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Juma D, Stordal K, Kamala B, Bishanga DR, Kalolo A, Moshiro R, Kvaløy JT, Manongi R. Readiness to provide comprehensive emergency obstetric and neonatal care: a cross-sectional study in 30 health facilities in Tanzania. BMC Health Serv Res 2024; 24:870. [PMID: 39085821 PMCID: PMC11290101 DOI: 10.1186/s12913-024-11317-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
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.
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Affiliation(s)
- Damas Juma
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania.
- Manyara Regional Secretariat, Manyara, Tanzania.
| | - Ketil Stordal
- Department of Pediatric Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Benjamin Kamala
- Department of Research, Haydom Lutheran Hospital, Manyara, Tanzania
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Dunstan R Bishanga
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Albino Kalolo
- Department of Public Health, St. Francis University College of Health and Allied Sciences, Ifakara, Tanzania
| | - Robert Moshiro
- Department of Research, Haydom Lutheran Hospital, Manyara, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Rachel Manongi
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
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Metta E, Unkels R, Mselle LT, Hanson C, Alvesson HM, Al-Beity FMA. Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study. BMC Pregnancy Childbirth 2024; 24:290. [PMID: 38641769 PMCID: PMC11027221 DOI: 10.1186/s12884-024-06396-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/07/2024] [Indexed: 04/21/2024] Open
Abstract
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.
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Affiliation(s)
- Emmy Metta
- Department of Behavioural Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Regine Unkels
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lilian Teddy Mselle
- Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Fadhlun M Alwy Al-Beity
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Department of Obstetrics/Gynaecology, School of Clinical Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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Matolengwe A, Murray D, Okafor UB. The Challenges of Implementing a Health Referral System in South Africa: A Qualitative Study. Risk Manag Healthc Policy 2024; 17:855-864. [PMID: 38623578 PMCID: PMC11017115 DOI: 10.2147/rmhp.s450998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 04/17/2024] Open
Abstract
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.
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Affiliation(s)
- Aseza Matolengwe
- Department of Public Health, University of Fort Hare, East London, South Africa
| | - Daphne Murray
- Department of Public Health, University of Fort Hare, East London, South Africa
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Binyaruka P, Foss A, Alibrahim A, Mziray N, Cassidy R, Borghi J. Supply-side factors influencing demand for facility-based delivery in Tanzania: a multilevel analysis. HEALTH ECONOMICS REVIEW 2023; 13:52. [PMID: 37930445 PMCID: PMC10629065 DOI: 10.1186/s13561-023-00468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania.
| | - Anna Foss
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Abdullah Alibrahim
- College of Engineering and Petroleum, Kuwait University, Kuwait City, Kuwait
| | - Nicholaus Mziray
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Rachel Cassidy
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- KPM Center for Public Management, University of Bern, Schanzeneckstrasse 1, Bern, 3012, Switzerland
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Mselle L, O'Hearn S, Aston M, Murphy GT, Rigby J. Improving comprehensive emergency obstetric and newborn care in Tanzania: A qualitative study. Midwifery 2023; 123:103698. [PMID: 37187099 DOI: 10.1016/j.midw.2023.103698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
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.
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Affiliation(s)
- Lilian Mselle
- Muhimbili University of Health and Allied Sciences, Department of Clinical Nursing, Dar es Salaam, Tanzania
| | - Shawna O'Hearn
- Dalhousie University, Faculty of Medicine, Halifax, Nova Scotia, Canada.
| | - Megan Aston
- Dalhousie University, School of Nursing, Halifax, Nova Scotia, Canada
| | | | - Janet Rigby
- WHO/PAHO Collaborating Centre on Health Workforce Planning & Research, Halifax, Nova Scotia, Canada
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Enumah ZO, Rafiq MY, Juma O, Manyama F, Ngude H, Stevens K, Sakran J. Access to Health Services Among Forced Migrants in Tanzania: A Cluster Randomized Cross Sectional Study of 3560 Congolese and Burundian Refugees. J Immigr Minor Health 2023; 25:115-122. [PMID: 36040581 DOI: 10.1007/s10903-022-01387-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Zachary Obinna Enumah
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | | | - Omar Juma
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Frank Manyama
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Hilary Ngude
- Tanzania Red Cross Society, Dar es Salaam, Tanzania
| | - Kent Stevens
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Joseph Sakran
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge 600 N. Wolfe Street, Baltimore, MD, 21287, USA
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Dominico S, Serbanescu F, Mwakatundu N, Kasanga MG, Chaote P, Subi L, Maro G, Prasad N, Ruiz A, Mongo W, Schmidt K, Lobis S. A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00485. [PMID: 35487553 PMCID: PMC9053146 DOI: 10.9745/ghsp-d-21-00485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/02/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Florina Serbanescu
- U.S. Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA, USA.
| | | | | | - Paul Chaote
- President's Office Regional Administration and Local Government, Health Social Welfare and Nutrition Division, Dodoma, Tanzania
| | - Leonard Subi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | | | - Alicia Ruiz
- U.S. Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA, USA
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Kaaya ES, Ko J, Luhanga E. Maternal knowledge-seeking behavior among pregnant women in Tanzania. ACTA ACUST UNITED AC 2021; 17:17455065211038442. [PMID: 34387125 PMCID: PMC8369856 DOI: 10.1177/17455065211038442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Elsie Somi Kaaya
- School of Computational and Communication Science and Engineering, The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Jesuk Ko
- Department of Industrial Engineering, Universidad Mayor de San Andrés (UMSA), La Paz, Bolivia
| | - Edith Luhanga
- School of Computational and Communication Science and Engineering, The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
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Ameyaw EK, Amoah RM, Njue C, Tran NT, Dawson A. An assessment of hospital maternal health services in northern Ghana: a cross-sectional survey. BMC Health Serv Res 2020; 20:1088. [PMID: 33243223 PMCID: PMC7690070 DOI: 10.1186/s12913-020-05937-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Edward Kwabena Ameyaw
- Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, Australia.
| | - Roberta Mensima Amoah
- Department of Public Health, School of Allied Sciences, University for Development Studies, Tamale, Northern Region, Ghana
| | - Carolyne Njue
- Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, Australia
| | - Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, Australia
| | - Angela Dawson
- Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, Australia
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Hulsbergen M, van der Kwaak A. The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania. BMC Pregnancy Childbirth 2020; 20:681. [PMID: 33176709 PMCID: PMC7656707 DOI: 10.1186/s12884-020-03278-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Myrrith Hulsbergen
- Royal Tropical Institute (KIT), Amsterdam, the Netherlands.
- Women's Healthcare Center (WHC), Amsterdam, the Netherlands.
| | - Anke van der Kwaak
- Royal Tropical Institute (KIT), Amsterdam, the Netherlands
- Vrije Universiteit (VU), Amsterdam, the Netherlands
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Alwy Al-Beity F, Pembe AB, Kwezi HA, Massawe SN, Hanson C, Baker U. "We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage. Glob Health Action 2020; 13:1707403. [PMID: 31928163 PMCID: PMC7006654 DOI: 10.1080/16549716.2019.1707403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Fadhlun Alwy Al-Beity
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hilda A Kwezi
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Siriel N Massawe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hanson
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Ulrika Baker
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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12
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Asefa A, Morgan A, Bohren MA, Kermode M. Lessons learned through respectful maternity care training and its implementation in Ethiopia: an interventional mixed methods study. Reprod Health 2020; 17:103. [PMID: 32615999 PMCID: PMC7331171 DOI: 10.1186/s12978-020-00953-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 06/18/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Anteneh Asefa
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia. .,Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Alison Morgan
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Meghan A Bohren
- Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Australia
| | - Michelle Kermode
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
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13
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Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care. BMC Pregnancy Childbirth 2019; 19:307. [PMID: 31443691 PMCID: PMC6708168 DOI: 10.1186/s12884-019-2420-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/19/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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14
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Lyimo MA, Mosha IH. Reasons for delay in seeking treatment among women with obstetric fistula in Tanzania: a qualitative study. BMC WOMENS HEALTH 2019; 19:93. [PMID: 31291928 PMCID: PMC6617583 DOI: 10.1186/s12905-019-0799-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 07/03/2019] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Mary A Lyimo
- School of Nursing and Midwifery, The Aga Khan University, PO Box 13129, Dar es Salaam, Tanzania.
| | - Idda H Mosha
- Behavioural Sciences Department, School of Public Health and Social Sciences, Muhimbili University of Health & Allied Sciences, PO Box 65004, Dar es Salaam, Tanzania
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15
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Frumence G, Goodman M, Chebet JJ, Mosha I, Bishanga D, Chitama D, Winch PJ, Killewo J, Baqui AH. Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania. BMC Public Health 2019; 19:895. [PMID: 31286930 PMCID: PMC6615291 DOI: 10.1186/s12889-019-7179-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/17/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- G Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O Box 65454, Dar es Salaam, Tanzania.
| | - M Goodman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - J J Chebet
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA.,Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Avenue, Tucson, AZ, 85724, USA
| | - I Mosha
- Department of Behavioral Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O Box 65015, Dar es Salaam, Tanzania
| | - D Bishanga
- Jhpiego Tanzania, PO Box 9170, Dar es Salaam, Tanzania
| | - D Chitama
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O Box 65454, Dar es Salaam, Tanzania
| | - P J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - J Killewo
- Department of Biostatistics and Epidemiology, Muhimbili University of Health and Allied Sciences, Box 65015, Dar es Salaam, PO, Tanzania
| | - A H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
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16
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Harahap NC, Handayani PW, Hidayanto AN. Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.100184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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