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Background: World Health Organization (WHO) strongly advocates for 'skilled care at every delivery' to reduce the global burden of 536,000 maternal deaths, 3 million still births and 3.7 million newborn deaths each year. Improving delivery care is an essential element of attaining improved maternal and child health. In the more developed countries, skilled attendance at delivery is about 99.5% where as that of Africa is 46.5% (WHO, 2008) and Zambia was at 47% in 2008 (2007 ZDHS) below the WHO target of 85% in 2010 (WHO, 2005). More than half of Zambian births (52%) occur at home. Kasama district has low institutional deliveries with more than half (56%) of pregnant women delivering at home without the assistance of a skilled attendant (Kasama District Health Action Plan, 2010). The number of deliveries conducted by skilled birth attendants in Kasama is lower than the national figures. This underscores the need to investigate factors responsible for low use of skilled attendants at birth. The main purpose of the study was to identify factors affecting utilization of skilled attendants at birth by pregnant women in Kasama district in order to help contribute to the reduction of maternal and child complications. Methodology: The study was conducted in Kasama district in Northern Province of Zambia. The study used the triangulation approach method to collect data which included one semi structured interview schedule which was administered to 340 eligible women (170 cases and 170 controls) who had children aged six months and below and those who may have lost a child during or after delivery in the first two quarter of 2011 accessing various health services at three selected health centres under study namely Lukupa, Chisanga and Location. This was done to ensure that the reasons for the loss of a child during or after delivery which could yield useful information about the care given during labour and after delivery were captured. In this study, the exposure of interest was skilled delivery and therefore the exposed were women who were delivered by unskilled birth attendants while the unexposed were those who were delivered by skilled birth attendants. Mothers who were delivered by skilled birth attendants were controls while those who were delivered by unskilled birth attendants were cases. Three clinics with delivery facilities were conveniently selected from the 31 government health centres in Kasama. The estimated number of pregnancies (5.4%) and deliveries (5.2%) for each clinic was considered in order to correctly identify clinics with the lowest deliveries. Three focus group discussions were also conducted one at each selected health centre. The health centre staff, TBAs and women of child bearing age (15-49 years) in the catchment areas participated in the focus group discussions. Women to be included in the focus group discussions were purposely selected. In order to ensure that the findings were valid, statistical significant was set at p<0.05. Results: One of the most interesting findings of this study was that the consultation of the services of TBAs by pregnant women did not affect their utilization of the skilled delivery services and most TBAs are educating women on HIV/AIDs. Therefore, it did not matter whether a woman consulted the services of TBAs for them to use the services of skilled attendants at birth. However, the study found that majority of the cases 131(77.1%) had a problem with male midwives attending to women during delivery compared to the controls 115(67.7%). Respondents who were not comfortable with male midwives attending to women during labour/delivery were 1.271 [OR (95%CI) = 1.271 (1.029, 1.570)] more likely to be delivered by unskilled birth attendants than those who were comfortable about it as they believe that it is against their tradition for a man other than their husbands to see their nakedness. The study also found that majority of the pregnant women take traditional herbs during pregnancy to quicken labour and prevent obstructed labour as they belief that most of the men end up having extra marital affairs when their wives are pregnant and this puts the pregnant women at risk of obstructed labour. The study discovered that majority of the cases 46(27.1%) took the traditional herbs in their last pregnancy compared to the controls 14(8.2%). Respondents who took the traditional herbs on their last pregnancy were 1.717 [OR (95% CI) = 1.717 (1.407, 2.096)] more likely to be delivered by unskilled birth attendants than those who did not take the traditional herbs. The study also found out that the knowledge levels of women on danger signs of pregnancy, labour and puerperium was alarmingly lower than expected. Majority of the women could not identify most of the danger signs of pregnancy, labour and puerperium Sixty seven point seven percent of the cases and 52.9% of the controls perceived dizziness as not being dangerous during pregnancy while majority of the controls 99(58.2%) and cases 93(54.7%) perceived fitting as not being dangerous during pregnancy. These are danger signs of pregnancy which should be known by every pregnant woman. Conclusion: The study found out that women are shunning delivering in health facilities by skilled attendants because of the presence of male midwives at the health facilities, use of traditional herbs to quicken labour and low levels of knowledge of danger signs of pregnancy, labour and puerperium. These factors and deficiencies need urgent attention for the district to reduce maternal and child suffering. Addressing these factors and deficiencies will not only contribute towards achievement of millennium development goals (MDGs) but also to the overall improvement of maternal and child health. The presence of TBAs in the communities did not affect the women's utilization of skilled attendants at delivery.

Effects of Malnutrition as a Co-Morbid Factor on Neurocognitive Functioning in HIV Positive Adults in Lusaka, Zambia