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Background: Although antenatal care coverage in Tanzania is high, worrying gaps exist in terms of its quality and ability to prevent, diagnose or treat complications. Moreover, much less is known about the utilisation of postnatal care, by which we mean the care of mother and baby that begins one hour after the delivery until six weeks after childbirth. We describe the perspectives and experiences of women and health care providers on the use of antenatal and postnatal services. Methods: From March 2007 to January 2008, we conducted in-depth interviews with health care providers and village based informants in 8 villages of Lindi Rural and Tandahimba districts in southern Tanzania. Eight focus group discussions were also conducted with women who had babies younger than one year and pregnant women. The discussion guide included information about timing of antenatal and postnatal services, perceptions of the rationale and importance of antenatal and postnatal care, barriers to utilisation and suggestions for improvement. Results: Women were generally positive about both antenatal and postnatal care. Among common reasons mentioned for late initiation of antenatal care was to avoid having to make several visits to the clinic. Other concerns included fear of encountering wild animals on the way to the clinic as well as lack of money. Fear of caesarean section was reported as a factor hindering intrapartum care-seeking from hospitals. Despite the perceived benefits of postnatal care for children, there was a total lack of postnatal care for the mothers. Shortages of staff, equipment and supplies were common complaints in the community. Conclusion: Efforts to improve antenatal and postnatal care should focus on addressing geographical and economic access while striving to make services more culturally sensitive. Antenatal and postnatal care can offer important opportunities for linking the health system and the community by encouraging women to deliver with a skilled attendant. Addressing staff shortages through expanding training opportunities and incentives to health care providers and developing postnatal care guidelines are key steps to improve maternal and newborn health. © 2009 Mrisho et al; licensee BioMed Central Ltd.
The study was conducted in Lindi Rural and Tandahimba Districts in southern Tanzania, a study area that has been described in detail elsewhere ([30,31]). In brief, these areas have a total population of about 300,000 people [32]. Lindi Rural has highland areas as well as low-lying plains with major permanent rivers (Lukuledi, Matandu and Mavuji). There are two main rainy seasons, November to December and February to May. The area has a wide mix of ethnic groups, most common being Yao, Makonde, Mwera and Matumbi. These groups frequently intermarry and are predominantly Muslim. Health services are delivered by the public health system. These consist of a network of dispensaries, health centers and hospitals that offer varying quality of care. There are also a few private not-for-profit dispensaries and hospitals run by Christian mission organisations. Three-quarters of the population live within about 5 km of their nearest facility [29]. Routine immunisation is the basis of the EPI activities. On a regular basis vaccines for measles, diphtheria, pertussis, tetanus, polio and tuberculosis, are provided in health facilities all over the country. Vaccinations are given in static, out-reach, and mobile health facilities. The immunisation schedule including the above vaccines stretches over the child’s first year and tetanus vaccination is given to women of childbearing age [33]. In Lindi and Mtwara regions, the proportion of heads of household and women of reproductive age (15–49 years) with no education was 35% and 27% respectively. Thirty-eight percent of a representative sample of 19,007 women aged 15–49 years interviewed in July and August 2004 had experienced the loss of at least one child [29]. Data was collected within a framework of ethnographic fieldwork for a larger project assessing community acceptability of intermittent preventive treatment for malaria in infants during March and April 2007. Follow-up data collection was carried out during January 2008. Using a network of female village based informants (VBI) in 8 villages of Lindi Rural and Tandahimba districts ([30,31]), we conducted a series of in-depth interviews (N = 16; N = 8 with VBI, N = 8 with health care providers (HCP)) and focus group discussions (FGD; N = 8). Each FGD was conducted in groups of 6 to 8 women with babies aged less than one year of age as well as pregnant women with similar backgrounds and experiences [34]. In total, 74 respondents participated in FGD and in-depth interviews. Participants in FGDs included 58 women of whom, 39 had young child less than one year old and 19 were pregnant. Almost all women who participated in FGD and in-depth interviews were aged between 15–42 years and had completed primary school education. Both in-depth interviews and FGD were intended to gather information about the timing and perceived reasons for ANC and PNC; services available in ANC and PNC; perceptions about the importance of ANC and PNC; home births and barriers to ANC and PNC; and lastly, suggestions on how to improve ANC and PNC (see Table Table2).2). The FGD generally took place at the VBI’s home. Before the FGD, the moderator introduced all participants, explained the general topics of discussion and encouraged all participants to contribute their ideas. An experienced moderator led the discussions with support from a note-taker, with both taking notes. The FGDs were recorded using an MP3 voice recorder. After the FGD, the note-taker and the moderator reviewed their handwritten notes. After revision of notes, the transcripts were typed and exported to NVivo 2 [35] qualitative data analysis software. Data analysis compared responses from both the in-depth interviews and FGDs. We triangulated responses from in-depth interviews with VBIs and HCPs as well as FGDs with mothers of infants and pregnant women. We found that the responses were in accordance with each other for most of the results. The only exception to this was for barriers to births and suggestions for improvement of ANC and PNC services. For these results we have shown the differences among the sources. Our major key themes emerged as a result of the interview guide (shown in Table Table22 below) and the coded transcripts from the FGDs and in-depth interview. Questions included in the topic guide used during FGDs and in-depth interviews We obtained informed consent verbally at the start of each interview or FGD. Most health care providers were not willing to be recorded, but gave their consent to be interviewed. Interviews with health care providers were done at their workplace and at a time that was convenient for them, particularly when there were few or no clients. In these cases, the analysis was done from written notes. Confidentiality of all study participants was assured and village names have been encoded in this manuscript. We chose a qualitative approach in order to improve our understanding of community views and perceptions regarding ANC and PNC services. The study was undertaken within the framework of the assessment of the community effectiveness of Intermittent Preventive Treatment for malaria in infants (IPTi). We received ethical approval from the local and national institutional review boards (Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee) through the Tanzania Commission for Science and Technology. In addition ethical and research clearance was also obtained from institutional review board of the London School of Hygiene and Tropical Medicine, UK, and Ethics Commission of the Cantons of Basel-Stadt and Basel-Land, Switzerland.
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