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Background: Antenatal care (ANC) provides an important opportunity for pregnant women with a wide range of interventions and is considered as an important basic component of reproductive health care.Methods: In 2008, severe maternal morbidity audit was established at Saint Francis Designated District Hospital (SFDDH), in Kilombero district in Tanzania, to ascertain substandard care and implement interventions. In addition, a cross-sectional descriptive study was carried out in 11 health facilities within the district to assess the quality of ANC and underlying factors in a broader view.Results: Of 363 severe maternal morbidities audited, only 263 (72%) ANC cards were identified. Additionally, 121 cards (with 299 ANC visits) from 11 facilities were also reviewed. Hemoglobin and urine albumin were assessed in 22% – 37% and blood pressure in 69% – 87% of all visits. Fifty two (20%) severe maternal morbidities were attributed to substandard ANC, of these 39 had severe anemia and eclampsia combined. Substandard ANC was mainly attributed to shortage of staff, equipment and consumables. There was no significant relationship between assessment of essential parameters at first ANC visit and total number of visits made (Spearman correlation coefficient, r = 0.09; p = 0.13). Several interventions were implemented and others were proposed to those in control of the health system.Conclusions: This article reflects a worrisome state of substandard ANC in rural Tanzania resulting from inadequate human workforce and material resources for maternal health, and its adverse impacts on maternal wellbeing. These results suggest urgent response from those in control of the health system to invest more resources to avert the situation in order to enhance maternal health in this country. © 2012 Nyamtema et al.;.
Kilombero is a rural district located in the south-western part of Tanzania. In 2002 it had a total population of 321,661 people with annual population growth rate of 2.6% [10]. Antenatal care services are offered in 44 health facilities including a 372-bed SFDDH (including maternity waiting home services), a 120 bed capacity Illovo (parastatal) hospital, 4 public health centers and 38 private and public dispensaries scattered around the district. The first phase of the 4 M study involved audit of all mothers with severe maternal morbidities and mortalities at SFDDH. The inclusion criteria and the auditing process have been described elsewhere [11]. The second phase of the study involved stratified sampling technique to obtain 11 health facilities out of 44 health institutions in Kilombero district (25% representation fulfilling WHO recommendation to cover at least 25-30% of the health facilities in the area when assessing quality of care [12]. These included 2 hospitals, 2 health centers and 7 dispensaries. All clients who came for antenatal clinics on the day of study were included in this study. Data of the first phase (severe maternal morbidities audit) was collected and entered in Access database. The second phase of the study was a cross-sectional descriptive study which was intended at assessing the quality of antenatal care in the district. Four tools were used in this phase i.e. two checklists and two semi-structured questionnaires. The first checklist was used at the exit of clients to assess ANC cards for completeness of parameters, routinely assessed during ANC visits. These parameters included weight, maternal height, blood pressure, hemoglobin estimation, glucose in urine, albumin in urine, VDRL test, HIV test, blood group and rhesus status, provision of hematenics (iron and folate) and mebendazole. The presence of risk factor(s) which are routinely recommended on the ANC card were also reviewed. These include history of Caesarean section, age below 20 years, primigravida at age above 34 years, grand multiparous (more than 5 previous deliveries) and stature less than 150 cm. The ANC guideline in Tanzania recommends that women with these risk factors deliver in a hospital with comprehensive emergency obstetric services. An exit interview of ANC clients was carried out using a semi-structured questionnaire to assess whether they were advised on delivery and if they were satisfied with the quality of service they received. Another checklist was used to assess the staffing level, availability of essential equipment, medical supplies and drugs necessary for provision of ANC services in each health facility. A second semi-structured questionnaire was also used to interview in-charges of health facilities about the factors that affected the quality ANC service. Ethical clearance for the study was obtained from SFDDH Research and Publication Committee. Permission to conduct the cross-sectional descriptive study was obtained from the office of the District Medical Officer and the respective in-charges of the selected health facilities. Verbal informed consent was obtained from all interviewees i.e. in-charge of health facilities and clients whose ANC cards were reviewed. Confidentiality, privacy and cultural values were also taken into consideration. Quantitative data was analyzed using SPSS software. The principal summary measures were proportions of essential parameters assessed during ANC visits and the corresponding 95% confidence intervals (95% CI). The relationship between assessment of essential parameters at first visit and the total number of visits made was determined using correlation analysis. Essential parameters (BP, Hb and albumin in urine) measured at first ANC visit were scored i.e. , each parameter was given one point when it appeared that it was assessed, making a maximum score of 3. The authors hypothesized that by assessing these parameters, involving her blood sample, urine sample and physique, a woman would feel adequately assessed and hence motivated to make more visits. Although blood and urine samples are also used for other tests, it was logically assumed that these tests may not have changed in the way how a woman felt to be assessed during the first visit. Mothers with complications of abortion, ectopic pregnancies and those who started ANC visits after 20 weeks of gestation were excluded from this correlation analysis because they were not expected to make a recommended minimum of four visits. Qualitative data was analyzed using a method described by Graneheim and Lundman [13]. Analysis included thorough reading of the transcribed text to identify meaning units. The meaning units were then condensed, abstracted, coded and then categorized according to similarities and differences in content.
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