An account for barriers and strategies in fulfilling women's right to quality maternal health care: a qualitative study from rural Tanzania

Readiness to provide comprehensive emergency obstetric and neonatal care: a cross-sectional study in 30 health facilities in Tanzania

BACKGROUND

Despite the global progress in bringing health services closer to the population, mothers and their newborns still receive substandard care leading to morbidity and mortality. Health facilities' capacity to deliver the service is a prerequisite for quality health care. This study aimed to assess health facilities' readiness to provide comprehensive emergency obstetric and newborn care (CEmONC), comprising of blood transfusion, caesarean section and basic services, and hence to inform improvement in the quality of care interventions in Tanzania.

METHODS

A cross-sectional assessment of 30 CEmONC health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out between December 2020 and January 2021. We adapted the World Health Organization's Service Availability and Readiness Assessment tool to assess amenities, equipment, trained staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher's exact test; for readiness scores, differences were tested by a linear mixed model analysis, taking into account dependencies within the regions. We used p < 0.05 as our level of significance.

RESULTS

The overall readiness to provide CEmONC was 69.0% and significantly higher for regional hospitals followed by district hospitals. Average readiness was 78.9% for basic amenities, 76.7% for medical equipment, 76.0% for diagnosis and treatment commodities, 63.6% for staffing and 50.0% for guidelines. There was a variation in the availability of items at the individual health facility level and across levels of facilities. We found a significant difference in the availability of basic amenities, equipment, staffing, and guidelines between regional, and district hospitals and health centres (p = 0.05). Regional hospitals had significantly higher scores of medical equipment than district hospitals and health centers (p = 0.02). There was no significant difference in the availability of commodities for diagnosis and treatment between different facility levels.

CONCLUSION

Facilities' readiness was inadequate and varied across different levels of the facility. There is room to improve the facilities' readiness to deliver quality maternal and newborn care. The responsible authorities should take immediate actions to address the observed deficiencies while carefully choosing the most effective and feasible interventions and monitoring progress in readiness.

Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study

BACKGROUND

Women's childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women's childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user's needs.

AIM

This study aimed to explore women's childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania.

METHODS

This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization's Quality of Care framework on experiences of care domains.

RESULTS

Three themes emerged from the data: (1) Women's experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were.

CONCLUSION

The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women's needs.

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.

Supply-side factors influencing demand for facility-based delivery in Tanzania: a multilevel analysis

BACKGROUND

Improving access to facility-based delivery care has the potential to reduce maternal and newborn deaths across settings. Yet, the access to a health facility for childbirth remains low especially in low-income settings. To inform evidence-based interventions, more evidence is needed especially accounting for demand- and supply-side factors influencing access to facility-based delivery care. We aimed to fill this knowledge gap using data from Tanzania.

METHODS

We used data from a cross-sectional survey (conducted in January 2012) of 150 health facilities, 1494 patients and 2846 households with women who had given births in the last 12 months before the survey across 11 districts in three regions in Tanzania. The main outcome was the place of delivery (giving birth in a health facility or otherwise), while explanatory variables were measured at the individual woman and facility level. Given the hierarchical structure of the data and variance in demand across facilities, we used a multilevel mixed-effect logistic regression to explore the determinants of facility-based delivery care.

RESULTS

Eighty-six percent of 2846 women gave birth in a health facility. Demand for facility-based delivery care was influenced more by demand-side factors (76%) than supply-side factors (24%). On demand-side factors, facility births were more common among women who were educated, Muslim, wealthier, with their first childbirth, and those who had at least four antenatal care visits. On supply-side factors, facility births were more common in facilities offering outreach services, longer consultation times and higher interpersonal quality. In contrast, facilities with longer average waiting times, longer travel times and higher chances of charging delivery fees had few facility births.

CONCLUSIONS

Policy responses should aim for strategies to improve demand like health education to raise awareness towards care seeking among less educated groups and those with higher parity, reduce financial barriers to access (including time costs to reach and access care), and policy interventions to enhance interpersonal quality in service provision.

Improving comprehensive emergency obstetric and newborn care in Tanzania: A qualitative study

AIM

The purpose of this qualitative study was to explore how health care professionals, managers and community members experienced the implementation of a training program in comprehensive emergency obstetric and neonatal care training in rural Tanzania.

BACKGROUND

Given the high rates of maternal and newborn mortality in Tanzania, the government committed to improving maternal health by increasing access to health care; improving reproductive, maternal, newborn health; reducing maternal and neonate mortality; and increasing the number of public health centers with emergency obstetric and neonatal care. To address the gap in emergency obstetric and neonatal care amongst the health workforce, five health care facilities in rural Tanzania participated in a 3-month specialized training program. The training was geared to increase access to skilled deliveries, prevent maternal and neonate deaths, and reduce referrals to district hospitals.

METHODS

Twenty-four focus group discussions were held with members of Council Health Management Team, Health Facility Management Team, staff who received training, and community members. Data collection and analysis was guided by content analysis and the World Health Organization's availability, accessibility, acceptability, and quality framework.

FINDINGS

Participants reported acquiring necessary skills that enabled them to provide quality and safe obstetric and newborn care. Five themes emerged from the analysis 1) competent and confident health care teams, 2) renewed commitment to teamwork, 3) community confidence and trust in the health team, 4) mentorship as a critical element of success, and 5) enhancing training and practice. These five emerging themes demonstrate enhanced confidence and trust by the community and increased competency of health care teams to support mothers through pregnancy and birth at the health centre.

CONCLUSION

The competencies acquired by health care providers demonstrate an increase in staff commitment and teamwork. There is an increased number of deliveries in health centres, a declining trend of maternal and neonate deaths and referrals to other health centres because the health care providers are capable of competently and confidently providing emergency obstetric and neonatal care services.

Access to Health Services Among Forced Migrants in Tanzania: A Cluster Randomized Cross Sectional Study of 3560 Congolese and Burundian Refugees

Despite significant advances in the understanding of the global burden of surgical disease, limited research focuses on access to health and surgical services among refugees, especially in east Africa. The goal of this study was to describe patterns of access to transportation to health services among Congolese and Burundian refugees in Tanzania. We utilized cluster random sampling to perform a large, cross-sectional study in Nyarugusu refugee camp, Tanzania using an adapted version of the Surgeon Overseas Assessment Tool (SOSAS). We randomly selected 132 clusters out of 1472 clusters, randomly selected two people from all households in those clusters. Data analysis was performed in STATA (Stata Version 16, College Station, TX). A total of 3560 participants were included in the study including 1863 Congolese refugees and 1697 Burundian refugees. The majority of refugees reported they were generally healthy (n = 2792, 79.3%). The most common period of waiting to be seen at the health center was between three and 5 h (n = 1502, 45.8%), and over half of all refugees waited between 3 and 12 h to be seen. There was heterogeneity in other intra-camp referral networks (e.g. to and from traditional healer and hospital). Finally, a low percentage (3%) of participants reported leaving the refugee camp to seek health care elsewhere, and Congolese refugees were more likely to pursue self-referral in this manner. To our knowledge, this is the largest study focused on access to transportation among refugees in Tanzania and sub-Saharan Africa. Most participants reported financial difficulty always affording transportation costs with significant wait times occurring once arrived at the hospital. Our study does suggest that some independent health care seeking did occur outside of the camp-based services. Future research may focus more specifically on barriers to timely servicing of patients and patterns of self-referral.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Zachary Obinna] Last Name [Enumah] and Author 2 Given name: [Mohamed Yunus] Last Name [Rafiq]. Also, kindly confirm the details in the metadata are correct.Confirmed.

A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania

Efforts to increase the availability and utilization of high-quality emergency obstetric and newborn care and routine delivery care services in Kigoma were successful and subsequently contributed to significant reductions in maternal and perinatal mortality in the region.

Introduction:

To address high levels of maternal mortality in Kigoma, Tanzania, stakeholders increased women's access to high-quality comprehensive emergency obstetric and newborn care (EmONC) by decentralizing services from hospitals to health centers where EmONC was delivered mostly by associate clinicians and nurses. To ensure that women used services, implementers worked to continuously improve and sustain quality of care while creating demand.

Methods:

Program evaluation included periodic health facility assessments, pregnancy outcome monitoring, and enhanced maternal mortality detection region-wide in program- and nonprogram-supported health facilities.

Results:

Between 2013 and 2018, the average number of lifesaving interventions performed per facility increased from 2.8 to 4.7. The increase was higher in program-supported than nonprogram-supported health centers and dispensaries. The institutional delivery rate increased from 49% to 85%; the greatest increase occurred through using health centers (15% to 25%) and dispensaries (21% to 46%). The number of cesarean deliveries almost doubled, and the population cesarean delivery rate increased from 2.6% to 4.5%. Met need for emergency obstetric care increased from 44% to 61% while the direct obstetric case fatality rate declined from 1.8% to 1.4%. The institutional maternal mortality ratio across all health facilities declined from 303 to 174 deaths per 100,000 live births. The total stillbirth rate declined from 26.7 to 12.8 per 1,000 births. The predischarge neonatal mortality rate declined from 10.7 to 7.6 per 1,000 live births. Changes in case fatality rate and maternal mortality were driven by project-supported facilities. Changes in neonatal mortality varied depending on facility type and program support status.

Conclusion:

Decentralizing high-quality comprehensive EmONC delivered mostly by associate clinicians and nurses led to significant improvements in the availability and utilization of lifesaving care at birth in Kigoma. Dedicated efforts to sustain high-quality EmONC along with supplemental programmatic components contributed to the reduction of maternal and perinatal mortality.

Maternal knowledge-seeking behavior among pregnant women in Tanzania

BACKGROUND

Maternal mortality continues to be a global challenge with about 830 women dying of childbirth and pregnancy complications every day. Tanzania has a maternal mortality rate of 524 deaths per 100,000 live births.

OBJECTIVE

Knowing symptoms associated with antenatal risks among pregnant women may result in seeking care earlier or self-advocating for more immediate treatment in health facilities. This article sought to identify knowledge-seeking behaviors of pregnant women in Northern Tanzania, to determine the challenges met and how these should be addressed to enhance knowledge on pregnancy risks and when to seek care.

METHODS

Interview questions and questionnaires were the main data collection tools. Six gynecologists and four midwives were interviewed, while 168 pregnant women and 14 recent mothers participated in the questionnaires.

RESULTS

With the rise in mobile technology and Internet penetration in Tanzania, more women are seeking information through online sources. However, for women to trust these sources, medical experts have to be involved in developing the systems.

CONCLUSION

Through expert systems diagnosis of pregnancy complications and recommendations from experts can be made available to pregnant women in Tanzania. In addition, self-care education during pregnancy will save women money and reduce hospital loads in Tanzania.

An assessment of hospital maternal health services in northern Ghana: a cross-sectional survey

BACKGROUND

Access to and delivery of comprehensive emergency obstetric and neonatal care (CEmONC) services are often weak in low and middle-income countries affecting maternal and infant health outcomes. There are no studies on resources for maternal healthcare in the Northern region of Ghana. This knowledge is vital for health service planning and mobilising funding to address identified gaps. We investigated the available resources for managing CEmONC and referral services in the region.

METHODS

This study involved a cross-sectional survey of maternity facilities in ten hospitals in the Northern region of Ghana, serving a population of 2,479,461, including 582,897 women aged 15-49. Public and faith-based hospitals were included in the study. We used the Service Provision Assessment tool to gather data for this study between October and December 2019. Given the small sample size, we used descriptive statistics to summarise the data using SPSS version 25 and Excel 2016.

RESULTS

A total of 22,271 ANC visits from women to these hospitals occurred in the past 3 months preceding the study; however, 6072 birth events (cases) occurred within the same period. All the hospitals had less than one general medical doctor per 10,000 population (range 0.02-0.30). The number of midwives per 10,000 population ranged from 0.00 (facility H and J) to 1.87 (facility E), and none of the hospitals had a university-trained nurse designated for maternity care. Only one hospital had complete equipment for emergency obstetric and newborn care, while four others had adequate emergency obstetric care equipment. The number of maternity and delivery beds per 10,000 population was low, ranging from 0.40 to 2.13.

CONCLUSIONS

The management of emergency obstetric care and referrals are likely to be affected by the limited human resources and equipment in hospitals in Northern Ghana. Financial and non-financial incentives to entice midwives, obstetricians and medical officers to the Northern region should be implemented. Resources should be mobilised to improve the availability of essential equipment such as vacuum extractors and reliable ambulances to enhance referral services. Considerable health system strengthening efforts are required to achieve the required standards.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania

BACKGROUND

An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate.

METHODS

This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included.

RESULTS

Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels.

CONCLUSIONS

To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

"We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage

Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH).

Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers’ perceptions of their health facilities’ readiness to provide PPH care.

Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software.

Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care.

Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed.

Lessons learned through respectful maternity care training and its implementation in Ethiopia: an interventional mixed methods study

Background

Improving respectful maternity care (RMC) is a recommended practice during childbirth as a strategy to eliminate the mistreatment of women and improve maternal health. There is limited evidence on the effectiveness of RMC interventions and implementation challenges, especially in low-resource settings. This study describes lessons learned in RMC training and its implementation from the perspectives of service providers’ perceptions and experiences.

Methods

Our mixed methods study employed a pre- and post-intervention quantitative survey of training participants to assess their perceptions of RMC and focus group discussions, two months following the intervention, investigated the experiences of implementing RMC within birthing facilities. The intervention was a three-day RMC training offered to 64 service providers from three hospitals in southern Ethiopia. We performed McNemar’s test to analyse differences in participants’ perceptions of RMC before and after the training. The qualitative data were analysed using hybrid thematic analysis. Integration of the quantitative and qualitative methods was done throughout the design, analysis and reporting of the study.

Results

Mistreatment of women during childbirth was widely reported by participants, including witnessing examinations without privacy (39.1%), and use of physical force (21.9%) within the previous 30 days. Additionally, 29.7% of participants reported they had mistreated a woman. The training improved the participants’ awareness of the rights of women during childbirth and their perceptions and attitudes about RMC were positively influenced. However, participants believed that the RMC training did not address providers’ rights. Structural and systemic issues were the main challenges providers reported when trying to implement RMC in their contexts.

Conclusion

Training alone is insufficient to improve the provision of RMC unless RMC is addressed through a lens of health systems strengthening that addresses the bottlenecks, including the rights of providers of childbirth care.

Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care

Background

Healthcare providers are the vital link between evidence-based policies and women receiving high quality maternity care. Explanations for suboptimal care often include poor working conditions for staff and a lack of essential supplies. Other explanations suggest that doctors, midwives and care assistants might lack essential skills or be unaware of the rights of the women for whom they care. This ethnography examined the everyday lives of maternal healthcare providers working in a tertiary maternity hospital in Kabul, Afghanistan between 2010 and 2012. The aim was to understand their notions of care, varying levels of commitment, and the obstacles and dilemmas that affected standards.

Methods

The culture of care was explored through six weeks of observation, 41 background interviews, 23 semi-structured interviews with doctors, midwives and care assistants. Focus groups were held with two diverse groups of women in community settings to understand their experiences and desires regarding care in maternity hospitals. Data were analysed thematically.

Results

Women related many instances of neglect, verbal abuse and demands for bribes from staff. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies and inadequate support from management. Closer inspection revealed a complex reality where care was impeded by low levels of supplies and medicines but theft reduced them further; where staff were unfairly blamed by management but others flouted rules with impunity; and where motivated staff tried hard to work well but, when overwhelmed with the workload, admitted that they lost patience and shouted at women in childbirth. In addition there were extreme examples of both abusive and vulnerable staff.

Conclusions

Providing respectful quality maternity care for women in Afghanistan requires multifaceted initiatives because the factors leading to suboptimal care or mistreatment are complex and interrelated. Standards need enforcing and abusive practices confronting to provide a supportive, facilitating environment for both staff and childbearing women. Polarized perspectives such as ‘villain’ or ‘victim’ are unhelpful as they exclude the complex realities of human behaviour and consequently limit the scope of problem solving.

Reasons for delay in seeking treatment among women with obstetric fistula in Tanzania: a qualitative study

BACKGROUND

Obstetric fistula is among the serious and distressing maternal morbidities in Tanzania. Obstetric fistula is a childbirth-related injury caused by prolonged and obstructed labor which has a devastating impact on affected women and their families. The aim of this study was to explore reasons why women with obstetric fistula admitted to the Comprehensive Community- Based Rehabilitation in Tanzania (CCBRT) hospital delayed seeking fistula treatment.

METHODS

This exploratory study incorporated qualitative approach. In-depth interviews were used to collect data from 18 women with obstetric fistula admitted to CCBRT hospital. The interviews were conducted in Kiswahili and lasted for 40-45 min. Audio-recordings of the interviews were transcribed verbatim and translated into English. Thematic analysis was used to extract reasons for the delay in seeking treatment for obstetric fistula.

RESULTS

The study sample (n = 18) ranged in age from 20 to 57 (μ = 37; SD = 11.67), married (n = 14), unemployed (n = 15), and very low level education (n = 15) with primary education. Delay in seeking treatment for obstetric fistula was related to the following themes: inadequate knowledge about the causes and treatment of obstetric fistula, distance and transport cost to a health facility, stigma, community isolation, social isolation and use of traditional and cultural.

CONCLUSION

The Tanzanian Ministry of Health in collaboration with private institutions should strengthen education programmes on the nature and causes of obstetric fistula, and increase the availability of treatment to decrease the effect of this condition for women in Tanzania.

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

BACKGROUND

It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania.

METHODS

This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.

RESULTS

Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities.

CONCLUSIONS

We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.