Humanizing birth in Tanzania: a qualitative study on the (mis) treatment of women during childbirth from the perspective of mothers and fathers

Women's and maternity care providers' perceptions of pain management during childbirth in hospitals in Southern Tanzania

BACKGROUND

The majority of women experience pain during childbirth. Offering and supporting women to use different methods for coping with pain is an essential competency for maternity care providers globally. Research suggests a gap between what women desire for pain management and what is available and provided in many low-and middle-income settings. The study aimed to understand how pain management is perceived by those involved: women experiencing childbirth and maternity care providers.

METHODS

Individual semi-structured interviews with women (n = 23), maternity care providers (n = 17) and focus group discussions (n = 4) with both providers and women were conducted in two hospitals in Southern Tanzania in 2021. Transcribed interviews were analysed using reflexive thematic analysis. Coding and analysis were supported by the software MAXQDA.

RESULTS

Three main themes were generated from the data. The first, 'pain management is multifaceted', describes how some providers and women perceived pain management as entailing various methods to manage pain. Providers perceived themselves as having a role in utilization of pain management to varying degree. The second theme 'pain management is primarily a woman's task' highlights a perception of pain management as unnecessary, which appeared to link with some providers' perceptions of pain as natural and necessary for successful childbirth. Few women explicitly shared this perception. The third theme 'practice of pain management can be improved' illustrates how women and maternity care providers perceived current practices of pain management as suboptimal. According to providers, this is primarily due to contextual factors such as shortage of staff and poor ward infrastructure.

CONCLUSION

Women's and maternity care providers' perceptions ranged from perceiving pain management as involving a combination of physiological, psychological and social aspects to perceive it as related with limited to no pain relief and/or support. While some women and providers had similar perceptions about pain management, other women also reported a dissonance between what they experienced and what they would have preferred. Efforts should be made to increase women's access to respectful pain management in Tanzania.

Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania

BACKGROUND

Respectful maternity care (RMC) is a rights-based approach to childbirth that centers the dignity, autonomy, and well-being of birthing women. This study aimed to examine factors associated with RMC among women giving birth in Tanzania and to examine whether HIV status was associated with self-reported RMC.

METHODS

We enrolled 229 postpartum women in six clinics in the Kilimanjaro Region; of them, 103 were living with HIV. Participants completed a survey within 48 h after birth before being discharged. RMC was measured using a 30-item scale with three subscales (dignity and respect; supportive care; communication and autonomy), each standardized from 0 to 100. Univariable and multivariable regression models examined factors associated with RMC.

RESULTS

The median score of the full RMC score was 74, differing slightly by subscale: 83 for dignity and respect, 76 for supportive care, and 67 for communication and autonomy. RMC did not differ by HIV status (median 67.0 vs. 67.0, p = 0.89). In multivariable linear regression, women who would not recommend the birth facility to their friends and who did not receive breastfeeding education had significantly lower RMC scores on the full RMC scale. In the dignity and respect subscale, variables associated with significantly lower RMC scores were not being able to read and write, delivering in a public facility, and delivering vaginally.

CONCLUSIONS

Although self-reported RMC was generally high, we identified areas for improvement. Practitioners need ongoing training on RMC principles and the delivery of equitable care.

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.

Dimensions of patient-centred care from the perspective of patients and healthcare workers in hospital settings in sub-Saharan Africa: A qualitative evidence synthesis

INTRODUCTION

The United States Institute of Medicine defines patient centred care (PCC), a core element of healthcare quality, as care that is holistic and responsive to individual needs. PCC is associated with better patient satisfaction and improved clinical outcomes. Current conceptualizations of PCC are mainly from Europe and North America. This systematic review summarises the perceived dimensions of PCC among patients and healthcare workers within hospitals in sub-Saharan Africa (SSA).

METHODS

Without date restrictions, searches were done on databases of the Web of Science, Cochrane Library, PubMed, Embase, Global Health, and grey literature, from their inception up to 11th August 2022. Only qualitative studies exploring dimensions or perceptions of PCC among patients, doctors and/or nurses in hospitals in (SSA) were included. Review articles and editorials were excluded. Two independent reviewers screened titles and abstracts, and conducted full-text reviews with conflicts resolved by a third reviewer. The CASP (critical appraisal skills program) checklist was utilised to assess the quality of included studies. The framework synthesis method was employed for data synthesis.

RESULTS

5507 articles were retrieved. Thirty-eight studies met the inclusion criteria, of which 17 were in the specialty of obstetrics, while the rest were spread across different fields. The perceived dimensions reported in the studies included privacy and confidentiality, communication, shared decision making, dignity and respect, continuity of care, access to care, adequate infrastructure and empowerment. Separate analysis of patients' and providers' perspective revealed a difference in the practical understanding of shared-decision making. These dimensions were summarised into a framework consisting of patient-as-person, access to care, and integrated care.

CONCLUSION

The conceptualization of PCC within SSA was largely similar to findings from other parts of the world, although with a stronger emphasis on access to care. In SSA, both relational and structural aspects of care were significant elements of PCC. Healthcare providers mostly perceived structural aspects such as infrastructure as key dimensions of PCC.

TRIAL REGISTRATION

PROSPERO Registration number CRD42021238411.

"It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania

OBJECTIVE

To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania.

DESIGN

A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis.

SETTING

This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care.

PARTICIPANTS

Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility.

FINDINGS

Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility.

KEY CONCLUSIONS

The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities.

IMPLICATIONS FOR PRACTICE

Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision.

TRIAL REGISTRATION NUMBER

NCT04685668 Date of initial trial registration: December 28th, 2020.

A virtual simulation-based training program on birthing positions: a randomized controlled trial

BACKGROUND

Restricting parturient women in healthcare facilities from choosing positions that provide the greatest comfort and benefit during labor is a global barrier. Several complex factors, including caregiver preference and medical intervention, shape the limitation. Therefore, a practical need exists to train midwives on the knowledge and skills to change this condition.

METHODS

The study used a parallel, single-blind, randomized controlled trial at a provincial maternity and child health hospital in Fujian, China, from June 1 to December 31, 2019. The midwives in a birth suite were selected and randomly enrolled in a one-month simulation-based hybrid training or face-to-face teaching in September 2019. The four-level Kirkpatrick's model, including reaction, learning, behavior, and results, was used to evaluate training effects before and after the program. Data were analyzed with SPSS 25.0 using Student's t-test, Spearman's correlation test, Mann-Whitney U test, Wilcoxon signed-rank test, and chi-square test analysis of variance. The significance level was set at p < 0.05.

RESULTS

Forty-two midwives were initially randomized to either the virtual simulation group or the face-to-face group. One midwife was excluded from the analysis due to intervention discontinuation, resulting in a final analysis of 41 midwives (n1 = 21, n2 = 20). Post-intervention, the virtual simulation group exhibited higher satisfaction and learning effects compared to the face-to-face group, while the rate of perineal incision in primiparas was lower (p<0.05). No significant changes or differences were observed in self-rated behavior between the two groups (p>0.05). The virtual simulation group demonstrated an increase in non-supine birth rate (p = 0.030) and a decrease in perineal incision rate among primiparas compared to pre-intervention (p = 0.035). Moreover, knowledge performance was associated with the duration of virtual simulation (r = 0.664, p = 0.001).

CONCLUSIONS

Virtual simulation is a fascinating innovation that enables midwives to develop birthing positions without practicing on real pregnant women and is one solution to achieve work competency within a shortened training period.

Iranian mother's perspectives about aspects and determinants of disrespect and abuse during labor and delivery: a qualitative study

Respectful maternity care (RMC) is a crucial strategy in improving postpartum experiences of mothers. This study aimed to explain women's perception of determining aspects and determinants of disrespect and abuse (D&A) during childbirth. This study was carried out from October 2019 to February 2020 in Tabriz-Iran. A total of 12 postpartum women were enrolled in this qualitative study by purposive sampling. The data were collected through in-depth semi structured interviews and simultaneously analyzed with a conventional content analysis approach. Thirty eight sub-themes and 11 main themes extracted from data analysis. The main themes included: "physical abuse," "psychological violence," "discrimination," "violation of privacy," "unmet needs and preferences," "nonparticipation in decision-making," "abandonment of women," "Lack of sympathy," "shortage of human and non-human resources," "unpleasant psychological atmosphere of the ward" and "facilitators of D&A." The results of our study indicated the importance of sympathy with mothers and professional ethics. Moreover, healthcare providers, administrators, and policy-makers should design patient-centered interventions in order to secure the material, psychological, and legal needs of women to receive respectful maternity care.

Qualitative Exploration Study of Perceptions of Women and Nurse-Midwives on Antenatal Care Information and Communication in Tanzania

Background

Antenatal health information enables pregnant women to make informed choices for their health during pregnancy and childbirth. Worldwide, evidence shows inadequate coverage of the information provided to women during antenatal care visits. Interaction between women and providers is important to ensure effective information exchange. This study aimed to explore women's and nurse midwives' perceptions of their interactions and the information they shared about care during pregnancy and childbirth in Tanzania.

Methods

Formative explorative research using in-depth interviews was conducted with eleven Kiswahili-speaking women who had normal pregnancies and had more than three antenatal contacts. Also, five nurse-midwives who worked in the ANC clinic for a year or more were included in the study. A thematic analysis based on descriptive phenomenology guided the analysis of data that was informed by the WHO quality of care framework.

Results

Two major themes emerged from the data, enhancing communication and respectful delivery of ANC information and receiving information about pregnancy care and safe childbirth. We found that women felt free to communicate and interact with midwives. Some women feared interacting with midwives and other midwives were difficult to approach. All women acknowledge receiving antenatal care information. However, not all women reported receiving all ANC information as per national and international guidelines. Inadequate staffing and time were the reasons for poor prenatal care information delivery.

Conclusion

Women did not report most of the information provided during ANC contacts as per the national ANC guidelines. The inadequate number of nurse-midwives, increased number of clients, and insufficient time were reported to contribute to inadequate provision of information during antenatal care. Strategies for effective provision of information during antenatal contacts should be considered including using group antenatal care and information communication technology. Further, nurse-midwives should be sufficiently deployed and motivated.

Community perceptions and experiences on the events leading to facility maternal death; a verbal autopsy qualitative study

BACKGROUND

Tanzania Maternal Death Surveillance and Response (MDSR) system introduced in 2015 emphasizes review of facility maternal deaths with little community involvement. Involving the community in deaths enquiry can help to make better strategies to prevent future deaths. We aimed to explore family members (caregivers) perceptions and experiences on the events leading to facility maternal deaths to inform future community involvement in MDSR.

METHODS

Narrative interviews were conducted with 20 caregivers who cared for women who died in childbirth to investigate into delays and health care seeking experience. The unstructured questions on perceptions and experiences of events leading to death were administered together with standard verbal autopsy questionnaire. Two regions, Lindi and Mtwara of Southern Tanzania were selected for the study in 2018. Narrative thematic analysis was used for data analysis.

RESULTS

Three main themes evolved: 'Prepared for birth but not ready for complications', 'Disconnect between caregivers and providers' and 'The bitter impact of maternal deaths. Caregivers made efforts to prepare for birth but their preparation were severely inadequate when complications that necessitated referral occurred. Decision to seek care was made jointly between the pregnant woman, husband and other family members. Caregivers tried with little success in communicating with heathcare providers regarding their admitted patients. They also experienced emotions of grief such as denial, anger, depression, bargaining and acceptance once maternal deaths occurred. Caregivers (mostly old women) were left with the burden of caring for the newborns and other children left by the deceased mother.

CONCLUSION

Caregivers' perceptions and experiences of maternal deaths events provide valuable information for community interventions on birth preparedness, decision making, communication and providers' accountability. Maternal deaths bring far reaching mental, social and economic consequences to the family and society.

Strengthening midwives' competencies for addressing maternal and newborn mortality in Tanzania: Lessons from Midwifery Emergency Skills Training (MEST) project

INTRODUCTION

In Low- and Middle-Income Countries (LMICs), maternal and infant mortality remains a significant problem. Inadequate healthcare provider competencies, including those of midwives, are cited as one of the major contributors to the high maternal and newborn mortality rates. Thus, enhancing the skills of midwives is a prerequisite for enhancing positive maternal and newborn health outcomes. This study describes the lessons learned from a Midwifery Emergencies Skills Training (MEST) project implemented in Tanzania between 2013 and 2018.

METHODS

An exploratory qualitative study was used to purposefully recruit and interview twelve health facility in-charges and eighteen midwives from twelve selected health facilities in six districts of Tanzania mainland to discover their perceptions about the midwifery practice after MEST training. The data were transcribed verbatim and analysed with qualitative content analysis.

RESULTS

Four categories were generated from the analysis (i) enhanced knowledge and skills in the provision of midwifery care and management of obstetric emergencies, (ii) improved midwives' communication skills, (iii) increased trust and support between midwives and community and (iv) transformed attitudes of midwives toward continued professional development (CPD).

CONCLUSION

MEST enhanced the knowledge and skills of midwives in the management of obstetric emergencies and referral protocol practice. However, notable gaps remain in the capacity of midwives to provide human rights-based respectful maternity care. Continued professional development for nurses and midwives through training, mentorship and supervision programs is recommended for improving maternal and newborn health.

Quality intrapartum care expectations and experiences of women in sub-Saharan African Low and Low Middle-Income Countries: a qualitative meta-synthesis

BACKGROUND

Woman-centred maternity care is respectful and responsive to women's needs, values, and preferences. Women's views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries.

METHODS

We undertook a qualitative meta-synthesis using a framework synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order and second-order constructs relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis.

RESULTS

Of the 7197 identified citations, 30 articles were included in this review. Women's needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for woman-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors.

CONCLUSION

To improve care seeking and satisfaction with health services, woman-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for woman-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women's needs and preferences.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Local knowledge and derived practices of safety during pregnancy, childbirth and postpartum: a qualitative study among nurse-midwives in urban eastern Tanzania

BACKGROUND

Maternal and newborn mortality are still high in low-income and middle-income countries despite global efforts to improve the quality of care by prioritising evidence-based practices and increasing the number of births attended by skilled personnel. During childbirth, women are hesitant to use the health facility services. Concerns about safety and risks during pregnancy, childbirth and postpartum period are deeply rooted in local health practices and beliefs.

OBJECTIVE

The aim of this study was to explore the perceptions of local health knowledge and derived practices among nurse-midwives in urban eastern Tanzania.

METHODS

An exploratory qualitative study design was carried out in a district hospital in eastern Tanzania. Twenty-one nurse-midwives participated in two focus group discussions. The data were analysed using qualitative content analysis.

RESULTS

Based on existing scientific data, local knowledge and derived practices were categorised as potentially beneficial, neither beneficial nor harmful and potentially harmful. Our study identified a wide range of local knowledge and derived practices used by women. These include to refrain from shouting or crying to prevent exhaustion during labour, drinks and foods restrictions during labour and after birth, and use of local herbs to stimulate labour. In addition, midwives reinforced the importance of integrating local knowledge and practices with potential benefits with evidence-based practices. Encouraging and listening to women would offer an opportunity to reduce harmful practices.

CONCLUSIONS

While non-harmful and beneficial practices for ensuring safety during pregnancy, childbirth and postpartum period should be accepted and supported as a part of our cultural richness, harmful practices should be discouraged. This can be achieved through antenatal health education and afterbirth health messages on hospital discharge to promote positive childbirth health outcomes.

An analysis of the quality of maternity services in Nampula, Mozambique: implementation research

Introduction

the quality of maternity services is an essential factor in reducing maternal and newborn morbidity and mortality, which remains extremely high in Africa. In Mozambique, maternal mortality rate is 451.6 deaths per 100,000 live births (2017). The reasons for this are complex, but one important factor to reduce this burden is to provide effective and efficient care, to improve institutional deliveries. To reduce maternal and newborn mortality rates in Nampula, researchers from Lúrio University and the University of Saskatchewan, carried out an implementation research program, including various interventions such as training activities for health professionals in maternal and child health care. We planned a mid-project evaluation, to assess the trainings´ impact on the quality of services at Marrere Hospital Maternity.

Methods

quantitative pre-post study, carrying out two cross-sectional surveys about maternity service quality, one being conducted after five health professionals´ trainings and the other after six more trainings. The two surveys included samples of post-partum women in the maternity, calculated with a 10% margin error and 90% confidence interval for the first survey, and with a 7% margin error and 95% confidence interval for the second. The surveys were entered into REDCap and analysed to assess frequencies, percentages, mean and standard deviations. This research was approved by the Institutional Committees of Bioethics at Lúrio University and at the University of Saskatchewan.

Results

one hundred and sixteen post-partum women were surveyed at the maternity, assessing standards of patient centred care during delivery labour. Most areas showed no improvement. Some positive improvements were delivering women were given the option to have a person of their choice accompany them during labour (75%), notably a traditional birth attendant (34%), and they had continuous support from a health professional (68%). But many shortcomings persisted in areas of privacy (33%) and confidentiality (57%).

Conclusion

the quality of patient centred care at Marrere Hospital Maternity did not improve much with health professionals´ trainings. Decreasing the large turnover rate of such staff, reviewing their learning styles, and promoting continuous professional capacity building would be the next steps to improve quality of care.

Women's experiences and perceptions of women-centered care and respectful care during facility-based childbirth: A meta-synthesis

AIM

The World Health Organization has recommended intrapartum care for a positive childbirth experience through respectful care based on women-centered care. This study aimed to explore women's experiences of facility-based childbirth to gain insights into their perceptions of women-centered care, including humanized childbirth and respectful maternity care during intrapartum care.

METHODS

Used the Joanna Briggs Institute method as the framework for this meta-synthesis, we searched the PubMed, EMBASE, CINAHL, PsycINFO, and LILCAS databases, and included qualitative studies and interviews of women's experiences and perceptions of women-centered care during facility-based childbirth published from 1990 to 2020 in English. Study quality was assessed using the Critical Appraisal Skills Programme checklist. NVivo software was used for data extraction and synthesis.

RESULTS

There were 22 studies from 19 countries that met the established inclusion criteria. Five categories of experiences of facility-based childbirth and perceptions of women-centered care from the synthesized voices of women were generated: (i) value of women through childbirth; (ii) overwhelmed by unpleasant childbearing experiences; (iii) a sense of being respected and valued; (iv) a sense of being disrespected and abused; and (v) inadequate systems and resources. Our meta-synthesis indicated that respectful and helpful interaction between women and healthcare providers produced positive perceptions among women.

CONCLUSIONS

This study emphasizes the importance of respectful interactions and intrapersonal experiences. Strong systems and positive environments lead to positive interactions between women and healthcare providers. Future studies need to consider cultural and economic differences in women-centered care and respectful care for childbirth in different contexts.

Lay and healthcare providers' experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry

OBJECTIVES

Disrespectful care, which remains prevalent in low and middle-income countries (LMICs), acts as a barrier to women accessing skilled birth attendance, compromising care when services are available. Building on what was positive in facilities, we aimed to explore lay and healthcare providers' experience of respectful care to inform future interventions.

SETTING

Five maternity facilities in Mwanza Tanzania and Lilongwe Malawi.

PARTICIPANTS

94 participants in Malawi (N=46) and Tanzania (N=48) including 24 women birthing live baby within the previous 12 months; 22 family members and 48 healthcare providers who regularly provided maternity care in the included facilities DESIGN: The study was guided by Appreciative Inquiry (AI). Semistructured, one-to-one interviews were conducted between January and December 2019. Interviews were audio-recorded, translated where necessary, transcribed verbatim, and analysed using the framework approach.

RESULTS

Four main themes describing participants positive experience and their vision of respectful care were identified: (1) empathic healthcare provider-woman interactions including friendly welcome and courteous language, well-timed appropriate care and information sharing, (2) an enabling environment, characterised by improvement of physical environment, the use of screens, curtains and wall partitions for privacy, availability of equipment and provision of incentives to staff, (3) supportive leadership demonstrated by the commitment of the government and facility leaders to provision of respectful care, ensuring availability of guidelines and policies, supportive supervision, reflective discussion and paying staff salaries timely, (4) providers' attitudes and behaviours characterised by professional values through readiness, compassionate communication and commitment.

CONCLUSION

The positive experiences of service users, families and healthcare providers provided insight into key drivers of respectful care in facilities in Tanzania and Malawi. Interventions targeting improved environment and privacy, healthcare provider communication and developing positive leadership structures in facilities could provide the basis for sustained improvement in respectful and dignified maternal and newborn care in LMICs.

Provider perceptions of lack of supportive care during childbirth: A mixed methods study in Kenya

Supportive care is a key component of person-centered maternity care (PCMC), and includes aspects such as timely and attentive care, pain control, and the health facility environment. Yet, few researchers have explored the degree of supportive care delivered or providers’ perceptions on supportive care practices during childbirth. The researchers’ aim is to evaluate the extent of supportive care provided to women during childbirth and to identify the drivers behind the lack of supportive care from the perspective of maternity providers in a rural county in Western Kenya. Data are from a mixed-methods study in Migori County in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical). Providers were asked structured questions on various aspects of supportive care followed by open ended questions on why certain practices were performed or not. We conducted descriptive analysis of the quantitative data and thematic analysis of the qualitative data. We analyzed data and found inconsistent and suboptimal practices with regards to supportive care. Some providers reported long patient wait times in their facilities as well as the inability to provide the best care due to staff shortages in their facilities. Others also reported low interest and inquiry about women’s experience of pain during childbirth, which was driven by perceptions of pain during childbirth as normal, facility culture and norms, and lack of pain medicine. For the facility environment, providers reported relatively clean facilities. They, however, noted inconsistent water and electricity as well as inadequate safety. We conclude that many drivers of the lack of supportive care are caused by structural health systems issues, therefore a health system strengthening approach can be useful for improving the supportive care dimension of PCMC, and thus quality of care overall.

Respectful care an added extra: a grounded theory study exploring intrapartum experiences in Zambia and Tanzania

Background

Quality of maternal and newborn care is integral to positive clinical, social and psychological outcomes. Respectful care is an important component of this but is suboptimum in many low-income settings. A renewed energy among health professionals and academics is driving an international agenda to eradicate disrespectful health facility care around the globe. However, few studies have explored respectful care from different vantage points.

Methods

We used Strauss and Corbin’s grounded theory methodology to explore intrapartum experiences in Tanzania and Zambia. In-depth interviews were conducted with 98 participants (48 women, 18 partners, 21 health-providers and 11 key stakeholders), resulting in data saturation. Analysis involved constant comparison, comprising three stages of coding: open, axial and selective. The process involved application of memos, reflexivity and positionality.

Results

Findings demonstrated that direct and indirect social discrimination led to inequity of care. Health-providers were believed to display manipulative behaviours to orchestrate situations for their own or the woman’s benefit, and were often caring against the odds, in challenging environments. Emergent categories were related to the core category: respectful care, an added extra, which reflects the notion that women did not always expect or receive respectful care, and tolerated poor experiences to obtain services believed to benefit them or their babies. Respectful care was not seen as a component of good quality care, but a luxury that only some receive.

Conclusion

Both quality of care and respectful care were valued but were not viewed as mutually inclusive. Good quality treatment (transactional care) was often juxtaposed with disrespectful care; with relational care having a lower status among women and healthcare providers. To readdress the balance, respectful care should be a predominant theme in training programmes, policies and audits. Women’s and health-provider voices are pivotal to the development of such interventions.

Birth companionship in a government health system: a pilot study in Kigoma, Tanzania

BACKGROUND

Having a companion of choice throughout childbirth is an important component of good quality and respectful maternity care for women and has become standard in many countries. However, there are only a few examples of birth companionship being implemented in government health systems in low-income countries. To learn if birth companionship was feasible, acceptable and led to improved quality of care in these settings, we implemented a pilot project using 9 intervention and 6 comparison sites (all government health facilities) in a rural region of Tanzania.

METHODS

The pilot was developed and implemented in Kigoma, Tanzania between July 2016 and December 2018. Women delivering at intervention sites were given the choice of having a birth companion with them during childbirth. We evaluated the pilot with: (a) project data; (b) focus group discussions; (c) structured and semi-structured interviews; and (d) service statistics.

RESULTS

More than 80% of women delivering at intervention sites had a birth companion who provided support during childbirth, including comforting women and staying by their side. Most women interviewed at intervention sites were very satisfied with having a companion during childbirth (96-99%). Most women at the intervention sites also reported that the presence of a companion improved their labor, delivery and postpartum experience (82-97%). Health providers also found companions very helpful because they assisted with their workload, alerted the provider about changes in the woman's status, and provided emotional support to the woman. When comparing intervention and comparison sites, providers at intervention sites were significantly more likely to: respond to women who called for help (p = 0.003), interact in a friendly way (p < 0.001), greet women respectfully (p < 0.001), and try to make them more comfortable (p = 0.003). Higher proportions of women who gave birth at intervention sites reported being "very satisfied" with the care they received (p < 0.001), and that the staff were "very kind" (p < 0.001) and "very encouraging" (p < 0.001).

CONCLUSION

Birth companionship was feasible and well accepted by health providers, government officials and most importantly, women who delivered at intervention facilities. The introduction of birth companionship improved women's experience of birth and the maternity ward environment overall.

Legal and Ethical Considerations in the Delivery of Sexual Health Care in Tanzania

Tanzania is a country with multiple sexual health challenges including high rates of HIV/STIs, early sexual debut, forced sex, sexual dysfunction, and teen pregnancy. Training in sexual health care is limited, while courses on how to address the ethical aspects of sexual health are non-existent. To address this gap, this paper explores legal and ethical challenges to providing sexual health care in Tanzania. First, we describe the sexuo-cultural and epidemiologic challenges, and the key laws regulating sexual health. Six case studies identify ethical dilemmas in healthcare delivery. They are: (a) how to address sexual and intimate partner violence; (b) treatment of illegal or stigmatized key populations; (c) treatment of couples in HIV serodiscordant, non-monogamous, and/or polygamous relationships; (d) requests for and participation in illegal healthcare; (e) treatment of women and children in the presence of their husbands and fathers; and (f) addressing child sexual abuse. We apply the ethical principles of autonomy, justice, beneficence and non-malfeasance. A second challenge is ensuring confidentiality in a setting where medical record keeping practices vary widely, and violations to confidentiality are perceived as common. Finally, we identify a set of best practices in sexual healthcare delivery tailored to the Tanzanian context.

A qualitative study of the barriers to utilizing healthcare services among the tribal population in Assam

OBJECTIVE

We aim to explore the barriers to accessing modern healthcare services in two tribal populations in Assam.

METHODS

In March 2018, we conducted qualitative research through 60 in-depth interviews with men and women aged 15 to 50 from Bodo and Rabha tribes in Udalguri and Baksa districts of Assam. We interviewed a group of health-service providers from public health facilities to understand the demand-supply balance in those facilities.

FINDINGS

On the demand side, direct and indirect financial obstacles, distance to health facilities, poor public transportation, perceived negative behavior of hospital staff, and lack of infrastructure were the main barriers to utilizing healthcare facilities. On the supply side, doctors and nurses in government health facilities were overburdened by demand due to a lack of human resources.

CONCLUSIONS

Our study highlights the barriers to utilizing health facilities; these are not always driven by factors linked to the patient's socio-economic status but also depend significantly on the quality of the health services and other contextual factors. Although the government has made efforts to improve the rural healthcare system through national-level programs, our qualitative study shows that these programs have not been successful in enhancing the rural healthcare system in the study area.

Patient satisfaction with peri-partum care at Bertha Gxowa district hospital, South Africa

BACKGROUND

Patient satisfaction is one of the key outcome measures of healthcare services.Aim and Setting: To explore factors that influence women's satisfaction with peri-partum care at Bertha Gxowa district hospital, South African primary care.

METHODS

A cross-sectional study involving 260 women was conducted. A structured questionnaire collected information from participants on pain relief, health education provided by healthcare providers, privacy, cleanliness of the ward and their participation in decision-making about care received in the peri-partum period.

RESULTS

Most respondents were co-habiting with their partners (100, 38%) and had completed only secondary school education (119, 46%). The average participant age was 27 years, with an average parity of two children. Most participants were satisfied with the privacy (218, 84%) and the general cleanliness of the wards (233, 90%). However, large proportions of women were dissatisfied with the information given to them by doctors (104, 55%) and nurses (89, 37%), and the rest were unsure. About 189 (73%) participants were dissatisfied with the extent of their participation in decision-making about their own care. The study had a caesarean rate of 53 (20%). Compared to normal vaginal delivery, participants who had caesarean section were significantly more likely to report being satisfied with pain relief during labour (p 0.001).

CONCLUSION

The study findings showed varying levels of satisfaction with different aspects of peri-partum care and suggested the need for better pain relief during vaginal delivery, information sharing by doctors and patient emancipation for decision-making about their own care.