Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members

The Challenges of Implementing a Health Referral System in South Africa: A Qualitative Study

Introduction

Health system strengthening efforts also entails streamlining an existing referral system in a particular context to improve quality of health care offered to people. Conceptually, the referral system in South Africa, is seemingly sound. Nevertheless, gaps exist in its implementation. The aim of this study was to explore health care professionals' perceptions of referral system implementation in the Buffalo City Metropolitan Municipality (BCMM) in the Eastern Cape Province of South Africa.

Methods

This qualitative study included 12 health care professionals as participants. Each participant was interviewed using a semi-structured interview guide; with their consent, the interviews were audio recorded and transcribed verbatim. For data analysis, a thematic content analysis was used.

Results

The participants identified many impediments to the effective implementation of the referral system in BCCM. The main obstacles were deteriorating infrastructure, inadequate staffing, lack of transportation, and inadequate medical supplies and medications.

Conclusion

In mitigation, the participants proposed suggestions such as increasing the capacity of the health workforce, allocating personnel appropriately, increasing the availability of transportation, and providing essential medications to all levels of care. They also suggested involving all stakeholders in the referral process, providing education and training to health professionals on the referral system, and enhancing communication and feedback between the various levels of care. These challenges emphasised in this study highlight the need for targeted interventions to improve the referral system in this setting.

Gender transformative approaches in mHealth for maternal healthcare in sub-Saharan Africa: a systematic review

Background

This review focuses on studies about digital health interventions in sub-Saharan Africa. Digital health interventions in sub-Saharan Africa are increasingly adopting gender-transformative approaches to address factors that derail women's access to maternal healthcare services. However, there remains a paucity of synthesized evidence on gender-transformative digital health programs for maternal healthcare and the corresponding research, program and policy implications. Therefore, this systematic review aims to synthesize evidence of approaches to transformative gender integration in digital health programs (specifically mHealth) for maternal health in sub-Saharan Africa.

Method

The following key terms "mobile health", "gender", "maternal health", "sub-Saharan Africa" were used to conduct electronic searches in the following databases: PsycInfo, EMBASE, Medline (OVID), CINAHL, and Global Health databases. The method and results are reported as consistent with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data synthesis followed a convergent approach for mixed-method systematic review recommended by the JBI (Joanna Briggs Institute).

Results

Of the 394 studies retrieved from the databases, 11 were included in the review. Out of these, six studies were qualitative in nature, three were randomized control trials, and two were mixed-method studies. Findings show that gender transformative programs addressed one or more of the following categories: (1) gender norms/roles/relations, (2) women's specific needs, (3) causes of gender-based health inequities, (4) ways to transform harmful gender norms, (5) promoting gender equality, (6) progressive changes in power relationships between women and men. The most common mHealth delivery system was text messages via short message service on mobile phones. The majority of mHealth programs for maternal healthcare were focused on reducing unintended pregnancies through the promotion of contraceptive use. The most employed gender transformative approach was a focus on women's specific needs.

Conclusion

Findings from gender transformative mHealth programs indicate positive results overall. Those reporting negative results indicated the need for a more explicit focus on gender in mHealth programs. Highlighting gender transformative approaches adds to discussions on how best to promote mHealth for maternal health through a gender transformative lens and provides evidence relevant to policy and research.

Systematic review registration

PROSPERO CRD42023346631.

Factors that influence compliance for referral from primary care to hospital for maternal and neonatal complications in Bosaso, Somalia: a qualitative study

OBJECTIVES

To estimate referral compliance and examine factors that influence decisions to comply with referral for newborn and maternal complications in Bosaso, Somalia.

SETTING

Bosaso, Somalia, is a large port city that hosts a large proportion of internally displaced persons. The study was conducted at the only four primary health centres offering 24/7 delivery services and the only public referral hospital in Bosaso.

PARTICIPANTS

All pregnant women who sought care at four primary centres and were referred to the hospital for maternal complications or mothers whose newborns were referred for neonatal complications were approached for enrolment from September to December 2019. In-depth interviews (IDIs) of 54 women and 14 healthcare workers (HCWs) were conducted.

OUTCOME MEASURES

This study examined timely referral compliance from the primary centre to the hospital. IDIs were analysed for a priori themes investigating the decision-making process and experience of care for maternal and newborn referrals.

RESULTS

Overall, 94% (n=51/54) of those who were referred, 39 maternal and 12 newborns, complied with the referral and arrived at the hospital within 24 hours. Of the three that did not comply, two delivered on the way, and one cited lack of money as the reason for noncompliance. Four themes emerged: trust in medical authority, cost of transportation and care, quality of care, and communications. The factors that facilitated compliance were the availability of transportation, family support, concern for health, and trust in medical authority. HCWs raised the importance of considering the maternal-newborn dyad throughout the referral process, and the need for official standard operating procedures for referrals including communications between the primary care and the hospital.

CONCLUSIONS

High compliance for referral from primary to hospital care for maternal and newborn complications was observed in Bosaso, Somalia. Costs associated with transportation and care at the hospital need attention to motivate compliance.

Women's experiences with hypertensive disorders of pregnancy from a national referral hospital in Tanzania: A qualitative study

AIM

This study aimed to explore the experiences among postpartum women with hypertensive disorders of pregnancy, from pregnancy to admission at a referral hospital in Tanzania.

METHODS

This was a descriptive cross-sectional design with purposive sampling. Data were collected from semi-structured in-depth interviews with postpartum women diagnosed with hypertensive disorders and who were admitted to the maternity ward of Muhimbili National Hospital. Data were analyzed using NVivo software for qualitative content analysis.

RESULTS

Fourteen women participated in interviews. Half were primipara and two-thirds had over four antenatal visits. Data analysis yielded four categories and 27 sub-categories. The four categories were: "I'm shocked; I thought I was normal," "The treatment journey," "What health care providers did and did not teach me," "I have a risky future; I hope health care providers can help me."

CONCLUSION

Women regarded themselves going from being normal to having a risk through the process of experiencing their treatments. They did not expect to be admitted or referred to a major hospital and while they demanded more information and education, they also expressed appreciation for their health care providers. Education during pregnancy addressing their needs and level of understanding is recommended for improvement of early detection and access to the health service.

Understanding barriers to implementing referral procedures in the rural and semi-urban district hospitals in Tanzania: Experiences of healthcare providers working in maternity units

INTRODUCTION

Maternal and perinatal deaths occurring in low and middle income countries could be prevented with timely access to maternal and new-born care. In order to increase access to maternal and child health services, a well-functioning referral system that allows for continuity of care across different tiers of healthcare is required. A reliable healthcare system, with adequate numbers of skilled staff, resources and mechanisms, is critical to ensuring that access to care is available when the need arises.

MATERIAL AND METHODS

This descriptive, qualitative study design was used to explore barriers to implementing a reliable referral system. Twelve individual qualitative interviews were conducted with health care providers working in rural and semi-urban district hospitals in the Northern, Western, Eastern and Southern zones of Tanzania. Thematic analysis guided analysis of data.

RESULTS

Three (3) main and interconnected themes were abstracted from the data relating to participants' experiences of referring women with obstetric complications to adequate obstetric care. These were: 1. Adhering to a rigid referral protocol; 2. Completing the referral of women to an adequate health facility and 3. Communicating the condition of the woman with obstetric complications between the referring and receiving facilities.

CONCLUSION

Because of referral regulations, assistant medical officers were unable to make referral decisions even when they felt that a referral was needed. The lack of availability of hospital transport as well as the lack of a reliable feedback mechanism, prohibited effective referrals of patients. The Ministry of Health should revise the referral protocol to allow all clinicians to provide referrals, including assistant medical officers- who make up the majority of clinical staff in rural health care facilities. A mechanism to ensure effective communication between the referral facility and the tertiary care hospital should be instituted for quality and continuity of care. Furthermore, health care facilities should put aside budget for fuelling the ambulance for effective referrals.

'Violence exists to show manhood': Nepali men's views on domestic violence - a qualitative study

Background

There is significant evidence of the prevalence and factors associated with domestic violence in high and low-income country settings. However, men’s views on domestic violence are still understudied and have never been reported in Nepali society.

Objective

The aim of the study was to explore Nepali men’s perceptions regarding domestic violence in their communities.

Method

The authors undertook a qualitative study using focus group discussions.

Results

Sixty-six married men, considered they were responsible for upholding family discipline and physically demonstrating their masculinity, and they suggested that violence was a mean for achieving this. Men’s frustration when unable to fulfil their family’s expectations or material needs, and cultural attitudes that precluded interference in other families’ lives, were perceived as factors contributing to domestic violence. The men held the opinion that women also perpetrated domestic violence. Some men were reluctant to accept domestic violence as a norm in Nepali families and were aware of recent changes in societal expectations regarding gender roles.

Conclusion

Overall, the Nepali men who participated in the study held different and sometimes opposing views on domestic violence, ranging from violence justified as a necessity for family discipline, uneasy acceptance that violence was commonplace in families, to definite opposition to the use of domestic violence. The study’s findings provide information for identifying points of intervention for violence-prevention efforts and strategies to alter the social and cultural norms that lead to acceptance of domestic violence.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.

"Our voices matter": a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya

Background

Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age.

Methods

Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test.

Results

Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1–3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = − 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = − 0.698, P = 0.03).

Conclusions

A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3739-9) contains supplementary material, which is available to authorized users.

When, where and who? Accessing health facility delivery care from the perspective of women and men in Tanzania: a qualitative study

BACKGROUND

Childbirth is a momentous event for women and their partners, yet women continue to die in childbirth worldwide, particularly in sub-Saharan Africa. To reduce maternal mortality and increase the number of women delivering at health facilities, it is important to understand reasons why women who do deliver at health facilities chose to do so. Therefore, the objective of this qualitative study was to explore the perceptions of women and men on (i) when women go to the hospital; (ii) where women deliver; and (iii) who is involved in the delivery process related to accessing health facilities for delivery care in Tanzania.

METHODS

Using a qualitative design, four focus group discussions (n = 23) and semi-structured interviewers (n = 12) were held with postnatal women and men who were attending a postnatal clinic in the Lake Zone region of Tanzania. Data was analyzed using thematic coding.

RESULTS

Women and men expressed factors that influenced when, where, and with whom they accessed health facilities for delivery care, with the quality of care received providing a significant influence. When decisions were made about going to the hospital, there were challenges that resulted in delayed treatment seeking; however, couples recognized the need to seek care earlier to prevent complications. Private hospitals were the preferred location for delivery with public hospitals and home deliveries with traditional birth attendants being less desirable. Both when and where delivery took place was influenced by the desire for better quality of care received as well as financial costs. Finally, there was mixed evidence on who was involved in decision making around delivery location from the perspective of women and men, but both groups expressed a preference for more male involvement during the delivery.

CONCLUSION

Men and women show desire for women to delivery at health facilities; however, improvements are needed with respect to maternal care and humanizing the birth process in Tanzania. Greater emphasis needs to be placed on including men during the birth process, improving the quality of care received in public hospitals, and reducing the barriers to accessing health facilities for delivery care.

Husband's role in handling pregnancy complications in Mangochi District, Malawi: A call for increased focus on community level male involvement

OBJECTIVE

The objective of the current study is to provide information about husbands' role in decision-making and healthcare seeking in cases of pregnancy complications in Mangochi district, Malawi with an analysis of qualitative interviews using the concepts of "capital" and "field" from Bourdieu's social field theory.

STUDY DESIGN

Twelve husbands and wives who had experienced pregnancy complications and six key informants from a semi-rural area of Mangochi district were interviewed individually. Thematic analysis was conducted based on the concepts of capital and field in Bourdieu's social field theory.

RESULTS

Husbands have significant economic and symbolic capital in decisions about healthcare seeking during instances of pregnancy complications as a result of their roles as father, head of the household and main income earner. Lack of money is the only acceptable reason for husbands to deny their wives healthcare. Husbands have limited access to knowledge of maternal health, which can compromise their decisions about seeking healthcare. Joint decision-making within families can be bypassed to allow for prompt healthcare seeking in emergencies.

CONCLUSIONS

Husbands are important decision makers regarding seeking healthcare for pregnancy complications because of their economic and symbolic power and despite their limited access to knowledge of maternal health. Maternal healthcare seeking practices would benefit from wives gaining an empowered role as well as improved knowledge of maternal health among husbands.