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

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Study Justification:
– The study aims to understand the delivery of maternal health services from the perspective of rural health workers in Tanzania.
– It seeks to identify barriers and strategies for realizing the right to quality maternal health care.
– The study is important because Tanzania has ratified legal treaties indicating the obligation of the state to provide essential maternal health care as a basic human right, yet the quality of care is disproportionately low.
Highlights:
– Three themes emerged from the study: “It’s hard to respect women’s preferences”, “Striving to fulfill women’s needs with limited resources”, and “Trying to facilitate women’s access to services at the face of transport and cost barriers”.
– The health system has left health workers frustrated and disempowered, due to inadequate resources, lack of motivation, and lack of supervision.
– Pregnant women, as users of health services, also face frustration and incur out-of-pocket costs for services that should be provided free.
Recommendations:
– Increase the availability of adequate material and human resources to improve the provision of quality maternal health care services.
– Provide motivation and supervision for health workers to enhance their performance and job satisfaction.
– Address transport and cost barriers to improve women’s access to maternal health services.
Key Role Players:
– Ministry of Health: Responsible for policy-making and resource allocation.
– District Health Management Team: Oversees health services at the district level.
– Health Facility Managers: Responsible for the day-to-day operations of health facilities.
– Health Workers: Provide direct care to pregnant women and play a crucial role in service delivery.
Cost Items for Planning Recommendations:
– Procurement of medical equipment and supplies.
– Recruitment and training of additional health workers.
– Incentives and motivation programs for health workers.
– Supervision and monitoring activities.
– Transportation and logistics for improving access to services.
– Public awareness campaigns to educate women about their rights and available services.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a qualitative study that involved in-depth interviews and structured observations with 11 health workers in rural Tanzania. Thematic analysis was used to analyze the data, and the findings highlight the barriers and strategies in fulfilling women’s right to quality maternal health care. The study provides specific details about the study location, population, and healthcare facilities. To improve the evidence, the abstract could include information about the selection criteria for the health workers and the specific themes that emerged from the analysis.

Background: Tanzania has ratified and abides to legal treaties indicating the obligation of the state to provide essential maternal health care as a basic human right. Nevertheless, the quality of maternal health care is disproportionately low. The current study sets to understand maternal health services’ delivery from the perspective of rural health workers’, and to understand barriers for and better strategies for realization of the right to quality maternal health care. Methods: Semi-structured in-depth interviews were conducted, involving 11 health workers mainly; medical attendants, enrolled nurses and Assistant Medical Officers from primary health facilities in rural Tanzania. Structured observation complemented data from interviews. Interview data were analyzed using thematic analysis guided by the conceptual framework of the right to health. Results: Three themes emerged that reflected health workers’ opinion towards the quality of health care services; “It’s hard to respect women’s preferences”, “Striving to fulfill women’s needs with limited resources”, and “Trying to facilitate women’s access to services at the face of transport and cost barriers”. Conclusion: Health system has left health workers as frustrated right holders, as well as dis-empowered duty bearers. This was due to the unavailability of adequate material and human resources, lack of motivation and lack of supervision, which are essential for provision of quality maternal health care services. Pregnant women, users of health services, appeared to be also left as frustrated right holders, who incurred out-of-pocket costs to pay for services, which were meant to be provided free.

This qualitative study was carried out in Mkinga, which is one of the eight districts in the Tanga region of Northern eastern Tanzania. The district is rural, with moderate level of socio-economic development and accessible in terms of transportation and communication. The district has 21 wards, and according to the 2012 Tanzania National Census [32] the population of Mkinga district was 118,065, of these 51% were women. The dominant religions in the area are Muslim and Christian; where Muslims are predominant than Christian. The health care services in the district are largely based on primary public health facilities, with three health centers and 26 dispensaries. At the time, we conducted the study, there was no hospital in the district and none of the facilities provided Comprehensive Emergency Obstetric Care (CEmOC) services. Maternal and child health services including Basic EmOC, were provided from health centers (headed by an Assistant Medical Officer and include; 16-bed inpatient services and minor surgeries and staffed with four clinicians and nine nurses) and dispensaries (clinical officer heads services and they are all outpatient except for deliveries and staffing level here is two clinical officers and two nurses). Patients, who needed caesarean section or blood transfusion, were referred to Tanga Regional Referral Hospital (Bombo hospital) which is approximately 50 to 60 km away from Mkinga district. The government of Tanzania advocates for high coverage of basic EmOC services, (that includes; parenteral antibiotics; oxytocin; parenteral anticonvulsants; manual removal of placenta; removal of product of conception and assisted vaginal delivery) and CEmOC services (that includes Basic EmOC plus blood transfusion and caesarean section) for dispensaries and health centers [23]. Participants in the study were 11 health care workers of Mkinga district who worked at nine facilities (health centers and dispensaries). To ensure maximum variation we included medical attendants (4), enrolled nurses (5) and assistant medical doctors (2). Participants worked in either labor ward and/or antenatal clinic, in nine facilities. Six participants were the only health workers working at labor ward and/ or antenatal clinic at their respective facilities. Two facility managers were also selected due to their involvement in every department, including labor ward and antenatal clinic. Participants differed in terms of sex/gender (3 men and 8 women), and time working at the facility- ranging from 1 year to 29 years. Facilities were located between 30 km and 90 km from the nearest hospital. TWJ (first author) conducted all the interviews between June and August 2015 that lasted between 60 and 90 min. Participants were visited at their facilities, and requested to choose a convenient time and place for interview. Interviews were conducted in Swahili language by the first author (TWJ), who has a medical background and is a Swahili native speaker. He also has previous experience of working in one of the health centre in Mkinga district. Interviews were conducted using semi-structured interview guide with open-ended questions on issues concerning; availability; accessibility; acceptability and quality of health care and interviewer remained open to other new emerging issues. Information were recorded using notebooks and tape recorders and preliminary analysis of data was done upon collection. The process was useful in generating insight, and emerging issues were followed in subsequent interviews. The sample size was not predetermined, and saturation was attained with 11 interviews, whereas we noticed repetition of the earlier gained information with little or no new information in regards to our research question. TWJ also did structured observations, whereas he did some observations on arrival at the facility before he conducted interviews, this lasted for about 30 min to 2 h. Things like the appearance of the labor room, the number of health providers at the labor ward and RCH unit, general cleanness of the condition, the presence of electricity, running water, presence of blank patography, sterile gloves, suction machine and oxygen cylinder among others, were noted. The observation took place in seven out of nine facilities. Thematic analysis as described by Braun and Clarke [33], was employed and the domains of availability; accessibility; acceptability and quality were used to guide the analysis. Generated data from interviews were reviewed daily to ensure accuracy and completeness. Field notes were checked against audio-recorded information. Recorded interviews were transcribed verbatim and then translated into English. Translation was done in collaboration of two authors who have Swahili language as their mother tongue. Thorough double-check of the translated transcripts against the original was done to ensure quality of the translation. English transcripts were made available to all authors to familiarize with the data and generate insight on the contents. TWJ in collaboration with other three authors (IG, DAM and GF) conducted the analysis. We used open code version 4 computer software to manage the coding process. Initially codes were developed inductively (inductive approach), these codes were generated by coding every sentence of the transcript. In the second step, codes were examined and re-examined to identify differences and similarities and organized around the conceptual framework domains of availability; accessibility; acceptability and quality as preliminary themes (deductive approach). Other emerging domains beyond the ones included in the framework were identified and labelled accordingly. Triangulation was conducted by combining information from the structured observation of the facilities and the individual interviews. In addition, the researcher’s with different levels of familiarity with the setting and from different disciplines were involved, which can be considered also as triangulation. These strategies enhanced credibility. We gathered information obtained during the observation, tally them in a sheet, and did simple statistical analysis, and results are presented as frequencies of events as in Table 2. Proportion of the presence of clinical instruments/tools or recommended drugs observed in seven out of 9 visited facilities, n = 7

Based on the information provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that can travel to rural areas, providing essential maternal health care services to women who may not have easy access to healthcare facilities.

2. Telemedicine: Utilizing telemedicine technology to connect rural health workers with specialists in urban areas, allowing for remote consultations and guidance in providing quality maternal health care.

3. Community health workers: Training and empowering community health workers to provide basic maternal health care services, including prenatal care, education, and support, in rural areas where healthcare facilities are limited.

4. Transportation support: Establishing transportation support systems, such as ambulances or transportation vouchers, to help pregnant women in rural areas access healthcare facilities for prenatal care, delivery, and emergency obstetric care.

5. Financial incentives: Implementing financial incentives for healthcare workers to encourage them to work in rural areas, where there may be a shortage of skilled professionals, to ensure access to quality maternal health care services.

6. Public-private partnerships: Collaborating with private healthcare providers to expand access to maternal health care services in rural areas, through initiatives such as public-private partnerships or subsidized services.

7. Health information systems: Implementing robust health information systems to track and monitor maternal health indicators in rural areas, allowing for better resource allocation and planning to improve access to care.

These recommendations aim to address the barriers identified in the study, such as limited resources, lack of motivation, and transportation and cost barriers, in order to improve access to quality maternal health care in rural Tanzania.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health would be to address the barriers identified in the study and implement the strategies suggested by the health workers.

The study identified three main barriers to accessing quality maternal health care:

1. Difficulty in respecting women’s preferences: Health workers reported challenges in meeting the preferences of pregnant women due to limited resources and constraints within the health system. This barrier could be addressed by improving communication and collaboration between health workers and pregnant women, ensuring that women’s preferences are taken into account as much as possible.

2. Limited resources and striving to fulfill women’s needs: Health workers expressed frustration with the lack of adequate material and human resources, lack of motivation, and lack of supervision, which are essential for providing quality maternal health care services. To address this barrier, it is important to invest in improving the availability of resources, providing adequate training and support for health workers, and implementing effective supervision and monitoring systems.

3. Transport and cost barriers: Pregnant women faced challenges in accessing maternal health services due to transport and cost barriers. To overcome this barrier, strategies such as improving transportation infrastructure, providing financial support or subsidies for transportation costs, and strengthening community-based referral systems could be implemented.

In summary, to improve access to maternal health, it is recommended to address the barriers identified in the study by improving communication and collaboration, investing in resources and training for health workers, implementing effective supervision and monitoring systems, improving transportation infrastructure, and providing financial support for transportation costs.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase availability of resources: Address the shortage of material and human resources in health facilities by recruiting and training more healthcare workers, ensuring an adequate supply of medical equipment and supplies, and improving infrastructure.

2. Improve transportation services: Enhance transportation options for pregnant women in rural areas by providing ambulances or other means of transportation to facilitate access to healthcare facilities.

3. Reduce financial barriers: Implement policies to eliminate out-of-pocket costs for maternal health services, such as providing free or subsidized healthcare for pregnant women.

4. Enhance community engagement: Promote community involvement and awareness through education and outreach programs to increase knowledge about maternal health and encourage women to seek timely care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure access to maternal health, such as the number of women receiving antenatal care, the percentage of deliveries attended by skilled birth attendants, or the distance traveled to reach a healthcare facility.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area, including the selected indicators. This can be done through surveys, interviews, or existing data sources.

3. Introduce interventions: Implement the recommended interventions, such as increasing resources, improving transportation services, reducing financial barriers, and enhancing community engagement.

4. Monitor and evaluate: Continuously monitor the implementation of interventions and collect data on the selected indicators. This can be done through regular surveys, interviews, or data collection from healthcare facilities.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Draw conclusions: Based on the analysis, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Identify any gaps or areas for further improvement.

7. Make recommendations: Use the findings to make recommendations for future interventions or policies to sustain and further enhance access to maternal health.

It is important to note that this is a general methodology and may need to be adapted based on the specific context and resources available for the simulation.

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