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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
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