Covid was spread by healthcare workers as they were
the host of the disease. Failure to adhere to physical distancing, not washing hands and not
wearing a mask. R6: a 24-year-old mother “what they already said that there is no social distance
we don’t see it, not washing hands and wearing a mask can make you get infected with COVID -
19” The women were also able to articulate COVID- 19 prevention measures such as Masking
up, social distance, staying home, regular hand wash and sanitizing.
COVID -19 Source of information

Covid being a new disease had its information got from speculation. It was noted that in the
absence of correct and consistent information the mothers depended on the grapevine for the
information. One mother mentioned that they get their information on Covid 19 from social
media, which provided several but conflicting statements about Covid 19.
Social culture practice/beliefs/misconception preventing access to regular ANC / PNC

services
Social culture practice/beliefs/misconception preventing access to regular ANC and PNC
services amidst the COVID -19 pandemic included misconception on the process and fear of being
told you have COVID -19 If found with high temperature.
To understand health seeking behaviors for routine ANC and PNC services in the wake of
COVID -19
Knowledge about Antenatal Services and more so the importance of ANC checkups at the
facility amidst the COVID -19 era
The mothers were asked questions to test their knowledge and views about the importance of
ANC checkups at the facility amidst the COVID -19 era. The mothers were knowledgeable on
the importance of ANC checkups even amidst the pandemic, as there were able to state the
importance and benefits of antenatal clinic checks ups such as check the growth of the baby and
health of the mother, seek medical care from qualified staff and timely treatment in case the
mother is COVID19 positive and ensure a healthy baby.
R7 noted that It is important to come to the antenatal clinic because if you have signs and
symptoms of COVID -19 they will know how to prevent it and that you should not get it and that
the virus does not affect the unborn baby. R8 also added that there is a benefit to check if the baby
is developing health and, in their womb, and if the mother is also healthy. She added also that it
is important to know if there are any complications in one’s body.
Views on when (period) 1st ANC should be done amidst COVID -19
Three quarters of the mothers were unaware of the timings. They had mixed levels of
understanding as some said as soon as one notices that they are pregnant while others said ANC
starts at 3 months:
R4: A woman should start coming for screening at 3 months’ pregnancy. ‘As soon as one knows
that they are pregnant it is important to access ANC services for the good health of the mother
and the unborn baby’
Views on Facility Delivery. Knowledge on importance of facility delivery during COVID -19
All the mothers were knowledgeable about the importance of delivering at the facility. Echoing
that it is easier to seek medical attention and for one to have a safe delivery at the facility as
echoed by expectant mothers:
“For me, all my children I delivered from here at the facility, the answer I have is
that at the clinic the doctors encourage us to deliver from the clinic because there
are times when the baby will be entangled with the intestines, or you may find that
the baby drowns in the fluid during birth. If you give birth at the clinic, they will
know how to care for you, if you take long, they will take you for Caesarean – section
21
so this has made many pregnant mothers not to come early but chose to delay.
Views on delivering at the facility amidst the COVID -19 outbreak”. R8.
All the mothers acknowledged that they plan to deliver at the facility for a health delivery
process. Where were the mothers planning to deliver from amidst the COVID -19 outbreak and
why?
“Me, I planned that I would deliver from here, because I just came here so I did not
know how they work. But I discovered that the delivery process here was, they do
not allow you to go in the toilet or the bathroom, but you will go to bath, and you
need to clean or leave the place clean or if not, when that dirty is cleaned, nobody
can enter there”. R2.
“Like my sister who gave birth last month at Chingwere clinic she said like the issue
of handing washing is there and they take all the tests to see if you are health, just
like the way they used to do long time if you are still very far to deliver you do not
sit together with those that are about to deliver, I think it is one way of ensuring
social distancing. So, they take those that are only ready to deliver at the labour
room”. R7.
All expectant mothers preferred facility delivery because at the facility there are qualified staff
and equipment to handle different issues that any mother can encounter. However, the
majority did not plan to deliver from Kanyama 1st level hospital, because of poor staff
attitude in the labour ward citing that staff do not respond to the needs of the mothers, the
mothers are not allowed to use the bathroom after delivery that they will make them dirt, hence
3 quarters of the respondent delivered elsewhere.
Availability of outreach post amidst COVID -19. When asked about establishment of ANC
outreach posts, the researcher found out that there were no ANC or PNC Outreach posts except
for HIV testing, most mothers relied on Kanyama Hospital for ANC checks. This was affirmed
by R8 who said: ‘I have never seen one for antenatal or postnatal but only those for HIV testing
like at Mutandabantu there those outreach posts for HIV/AIDS but not for checking pregnancies
no its not there’. And Reaffirmed by R5 who concurred with R8: ‘Around this area there is only
Kanyama Hospital which is available for antenatal clinic, review, and delivery of pregnant
women.’
Mitigating factors put in place to ensure continuation of routine Maternal and Child
health services following the COVID -19 pandemic
Safety while accessing ANC/PNC amidst COVID -19 at the facility
All the mothers interviewed did not feel safe to access ANC and PNC services during this period
of COVID 19 citing that they fear being infected because COVID 19 measures are not
implemented, no hand washing, no sanitizing, no social distance except wearing masks. R7:
Myself, I do not feel safe. Even when coming, I only say my God! where I am going there is
congestion. Where I am going, I will find people, look after me my God! Otherwise, there is a need
to test for Covid for those entering, hand sanitizing and hand washing. When you reach the
reception, you will find people washing, you will see that someone is coughing whilst others are
seated and there is nowhere you can wash hands, no hand sanitizer and this brings fear in me’’.

Availability of hand washing points

Evidence of the availability of the hand washing point at the entrance although most of the times
the bucket does not have water and it was observed that there are no strict personnel to enforce
handwashing as such mothers do not bother to wash hands and go to access services straight
away. R7: “There is nothing like washing hands. You will find that at the entrance there is no soap,
no water so we do not wash hands. There is no handwashing, social distancing, and communal
hand sanitizer”. R2: “Sometimes there is water, sometimes there is no water.
Space for COVID -19 positive or suspected pregnant mothers

There was no special space allocated for suspected COVID 19 mothers at the ANC or PNC. In
fact, the ANC and PNC clinic is mixed hence the congestion. R2: “No, we are together with those
with babies there is no specific place for pregnant women or Allocate spaces for suspected Covid
19 mothers.”
Waiting period to access ANC / PNC services

Waiting period to be attended by the HCW - now during COVID 19 and before COVID 19 mothers
mentioned that since the outbreak of COVID19, they spend few hours at the ANC and PNC
checks compared to before when mothers will wait for over 5 hours but now within 2 hours
one would be attended to. “It does not take a lot of time. You find that if you come at 07:00 hours,
08:00 hours you will be at home, now we do not reach 15:00 hours or 16:00 hours to be attended
to, it's faster you are attended to. Time is short”. R8.
Specific COVID -19 guidelines being practiced

In the labour ward stickers are placed to guide mothers where to sit to observe to adhere to
physical distance, each bench accommodating 3 mothers only. The HCWs in the labour ward
also use gloves which they change regularly. In the labour ward mothers who show symptoms
are swabbed for COVID -19 and isolated although the isolation space is limited. Heath Workers
always sanitize and mask up when attending to postnatal and antenatal mothers. At the ANC
and PNC social distance is not practiced due to congestion but they ensure that all the mothers
are wearing a mask.
“For the labour ward on admission, we have put stickers where mothers sit. We only
make sure that we have three mothers, three antenatal mothers who have come for
admission. We put them, what's this, on the benches, yes, so we don't put more than
three mothers on the bench just to avoid that congestion. And then for us providers,
we always sanitize and always put-on masks all the time. Once you touch a mother
and go to the next one you make sure you sanitize. And if we come across any
mother whom we suspect that this could be COVID -19 or anything we call the
people to come and swab, those responsible for swabbing”. R1.
“And that person is isolated. We isolate them although the space is limited, we make
sure that we do not mix them with those we think are ok. And we also make sure
that we put on masks.” R2.
“So, for MCH we also make sure that the mothers mask up every time when you are
The research established challenges with regards to health workforce, supplies and
equipment, which ultimately affected quality provision of health services.
23
Perspectives of Community Health Care Workers (CHWs) on Mitigating factors put in

place by the health facility:
Safety of accessing ANC/PNC amidst COVID -19 at the facility
In addressing the gaps, the facility has increased the frequency of ANC and PNCs days, they have
been increased from 2 to 5 days in a week hence mothers can choose a preferable day to go.
This has reduced crowds and reduced the time of waiting to be attended to for mother:
“Another thing which I have seen which is very good is that when pregnant women
come, they are not being turned away anymore because of them being many. They
are now all accepted and if they were not accepting them and chasing them away,
many women would be dying in the community. But then many still don’t come;
some are still afraid of contracting COVID -19, do not come and deliver from their
homes”. R2.
Enablers to improve regular access of PNC/ANC service
The facility should support the SMAGs to conduct sensitization sessions especially during this
pandemic to correct the myths and misconception on COVID 19 among pregnant women and
mothers. “What the facility should do mostly is to remove the fear and stigma from men and
women surrounding COVID -19 during this pandemic time because people are having different
perceptions of the disease. There is a great fear, and this has even contributed to women not
coming to the hospital, so the hospital staff need to work together with the volunteers to continue
sensitizing the women.
Quality of delivery for ANC/PNC services were to some extent compromised at the facility, as
outreach services were disrupted. Although the health facility responded well in providing
alternative schedule to cope with the influx of mothers at the center from the closed outreach
activities, the epidemic preparedness in responding to the epidemic was not up to the expected
standards. Reduction in PNC and ANC attendance was noted, and home deliveries and deaths
had suddenly increased. The HCW, CHWs had challenges in providing adequate services during
the Covid- 19 era which ranged from lack of psychosocial support / PPEs, limited space, low
staffing levels and inadequate training. Furthermore, frontline workers had inadequate
knowledge on triaging a Covid-19 suspected pregnant mothers. Lack of tracking system for
follow up on missed appointments due to fear of contracting COVID -19, essential drug stock
out was another gap noted during the pandemic. Monitoring and evaluation system was in place
but irregular and not in tandem with prompt feedback.
Management to ensure that CHWs/ SMAG activities are consistent in the communities; and plan
for deliberate capacity building sessions for the CHWs and SMAGs on current health information
trends”. R1 (64 years old CHW).
R3 (26-year-old CHW) shares her sentiments “Also, they must ensure that they keep transport
money. Women should be told to keep the transport money, not their husbands. Whatever money
they get for transport money, they should keep it themselves because men these days will say that
they but when the time for delivery comes, you find that they have spent it on alcohol. So, women
must be urged to keep the money.”

Challenges faced in providing maternal and child health services amidst the pandemic
The community health workers are not provided with personal protective equipment such as
masks and hand sanitizers:
“We are not given masks nor any hand sanitizer. I have never seen hand sanitizer.
We work without masks or hand sanitizer. Then we have no uniform, no gumboots.
During this time in the rainy season, there is water everywhere. Sometimes a pit
latrine has collapsed, and you might not even know, you just wade through. Perhaps
we may even get a disease. Terms and conditions of the SMAGs during this pandemic
need to be revealed and adapted to suit the prevailing environment and lower the
risk of exposure to COVID -19. Management must also ensure that the payments or
donation to this cadre are made as this will not only motivate them but also propel
them to attainment of results in program execution”. R7.
Lack of identity clothing such as SMAG t-shirts caps or Chitenge and identity card for easy
identification leading to low community confidence in SMAGs.
Views on safety – operations

Hospital does not provide adequate protective tools for CHW and NHC to carry out their
activities safely:
“What they have said is true. We have no proof nor proper direction. And just as
the others have said, when we enter homes, we do not know if someone had
contracted COVID -19, whether they were treated or not, we do not know, we just
go there in the dark. While speaking with them, we may contract it. So, what others
have said is very true”. R4.
Mitigating measures, the facility has put in place for their safety:
Hand washing points and screening desks at the entrance of the hospital are there by the main
reception although screening is rarely done, and measures are not adhered to strictly.
Any special training received on COVID -19

“One training was held on basic orientation on COVID -19 although only a few were trained 30
in total. I think training on COVID -19 was there but there were too few. Let’s say they want 30
people; they will get a few SMAG members and a few community health workers and add them
together to make 30. So, we were trained in handwashing and COVID -19 sensitization.” R7.
Availability of PPEs and type of PPEs for the CHW/SMAG use

The CBVs improvise for themselves, the facility has never been provided. All Respondents:
(mixed voices) Nothing, we fend for ourselves.
Type of Incentives for CHWs to motivate received (material, psychosocial support, PPE,
isolation etc.):
No support is provided in any form of money, material, psycho-social support or PPE etc.
However, the respondents highlighted that despite working overtime they are not paid any
money to support themselves, they are emphasizing that as volunteers they are not respected
like other volunteers from other countries, even when community fund is allocated it can only
cover a few volunteers at a less amount of K30 or K50, its irregular and comes only after 3 to 6
months. They also expressed the need to standardize their payment to a reasonable fee. They
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used to get a certain incentive in the form of cash but now it takes months for them to get those
incentives. They also strongly expressed awareness and cited several examples where material
support was donated for COVID -19 to benefit them but was diverted to HCWs. Some were also
involved in COVID 19 sensitizations were paid only half up to now their follow up has been in
vain. Terms and conditions of SMAGs during this pandemic need to be revealed and adapted to
suit the prevailing environment and lower risk of exposure to COVID -19- need to standardize
volunteer incentives.
“No, we have never been given any support of any form to support us during this
COVID -19. And most of the time the amounts they give us are different amounts,
they even say K30, K50 per volunteer at the month-end. it is an insult. So, the trend
must change, the trend must change to care for the volunteer. I wish there were a
camera, to express my anger. The volunteers are not respected”. R8.
Views of the policy makers on Mitigating measures, put in place to enable mothers’
Access MCH services amidst the pandemic at facility level . Following the outbreak of COVID -19,
policy makers at the central level put in place mitigating factors to ensure that essential routine
maternal and child health services were not disrupted. The policy makers cited the following.
Policy maker R2: At the facility level if you go around, you will find that they are trying to adhere
to Covid 19 guidelines such as providing IEC on COVID -19, they are put in groups, when I say
groups high volume facilities like Kanyama or Matero we make them wait at an area to follow the
Covid 19, one group goes in followed by another. Specific appointments have also helped to
decongest the facilities. Involvement of CBVs such as SMAGs to scale up sensitization. And
integrated outreach for MCH where mothers are followed in the community. So that those who
still have fears we can still find them in the community to access the services from where they come
from.
When the central level observed a reduction in service utilization, mitigating measures were
put in place; radio and TV promotional programs were produced and placed for airing,
developed guidelines, and virtually trained the HCWs in the specific guidelines on how to
provide essential RMNCH-N services amidst the pandemic, frontline HCWs were encouraged to
disseminate key messages to the community following their orientation. Use of SMAGs to scale
up community level sensitization and integrating COVID -19 messages during health talks were
instituted.
Specific COVID -19 guidelines being practiced

In most cases, adherence to guidelines and measure of success can only be done when specific
behaviors practices are implemented. With COVID -19, practices such as social distance, regular
hand washing or sanitizing, masking and regular screening at the entrance to the facility is
cardinal. The policy makers shared the following sentiments:
“I am sure even when you go at Kanyama 1st level Hospital, you will be greeted with
hand washing facilities which are placed mostly at the entrance of departments or
at the gate, we encourage mothers to mask up and just at the beginning of Covid
19 last year most NGOs were donating the face masks the masks were given to the
mothers those who did not have at that time, and apart from hand washing,
masking we are also encouraging social distancing I am sure if you go to facilities
under Lusaka you will find benches marked with social distance on them this is to

encourage mothers to practice social distance so those guidelines are really

encouraging the mothers, and apart from that during every IEC session the mothers
should be taught what to do when coughing by coughing in the elbow or using a
tissue if they have that moment . All the guidelines are being followed in the facility
with support from the health promotion desk and public health office”. Policy maker
R2:
“You will find the posters that are saying mask up. so that was part of the guidelines
because we included a component of infection prevention in there. incorporating
COVID -19 messages during IEC talks including giving out brochures, masking up
as well as sanitizing the hands regularly and hand washing facilities have them
there. Facilities have identified space where HCWs can put those suspected of Covid
19. So, protocol was also developed though I am not very sure that Kanyama had a
chance to look at those protocols. only soft copies are available now, hard copies
are in the process of being printed. The COVID 19 guidelines for RMNCH-N are yet
to be launched.” Policy maker R1:
The policy maker further shared that “The health workers are also adhering to the same
guidelines which mothers are being taught, that is masking up, social distance, and hand
washing and using protective clothing like apron gowns and on top of that using the PPEs.
The following specific practices are mandatory at every health facility. Posters communicating
the key guidelines on masking up and hand washing, sanitizing including social distance.
Placement of hand washing or sanitizer at the main entrance, screening for COVID -19 and
wearing of masks. Separate space for COVID -19 suspected mothers and displayed infection
prevention protocols in the MCH units.
Availability Space in MCH for COVID -19 suspected mothers

To avoid mothers and children from being exposed to COVID -19 while accessing maternal and
child health services at the same time ensuring that all the mothers are provided with the
required health care despite their status, infection prevention measures such as establishment
of a quarantine room for COVID -19 positive or suspected mothers is essential. The policy
makers had this to say:
The health care providers themselves had training and orientations on Covid 19
and were also guided to identify space where they can keep those suspected of
COVID -19. Although most clinics in Lusaka district have limited space allocated for
MCH services due to the high population, guidance was provided to all facilities to
secure a separate case in MCH to isolate mothers suspected or positive with COVID
-19, but because of space further guideline were given of transferring suspected
COVID -19 pregnant mothers to the quarantine Centre but for those in the last stage
they should be attended to the isolation ward and after delivery transferred to
quarantine centers such as Levy hospital and Mother and Newborn hospital at UTH
with support from the Environmental Health Technicians (EHTs). Policy Maker R
1 & R 2:
Increase in frequency or reduction of MCH space at the static point: Another
demanding area that comes with disease outbreaks is the need for facilities to
identify and create space to manage that disease, in this case COVID -19 is no
27
exception. This may result in limiting available space for other essential services
including maternal and child health services. However, the policy makers shared
that “,
“Community is once you say come tomorrow or next week she is going to spread to
the whole community, and everyone will take it as gospel truth. So any mother who
comes to the facility pregnant The space in the facilities has inadequate
infrastructure so when you speak of that the nurses, midwives are trying to
accommodate every woman because when you say we reduce on the number of
mothers coming to the facility, we are fighting on the rate for antenatal booking
so we may loss out as some may not come back meaning that even maternal death
will continue to rise as they will stay and deliver from home in the name of being
sent back from the clinic as such access to services even for under five children
clinics they are supposed to been seen on that very day. So, there are facilities that
do supermarkets and that has continued. There are facilities that have days for
postnatal, family and antenatal planning that has continued.” Policy maker R2.
The Ministry has released guidance on where to establish quarantine centers to avoid
interruption of routine activities. As such, most facilities, especially high-volume facilities like
Kanyama who have inadequate space for MCH activities. Space has been maintained and all
mothers are attended to and never sent back.
Increase in frequency or reduction of outreach posts

To decongest the health facilities and to meet the ministry of health policy to bring health care
services as close to the community as possible. It was noted by all the policy makers
interviewed that the frequency of outreach services reduced due to limited resources had this
to say.
“Yes, the frequency of outreach MCH reduced due to inadequate resources but in the
guidelines, we actually emphasize that it is done to reduce the number of women
flocking to the facility and avoid overcrowding to prevent contracting the disease.”
Policy maker R1.
Demand creation initiatives
To ensure championing of essential services such as MCH services amidst pandemics. It is
important to put in place demand creation initiatives for effective health promotion:
“Yes, we have put demand creation activities on radio, and you have seen most
recently on radio two and TV one talking about it, especially now we are
emphasizing on family planning. When people are mostly at home, chances of them
conceiving and having unwanted pregnancies goes high. So, we have put in a lot of
messages pertaining to access to family planning so that it increases. We have also
oriented the community volunteers including the peer educators to provide the
information to their peers on the availability of services. And some of the peers have
also been trained as community-based distributors of family planning to distribute
in the communities”. Policy maker R1
The ministry of health has continued to promote availability of services amidst the COVID -19
pandemic through scaling up mass media (Radio and TV) sensitization on MCH programs with
emphasis on creating awareness on availability of family planning services to sustain family

planning strategies, scaling up community sensitization using the CBVs and Public
announcement system. Printing and distribution of IEC materials although the IEC printed
materials are not adequate.
Availability of tracking system for pregnant mothers – registers

Most mothers especially during pandemics such as COVID -19 may miss important antenatal
and postnatal services. It is thus imperative to have a functional tracking system to aid the
community-based volunteers to follow up and ensure that all pregnant mothers and the under
five children access the required services at MCH and deliver at the facility.
“We are requesting every health facility to have a register where they enter those
mothers with conditions (high risk mothers) that register under the custody of MCH
and public health office. So, the SMAGs if they must follow the mothers, they are
using that register were addresses and contact phones are documented. And these
mothers who have no problems are rarely followed because there is the shortage of
staff in the department? This also goes to antenatal and postnatal mothers.” Policy
maker R2: “Yes, the central level has developed and disseminated ANC and PNC
registers and most recently the RISK Registers to help track women who are at risk
in the community through the SMAGs. However, utilization of these registers is
limited by factors such as the limited number of Heath Care Workers (HCWs) who
are supposed to accompany the community-based volunteers when conducting
home visits, particularly visits to mothers with risks”. Policy maker R 1
Staffing Levels / status
When pandemics hit, there is need for extra human resources to adequately respond to the
problem at hand. In most cases, frontline health care workers are re-assigned to attend to
emergencies. Without proper planning, other health care services may suffer with a limited
number of frontline health care workers following the re-assignments. With the outbreak of
COVID -19, this is no exception:
“Kanyama has been operating at less than 50% of the required number of midwives
for a long time looking at the population that they are serving. So those that were
at Kanyama were not moved to the Covid centers. Policy maker R1: “You may know
that from time memorial we have been limping with staffing and with the coming
of Covid 19 it has worsened.”. Policy maker R2. “Its 50/50 in some facilities staff
have been moved to support COVID -19 activities and in other areas staffing levels
have been maintained despite having a shortage of Midwives. The ministry utilizes
recent graduates and nurses to aid COVID -19 activities in the quarantine centers
as much as possible”. Policy maker R2
Support provided to the HCWs (summary)
a. Psychosocial support: When pandemics hit, unprecedented change occurs. Health care
workers tend to experience fear, stress, and anxiety as they are concerned about their own
personal safety including the risk they put their families on. It is thus important for health
care leaders to offer timely support. This should include psychosocial support, incentives to
keep them motivated, adequate personal protective materials and capacity building.
“Nurses are also human beings they fear to contract Covid -19. It is really a challenge, but nurses
are now used to it. The issue is counselling and encouraging them. They need to be counselled,
they need to be motivated, as we encourage them, we provide the clothing (PPEs), so that as they
29
go to attend to mothers and women there, they are protected. It has been a challenge, but
counselling has been going on. It hasn’t been all that much and just self-motivation on the part of
the staff and they also got the fears of getting the covid19”. Policy maker R2.
“Guidance is clear that all facilities should provide psychosocial support to Health care workers to
help them manage anxiety, fear and stress that comes with the unprecedented pandemics.
However, counselling has not been sufficient in most cases HCWs learn to cope on their own”.
Policy maker R2.
b. Capacity building: Capacity building is cardinal on how to handle or respond to pandemics. It

is thus important to train frontline health care workers for them to have the right knowledge
and skills on how to efficiently handle new cases. When new guidelines are developed, it is
imperative to build the capacity of implementers such as the front-line health care workers
through organized training or orientation meetings. This will enhance standardization and
quality of service delivery.
“Yes, ‘Virtual orientation was done and orientation is still ongoing. The midwives were also
orientated on how to triage and manage a COVID 19 positive mothers in labor (MCH). we trained
400 participants, specifically on how to manage a client who has come in labor or delivery and is
suspected or is positive with COVID -19. The guidelines were disseminated virtually, meaning that
the information was able to reach the facility staff and they were able to disseminate the
information to the community.” Policy maker R1.
“Capacity building has been going on since last year on how to handle such cases and that they
should send the mothers away and any woman along as she has come, or they have the signs and
symptoms they have to attend to that mother and in some facilities, they have put some systems of
fast-tracking these mothers and if they come coughing and sneezing there are taken for covid19
testing. So, the health workers have been taken through capacity building on how to protect
themselves on how to handle the positive mothers”. Policy maker R1.
c. Personal Protective Equipment: Infection prevention cannot be overstated in any health

facility. This is a priority for a functional health system. Healthcare workers and clients need
to protect from infections while attending to clients and clients need to be protected from
any possible infection too. As such, pandemics like COVID -19 require sufficient personal
protective equipment.
“Yes, so if they have a suspected case, they can actually use those gowns and protect themselves
from acquiring the Covid.” Policy maker R1.
“Yes, nurses are provided with PPEs as they are also human beings, they fear to contract covid19.
So that as they attend to the woman there are protected but really supplies have been a challenge
to meet the demand. The PPEs include gloves, gowns, hand sanitizer and medical masks although
the supply cannot meet the demand”. Policy maker R2.
d. Isolation: Infection prevention requires that exposed cases be isolated for a period of 14
days to monitor for possible symptoms. This applies to HCWs too; they need to be isolated
once they are exposed or test positive to COVID -19.
“So, when they are exposed, they are given 14 days off and it is self-quarantine so they will go home
and stay home for 1- to 14 days. Then thereafter they are tested to find out if they have the infection
or not then that is when they can go back for work. The policy stipulates that all exposed health
care workers should quarantine themselves from their homes for about 14 days”. Policy maker R.
e. Incentives: Incentives such as risk allowance are important to keep the health care workers
motivated as they risk their lives attending to COVID -19 cases.
” So apart from information there was a plan to incentivize them though the incentives have not
yet been provided to them but information was collected on the number of midwives currently
working in those sites and details of their bank and as well as their employee numbers so I think
in the long run they will be able to get their incentives. The plan was put in place and then they
are also provided with PPEs to make sure they are protected”. Policy maker R1.
“For those who work for maternal service, no there is no reward just their salary”. There are no
incentives currently being provided but plans are underway incentivize the health care workers
working on COVID -19 cases.” Policy maker R2.
f. Availability of essential medicines for MCH: When health care systems do not plan adequately,
resources are channeled to COVID -19 response. it is thus important to maintain a good supply
chain for essential medicines for the good health of mother and child.
“Yes, in terms of drugs we have most of the drugs that we need. Ferrous, folic 5mg are available
and we also have magnesium sulphate for those with severe hypertension. What we are lacking
now is the folic acid 0.4mg. So, information was sent to them that they can continue giving these
women the 5 mg. If you look at statistics, 35% of women of childbearing age are anemic. Those
women can benefit from the 5 mg that we use for treatment”. Policy maker R 1
“I think we have strengthened our collaboration with clinic care. Yes, we have two meetings, safe
motherhood, two meetings that we hold quarterly and during our meetings we also have
somebody from the pharmacy that presents on commodities. So, we look at reproductive health
commodities and when we run out, we know the channels that we use to make sure that those
supplies are provided within the shortest period. So, we have been tracking the supply chain”.
Policy maker R1.
“Prophylaxis drugs we are giving but they are not adequate due to erratic supply of medical drugs.
I would really know but there could be a problem with the supply chain. Yes, because this problem
has been there since last year, we have been encountering the prophylaxis drug at some point we
did not even have Fansidar”. Policy maker R2
“Folic acid drug and Magnesium sulphate, these are the drugs I am talking about. There has been
a shortage, there are not always there. Essential drugs such as ferrous, folic and Fansidar are
erratic and inadequate across the country since last year. Only mebendazole is available, hence,
the mothers are not provided with those drugs and even when chance allows. What is provided is
below the quantities required. There is a sense that COVID -19 treatment is being prioritized”.
Policy maker R2.
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“In some facilities it’s so difficult like the case I can remember an expectant mother will not
mention that I am Covid 19 positive unless after the nurse has checked her book from that moment
the nurse will need to find a room where to isolate her and for those with adequate infrastructure
that is our message to isolate an infectious woman”. Policy maker R2.
g. How the facility triages a COVID -19 positive pregnant woman: For effective infection
prevention, there is need for every health facility particular the MCH to put in place
functional measures on how mothers are triaged.
“There is always a triaging site or a room that has been designed for triaging before they get into
MCH. So, all the clients get into that room. from there they will take their temperatures and they
will take their blood pressures and they will do a quick assessment to know the status of the given
client”. Policy maker R1.
h. Support the ministry provides to the CBVs to aid their routine community activities amidst the
COVID -19: A functional primary health care system should provide a platform for
stakeholder engagement and involvement. Functional community platforms such as the
NHCs and CBVs are key to primary service delivery. It is thus important to have a team’s
capacity built, protected, and motivated community cadre to aid the already limited number
of frontline health care workers at grassroots level.
“The community volunteers, the SMAGs and the NHCs have also been oriented in Covid prevention.
SMAGS in some facilities were oriented on prevention as well as the identification of suspected
cases of Covid and emphasizing that there is need now to integrate services including COVID -19
messages even as they go back to the community. That way the mothers will know that the service
is available even amidst the COVID -19” Policy maker R1.
The guidance has been issued to all facilities to orient the CBV on COVID -19 messages and ensure
that the CBV incorporates these messages in the routine community activities. Where possible also
provide PPEs for their safety”. Policy maker R2.
Summary of challenges faced by HCWs, and Measures put in place to address gaps
• Challenges are there, like the protective clothing sometimes you will find that they are
not there.
o Prophylaxis drugs in some facilities, BP machines and thermometers are a
challenge. Policy maker R2:
• Inadequate knowledge on how to effectively provide services amidst the COVID -19,
• Stock outs of commodities medicines such as magnesium sulphate
• Inadequate resources at that time so those supplies were even provided for us even on
credit so that we could pay at a later stage, and they were delivered and distributed to
the facilities.
• Inadequate PPEs. We did not know the magnitude of the problem meaning that we had
not planned to procure adequate supplies of PPEs, so we started to run out of the PPEs
but through the donations we received both in and outside the country from
international donors, we were able to procure those PPEs and distribute them to
facilities.

• Then the other challenge that we faced was the mixed messages.
• Then we also faced challenges with staffing because we had to draw staff from the sites
that they were working from.
• Stock outs of essential commodities such as PPEs and prophylaxis medicine, limited
number of midwives, and lack of standardized promotional messages to avoid mixed
messages.
• Facility faces several challenges such as shortage of essential service, insufficient PPEs,
and limited number of healthcare workers. Policy maker R1.
Recommended measures facility should put in place to address the gaps

The policy makers made the following recommendations to bridge existing gaps:
• Need for the country to get ready for epidemics.
• Sustain the Implementation of multi sectoral meetings Prophylaxis drugs, folic acid
Fansidar facilities should be bought when they run out of them. Facilities should use the
emergency drug related funds to procure
• Health care workers should be provided with adequate protective clothing.
• The main cry is the low staffing levels. If the staffing levels are improved even mothers
will have a shorter stay at the facility.
• Need for necessary equipment to use in the maternity wing that will help the midwives
to see the mother on time.
• Improve on the supply of inadequate and erratic test regents and the RPR.
o Zambia needs to have an epidemics preparedness plans. Strengthen routine
monitoring using service quality assessment tools (SQA), strengthen multi
sectoral coordination, improve staffing levels, strengthen supply chain for
essential commodities and medicines even amidst pandemics. Policy maker R2.
Availability of a special monitoring plan that you have put in place to ensure that
guidelines are adhered
Monitoring is an essential part of a functional health care system. It’s always important to
provide checks and balances on the grassroots to ensure that guidelines are adhered to and
gaps are identified for efficient strategizing.
“Yes, I mentioned that we are now emphasizing on the integration of services, so we
developed a monitoring tool to monitor integration of services in our facilities. And
then we have also strengthened service quality assessment services. we have tools
that were developed for the entire RMCAH+N program and we also use them for
new programs that have come on board for example comprehensive abortion care
services " Policy maker R1.
Monitoring is an ongoing routine activity by the health care leaders. Even amidst the COVID -
19 monitoring has continued but there is a need to strengthen regular monitoring. Monitoring
will confirm if the health care workers (front liners and others) are following the laid down
guidelines in pursued for continuation of routine Maternal and Child health services following
the COVID –19 pandemic.
33
CHAPTER FIVE
Discussion of findings
Introduction
This chapter discusses the findings of the research using the Framework for indirect effects of
COVID-19 Pandemic adopted from the Global Health Live Saving Tools to hypothesize inquiry
on how the health systems has responded in continuation of delivery of essential routine
maternal and child health services amidst the COVID-19 pandemic at Kanyama first level
hospital – Lusaka, Zambia. The results will further be discussed under the themes
DISCUSSIONS
The findings of the research using the Framework for indirect effects of COVID-19 Pandemic
adopted from the Global Health Live Saving Tools to hypothesize inquiry on how the health
systems has responded in continuation of delivery of essential routine maternal and child
health services amidst the COVID-19 pandemic at Kanyama first level hospital – Lusaka,
Zambia. The results will further be discussed under the themes in each key area as generated
by the ANC and PNC mothers, CHWs, HCW and policy makers. On the other hand, the
framework mirrors well the WHO six building blocks that describes the main pillars for a
functional health system ( xliv World health report, 2000). The frameworks’ purpose is to
promote common understanding of what a health system is and what constitutes health
systems strengthening, giving it a clear definition and communicating the problems, where and
why investment is needed, what will happen as a result, and by what means change can be
monitored. These building blocks include service delivery; health workforce; information;
medical products, vaccines and technologies; financing; and leadership and governance
(xlvWHO, 2007) to answer the mitigating factors put in place by the health facility under study.
In this study the researcher used the framework for the indirect effects of COVID-19 Pandemic,
which mirrors the WHO six building blocks framework. The framework for the indirect effects
of COVID-19 Pandemic, includes the following six key areas: Availability of health workers,
availability of supplies and equipment, provision of health services, demand for health services,
access to health services and utilisation of health services.
To establish awareness of COVID-19 practices among mothers accessing ANC and PNC
The study reviewed that the Antenatal and postnatal mothers were aware of the signs and
symptoms of COVID -19 that included headache, flu, feverish, high body temperature, body
aches, chest pains, failing to breath, coughing. The mothers also stated positive prevention
measure masking up, social distance, staying home, regular hand wash and sanitizing. However,
the mothers had misconceptions on how COVID-19, citing that it was spread by healthcare
workers as they were the host of the disease. Social culture practice/beliefs/misconception
preventing access to regular ANC and PNC services amidst the COVID -19 pandemic included
misconception on the process and fear of being told you have COVID -19 If found with high
temperature. The comfortability of mothers putting on a mask all the time during the visits was
also a concern. Myths have it that the use of a mask suffocates the user if used for a long time.
The study further reviewed that Kanyama 1st level hospital was over crowed resonating to
failure to adhere to the COVID-19 guidelines especially that of social distance. The COVID-19
corner at the entrance was available but non-functional. Mothers were only told to mask up.

COVID -19 Source of information. Covid being a new disease had its information gotten from
speculation. It was noted that in the absence of correct and consistent information the mothers
depended on the grapevine for the information. One mother mentioned that they get their
information on Covid 19 from social media, which provided several but conflicting statements
about Covid 19. As such the information about COVID 19 is there among the mothers but it
seems not to be consistent with the practices at the facility. It is important to educate pregnant
mothers on how to prevent COVID 19 infections with institutional practices as much as the
theory around COVID 19 are shared to them.
The study findings were similar to that of Kruk ME et al (2015) in the Lancet article “What is a
resilient health system? Lessons from Ebola”, based on lessons from Ebola infections in
developing countries fear and anxieties among persons that seek care from the health facilities
may occur. Unfortunately, such fears and anxieties may fuel stigma and labelling of health
workers and thus influencing health seeking behaviours.
The WHO recommends four antenatal care (ANC) visits, delivery in health facility and three
postnatal care (PNC) visits for women to optimise the maternal health outcomes. xlviMazharul
et al (2020) in their seminal work observed that in Sylhet, Chittagong and Barisal only 31%
mothers had recommended four or more ANC visits, 37% births were delivered at health
facilities, and 65% mothers received at least one PNC visit. Only 18.0% mothers received the
WHO recommended optimal level of four or more ANC visits, births in a health facility and at
least one PNC visit. Mothers aged less than 20 years, living in rural area, having no education
and media exposure, multiparous, poor wealth status, husband with no education and
husband's employment status appeared as significant predictors of optimal level maternal
health care after adjusting for other factors. Mothers living in Sylhet, Chittagong and Barisal
regions were less likely to receive the optimum level health care. xlviiBenebo et al (2020) based
on his work in Ibadan, Nigeria, agrees with findings of Mazharul et al (2020) that in most third
world countries facility deliveries were low and the WHO recommended ANC (four) and PNC
(three) visits were not achieved by most women.
The findings of this study indicated that most mothers were aware of the importance of ANC
and PNC visits but there were not sure of the WHO recommended number of visits. On the
danger signs of pregnancy the mothers were very much aware and cited some of them which
validated their knowledge of the danger signs of pregnancy. The mothers were in support of
facility delivery and were planning to do so but had reservations on the facility’s ability to
adequately care for the mothers due to overcrowding as the population had out grown the
facility. Additionally, the study reviewed that outreach services for ANC and PNC check-ups
were not available. The researcher got feedback that outreach services for ANC and PNC check-
ups were not available contributing to poor health seeking behaviors for the mothers. Their
presence would have reduced overcrowding at the Kanyama 1st level health facility. Limited
space that allows practicing of social distance also contributed to poor health seeking behaviors
of some mothers as they shunned away services for fear of being infected due to overcrowding.
Lack of free masks to provide to the mothers who cannot afford to buy one also contributed to
negative health seeking behaviors for some mothers. In other cases, mothers did not feel
comfortable to wear a mask, hence, shunning away to access ANC and PNC services.
35
From the frontline health care workers’ perspective on health seeking behaviors, they noted
that the impact of COVID 19 on health seeking behaviors had shown a reduction in daily
numbers of about 25% attendance linking the reduction to mothers shunning away from the
long screening process at the gate for COVID 19 before accessing the antenatal and postnatal
services, leading to most mothers accessing services at private facilities. xlviii Wilson, (2000)
affirms to this observation when he notes that health seeking behaviour of ANC and PNC
mothers is affected by the lethargy of procedures that take place at the facility. The longer the
procedures that less mothers will feel compelled to attend the antenatal and postnatal clinics
and the opposite is true too. The findings also revealed that myths and misconception on the
COVID 19 screening and testing also led to the noted reduction in accessing services as most
mothers believed that once you are tested/screened that is when you get infected with COVID
-19. Consistently, community health workers (CHWs) noted that on the impact of COVID 19 on
health seeking behaviors did reduce because mothers fear contracting the virus with the
perception that HCWs are the ones who have the virus. Fear of being tested for COVID 19 due
to misconception on how the test is done linking it to blood draws and inserting of a pipe in the
nostril which is painful. This was an echo to what the HCWs noted.
Demand creation initiatives are incentives aimed at increasing health seeking behaviors among
mothers. The research revealed that nothing special was put into place to enhance promotion
of early health seeking behaviors for MCH services amidst the COVID -19 pandemic except the
routine sensitization done even before the pandemic. However, the facility did incorporate key
messages on COVID -19 during the regular health talks. The facility has also reduced the period
of admission in the labour ward and shortened the ANC and PNC session.
To understand health seeking behaviors for routine ANC and PNC services in the wake of
COVID -19
Health seeking behaviour were affected by availability of space at the facility. The picture at
Kanyama level one health facility is dire. Due to limited space at the facility isolation of COVID
19 suspected mothers couldn’t be done, space for mothers after delivery was also unavailable.
Mothers described the situation in the after-delivery room as a being overcrowded together as
rats! they would put four (4) expectant mothers on one bed, in a room (approximately 5x5
meters room).
According to (xlixShakarishvili, 2010) his study is in tandem with this study findings, he wrote
that one of the disabling factors for mothers to attend ANC and PNC is space. This could include
physical and social space, and more so privacy. l Jinga, (2019), also supports that above
assertion in his works titled “Reasons for late presentation for antenatal care, healthcare
providers’ perspective” in Gauteng, South Africa, the study revealed that health infrastructure
and system failures such as limited dedicated spaces for service provision such as confidential
counselling, delivery room are important deterrents for patients and causes of frustrations for
both pregnant women and healthcare providers.
Social distance in relation to provision of services: The study revealed that space at the static
MCH point was a challenge. This includes space at the ANC/PNC clinic and bed space in the
delivery room. Availability of space that allows not less than 1 to 2 meters during ANC and PNC
clinic: The hospital does not have enough space to practice social distance as there are too many

women seeking health services from the facility. The ANC and PNC clinics are small to meet the
health needs and demands of the population in Kanyama.
Disease outbreaks create the need for facilities to identify and create space to manage
outbreaks, in this case COVID-19 is no exception. The research findings are contrary to the MOH
2020 General Guidance on Provision of Essential Public Health Services During the COVID-19
Pandemic which stipulates the recommendation on practice of social distance in public places
that includes health facilities. The guidelines clearly point out the need to maintain space of 1
meter and all public places should put up signage to enhance practice of social distance. There
was signage to maintain 1-meter social distance, but this was not enforced as the facility was
overcrowded.
Health information as a tool to enhance functional health system: The research revealed that
there were no follow ups done on ANC/PNC defaulting mothers and children. This was
attributed to inadequacy in the operational of the information management system to function
fully. liHotchkiss, (2006), notes that a well-functioning health information system is one that
ensures the production, analysis, dissemination and use of reliable and timely information on
health determinants, health system performance and health status. He further notes that a well-
functioning health information system is one that ensures the production, analysis,
dissemination and use of reliable and timely health information by decision-makers at different
levels of the health system, both on a regular basis and in emergencies. It involves three
domains of health information: on health determinants; on health systems performance; and
on health status. To achieve this, a health information system must:
• Generate population and facility-based data: from censuses, household surveys, civil
registration data, public health surveillance, medical records, data on health services and health
system resources (e.g. human resources, health infrastructure and financing);
• Have the capacity to detect, investigate, communicate and contain events that threaten public
health security at the place they occur, and as soon as they occur.
• Have the capacity to synthesize information and promote the availability and application of
this knowledge.
One of the tools that a functional health system must have is the mother and child health
tracking system. This could enable the capturing of data on the health status of the mother and
child to enable correct monitoring and prognosis of health problems. This is a basic
management information tool for health workers. Unfortunately, the facility under study didn’t
have a robust system apart from just registers. In the words of liiGrun (2006), there is need for
clear and updated information to support the health workforce and front liners at the ground
to implement effective interventions. This cannot be overstated as a basic need for a functional
health system.
Demand for health services

The MCH demand creation strategy employs a community mobilization/empowerment process
to improve demand for health services. The MOH had put in place the MCH demand creation
strategy at the national level that encompassed the use of public media. Radio and TV
presentations were done to support health seeking behavior around MCH.
37
The research established that demand creation activities at central level using mass media
communication such as radio and TV were put in place. These findings are similar with demand
creation initiatives documented by MOMENTUM (2020) forum supported by USAID practiced
by countries such as Sierra Leone and Bangladesh. The countries scaled up daily COVID -19
situation update through TV with specific message on IPC, immunization, nutrition, and child
care; Development of communication materials for immunization and MNCH service utilization
during COVID; Utilization of traditional methods of communication–IPC by community level
health care provider, milking on immunization day at outreach vaccination center, increase in
call centers and number of doctors voluntarily providing hot lines for counselling services.
However, at the actual study facility, the frontline health care workers shared that Kanyama 1st
level hospital had no special demand creation initiatives put in place following the outbreak of
COVID-19 besides the routine incorporation of COVID-19 message during health education as
outreach activities were no longer available due to lack of resources.
The study further revealed that, with respect to health seeking behaviors, home deliveries had
gone up. This may be due to fear and anxieties that may result in poor health seeking behavior
for essential services such as maternal and child health. Apart from that, there was the issue of
high-volume facilities and Kanyama is one of them. Considering the drop in health seeking
behavior among the mothers the policy makers at MOH addressed the situation by broadcasting
promotional radio messages as well as TV messages to create demand for MCH services even
amidst the pandemic.
Similar situations were prevalent during epidemics as cited in a study of the 2014 epidemic of
Ebola virus undertaken by liiiSochas and Channon, (2018) estimated that, during the outbreak,
antenatal care coverage decreased by 22 percentage points, and there were declines in the
coverage of family planning (6 percentage points), facility delivery (8 percentage points), and
postnatal care (13 percentage points). Additional studies have revealed that the 2014 Ebola
outbreak in West Africa recorded a decline of service utilization by 27% and inpatient care by
44%. This was as a result in disruption of essential routine services that also includes maternal
and child health services. During the Ebola epidemic in West Africa in 2014–2016, the use of
reproductive and maternal healthcare services plummeted so much that maternal and neonatal
deaths and stillbirths indirectly caused by the epidemic outnumbered direct Ebola-related
deaths. Women were unable to access family planning, completed fewer antenatal care visits,
and were more likely to give birth at home. Some of these women stopped going to facilities
due to fear of infection and increased physical and financial barriers. Others were denied care
if they were suspected of having Ebola as many facilities were not equipped to provide maternal
healthcare to infected women. (livEmanuel et al. 2020)
Access to health services

Mother’s attitude as to the COVID 19 transmission method had myths around it and the fact the
dissemination of information was based on grape vine that created a recipe in deterring
mothers accessing MCH services as it was seen that HCWs were the transmitters of the COVID
19 virus. Enablers to access include the COVID-19 non-pharmacological measures instituted at
the health facilities, community sensitization on healthcare access during the pandemic, and
alternative strategies for administering immunization service at the clinics. The enables to
accessing MCH services for the mothers at our site of study was purely intrinsic. The external
enablers were not so much at play among the mothers. The fact that they know the need for a
health check-up on themselves and their baby was enough impetus to seek medical health care.
Akin to the research findings, lv Akaba (2021) cites that barriers to accessing MCH services
during the first wave of Covid-19 pandemic in Nigeria included fear of contracting COVID-19
infection at health facilities, transportation difficulties, movement restriction, stigmatization of
sick persons, lack of personal protective equipment (PPE) /medical commodities, long waiting
times at hospitals, shortage of manpower, lack of preparedness by health workers, and
prioritization of essential services. In additional, Qualitative studies like one conducted
(lviElston, 2016) in West Africa “The health impact of the 2014-15 Ebola outbreak’’, recorded
similar results suggesting that these reductions were due to fear of contracting Ebola virus at
health facilities, distrust of the health system, and rumors about the source of the disease. A
similar picture took place in Taiwan during the 2003 severe acute respiratory syndrome
epidemic, ambulatory care decreased by 23·9% and inpatient care decreased by 35·2%,
lvii (Chang et al. 2004) in a study on “The Impact of the SARS Epidemic on the Utilization of
Medical Services: SARS and the Fear of SARS’’, in Taiwan. The study further revealed that
People’s fears of SARS appear to have had strong impacts on access to care. Adverse health
outcomes resulting from accessibility barriers posed by the fear of SARS should not be
overlooked.
With regards to increase in frequency or reduction of outreach posts to decongest the health
facilities and to meet the ministry of health policy to bring health care services as close to the
community as possible. Health facilities are required to identify outreach sites and develop
outreach schedules for effective service provision. However, with the outbreak of COVID-19
came restrictions and demands for already limited resources which compromised the outreach
services.
The study revealed that despite the guidelines on provision of RMNCH services amidst the
COVID-19 emphasizing the need to maintain routine outreach activities. Outreach posts were
not functional following the outbreak of COVID-19 due to inadequate resources to carry out
outreach activities. The researcher established that there were no ANC or PNC Outreach posts
except for HIV testing, as a result, most mothers relied on Kanyama 1st level Hospital for ANC
checkups. This was affirmed by R8: ‘I have never seen one for antenatal or postnatal but only
those for HIV testing like at Mutandabantu there those outreach posts for HIV/AIDS but not for
checking pregnancies no its not there’. Their presence would reduce overcrowding at the
Kanyama 1st level health facility.
The findings of this study are similar to those of the Global Health Report 2020, which argue
that if health systems are overwhelmed resources are diverted to response to COVID-19 cases
resulting in disruption of routine service provision such as disrupted outreach and community
health workers’ routines threaten to exacerbate limited access to care and negatively impact
women and children’s health. This requires undivided attention for health systems response to
ensure non disruption of routine essential services.
Furthermore, the researcher found out that community health outreach services had waned off
and CBVs were not equipped with gumboots and raincoats as the area was flooded.) The policy
makers also shared that they integrated outreach for MCH where mothers are followed in the
community, so that those who still have fears could still be found in the community and access
39
the services from where they come from. The study revealed that such was never the case at
the facility where the study was conducted.
These findings review the opposite recommendations from the WHO and UNICEF 2020 in a
report on “Community-based health care, including outreach and campaigns, in the context of
the COVID-19 pandemic Interim guidance” that state that community-based prevention
activities include outreach services (an extension of facility-based primary care services used
to reach the underserved), campaigns (supplementary activities to routine services used to
achieve high population coverage) and outbreak responses (used to curb an emerging health
threat) these activities are life-saving, the must continue but be modified to reduce the risk of
COVID-19 transmission
Utilization of health services

The study revealed that a number of factors were associated with utilisation of health services
among the ANC and PNC mothers. These include the behaviour of health workers, availability
of essential MCH drugs, waiting time to be attended to at the clinic, quality of health services
with respect to space, distance to the facility and transport costs, attitude of community
members, seasonal flooding, educational levels, support from husbands and age of mothers. A
study done by lviii Agunwa et al. (2017), discovered that increasing age, educational level,
monthly income, number of children and occupation of both women and their husbands were
associated with increased MCH service utilization. Average monthly income (OR: 1.317, p =
0.048, CI: 0.073–0.986) and number of children (OR: 1.196, p < 0.01, CI: 1.563–7.000) were
determinants of increased use of child care services while educational level (OR: 0.495, p <
0.001, CI: 1.244–2. 164) and age (OR: 0.115, p < 0.001, CI: 0.838–0.948) determined better use
of delivery and family planning services respectively. This study is in tandem with our findings.
lix Gilson, Palmer and Schneider, (2005) adds to say that while the concentration of health
workers was important, their behaviour and attitude toward patients was even more important
to the community. Bad health worker attitude discouraged some people from going to health
facility and was cited as a reason for long waiting time at health centers rather than the lack of
human resources. Other studies have reported similar concerns about the attitude of health
workers and how it has an influence on service utilisation. The foregoing assertion is supported
by lxMutale et al. (2013), who notes that the staffing levels at health facilities appeared to have
a bearing on the patient/provider relationship. It appeared that it was not possible to improve
the relationship between the community and the health facility by simply increasing the
number of health workers disregarding the issues of behaviour and attitude of health workers.
Most members of the community were discouraged from seeking medical attention if the health
workers were rude and uncaring. Some community members only came to seek services if the
right health workers were on duty. While most health workers blamed the bad relationship
between the community and health workers on fewer numbers of health workers, the
community members felt that it was not enough to have more health workers. They insisted
that the health workers must be caring and have a positive attitude towards work. Waiting time
before being seen by a health worker was one indicator of not only the low number of health
workers but also a reflection of bad working practices and attitude by health workers. The long
waiting hours were a recipe for poor relationship, and this was self-reinforcing: On the question
if mothers made the facility as their preferential choice for the next facility delivery. Most PNC
mothers did not plan to deliver from Kanyama 1st level hospital, the reason was because of
poor staff attitude in the labour ward citing that staff do not respond to the needs of the
mothers, the mothers were not allowed to use the bathroom after delivery as that they would
make the bathroom dirt due to erratic water supply.
Community members have a duty to help health workers to perform their duty without risking
their lives. Therefore, the issue of improving relationships at health centers has both demand
and supply side. Findings from this study showed that the community does not seem to see
their responsibility to be crucial in improving relationships with health workers. Community
members expected health workers to improve their attitude and not the community needing to
change to accommodate health workers. Sometimes the community delayed in seeking medical
help until the case was very serious. This was seen as bad community practice that needed to
change. However, the community blamed the delays on health workers who they said were
unwilling to attend to nonserious cases, so community members had no choice but to wait until
the illness was very serious in order to draw attention from health workers. (Mutale et al. 2013)
To identify mitigating factors put in place to ensure continuation of routine Maternal and
Child health services following the COVID -19 pandemic
Availability of health workforce: With regard to health workforce, the study revealed that the
staffing levels at the health facility amidst Covid 19 were static and were at 50% as revealed by
the policy makers and HCW.
Policy makers also noted that from time memorial the MOH has been limping with staffing and
with the coming of Covid 19 it has worsened. In trying to get additional staff at Covid centres
the ministry has been utilizing recent graduates and nurses to aid COVID-19 activities in the
quarantine centres as much as possible.
However, the MOH responded in line with guidelines on continuation on provision of essential
services amidst the pandemic not to shift or reduce the staffing levels in the MCH department.
The findings are contrary to (lxiFridell M et al. 2020) who stated that when pandemics hit, there
is a need for extra human resources to adequately respond to the problem at hand. In most
cases, frontline health care workers are re-assigned to attend to emergencies. Without proper
planning, other health care services may suffer with a limited number of frontline health care
workers following the re-assignments. With the outbreak of COVID-19, this is no exception.
lxiiAqil and Hozumi, (2009) further noted that a well-performing health workforce is one that
works in ways that are responsive, fair and efficient to achieve the best health outcomes
possible, given available resources and circumstances (i.e. there are sufficient staff, fairly
distributed; they are competent, responsive and productive).
On the other hand, shortage of staffing caused congestion and long waiting time at the facility
for ANC and PNC mothers compromising service delivery and utilization. Coupled with lack of
space at the facility, this made social distance of one metre or more nearly impossible. Notably
the waiting time ordinary has been between three to seven hours for a mothers to be attended
to.
The study findings were contrary to the guidelines by MOH (RMNACHN in COVID-19
Containment, 2020) which uses an algorithm on general measures to minimize exposure of
patients and health care providers and antenatal clinic hospital outpatients. Which includes (i)
Decrease visits for low-risk clients and supplement with telephone calls at scheduled visits. (ii)
41
Request patients to come to clinic unaccompanied unless inevitable due to sickness. (iii)
Integrate services as much as possible during a single visit.
However, on the positive aspect, the above guidelines were put into place by the MOH to
address the Covid 19 pandemic. The researcher found an interesting scenario at the area of
study, where mothers at the initial of COVID – 19 era, waiting time for mothers was about five
hours but reduced to two hours! This was made possible through planning and better
scheduling and realignment of activities, as priority was given to mothers to have them
attended to as soon as they come to the facility.
The major change in the system included the strategy to increase the number of days for
Antenatal and postnatal clinics from 2 to 5 days in a week.
This practice was in line with the MOH guidelines that states “Where possible, those with
one/two day per week schedules should spread out to more days (“Supermarket approach”) to
avoid overcrowding. In the same vein, those that limit services only should consider full day
services, especially for those that use the one day per week schedule. (MOH, 2020)
Community Health Workers (CHWs)

The facility has only managed to maintain 30 out of the more than 100 CHWs. The attrition
levels are high due to poor working conditions as incentives, protective clothes and equipment
are not available. see table below: lxiiiBhattacharyya et al. (2001) agrees with our assertion on
attrition by noting that attrition rates for CHWs of 3.2 percent to 77 percent are reported in the
literature, with higher rates generally associated with volunteers. Again, one review (lxivParlato
& Favin, 1982) found attrition rates of 30 percent over nine months in Senegal and 50 percent
over two years in Nigeria. CHWs who depend on community financing have twice the attrition
rate as those who receive a government salary. The biggest challenge has been the MOH’s
inability to devise a sustainable incentive system for CHWs. Understandably, the resources
received by hospital management is erratic and inadequate to pay all the CHWs.
In addition, no support was provided in any form to CHWS. Neither of money, material,
psychology, PPE etc. However, the respondents highlighted that despite working overtime they
are not paid any money to support themselves, they are emphasizing that as volunteers they
are not respected like other volunteers from other countries, even when a community fund is
allocated it can only cover a few volunteers at a less amount of K30 or K50. It is irregular and
comes only after 3 to 6 months. This was acknowledged by Policy makers too.
The CHW also expressed the need to standardize the payment to a reasonable fee. They used
to get a certain incentive in the form of cash but now it takes months for them to get those
incentives. They also strongly expressed awareness and cited several examples where material
support was donated for COVID-19 to benefit them but was diverted to HCWs. Some were also
involved in COVID 19 sensitizations were paid only half up to now their follow up has been in
vain. In this regard, the terms and conditions of CHWs during this pandemic need to be revealed
and adapted to suit the prevailing environment and lower risk of exposure to COVID-19 - need
to standardize Volunteer incentives.

The findings are in line with (Chaouachia, 2017), who noted that the question of whether CHWs
should be volunteers or remunerated in some form remains controversial. E.g. ‘Volunteerism
and government/community responsibility where is the bottom line?’ He further notes that
there exists virtually no evidence that volunteerism can be sustained for long periods: as a rule,
community health workers are poor and expect and require an income. Although in many
programs they are expected to spend only a small amount of time on their health-related duties,
leaving time for other breadwinning activities, community demand often requires full-time
performance. The reality is that CHWs as a rule and by their very nature provide services in
environments where formal health services are inaccessible, and people are poor. This also
complicates the issue of community financing, which is rarely successful unless
institutionalized, as in most developed countries. Most of the evidence reflects failures of
community financing schemes, leading to high drop-out rates and the ultimate collapse of
programs.
Health Care Workers (HCW)

The staffing is not adequate at the facility. There are fewer nurses and doctors and more so less
staff at the MCH department. The frontline health workers were overwhelmed with work, in
light of the outbreak of COVID 19. This causes stress and anxiety among them compounded with
low staff welfare and incentives. Risk allowance is important to keep the health care workers
motivated as they risk their lives attending to COVID-19 cases.
The researcher learnt that apart from the information that was given to HCWs there was a plan
to incentivize them, though the incentives have not yet been provided to them. Information
was collected on the number of midwives currently working in those sites and details of their
bank and as well as their employee numbers so I think in the long run they will be able to get
their incentives. The plan was put in place and then they are also provided with PPEs to make
sure they are protected.
This is contrary to the (International Labour Organization; 2020) that clearly states that health
workers may be exposed to occupational hazards that put them at risk of disease, injury and
even death in the context of the COVID-19 response. It is thus important to reward them to keep
them motivated this may otherwise result in reduced productivity and diminished quality of
care.
Management noted that due to low staffing at the facility staff isolation when suspected to have
been infected with COVID 19 was not followed as prescribed by Infection prevention requires
that exposed cases be isolated for a period of 10-14 days to monitor for possible symptoms. On
the contrary, the researchers’ findings were the opposite as reported by policy maker. Health
care workers were given two days’ quarantine period of isolation and they continued working
and encouraged to mask up. This is because of the inadequate midwives at the facility. We earnt
that staff infected with COVID-19 are given only 2 days out and there is no support for their
families leading to family members of three affected staff being infected. This was a stressor.
No drugs are set aside for staff in case they fall sick, and they are not given any form of support
even psychosocial support.
The findings are similar to the lxvUnited Nation Appeal (2020) report that states that Zambia
has seen an increase in the number of healthcare workers infected by the COVID-19 virus
43
resulting in shortage of essential frontline healthcare workers. As part of infection control

measures, Health Care Workers must go through quarantine for a period of not less than two
weeks (United Nations, 2020). How do we expect to control the pandemic when frontline health
care workers who deal with a lot of clients are exposed! This is a serious action that government
should consider employing more frontline healthcare workers to control the pandemic. when
health care workers are infected, it is important that they too follow the 14 days’ quarantine
rule.
Availability of supplies and equipment

The research reviewed that facility lacks basic supplies and equipment fit for a level one
hospital. Basic medicine such prophylaxis drugs at the facilities has been a challenge. Tools such
as BP machines are not available including thermometers. This was contrary to the World
Health Organization (WHO) guidance on the essential medicines to stock for ANC/PNC. The
guidelines say that an expectant mother must be provided with a daily oral iron and folic acid
supplementation with 30 to 60 mg of elemental iron and 400 μg (0.4 mg) of folic acid is
prevalent to prevent maternal anemia, puerperal sepsis, low birthweight, and preterm birth.
The medicines such as Ferrous, Folic and Fansidar were out of stock for over 4 months except
for mebendazole, hence, the mothers were not provided with those drugs and even when
chance allows, what was provided was below the quantities required. Further, the findings
agree with the 2020 World Health Organization guidelines completed in Geneva on
“maintaining essential health services: operational guidance for the COVID-19 context’’. States
that in many cases across the world, People, efforts, and medical supplies all shift to respond to
the emergency. This often leads to the neglect of basic and regular essential health services.
People with health problems unrelated to the epidemic find it harder to get access to health
care services. The need to redirect supplies to treat patients with COVID-19, compounded by
general supply chain disruptions because of the outbreak on other sectors, is likely to lead to
stock-outs of resources needed for essential services.
The guidelines went on to state that, supply is dynamic during a pandemic and there are
elevated risks of shortages. Lists of priority resources linked to essential services should be
developed or adapted from existing lists, and planning should be executed in coordination with
the overall outbreak response. Therefore, public and private, can networked to allow for
dynamic inventory assessment and coordinated redistribution of supplies. Another study that
agrees with findings of this research is that of lxviRoberton, et al. (2020) in a global modelling
analysis study conducted in the United States on “Early estimates of the indirect effects of the
COVID-19 pandemic on maternal and child mortality in low-income and middle-income
countries: a modelling study’’. The study reviews that, due to the pandemic, the reduced
availability of health workers, supplies, and equipment, while simultaneously a higher demand
for health services lead to a potential increase in maternal mortality of 8 to 39 percent and in
child mortality of 10 to 45 percent. Within six months, the world could see up to an additional
57,000 maternal and 1.2 million child deaths.
Furthermore, the findings of this research align with that of a study conducted in Kenya in 2020
titled “Understanding the Impact of COVID-19 On Essential Medicine Supply Chains”. The study
reveals that COVID-19 pandemic has triggered unprecedented measures by national
governments around the world, trade disruptions, and a deep and global economic crisis. All
these factors are, in turn, threatening the supply of essential medicines and other commodities.
This is felt most acutely in developing countries (for example, early discussions highlight how
Kenya is exposed to medicine shortages), but also in wealthy nations. The widespread nature
of these problems reflects a highly complex and highly globalized supply chain for medicines
and healthcare commodities.
In an article titled; “Reasons for late presentation for antenatal care, healthcare providers’
perspective” in Gauteng, South Africa,2019 the study revealed that health infrastructure and
system failures such as limited dedicated spaces for confidential counselling, shortages of
equipment and drugs, and large patient to healthcare provider ratios are important deterrents
for patients and causes of frustrations for both pregnant women and healthcare providers.
Healthcare providers expressed their acute need for additional personnel, especially
counsellors during night shifts, to cope with the many required tasks. Healthcare workers
admitted that women endured long waiting times and were sometimes turned away because of
limited staff to see to all patients. In some cases, clinics imposed daily quotas and turned away
women who came after the quota was reached (Jinga et al. 2019).
Conclusions and Recommendations

However, the study results also revealed one positive aspect of knowledge on the importance
of ANC/PNC measures as being good, the end users expressed myths on the transmission of the
virus and the testing process.
In concluding the study, the results revealed that, preparedness for the pandemic that would
allow the continuation of essential services such as maternal and child health needed to have
a timely and comprehensive health system response that is elaborate and specific for it to
respond to all specifics of the health system, which was not the case as per the findings below:
• The facility responded well in providing alternative schedule to cope with the influx of
mothers at the center but it was not up to the expected standards (there was limited
safety measures which resulted in low ANC /PNC attendance
• Sudden increase in home deliveries and deaths in the community
• The facility had challenges in providing HCW and CHWs with adequate PPEs, it also
experienced stock out of essential drugs, limited capacity building on COVID 19 triage,
lack of protocol for use in the MCH and lack of psychosocial support for the same
workers.
• Lacked a tracking system for follow up on mothers who abscond services due to fear of
COVID-19. Essential drug stock out was another gap noted during the pandemic, the
Policy makers were cognizant to the disruption due to Covid 19 epidemic.
• PNC services were not disrupted at the facility, but quality in provision was
compromised and outreach services were disrupted.
• However, ANC and PNC mothers were aware of the signs and symptoms of Covid 19
infections, preventive measures, but had myths on the transmission of the virus and the
testing process.
• In was in line with the WHO six building blocks that mirrors with the Framework for
indirect effects of COVID-19 Pandemic; and established that the facility had challenges
with regards to health workforce, supplies and equipment, which ultimately affected
quality provision of health services, demand, access, and utilization of health services.
45
Another random document with
no related content on Scribd:
—Vast woar,.. snapperden en pieperden de anderen
er door heen.
Er klonk wat dof gemor in ’t donker. Rink de reuzige

lobbes wou wèl. Willem ook en Jan ’t gulst. Maar Dirk
en Piet mokten koppig. Piet wou eerst nog bakkeleien.
—Dirk jeukten de handen. Ze gromden de twee
broers, als buldoggen. Plots in ’n ruk, drong Rink ze bij
elkaar, de stugge haatdragende wraakgierige neven.
En in lol plots aangekitteld door de lachschelle meisjes
sloeg hun haat in dronkemanszwaai over in zang,
werd hun versmoorde jaloerschheid in verteederden
gevoelszwenk, afgunstige vriendschap.—Willem
greep Dirk vast, Piet, Jan, Rink, de reuzige lobbes,
omarmde ’t heele stel, en Henk, ’n takknoest in de
hand, smakte zich brutaal met z’n donk’ren kop
tusschen de meiden, slobberde in ’n ommezientje
[285]ze de vroolijke wangen vol met klink-zoete
zoenen.
Jan Grint die stommetje had gespeeld strompelde op

zij, en met z’n afgeknakten boomtak, slingerde ie vóór
den stoet uit, tamboermajorig manoeuvreerend.
In slinger en sliert eindelijk joolden ze den weg af, op

stillen havenkant áán. De meiden vonden dat de
knapen zich kranig gehouden hadden. In joligend-
mekaar-aangekijk, met de vroolijke oogen vol lach en
rumoerlust, bonsden en hotsten ze den krommigen
keiweg af, schreeuwden ze ’t uit, toen ze plots vóór
zich den rooden schemer, nòg dichter bij den
brandgloed van al ’t gas, toortsgewalm en
kraamlampen zagen opvlammen. In genotssidder
hoorden ze klankenorkaan van al de orgels loeien en
dreunen, tusschen het menschkermend en scheurend
gezang van kermisgangers, die dromden rond den
kook van ’t avondlicht, den roffel van trommels, den
gil-schater van den stoomdraaimolen.
Van den polderweg àf, waar de luidlooze weien in

angstige luistering trilden en de stilte staàrde naar ’t
hellekrochtige kermisgerucht en fakkelgevlam, gierde
de stoet, hossend uit ’t zomerlijke duister, al dichter op
de licht-razernij áán. De meiden joolden, sprongen, de
kerels brulden.
Oooauuw! wat ’n ska-ànde

Loage wroak van En-gè-land!
Van de Haven klonk terug, zwak-vergalmend tot

stilstaand gerucht, naar ’t polderland: Ooaauw.. wat ’n
skande.—Uit alle havenhoeken daverde en galmde ’t
refrein áán; in stikdonker, bij schaduwrood schijnsel
van wat eenzame lantaarns; onder bronsgloed van
walmende toortsen. En van overal doemden òp in ’t
licht, zingende rooie koppen, schal-monden,
aangegloeid ros-oranjig in den hellen brand van
kermiswoel.—
—Binne dur nou puur luchtskommels? gulzigde Griet,

smorend ’r dolle blijheid nou ’t kermisgetier al dichter
op ’r aandruischen kwam, oorscheurend fel.—
Ze voelden zich dronken de meiden, nu al, van

koortsig verlangend [286]genot. Huiverwellust
schroeide ze’t lijf; genot kittelde ze in de kaken en al
dichter naderden ze ’t vulkanisch getoorts van gas en
flonker-lampen, flambouwen en kleurig-schichtig
elektriek.
Sterker bulderden aan, orgeldreunen en ’n woeste

warrel en stuif van heete stemmenzang, krijsch en
fluitgegil spoog en hoosde ze in d’r begeertronies.
—Dur is dur t’met van alles Geert.… daa’s d’r puur

een prêcht! schreeuwde Willem opgewonden, en lievig
tegen z’n neef,—nie Dirk? dá’ hai jullie d’r vast nooit
sien.… dur is dur.. ’n reusin.… saife-honderd
pondjes.… en ’n ieder mog dur betaste en befoele.…
of dá’ sai dur ècht is.
—Jai weut d’r gain snars van, stampte Jan Grint

ertusschen,—je hep d’r ’n stoomdroaimole.. soo groot
krek aa’s ’n poardespul.… en je hep d’r ’n kie-me-tè-
mès-koop.… of hoe da loeder hiete mag.… je hep d’r
’n poardekirsis.… ’n skouburg en vaif kèfèe-setans.…
en ’n klodder goocheloars.. en woaresaisters.… en
skiettinte.. enne gruufelkoamers.. enne.…
—Hohee! gilde in schellen lach Rink er doorheen,

woar blaife de lekkere maide dan? wa kan main die
spullemikmak hoàmere.… De màide.… de maide.…
daa’s de klus! de fles.. dàas ’t faine werk.. aêrs f’rfail je
je aige stierlik!
—Ooaauuw! waa’t ’n ska-ande..
brulde Dirk midden in, met Willem die ’n maat

achterna strompelde; en hoog lolden de meiden mee.
—Hou d’r je snoater, nie veur je tait.. hakkekruk.. op
da terrain wee’k de sangbeweging te motte.. ikke
konsteteer van dâ ikke allainig de paàs sel merkeere
op dâ terrain.… hee Platneus.. hiere langst.… hiere
langst!.… Bolkie! En nou valle jullie d’r in.…
In bas-diepe brom zette Klaas Koome in.
’t Is de kerremis die je vreugte biet..

Van wa wai d’r nou rais lekker geniet! [287]
Wel sait d’r ’n droo-ooge—soo’n saa ie.. held’
Skaft d’r moar òf.. kost mooi je liefe geld.
Daa’t is d’r ’n la-amstroal van de ofskoàffersbond
’n Blaufe knoop in se jaa’s, gloasje mellik an sain
mond.
In stijgenden heeschen krijsch stond ie voor ’t eind en

heel de stoet sliertte ’t refrein de roodbegloeide lucht
in:
—Men singt, men host, men lacht, men moakt pelsier..

Je loa je waige of drink ’n gloasie bier!
Je soekt ’n maideke, da je spoedig vint!
In sukke doage binne sai goed gesind!
Nou goan je skiete in ’n linnen tint.
En roak ie waà’t, kraig je ’n mooi pirsint.
—Si-iint! galmden ze uit, meiden en kerels, vlak bij ’t

havenend waar ’n kankaneerende stoet uit
flambouwbrons weghoste, hen kruiste bij ’t duister
pakhuisgedrang, en rauw Klaas’ lied overschreeuwde
met ’t helsche refrein
—Oooaauw! waa’t ’n skande..

Loage wroak van En-ge-land.
Loslatend hun eigen lied galmden de Grints en

Hassels mee met den rauwen stemmenzwenk der o-
wat-’n-skande-krijschers.—Zoo, dansend en wulpsch
schaterend hosten ze áán in duivelsch gebaar onder
eersten ros-gloed van hel gloed-verruischende
flambouwenrij, voor groote tent-façade.—
Besefloos werden ze plots oversmakt door ’n

bulderstroom van hossers. Met moeite werkten ze zich
weer bijéén uit den bruisenden golfstoot van zwarte,
duistere, èven en half-begloeide stoeten.
Vlak voor de luchtschommels, dicht aaneengehaakt in

armenknel, bleven ze eindelijk staan.
Een rij flakker-felle gasflambouwen op koperen

schitterstang gloeiden voor de schommeltent, in hel
van rood-goud licht verzwommen. Er naast, vóór de
kinematograaf boogden drie elektrische lampen, ’t
boomlommer van kastanjelaan ingeheschen,
[288]tusschen twijgen en zwaar geblader, rood-paarse
trilgloed verflakkerend, tooverig-dekoratief
rondlichtend òver den kermiswoel. Al lichtsoorten
vochten en worstelden tegen elkaar in. Aan één kant
vergloeiden de elektriekbollen als paarse manen, een
hel-klare prachtnevel, over boomen en menschkoppen
en tenten; aan anderen kant, vlak er naast, dromden
en gierden tronies, rossig-aangegloeid in beefwalm
van gasflambouwen en petroleumlampetten,
hellemaskers gekerfd en duivelsch geschminkt in ’t
licht en de angst-zware schaduwen; satanische
storting van gloed op monden en oogen, kaken en
wangbrokken.—
Uit de nauwe steegjes worstelden lòs gistende

proppen bijeengeknelde kerels, meiden, jochies en
wijven. Achter de steegspleten met hun duister gewoel
gloedschijnselde brandroode lucht van Baanwijk, waar
vóórbrok van kermis joelde in helle lichtschatering.
Telkens nieuwe donkre drommen in de kronkelige
duistere gangetjes, stortten zich in den dampenden
avondgloei van vlam-spelige tenten en spullen. Lol,
zang en gebral botsten in rauwe hette onder den
elkaar-kruisenden menschenwoel in de donk’re
steegjes òp; gangetjes en kronkelspleten die er
duisterden als zwarte weggetjes tusschen twee rijken
vulkanisch beflambouwd: Baanwijk en Haven. Aan
ingang van wat kronkelgangetjes bloedde hier en daar
rood en groengeel gevlek, weerschijn van kleurig
tentglas op verweerde muurbrokken rond gekranst.
Maar de meesten donkerden als grotten, waar telkens
kankaneerende massa, uit ’t hellelicht van Baanwijk in
verzwelgde, voortwoelde ’n poos, in de grottennacht,
daar dobberde, terug bonkerde en weer voortgolfde;
gloeierig opdook plots weer in den fellen havenbrand,
den woest oranje-rood en paars-groenen gloed van
flonkerlampen, toortsen en elektriekbollen bij
kinematograaf, waarvoor ’t volk woelde klaar-belicht,
als in ’n plots opengebarsten dag.
Een orgelschallende orgie, demonische klankenroffel

en schetter tegen elkaar inzwirrelend, raasde rond in
hellesfeer op de Haven, kretenzee en brallende
geruchten, opgejaagd in de [289]gloeiheete tjink-tjinks
van bekkenslag en pauken, lawaaiend tot àchter den
spoordijk waar polderland eenzaamde in eindeloozen
weischemer. En rondom, de melankolieke zeur van
ééndeunige orgelwijs. De kastanjeboomen, diepe laan
van schel-brandend groen, doorblauwd en doorpaarst
van fel-elektriek, grilligde daar als tooneelpark in
dekoratieven brand, met z’n dampig poortperspektief,
waar aan ’t eind, op verren achtergrond van
petroleumfakkelend oranjig roodgoud, een dolle dans
van demonen raasde, uitzinnige wereld van rood-
donk’re en rood-lichtende, kangoeroesch-
kankaneerende wezens; vrouwen en meiden
opschuimend d’r rokken in witte branding en bruising
van ondergoed; mannen en dronken kerels in vetten
lach of strammen ernst, kwijlend, verhit en omgloeid
met de klankrazernij van orgelschetter, paukendreun
en krijschzang.
Vóór de luchtschommels propten de meiden en kerels

zich òp, kanaljeus en doorschroeid van zinnepassie, in
puffende omarmingen, wachtend tot de klingelende
bel, ronde van elken luchtgang afrinkelde, de
roffelende trommel van matroosje vóór ’t orgel, plots
dòfte en de kas-juffer àfluien liet tusschen geknars van
de plots geremde schommels, gepiep van de stangen,
en den rumoerig-beenschuifelenden terugsmak der
stil-staande lijven uit den geweldigen slingergang.
In overrompelenden drom sprongen Dirk, Piet, Willem

en Rink met de meiden naar voren, fel-loerend op
plaats. Dirk had zich woest op Geerts slank lijf
gesmakt. Piet schommelde met schalksch-vurige Trijn,
de aanhalige Trijn, en Willem, woedend dat hij Geert
niet handig genoeg mee had gesleurd, toch zich
goedhoudend, bonkerde er maar op los met de
snibbige Annie.—
Jan Grint had rondgekoekeloerd of ie Guurt ook zien

kon, al voelde ie vooruit, dat ze wel te trotsch zou zijn
om met den stoet mee te lollen.—
Rink had nog bij tijds ’n schommel gegrepen waarin ie

blonde zenuwachtige Cor droeg. Meer plaats was er
voor hun stoetje niet. Woedend, vol spijt holden de
overblijvenden terug van [290]de trap.—Klaas Koome
raasde wat tegen de luchtschippers die de sloepen
òpschoten, zonder den nijdas te woord te staan. Jan
Grint, Henk Hassel en de anderen dwarrelden
tusschen de aanhossende groepjes, toch niet te vèr
van hun klub, tukkig loerend op alleen staande
meiden, die meegesleurd wilden worden.
Bolk was verschrompeld en bleuïg, met z’n platten

polypneus berossigd en begroend, z’n grillig bevlamde
tronie de hoogte inkijkend, tusschen ’n troep meiden
weggeschuchterd; voelde zich niet meer thuis in ’t
lawaai. Dat hadden de kerels wel begrepen en
daarom ’m half aan zijn lot overgelaten. Op weg naar
de Grints hadden z’m ontmoet. Hij moest mee, of ie
wou of niet.
In ’n hos-storm was ie toen meegesleurd omdat ze

nog wat jool met den ouen rakker wilden hebben.—
Maar onder den wandel naar meiden en kermis wouên
ze’m al weer kwijt. Nou stond ie daar nog voor de
luchtschommel, bang-opkijkend naar de sloepjeszwier
hoog in de lucht,—in zijn tijd nooit bestaan—z’n ouden
kop omkolkt van geraas, bemokerd van
dreungeluiden. Telkens schrok ie òp, dacht ie dat ’n
sloepje, rakelings langs ’m scherend, tegen z’n
harsens zou aanbonsen. En telkens weer verschool ie
z’n klein krom lijf schuchterder achter ’n woest-
gillenden meidenstoet, bijzij de tent verwoelend, rossig
aangegloeid in flakkering van flambouwenvlammen.
Dirk met Geert, ’t mooie zwartje, slingerde ’t hoogst

boven tien sloepen uit. Rink rukte als ’n bezetene aan
de stangen, dat ie plots in ontzettenden zwier-zwaai
met Cor boven tentdak uitzweefde.—In luchtzuigende
vaart schoten de schommels òp en néér, scheerden
den vloer, zwierden weer òp, plonsden weer neer uit
bang-duizelenden slingergang. En hooger, in woesten
naijver op elkaar, schreeuwend en lallend, zetten de
kerels òp, lijfzwaar zich schurend op de meidlijven bij
elken terugzwaai en smak naar àchter, de tent in.—
—Set d’r op Dirk! set d’r op! barstte Geert uit, in

heeten schater om haar hoog-dolle vaart, met rillige
gloeiingen in ’r lijf van schommelgenot, d’r wellust-
woeste oogen strak op Hassels koeienkop gebrand.
Dirk voelde ’t warme zweetlichaam [291]op zich
aanzwellen bij elken nieuwen ruk en inbuig van ’r
opzet. En rukken nu deed ie als ’n bezetene, dat de
stangen kermden in de scharnieren. ’n Woeste
zweeflol, ’n dolle zwier, niet voelend meer waar ie
was, golfde door Dirk’s handen en beenen; bloed
spoot ’m naar den kop. En Geert genoot mee, in
schommelzwijmel, bang-heerlijk, hoog-wèg in heeten
suizenden duizel, dàn in de lucht, dàn beneden,
scherend den planken vloer, dat al meer gloeiende
rillingen door ’r heensidderden. Al de meiden in de
bootjes hitsten de kerels òp, hijgend, hooger-zwiepend
de ranke sloepjes, tot plots, midden in den
luchtzwijmel, de bel rinkelde, de rem-matroos
vastgreep en in smakkend gerucht de luchtvaart
gestuit stond in zachten wiegel.
—Wai blaife d’r.. blaife dr’! nog één ronde.… lekkere

metroosie, ’t is d’r soo ellendig lekker! krijschte ’n
lange meid, oranjegeel begloeid in valsch
flambouwlicht, smakkend met tongpunt paljassig d’r
heeten mond uit.
—Nog éénmaal dames, guitigde ’n mooie

matrooshelper, met glurende oogen lachend tegen de
knappe meiden, zoo maar voor ’t uitzoeken. Snel de
breed-bekraagde matroosjes, sprongen weer achter
de bootjes, duwden tegen ’t achterwerk der meiden,
dat ze gierden en raasden van opwinding om de
kriebelige duwen.—
En weer gingen in langzamen opzet, tegen elkaar, in

vaart-zwiep de ranke sloepjes, schoten ze ver buiten
tentfront de lucht in, boven het vloei-flakkerige
stangenlicht, dat als ’n toortsenrij ’t spul in z’n bont-
geel façade-geschitter bevlamde in helle-gloed. En
binnen in, langs de rood gevlagde wanden, bruiste
licht, licht, stond koppenwoeste drom meiden en
kerels, òp en neer, in storm en slinger; brasten de
sloepen door een brand-vlammigen nevel van
schijnsels. Dolle silhouetten schimden langs muren en
tentdoek, en midden in knarsend geruk, giegel en
gekrijsch, bleef dreun-deunen ’t orgel, z’n kanaljeuzen
strot òpen, waaruit éénzelfde trompettenschetter
verbrulde.—’t Kinder-matroosje aan den ingang,
roffelde voor ’t orgel-gebouw op z’n trommel, roffelde
ròffelde uit, de razende passie der schommelmeiden
en kerels, één dof-rollende dreun van grommingen.
[292]Eindelijk klonk de bel weer, smakte sloepjes-
luchtval terug.—Dirk en Geert strompelden dronken
en waggelend uit, en al de meiden aemechtig lieten
zich de bootjes uittillen door de opgedirkte knevel-
guitige matrozen, die gniepig streelden en knepen, als
felle kereltjes lonkten en tastten.
Dansend bijéén op de estrade, roffel-hakten en

stampten de Grints, Hassels en Rink de tent-trap af.
Henk, Klaas Koome en nog ’n paar makkers stormden
áán, ieder met ’n meid, die telkens wisselden van
vrijers.
Mooie Marie Pijler, prachtslanke blonde furie,

kankaneerde vóór den stoet ’n woesten dans, met één
been de hoogte in kapriolend, haar rokken kniehoog
opgerukt, onder krampigen zwenk van ’r lijf. De
Grintjes en verblufte kerels om haar, op de tent-trap,
klapperstampten en joolden mee van pret.—Maar
Hazewind alleen sprong in sluipende lenigheid vlak
voor de furie, danste ’n vervariëerde horlepijp met
slappe kuiten en slappe polsen, als ’n Engelsche
komiek dof klapperend met z’n zolen op ’t hout. De
meid Pijler draaide langzaam, één been al hooger
uitgerekt om ’m heen, in verwilderde oogen-extase.
Haar blonde haartooi vlamde òp in gouden rossigheid,
volgedrupt van flambouwenrood, en ’r zwijmeltronie, in
wondre omstraling van harenglans, begon plots te
proesten in helsch geschater. ’t Woelde om ’t stoetje,
de luidruchtigste lachende zangers van heel de
luchtschommeltent.
De Grintjes en Hassels, nu mèt Marie Pijler

bijééngegroeid, juichten plots, toen ze ’n endje van de
estrade, in ’t helle elektriek, Guurt Hassel oppikten;
Guurt, die alleen had staan te koekeloeren naar d’r
sekretarieheertje.—Jan Grint pakte ’r vast, lolde er
opgewonden meè. Aan één rij, in slingergang, dwars
door aanstormende en weghotsende stoeten,
kankaneerden ze de Haven àf.—Plots kwam golvende
massa opdeinen uit steegjes, die meesleurde ’t
stoetje, en al de kerels en meiden weer terugdrong en
neerwierp vóór de luchtsloepen, de plek waarvan ze in
zwier en zang, afgehost waren. Dat maakte Dirk en
Rink nijdig, en woester stortten ze zich in den
kermiswoel, sleurden de meiden in armenknel en dolle
vaart mee, werkten en trampelden [293]rond, in slag en
duw, waar ze wezen wilden.—Maar de kerels hadden
geen lol genoeg op straat. ’t Was nog te stil overal. D’r
zat nog geen steigerende furie in. Hazewind schold op
dà’ terain.. van dà’ tie konsteteerde van dà’ d’r gain
duusend minse nog enterd woare.… dà’ de heule
kermisbeweging in ’t honderd liep.…—
De meiden gilden, lalden, dat ze dan maar de kroeg of

de danshuizen moesten bestormen. De neven Hassel,
warm, opgeblazen, hijgend van hitte, en verdoofd van
orgeldreun-razernij konden ’t best vinden, zeiden lievig
tot mâlkaar dat ’t toch beter zóó was dan je met
gladden smoel voorbij te loopen, zonder woord. Ze
zeiden ’t maar, wijl ze voelden dat anders Geert er van
door zou schieten met ’n ander; Geert die beefde voor
ruzie. Dàn zeilde Jan Hassel bij Pijler, dàn Piet bij Cor,
dan Henk bij Annie, in stoerigen wissel van lijven en
zoen-wangen. De blonde furie Marie duivelde en
sprong vooruit, schreeuwde in vlammige dolheid als ’n
bezetene, in hysterische stemme-krijsch kanaljeuze
liedjes uit; holde en klauterde tusschen tenten en
spullen vooròp met den dikken takstronk van alles-
zoenenden Henk, den stoet betamboereerend.
Telkens schakelde hun slingerrij stuk, door alleen-
zwalkende dronken zwervers, die aansliertten en
rondrumoerden met stuipige gebaren, kokhalzend en
verspuwend brallende liedjes. Door de hosrijen
strompelden ze heen, in beestigen slemp weer
tusschen de donkere tentruggen verwaggelend hun
kaduke lijven.—
Tegen twaalf uur, bij losbreking van schouwburg en

Café-chantants van Baanwijk en Bikkerstraat, kwam in
helle-rumoer ’n zang-stoet, galm-rauwend de haven
overhossen, dat heel ’t Hassel-Grint-groepje en
aanhangsels overgolfd verstikte in de machtige
uitbarsting van elkaar-kruisenden menschenhos,
aangolvend, al dreunender en krijsch-zwellender uit
duisteren pakhuis-havenhoek bij polderweg. Drie uur
had die uitgolvende bende opgesloten gezeten, als
muizen in ’n val, en nu plots roerde er ’n stuip van
loswoelend herleven, voortschokkend en in branding
klotsend de heele kermisjool.
Na ’n half uur waren Dirk en Willem, Henk en Rink de

meiden [294]kwijt; vonden elkaar eindelijk weer,
tusschen zwirreling van hossers en zangers. En heel
den nacht zwierden ze van danskroeg naar
danskroeg, van herberg naar herberg, tot de Grints en
Hassels, stombezopen tegen elkaar aanvielen, lam-
gekankaneerd en lodderig zwaar, elkaar bijna niet
herkennend. De neven begonnen te krauwelen, de
meiden gierden. Marie Pijler drensde om ’n
jongenspak, sleurde zich d’r rokken van d’r lijf.
Eindelijk kwam politie die ’t dronken stelletje, achter
andere troepjes áán, van ’t kermis-terrein verduwde.
Zoo strompelden de meiden en dronken knapen, in

heesch-schreienden zang, de stik-duistere laantjes in,
om Wiereland en Duinkijk.—
[Inhoud]
III.
Ouë Gerrit had stierlijk ’t land, vloekte tegen Guurt en

zijn wijf dat de kerels ongehoord verzopen en
geradbraakt ’t huis inzwalkten. ’t Landwerk lag braak.
Tegen den ochtend waren de jongens weer op de
beenen gescharreld, stond Dirk met dikke oogen en
slappe beef-knieën tusschen de sperzieboonen,
gaaploeiend wat vruchten te zoeken in zoeten
luierrengel. Z’n oogen vol tranen gewaterd, branderig
en katterig door ’t heele lijf, loomde en sleurde ie zich
voort. Telkens op ’t pad geknield, onder ’t hoog boven
z’n hoofd dichtgegroeide ranken-groen van boonen,
zakte hij ronk-zwaar en lenden-lam in, zonder
weerstand, met al slappere slaapgloeiing en zoete
matheid in de knuisten. Zoo, met z’n wit-blonden kop
scheef tegen de rijzen en latten van z’n boonen,
voelde ie straks te zullen neerzinken in màf, op den
zonnenden gloeigrond.
De zon vlamde doòr ’t groen; ’t zand dampte hette uit.

Eén soezerigheid was over Dirk’s kop geduizeld. De
lucht had hem eindelijk heelemaal te pakken, en eer ie
’t goed wist lag z’n heele korpus, slaap-gebogen en
verzonken, dwars tegen ’t rijzenhout. Hij ronkte en
snoffelde als ’n varken.—’n Laan achter ’m lag ’n
plukker die ook den heelen ochtend al had
tegengeworsteld, [295]maar door de snikhitte overmand
was. Het gebukt zoeken naar jonge schepseltjes had
z’n verzopen en afgetobd lijf heelemaal tol-duizelig
gemaakt en de stille invretende Augustus-brand,
schroeide nu rondom de slaapkoppen op de
blakerende droge akkers.—Ouë Gerrit nuchter en bits,
de kermisweek vervloekend bij elken stap, botste op
den ronkenden Dirk, in ’t boonengroen.—
—Moar god-liefe-Hair! hai je ’t ooit sòo sout gaite..

hoho! Dir-rik! Hai hoo! Dir-rik! schud-schreeuwde ie
woest, bonzend tegen z’n gelen kop.—
Dirk schrok, kéék òp, z’n slaperige tronie onbewust

heffend in brandende zonnesteeken, dat ie plots
bukte, blindgegooid met licht. Z’n makker, door krijsch
van den Ouë ook opgeschrikt, greep lukraak naar de
ranken, angstig-gissend of ie wèl of niet gesnapt was.
—Wat gauw kwam toch die zoete luiheid door z’n
polsen en handen gestroomd. Nou had ie ’n suizend
gevoel in zich, of ie uren òp één stuk van z’n been had
gezeten. En Dirk voelde zich branderig alsof ze’m
stukken van z’n romp hadden afgezaagd.—.…
f’rdomd.. aa’s tie nie oppaste.. gong ie wèèr.. z’n
oogen loken àl en de Ouë, stom in woede, keek maar.
—Wâ is d’r an ’t handje Ouë, lijmerde hij eindelijk

kregel uit, wa nou?
—Moar main kristis! da goan tug te waid.… Hep jai d’r

dan heuldegoar gain koorakter!.. Piet lait d’r half-dood
veur de andaifie huhu! en de moffeboone legge te
wachte.. Main Jesus.. de hellepers sakke d’r glad-
wèg! hoho! ikke mot d’r tug laifere! Enne.. ikke.. mit
main ouë bast.. lap ’t vast nie allainig! eénmoal..
andermoal.. woar mot dâ haine! dâ haine! die
moffeboone stoan d’r puur te rotte op de grond hee?—
—Nou seur d’r soo nie! kom bai de huur t’regt! wat jou
Ouë? Murge is d’r Sondag.. enne moandag doene d’r
wai vast van sellefers niks.… vàst niks! dat weut je …
is d’r kerremis-moandag.… Mô jai d’r ook moar-rais
hain trekke.… omdá niet-en-kan? Och! loat ’t ouë bier
moar werreke!
Brommend en vloekend ging Ouë Gerrit wèg,

radeloos, toch [296]stom van angst. Wel had ie fellen
lust in ’m om te gaan kijken, maar hij was d’r doodelijk
bang voor z’n eigen natuur dáár. Voor vier jaar had ’m
zoo’n tentbaas juist betrapt op ’n klein gapperijtje. Hij
had den kerel ’t vijfdubbel betaald en die had zich toen
stom gehouden. Maar uit schaamte en angst voor dien
vent, had ie in vier jaar tijd nooit meer ’n stap op de
kermis gedaan.—En ’t was zoo glad van de hand
gegaan dat ie ’r eigenlijk nooit meer om dacht, en ’t
ook nimmer meetelde als ’n snappertje.—Want ’t
jeukte, kriebelde in ’m in de handen. Wat ie daar al
niet zien had? Hij zou zich niet weten te houên.…
Hoho … al die spulle.… die kleure.… die glommige
dingies. Sou die ’t tug-en-doen? Sou die ’t t’met
woage? Dur woa’s vast niemand die ’t wist! Most dus
puur tug ’n toeval weuse.. aàs tie die vint dur nog
antròf. Hoho.. hai waa’s dur soo malgroag.… Soo
malgroag! En ’t waa’s dur de heule eerste kair van s’n
laife daa’t ie op ’n klainighaidje betrapt wier!.… Aa’s
dur nou tùg nies van ’t land t’regt kwam, most hai s’n
aige dan hier allainig mit ’t waif doodkniese! arm,
doodarm waa’s tie tug! S’n aige brokkie grond waa’s
dur tug lang nie meer van sain. Hij poerde moar veur
’n aêr! Enne had ie dan nie s’n spulle? Wa kén d’r sain
de heule mikmak skaile? Most tie d’rof van sain grond,
wel nou! dan d’rof! hoho! F’rduufeld.. hij sou d’r nog
rais fleurig haingoan kenne.… En dan figilaire op de
klaintjes.. Hai sou d’r nou hain! Most d’r moar van
komme waa’t wou! Nou de kerels tùg de boel verloope
lieje … moar dan sou hài Sondag op stap goane …
hoho!.. Sondagòafed.. aa’s ’t drokst waa’s.. ’t dolst
t’met.. daatie nie in de lampies liep!
Brommerig en toch half voldaan dat ie ’t met zich zelf

eens was geworden klomperde hij ’t land àf, voor z’n
leegen rommel staan blijvend. Piet hurkte bij de kolen.
—
—Da koolgoedje gaif je tug moar smerige sintjes Ouë!

mos je moar nie meer sette! ikke sien d’r vast nies in!
—Hoho.. vier-en vaif en nie genog! d’r valt t’met niks
meer te sette, stotterde Gerrit verlegen, verbaasd Piet
weer zoo frisch en flink te zien poeren, hurkend
doorzwoegen of d’r niks met [297]’m gebeurd was. De
knaap had stiekem z’n heelen kop onder de pomp
geduwd, dat ’t water langs zijn wangen droop, z’n
haren plakten en sluikten langs de slapen. Nou voelde
ie zich weer doorrild van frischheid, galmde ie z’n
kermislied uit, met schorren klank in de zonnende
ruimte rondom.—De Ouë wègklomperend, hoorde nog
lang achter z’n rug Piet’s stem:
—Oooaauw wat ’n Ska-ande,

Loage wroak van En-ge-land.
Kermis woelde door, en gloedkrateriger stond in den

avond ’t stedeke in brand, laaide ruischend z’n ros-
gloeiende flambouwenhel òpen, waarin demonisch-
donkere stoeten uit en achter tentduister en
vlammenlicht inhosten, met woest-duistere sprongen
en gebaren van kannibalen om nachtvuren.
Toch met den Zondag, kwam pas ’t èchte

kermislawaai, van alle plaatsen tegelijk. Op den
middag,—uit de treinen, uit tentwagens, uit reus-
bakkige bolderende Jan-Pleziers, lodderig als
melancholieke tufs-tufs,—drongen de stoeten áán,
van Lemper, Kerkervaart, Duinkijk, Zeekijk, Overschie,
van overal.—
Heel ’t omliggend platteland was leeggeloopen en

opgestoet naar de Wierelandsche kermis. Vee- en
kaasboeren met schom’lige vervette buiken, tuinders,
kweekers en zeelui van Dijkland en al ’t landvolk,
dromden dooréén. Pracht-omsjaalde bevlagde
boerinnetjes, met d’r kleurgrillige mantels, bontvervige
lijfjes, rokken en vonkend gouden koppen, verdrongen
elkaar, hortend, stoeiend en woelend in zwirreling van
bloote armen, bontkleurige schouders, lachende
tronies, blank en glimmend; omlegerd van
schoremzootjes, saamgeplet met dronken, uitzinnig
krijschende zwierders, en teruggemalen tusschen
aanzwellenden kruisgang van al nieuwe kermisjolers.
—
Zoo duizenden en duizenden, op den middag al,

verwoelden in ’t enge ruim van Haven en Baanwijk.
Kleur-zwirrelende menschenzee golf-deinde en
klotste, bruiste en schuimspatte rondom, tusschen de
pronkspullen en tenten, kramen en draaimolens.—
Tegen den avond pas bulderde áán, ’t groot-geweldige

donk’re [298]rumoer, verklonk ’t stedeke in daverend
hellegerucht, gloeide en schuimflitste de kleurwoel,
donderden de bas-kelen uit hosstoeten, vergilden de
passie-meiden hun hysterischen krijsch-jubel, in
snerpenden scheurend fellen klankenmartel er
doorheen.
De lucht boven Baanwijk-breede boulevard hing laag

en starreloos-duister. In ’t diepe midden, den poortigen
allée-weg, achter de wafelkraam-ruggen, hing ros-
gouden damp, als van ’n uitbrekenden brand, angstig
moordrood in revolutie-nachten, heel den hemel daar
in gloed zengend, bang verrood van vlammen,
verborgen nog lekkend in kraterigen smeul en
windflakker. Hellegloei nevelde boven den boulevard
in de rondom duistere lucht.
Van ’t Stationsplein àf gezien, gloeide daar in

mysterisch toovervuur, de heele Baanwijk als een
verre, diepe laan, waar doorheen zwirrelden en
wemelden donk’re menschenstoeten, telkens èven en
anders weer aangegloeid in fakkelbrand en
toortsenhel, walmend gloedrood, helgeel en oranje
damp, vurig dooreenvloeiend voor tenten en façades.
En tusschen de zwart-ademende lampetten uit, van
stalletjes en kraampjes, doken òp van allen kant,
vergroot en verwilderd, donk’re woelmenschen in
sidderenden nevel; vergroeiend daarin tot titanische
wezens, met geweldszwaai van hun belichte armen,
den allegorischen gloed van hun vurige oranjekoppen,
en de geel-bronzen verflakkering van kermis-
hellesfeer die ze omzoog, omtrilde.—
Plots verdwenen de stoeten tusschen duistere mooten

en inhammen van tentruggen, ’n end dieper den
boulevard òp weer aanrossigend, onder ’t krijsch-wilde
alarm van hun kermiszang; verdreunend in kudde-
trampel, langs en om begloeide boomstammen, die
zelf verwoest stronkigden in hun schors-kervige
wildheid.
Zoo, de stoeten steigerden tusschen de verlichte

gevaarten-stammen; schuifelende troepen, wadend
door een vàl van elektrisch geflakker, blauwpaarsige
siddersfeer, dampend van boom tot boom, tent tot
tent. En daar achter weer, in duisterig diep,
overstroomd plots van avondkleuren, de woeste

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Statement of the problem

Significance of the study

Figure 1.2: Framework for indirect effects of the pandemic

Availability of health workforce

Supplies and equipment

Provision of Health Services (Access)

Provision of Health Services (Demand Creation)

Utilization of health services

Operational Definition of Terms

Knowledge, Attitude, and practice towards using routine ANC services

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A study conducted in Northern Ghana on ‘’exploring the Determinants of Antenatal Care

Services for Science and Education – United Kingdom 12

In another study conducted in Cambodia on “Sociodemographic characteristics associated with

Services for Science and Education – United Kingdom 14

Study / target Population

Services for Science and Education – United Kingdom 16

Services for Science and Education – United Kingdom 18

Ethical and Cultural Consideration

COVID -19 transmission and prevention

COVID -19 Source of information

Social culture practice/beliefs/misconception preventing access to regular ANC / PNC

Services for Science and Education – United Kingdom 22

Availability of hand washing points

Space for COVID -19 positive or suspected pregnant mothers

Waiting period to access ANC / PNC services

Specific COVID -19 guidelines being practiced

Perspectives of Community Health Care Workers (CHWs) on Mitigating factors put in

Services for Science and Education – United Kingdom 24

Views on safety – operations

Any special training received on COVID -19

Availability of PPEs and type of PPEs for the CHW/SMAG use

Specific COVID -19 guidelines being practiced

Services for Science and Education – United Kingdom 26

encourage mothers to practice social distance so those guidelines are really

Availability Space in MCH for COVID -19 suspected mothers

Increase in frequency or reduction of outreach posts

Services for Science and Education – United Kingdom 28

Availability of tracking system for pregnant mothers – registers

b. Capacity building: Capacity building is cardinal on how to handle or respond to pandemics. It

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Recommended measures facility should put in place to address the gaps

Services for Science and Education – United Kingdom 34