Factors Contributing to Born Before Arrival (BBA) Deliveries among Booked Pregnant Women in Harare City: A Health Systems Perspective

Abstract

Maternal and neonatal health remains a major public health concern, particularly in urban settings where rapid population growth and limited healthcare infrastructure hinder timely access to quality care. One challenge is the occurrence of Born Before Arrival (BBA) deliveries—births taking place outside health facilities despite mothers being booked for institutional deliveries. BBAs are associated with adverse maternal and neonatal outcomes and often reflect systemic, social, and behavioral barriers. This study aimed to determine factors contributing to BBAs among booked mothers in Harare City Polyclinics in 2018. An unmatched 1:1 case-control study was conducted using convenience sampling, involving 148 participants (74 cases and 74 controls) from twelve polyclinics. Data were collected through a structured interviewer-administered questionnaire assessing socio-demographic characteristics, knowledge and attitudes, and institutional factors. Quantitative data were analyzed using Epi Info version 7, while qualitative responses were analyzed manually. Multivariate analysis identified significant determinants of BBAs, including level of education (AOR 3.69, 95% CI 0.44–0.75, p<0.001), maternal age (AOR 2.01, 95% CI 2.49–5.86, p=0.002), place of residence (AOR 11.43, 95% CI 0.04–0.23, p<0.001), number of antenatal visits (AOR 8.30, 95% CI 1.21–1.71, p<0.001), convenience of clinic operating hours (AOR 0.30, 95% CI 0.23–0.50, p=0.003), and accessibility of health facilities (AOR 0.13, 95% CI 0.41–0.65, p<0.001). Bivariate analysis further highlighted perceived delays at clinics (OR 3.13, 95% CI 1.15–8.51, p=0.038), staff friendliness (OR 0.04, 95% CI 0.10–0.17, p<0.001), and maternal satisfaction during pregnancy (OR 0.33, 95% CI 0.17–0.64, p=0.001) as significant factors. The findings demonstrate that socio-demographic characteristics, healthcare accessibility, clinic operations, and quality of patient–provider interactions significantly influence the occurrence of BBAs. To reduce BBAs, Harare City should establish clinics in emerging suburbs, increase nursing staff to reduce delays, and ensure 24-hour clinic operations. Strengthening communication strategies, including social media use for maternal health education, and retraining clinical staff on public relations and customer care are also recommended to enhance maternal health outcomes and institutional delivery rates.