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Rural Transportation Infrastructure in Low- and Middle-Income Countries: A Review of Impacts, Implications, and Interventions. SUSTAINABILITY 2022. [DOI: 10.3390/su14042149] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The rural transport infrastructure sector is a critical force for sustainable development that is interwoven with many other sectors. Rural transportation is an underlying driver of many of the Sustainable Development Goals (SDGs) and a crucial contributor to many socioeconomic benefits for rural people around the world. This review paper expands upon, enhances, and cross-references the perspectives outlined in previous rural infrastructure-focused review papers. Firstly, this work gives a thorough look into the progress of the rural transportation sector in recent years by focusing on the thematic relationships between infrastructure and other components of sustainable development, namely, economics and agriculture, policy and governance, health, gender, education, and climate change and the environment. Secondly, several strategies, approaches, and tools employed by governments and practitioners within the rural transport sector are analyzed and discussed for their contributions to the wellbeing of rural dwellers in low- and middle-income countries (LMICs). These include rural roads, bridges, maintenance, and non-infrastructural approaches that include concepts such as advanced technological innovations, intermediate modes of transport (IMTs), and transport services. This paper concludes that enhancement, improvement, and extension of rural transportation infrastructure brings significant benefits to rural dwellers. However, this paper also calls for additional integration of the sector and increased usage of systems approaches that view rural transport as an active part of many other sectors and a key leverage point within rural development as a whole. Further, this paper notes areas for future research and investigation, including increased investigation of the relationship between rural transportation infrastructure and education, improved data collection and management in support of improved policymaking, improved prioritization of interventions and institutionalization of maintenance, and expansion of pro-poor transportation strategies and interventions.
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Straneo M, Beňová L, van den Akker T, Pembe AB, Smekens T, Hanson C. No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000345. [PMID: 36962703 PMCID: PMC10021586 DOI: 10.1371/journal.pgph.0000345] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022]
Abstract
Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.
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Affiliation(s)
- Manuela Straneo
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Athena Institute, VU University, Amsterdam, The Netherlands
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Lenka Beňová
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Tom Smekens
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- London School of Hygiene &Tropical Medicine, London, United Kingdom
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Use of geospatial analysis for priority setting in surgical system investment in Guatemala. LANCET REGIONAL HEALTH. AMERICAS 2021; 7:100145. [PMID: 36777659 PMCID: PMC9904083 DOI: 10.1016/j.lana.2021.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Two-hour and 30 min travel times to a hospital capable of performing emergency general surgery and cesarean section are benchmarks for timely surgical access. This study aimed to estimate the population of Guatemala with timely access to surgical care and identify existing hospitals where the expansion of surgical services would increase access. Methods The World Federation of Societies of Anaesthesiologists (WFSA) Anesthesia Facility Assessment Tool (AFAT) previously identified 37 public Guatemalan hospitals that provide surgical care. Nine additional public non-surgical hospitals were also identified. Geospatial analysis was performed to estimate walking and driving geographic access to all 46 hospitals. We calculated the potential increase in access that would accompany the expansion of surgical services at each of the nine non-surgical hospitals. Findings The percentage of the population with walking access to a surgical hospital within 30 min, 1 h, and 2 h are 5·1%, 12·9%, and 27·3%, respectively. The percentage of people within 30 min, 1 h, and 2 h driving times are 27·3%, 41·1%, and 53·1%, respectively. The median percentage of the population within each of Guatemala's 22 administrative departments with 2 h walking access was 19·0% [IQR 14·1-30·7] and 2 h driving access was 52·4% [IQR 30·5-62·8]. Expansion of surgical care at existing public Guatemalan hospitals in Guatemala would result in a minimal increase in overall geographic access compared to current availability. Interpretation While Guatemala provides universal health coverage, geographic access to surgical care remains inadequate. Geospatial mapping and survey data work synergistically to assess surgical system strength and identify gaps in geographic access to essential surgical care. Funding None.
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Straneo M, Benova L, Hanson C, Fogliati P, Pembe AB, Smekens T, van den Akker T. Inequity in uptake of hospital-based childbirth care in rural Tanzania: analysis of the 2015-16 Tanzania Demographic and Health Survey. Health Policy Plan 2021; 36:1428-1440. [PMID: 34279643 PMCID: PMC8505858 DOI: 10.1093/heapol/czab079] [Citation(s) in RCA: 4] [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: 07/31/2020] [Revised: 02/23/2021] [Accepted: 06/22/2021] [Indexed: 11/14/2022] Open
Abstract
Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.
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Affiliation(s)
- Manuela Straneo
- Athena Institute, VU Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Lenka Benova
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
- Faculty of Epidemiology and Population Health, LSHTM, Keppel Street, London WC1E 7HT, UK
| | - Claudia Hanson
- Karolinska Institutet, 171 77 Stockholm, Sweden
- Faculty of Infectious and Tropical Diseases, LSHTM, Keppel Street, London WC1E 7HT, UK
| | - Piera Fogliati
- Doctors with Africa-CUAMM, Av. Mártires da Machava n.º 859 R/C, Cidade de Maputo, Moçambique
| | - Andrea B Pembe
- Department of Obstetrics and Gynecology, Muhimbili University of Helath and Allied Sciences, PO Box 65001, Dar es Salaam, United Republic of Tanzania
| | - Tom Smekens
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Thomas van den Akker
- Athena Institute, VU Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
- Department of obstetrics and Gynecology, Leiden University Medical Center, Rapenburg 70, 2311 EZ Leiden, The Netherlands
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Gage AD, Carnes F, Blossom J, Aluvaala J, Amatya A, Mahat K, Malata A, Roder-DeWan S, Twum-Danso N, Yahya T, Kruk ME. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible? Health Aff (Millwood) 2020; 38:1576-1584. [PMID: 31479351 DOI: 10.1377/hlthaff.2018.05397] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.
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Affiliation(s)
- Anna D Gage
- Anna D. Gage ( ) is a student in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Fei Carnes
- Fei Carnes is a geographic information systems (GIS) specialist in the Center for Geographic Analyses, Harvard University, in Cambridge, Massachusetts
| | - Jeff Blossom
- Jeff Blossom is the GIS service manager in the Center for Geographic Analyses, Harvard University
| | - Jalemba Aluvaala
- Jalemba Aluvaala is a research fellow in the Department of Paediatrics and Child Health, University of Nairobi School of Medicine, in Kenya
| | - Archana Amatya
- Archana Amatya is an assistant professor of community medicine and public health at the Tribhuvan University Teaching Hospital, in Kathmandu, Nepal
| | - Kishori Mahat
- Kishori Mahat is an advisor in Quality Assurance and Regulation, Nepal Health Sector Support Programme, Department for International Development, in Kathmandu
| | - Address Malata
- Address Malata is principal of the College of Nursing, Malawi University of Science and Technology, in Limbe
| | - Sanam Roder-DeWan
- Sanam Roder-DeWan is a researcher in the Ifakara Health Institute, in Dar es Salaam, Tanzania
| | | | - Talhiya Yahya
- Talhiya Yahya is head of the Quality Management Unit, Ministry of Health, Community Development, Gender, Elderly, and Children, in Dar es Salaam
| | - Margaret E Kruk
- Margaret E. Kruk is an associate professor in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health
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Hanson C, Waiswa P, Pembe A, Sandall J, Schellenberg J. Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose. BMJ Glob Health 2020; 5:e003748. [PMID: 33055095 PMCID: PMC7559045 DOI: 10.1136/bmjgh-2020-003748] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- Claudia Hanson
- Global Public Health, Karolinska Institute, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Andrea Pembe
- Obstetric and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, Greater London, UK
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Wong KLM, Brady OJ, Campbell OMR, Banke-Thomas A, Benova L. Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania. Int J Equity Health 2020; 19:15. [PMID: 31992319 PMCID: PMC6988213 DOI: 10.1186/s12939-020-1123-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. METHODS We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. RESULTS The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. CONCLUSIONS Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.
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Affiliation(s)
- Kerry L M Wong
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Oliver J Brady
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for Mathematical Modelling for Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Aduragbemi Banke-Thomas
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Department of Public Health, Institute of Tropical Medicine, Kronenburgstraat 43, 2000, Antwerp, Belgium
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Shamba D, Tancred T, Hanson C, Wachira J, Manzi F. Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania. BMC Health Serv Res 2019; 19:225. [PMID: 30975142 PMCID: PMC6460539 DOI: 10.1186/s12913-019-4019-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 03/18/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.
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Affiliation(s)
- Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences-Global Health, Karolinska Institute, Stockholm, Sweden
| | - Juddy Wachira
- School of Medicine/AMPATH, Moi University, Nairobi, Kenya
| | - Fatuma Manzi
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Neke N, Reifferscheid A, Buchberger B, Wasem J. Time and cost associated with utilization of services at mobile health clinics among pregnant women. BMC Health Serv Res 2018; 18:920. [PMID: 30509269 PMCID: PMC6276179 DOI: 10.1186/s12913-018-3736-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022] Open
Abstract
Background Antenatal care (ANC) is provided for free in Tanzania in all public health facilities. Yet surveys suggested that long distances to the facilities limit women from accessing these services. Mobile health clinics (MHC) were introduced to address this problem; however, little is known about the client cost and time associated with utilizing ANC at MHC and whether these costs deter women from using the provided services. Methods Client-exit interviews were conducted by interviewing 293 pregnant women who visited the MHC in rural Tanzania. Two subgroups were created, one with women who travelled more than 1.5 h to the MHC, and the other with women who travelled within 1.5 h. For each subgroup we estimated the direct cost in US$ and time in hours for utilizing services and they hinder service utilization. The Wilcoxon–Mann–Whitney rank sum test was performed to compare the differences between the estimated mean values in the two groups. Result Total direct cost per visit was: US$2.27 (SD = 0.90) for overall, US$2.29 (SD = 1.03) for those women who travelled less than 1.5 h and US$2.53 (SD = 0.63) for those who travelled more than 1.5 h (p = 0.08). Laboratory and medicine cost accounted for 70 and 16% of the total direct cost and were similar across the groups. Total time cost per visit (in hours) was: 3.75 (SD = 1.83), 2.88 (SD = 1.27) for those women who travelled less than 1.5 h and 5.02 (SD = 1.81) for those who travelled more than 1.5 h (p < 0.01). The major contributor of time cost was waiting time; 1.89 (SD = 1.29) for overall, 1.68 (SD = 1.02) for those women who travelled less than 1.5 h and 2.17 (SD = 1.57) for those who travelled more than 1.5 h (p = 0.07). Participants reported having missed their scheduled visit due to lack of money (15%) and time (9%). Conclusion Women receiving nominally free ANC incur considerable time and direct cost, which may result in an unsteady use of maternal care. Improving availability of essential medicine and supplies at health facilities, as well as focusing on efficient utilization of community health workers may reduce these costs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3736-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nyasule Neke
- National Institute for Medical Research, Mwanza Centre, Isamilo Street, P O BOX 1462, Mwanza, Tanzania. .,Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany.
| | - Antonius Reifferscheid
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Barbara Buchberger
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Jürgen Wasem
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
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Fogliati P, Straneo M, Mangi S, Azzimonti G, Kisika F, Putoto G. A new use for an old tool: maternity waiting homes to improve equity in rural childbirth care. Results from a cross-sectional hospital and community survey in Tanzania. Health Policy Plan 2018; 32:1354-1360. [PMID: 29040509 PMCID: PMC5886146 DOI: 10.1093/heapol/czx100] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 11/12/2022] Open
Abstract
Limited quality of childbirth care in sub-Saharan Africa primarily affects the poor. Greater quality is available in facilities providing advanced management of childbirth complications. We aimed to determine whether Maternity Waiting Homes (MWHs) may be a tool to improve access of lower socio-economic women to such facilities. Secondary analysis of a cross-sectional hospital survey from Iringa District, Tanzania was carried out. Women who delivered between October 2011 and May 2012 in the only District facility providing comprehensive Emergency Obstetric Care were interviewed. Their socio-economic profile was obtained by comparison with District representative data. Multivariable logistic regression was used to compare women who had stayed in the MWH before delivery with those who had accessed the hospital directly. Out of 1072 study participants, 31.3% had accessed the MWH. In multivariable analysis, age, education, marital status and obstetric factors were not significantly associated with MWH stay. Adjusted odds ratios for MWH stay increased progressively with distance from the hospital (women living 6-25 km, OR 4.38; 26-50 km, OR 4.90; >50 km, OR 5.12). In adjusted analysis, poorer women were more likely to access the MWH before hospital delivery compared with the wealthiest quintile (OR 1.38). Policy makers should consider MWH as a tool to mitigate inequity in rural childbirth care.
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Affiliation(s)
| | | | - Sabina Mangi
- Tosamaganga Council Designated Hospital, Iringa, Tanzania
| | | | - Firma Kisika
- District Medical Office, Iringa District Council, Tanzania
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Abstract
Purpose The purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania. Design/methodology/approach A QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs. Findings Median monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months. Research limitations/implications The time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures. Originality/value Healthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings.
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Affiliation(s)
- Jennie Jaribu
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Suzanne Penfold
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Joanna Schellenberg
- Department of Disease Control and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Homer CSE, Castro Lopes S, Nove A, Michel-Schuldt M, McConville F, Moyo NT, Bokosi M, ten Hoope-Bender P. Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda. BMC Pregnancy Childbirth 2018; 18:55. [PMID: 29463210 PMCID: PMC5819639 DOI: 10.1186/s12884-018-1686-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 02/12/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce. METHODS The State of the World's Midwifery report 2014 used a broad definition of midwifery ("the health services and health workforce needed to support and care for women and newborns") and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework. RESULTS Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation. CONCLUSIONS The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued.
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Affiliation(s)
- Caroline S. E. Homer
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, City campus, Ultimo, NSW Australia
| | - Sofia Castro Lopes
- Instituto de Cooperación Social Integrare, Calle Balmes, 30, 3° - 1, 08007 Barcelona, Spain
| | - Andrea Nove
- Instituto de Cooperación Social Integrare, Calle Balmes, 30, 3° - 1, 08007 Barcelona, Spain
- Novametrics Ltd, DE56 4HQ Duffield,Derbyshire, UK
| | | | | | - Nester T. Moyo
- International Confederation of Midwives (ICM), Laan van Meerdervoort 70, 2517 AN The Hague, The Netherlands
| | - Martha Bokosi
- International Confederation of Midwives (ICM), Laan van Meerdervoort 70, 2517 AN The Hague, The Netherlands
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Hanson C, Gabrysch S, Mbaruku G, Cox J, Mkumbo E, Manzi F, Schellenberg J, Ronsmans C. Access to maternal health services: geographical inequalities, United Republic of Tanzania. Bull World Health Organ 2017; 95:810-820. [PMID: 29200522 PMCID: PMC5710083 DOI: 10.2471/blt.17.194126] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 10/03/2017] [Accepted: 10/05/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To determine if improved geographical accessibility led to increased uptake of maternity care in the south of the United Republic of Tanzania. Methods In a household census in 2007 and another large household survey in 2013, we investigated 22 243 and 13 820 women who had had a recent live birth, respectively. The proportions calculated from the 2013 data were weighted to account for the sampling strategy. We examined the association between the straight-line distances to the nearest primary health facility or hospital and uptake of maternity care. Findings The percentages of live births occurring in primary facilities and hospitals rose from 12% (2571/22 243) and 29% (6477/22 243), respectively, in 2007 to weighted values of 39% and 40%, respectively, in 2013. Between the two surveys, women living far from hospitals showed a marked gain in their use of primary facilities, but the proportion giving birth in hospitals remained low (20%). Use of four or more antenatal visits appeared largely unaffected by survey year or the distance to the nearest antenatal clinic. Although the overall percentage of live births delivered by caesarean section increased from 4.1% (913/22 145) in the first survey to a weighted value of 6.5% in the second, the corresponding percentages for women living far from hospital were very low in 2007 (2.8%; 35/1254) and 2013 (3.3%). Conclusion For women living in our study districts who sought maternity care, access to primary facilities appeared to improve between 2007 and 2013, however access to hospital care and caesarean sections remained low.
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Affiliation(s)
- Claudia Hanson
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT England
| | - Sabine Gabrysch
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Godfrey Mbaruku
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Jonathan Cox
- Bill and Melinda Gates Foundation, Seattle, United States of America
| | - Elibariki Mkumbo
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT England
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England
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Wong KLM, Benova L, Campbell OMR. A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africa. PLoS One 2017; 12:e0184432. [PMID: 28910302 PMCID: PMC5598961 DOI: 10.1371/journal.pone.0184432] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To (i) summarize the methods undertaken to measure physical accessibility as the spatial separation between women and health services, and (ii) establish the extent to which distance to skilled care for childbirth affects utilization in Sub-Saharan Africa. METHOD We defined spatial separation as the distance/travel time between women and skilled care services. The use of skilled care at birth referred to either the location or attendant of childbirth. The main criterion for inclusion was any quantification of the relationship between spatial separation and use of skilled care at birth. The approaches undertaken to measure distance/travel time were summarized in a narrative format. We obtained pooled adjusted odds ratios (aOR) from studies that controlled for financial means, education and (perceived) need of care in a meta-analysis. RESULTS 57 articles were included (40 studied distance and 25 travel time), in which distance/travel time were found predominately self-reported or estimated in a geographic information system based on geographic coordinates. Approaches of distance/travel time measurement were generally poorly detailed, especially for self-reported data. Crucial features such as start point of origin and the mode of transportation for travel time were most often unspecified. Meta-analysis showed that increased distance to maternity care had an inverse association with utilization (n = 10, pooled aOR = 0.90/1km, 95%CI = 0.85-0.94). Distance from a hospital for rural women showed an even more pronounced effect on utilization (n = 2, pooled aOR = 0.58/1km increase, 95%CI = 0.31,1.09). The effect of spatial separation appears to level off beyond critical point when utilization was generally low. CONCLUSION Although the reporting and measurements of spatial separation in low-resource settings needs further development, we found evidence that a lack of geographic access impedes use. Utilization is conditioned on access, researchers and policy makers should therefore prioritize quality data for the evidence-base to ensure that women everywhere have the potential to access obstetric care.
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Affiliation(s)
- Kerry L. M. Wong
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Oona M. R. Campbell
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Straneo M, Hanson C, Fogliati P, Mbaruku GM. Minimum obstetric volume in low-income countries. Lancet 2017; 389:698. [PMID: 28229874 DOI: 10.1016/s0140-6736(17)30342-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Claudia Hanson
- Global Health - Health system and policy; Dept of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. LANCET GLOBAL HEALTH 2016; 4:e845-e855. [DOI: 10.1016/s2214-109x(16)30180-2] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/23/2016] [Accepted: 07/20/2016] [Indexed: 01/22/2023]
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Armstrong CE, Martínez-Álvarez M, Singh NS, John T, Afnan-Holmes H, Grundy C, Ruktanochai CW, Borghi J, Magoma M, Msemo G, Matthews Z, Mtei G, Lawn JE. Subnational variation for care at birth in Tanzania: is this explained by place, people, money or drugs? BMC Public Health 2016; 16 Suppl 2:795. [PMID: 27634353 PMCID: PMC5025821 DOI: 10.1186/s12889-016-3404-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tanzania achieved the Millennium Development Goal for child survival, yet made insufficient progress for maternal and neonatal survival and stillbirths, due to low coverage and quality of services for care at birth, with rural women left behind. Our study aimed to evaluate Tanzania's subnational (regional-level) variations for rural care at birth outcomes, i.e., rural women giving birth in a facility and by Caesarean section (C-section), and associations with health systems inputs (financing, health workforce, facilities, and commodities), outputs (readiness and quality of care) and context (education and GDP). METHODS We undertook correlation analyses of subnational-level associations between health system inputs, outputs, context, and rural care at birth outcomes; and constructed implementation readiness barometers using benchmarks for each health system input indicator. We used geographical information system (GIS) mapping to visualise subnational variations in care at birth for rural women, with a focus on service availability and readiness, and collected qualitative data to investigate financial flows from national to council level to understand variation in financing inputs. RESULTS We found wide subnational variation for rural care at birth outcomes, health systems inputs, and contextual indicators. There was a positive association between rural women giving birth in a facility and by C-section; maternal education; workforce and facility density; and quality of care. There was a negative association between these outcomes and proportion of all births to rural women, total fertility rate, and availability of essential commodities at facilities. Per capita recurrent expenditure was positively associated with facility births (correlation coefficient = 0.43; p = 0.05) but not with C-section. Qualitative results showed that the health financing system is complex and insufficient for providing care at birth services. Bottlenecks for care at birth included low density of health workers, poor availability of essential commodities, and low health financing in Lake and Western Zones. CONCLUSIONS No region meets the benchmarks for the four health systems building blocks including health finance, health workforce, health facilities, and commodities. Strategies for addressing health system inequities, including overall increases in health expenditure, are needed in rural populations and areas of highest unmet need for family planning to improve coverage of care at birth for rural women in Tanzania.
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Affiliation(s)
- Corinne E. Armstrong
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Evidence for Action, Dar es Salaam, Tanzania
| | - Melisa Martínez-Álvarez
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Neha S. Singh
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Theopista John
- World Health Organization, 1 Luthuli Street, PO Box 9292, Dar es Salaam, Tanzania
| | - Hoviyeh Afnan-Holmes
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Independent consultant, London, UK
| | - Chris Grundy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Corrine W. Ruktanochai
- Department of Geography & Environment, University of Southampton, Highfield, Southampton, SO17 1BJ UK
| | - Josephine Borghi
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Moke Magoma
- Evidence for Action, Dar es Salaam, Tanzania
| | - Georgina Msemo
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Zoe Matthews
- Division of Social Statistics and Demography & Centre for Global Health, Population, Poverty and Policy, Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton, UK
| | - Gemini Mtei
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Joy E. Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
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