Community member and policy maker priorities in improving maternal health in rural Tanzania

Improving health care facility birth rates in Rorya District, Tanzania: a multiple baseline trial

BACKGROUND

Rates of maternal mortality and morbidity in Africa remain unacceptably high, as many women deliver at home, without access to skilled birth attendants and life-saving medications. In rural Tanzania, women face significant barriers accessing health care facilities for their deliveries.

METHODS

From January 2017 to February 2019 we conducted a multiple baseline (interrupted time series) trial within the four divisions of Rorya District, Tanzania. We collected baseline data, then sequentially introduced a complex intervention in each of the divisions, in randomized order, over 3 month intervals. We allowed for a 6 month transition period to avoid contamination between the pre- and post-intervention periods. The intervention included using community health workers to educate about safe delivery, distribution of birth kits with misoprostol, and a transport subsidy for women living a distance from the health care facility. The primary outcome was the health facility birth rate, while the secondary outcomes were the rates of antenatal and postpartum care and postpartum hemorrhage. Outcomes were analyzed using fixed effects segmented logistic regression, adjusting for age, marital status, education, and parity. Maternal and baby morbidity/mortality were analyzed descriptively.

RESULTS

We analyzed data from 9565 pregnant women (2634 before and 6913 after the intervention was implemented). Facility births increased from 1892 (71.8%) before to 5895 (85.1%) after implementation of the intervention. After accounting for the secular trend, the intervention was associated with an immediate increase in the odds of facility births (OR = 1.51, 95% CI 1.14 to 2.01, p = 0.0045) as well as a small gradual effect (OR = 1.03 per month, 95% CI 1.00 to 1.07, p = 0.0633). For the secondary outcomes, there were no statistically significant immediate changes associated with the intervention. Rates of maternal and baby morbidity/mortality were low and similar between the pre- and post-implementation periods.

CONCLUSIONS

Access to health care facilities can be improved through implementation of education of the population by community health workers about the importance of a health care facility birth, provision of birth kits with misoprostol to women in late pregnancy, and access to a transport subsidy for delivery for women living at a distance from the health facility.

CLINICAL TRIALS REGISTRATION

NCT03024905 19/01/2017.

Experiences of a multiple intervention trial to increase maternity care access in rural Tanzania: Focus group findings with women, nurses and community health workers

OBJECTIVES

In order to improve maternal health and women's access to maternity care services in Rorya District, Mara, Northern Tanzania, we introduced several interventions across the district from 2018 to 2019. The interventions were workshops with nurses to encourage respectful care of women and transportation subsidies for women to reach the health facilities for delivery. In addition, we trained community health workers to educate couples about safe birthing options using m-health applications, to collaborate with nurses to distribute clean birth kits with misoprostol and to hold village meetings to shift community norms. This article reports on the experiences of women, community health workers and nurses during the study.

METHODS

Focus group discussions were conducted with a convenience sample of these groups to understand the successes and challenges of the interventions.

RESULTS

The workshops with nurses to encourage respectful maternity care and the birth kits with misoprostol were appreciated by all and were an incentive for women to seek health services. While the m-health applications were innovative, the system required significant oversight and a stable network. The village meetings demonstrated some success and should be expanded. Travel subsidies were problematic to implement and only helpful to the minority who received them.

CONCLUSION

Multiple intervention strategies are needed to help women access maternity care services in rural locations and should be designed to meet needs within the local context. In Rorya District, access to quality health care was improved through training nurses to provide respectful care and using community health workers to educate the population about safe birthing practices and to provide women with clean birth kits. Despite the current limitations of m-health, there is much potential for development. Finding solutions to women's need for transport is a particular challenge and will likely require innovative community-based approaches.

A scoping review of researchers' involvement in health policy dialogue in Africa

BACKGROUND

Improving evidence-informed policy dialogue to support the development and implementation of national health policies is vital, but there is limited evidence on researchers' roles in policy dialogue processes in Africa. The objective of this study is to examine researchers' involvement in health policy dialogue in Africa.

METHODS

The database search of this scoping review was conducted from inception to January 24, 2021, by an expert searcher/librarian to determine the extent of evidence, barriers, and facilitators of researchers' involvement in health policy dialogues in Africa. PROSPERO, Wiley Cochrane Library, OVID Medline, OVID EMBASE, OVID PsycINFO, OVID Global Health, EBSCO CINAHL, BASE (Bielefeld Academic Search Engine), and Google/Google Scholar were searched using key words representing the concepts "policy dialogue", "health", and "Africa". No limits were applied. A narrative summary of results was presented.

RESULTS

There were 26 eligible studies representing 21 African countries. Significant discrepancies in researchers' involvement existed across countries. In 62% of the countries, there was suboptimal involvement of researchers in policy dialogues due to no or partial participation in policy dialogues. Major barriers included limited funding, lack of evidence in the public health field of interest, and skepticism of policymakers. The presence of an interface for exchange, demand for scientific evidence, and donors' funding were the most reported facilitators.

CONCLUSIONS

To improve the uptake of evidence in health policy-making processes, an environment of trust and communication between policymakers and researchers must be established. Policymakers need to demonstrate that they value research, by providing adequate funding, promoting knowledge translation activities, and supporting personal and professional development opportunities for researchers.

The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization

BACKGROUND

Existing studies in Tanzania, based mostly on rural samples, have primarily focused on individual behaviors responsible for the lower utilization of maternal health care. Relatively less attention had been paid to inequalities in structural circumstances that contribute to reduced utilization of maternal health care. More importantly, scholarship concerning the impact of the rural-urban divide on socioeconomic disparities in the utilization of maternal health care is virtually nonexistent in Tanzania.

METHODS

Drawing from the Demographic Health Survey (2015-2016) conducted in Tanzania, our study includes a total of 3,595 women aged between 15-49 years old, who had given birth in five years before the month of the interview and living in both rural and urban Tanzania. The maternal health care utilization was assessed by four variables (i.e., antenatal care, skilled delivery assistance, the before and after discharging postnatal care). The independent variables were wealth, education, residence, parity, occupation, age, and the head of the household's sex. We used bivariate statistics and logistic regression to examine the rural-urban differences in the influence of education and wealth on maternal health care utilization.

RESULTS

Significantly lower use of maternal health care in rural than urban areas demonstrated a stark rural-urban divide in Tanzania. We documented socioeconomic inequalities in maternal health care utilization in the form of lower odds of the utilization of such services among women with lower levels of education and household wealth. The educational inequalities in the utilization of skilled delivery assistance (or = 0.37, 95% CI: 0.16, 0.86; p = 0.021) and (before discharge) postnatal care (or = 0.60, 95% CI: 0.38, 0.95; p = 0.030) were significantly wider in rural than urban areas. The differences in the odds of the utilization of skilled delivery assistance between women in poorer wealth quintile and women in richer household wealth quintile were also significantly wider in rural areas than in urban areas. However, the statistically significant rural-urban divides in the impacts of socioeconomic status on antenatal care and (after discharge) postnatal care were not observed.

CONCLUSION

This study establishes the need for consideration of the rural-urban context in the formulation of policies to reduce disparities in maternal health care utilization in Tanzania.

Promoting respectful maternity care in rural Tanzania: nurses' experiences of the "Health Workers for Change" program

Background

Disrespectful and abusive care of women during their pregnancies has been shown to be a barrier for women accessing health care services for antenatal care and delivery. As part of an implementation research study to improve women’s access to health care services in Rorya District, Mara, Tanzania, we conducted a pilot study training reproductive health care nurses to be more sensitive to women’s needs based on the “Health Workers for Change” curriculum.

Methods

Six series of workshops were held with a total of 60 reproductive health care nurses working at the hospitals, health centres and dispensaries in the district. The participants provided comments on a survey and participated in focus groups at the conclusion of the workshop series. These qualitative data were analyzed for common themes.

Results

The participants appreciated the training and reflected on the poor quality of health care services they were providing, recognizing their attitudes towards their women patients were problematic. They emphasized the need for future training to include more staff and to sustain positive changes. Finally, they made several suggestions for improving women’s experiences in the future.

Conclusions

The qualitative findings demonstrate the success of the workshops in assisting the health care providers to become aware of their negative attitudes towards women. Future research should examine the impact of the workshops both on sustaining attitudinal changes of the providers and on the experiences of pregnant women receiving health care services.