Barriers and facilitators to humanizing birth care in Tanzania: Findings from semi-structured interviews with midwives and obstetricians Prof. Suellen Miller

Reproductive Health, Volume 15, No. 1, Year 2018

Interpretation

Background: In Tanzania, the provision of humanized care is increasingly being emphasized in midwifery practice, yet studies regarding perceptions and practices of skilled health personnel towards the humanization of birth care are scare. Previous reviews have identified that abuse and disrespect is not limited to individuals but reflects systematic failures and deeply embedded provider attitudes and beliefs. Therefore, the current study aims to explore the perceptions and practices of skilled health personnel on humanizing birth care in Tanzania by identifying current barriers and facilitators. Methods: Semi-structured interviews were held with skilled health personnel including midwives (n = 6) and obstetricians (n = 2) working in the two district hospitals of Tanzania. Data were analyzed using thematic coding. Results: Skilled health personnel identified systematic barriers to providing humanizing birth care. Systematic barriers included lack of space and limited facilities. Institutional norms and practices prohibited family involvement during the birth process,including beliefs that limited choice of birth position as well as disrespected beliefs, traditions, and culture. Participants also acknowledged four facilitators that improve the likelihood of humanized care during childbirth in Tanzania: ongoing education of skilled health personnel on respectful maternal care, institutional norms designed for continuous clinic support during childbirth, belief in the benefit of having family become active participants, and respecting maternal wishes when appropriate. Conclusion: To move forward with humanizing the birth process in Tanzania, it will be essential that systematic barriers are addressed as well as changing the mindset of personnel towards respectful maternal care. It will be essential for the government and private hospitals to revalue their labour wards to increase the space and staff allocated to each mother to enhance family-integrated care. Additionally, in-service training as well as incorporation of respectful maternal care during pre-service training is key to changing the culture in the labour ward. This study is part of a larger project exploring community and skilled health personnel perceptions and practices on humanizing birth care in Tanzania. The study was conducted in the two District hospitals in the Mwanza and Mara regions in the Lake Zone, Tanzania. Districts hospitals in Tanzania are the first referral level in the health system referral pyramid where necessary drugs, equipment, and skilled staff are supposed to be available to provide comprehensive EmOC. Further up in the health pyramid, there are regional hospitals, followed by zonal referral hospitals, and at the highest level are the national hospitals. The Lake Zone was chosen as it is one of the regions of Tanzania with the highest maternal mortality rates, with Mara having a maternal mortality ratio of 362 per 1000 births and 305 per 1000 births in Mwanza according to the 2012 census [23]. The aim of this study was to explore the perceptions and experiences of humanizing birth care in Tanzania. Therefore, eight skilled health personnel including six midwives and two obstetricians were conveniently selected from two hospitals in the Lake Zone. Only eight skilled health personnel were interviewed, however qualitative sample size has no rule it depends on what the researcher wants to know, the purpose of the research study, and what can be done with available time and resources. It is further recommended that the minimum samples for qualitative research should be based on expected reasonable coverage of the phenomenon given the purpose of the study and interest [24]. The inclusion criteria were midwives or obstetricians working in the labour ward for a minimum of two years providing birth care and agreed to participate in the study. A midwife in charge of the labour ward (not part of the interviewed midwives) identified midwives and obstetrician who met the inclusion criteria. Throughout this paper, the term “skilled health personnel”, as defined by the 2018 WHO [25], is used to include both nurse midwives and obstetricians because of the desire not to separate out the nurse midwives and obstetricians specific findings. The purpose of the study and principles of confidentiality were explained to participants, and thereafter, a convenient time for an interview was arranged. Semi structured interviews [26] with midwives and obstetricians who were on duty during the data collection period were conducted. A semi-structured interview guide was used focusing on skilled health personnels’perceptions and experiences of humanizing birth care (see Table 1). The guide with open-ended questions and probes used was flexible to allow the interviewer to explore issues of relevance as they emerged [27]. Interviews were conducted in aprivate, quiet room within the hospital premise at the end of the participants shift. In each interview, the participant was a major speaker and the researcher served as a guide and facilitator. The level of openness of the interviewees varied but seemed to be generally good. All interviewees agreed to the use of an audio-recorder and interviews lasted between 30–45 min. Notation of nonverbal expressions of the informants during the interview was taken during and immediately after the interview. Interview guide for Midwives and Obstetricians Semi-structured interviews were transcribed verbatim into Kiswahili, and then translated into English by hired research assistants fluent in both languages. It was essential to translate transcripts into English to ensure access of data to non-Kiswahili speaking members of the research team. Data were analyzed using thematic coding using the English transcripts with initial codes collected and reviewed, duplicates removed, and similar codes grouped together [28, 29]. Codes and corresponding quotes were reviewed and re-labeled if necessary [30]. The semi-structured interviews yielded significantly rich data whereby no additional themes seemed to emerge, suggesting sufficient data to develop themes [30]. This study was approved by the National Institute of Medical Research in Tanzania (Ref. no. NIMR/HQ/R.8a/Vol.IX/2143). All participants gave informed written consent to be interviewed. Participants were informed that their interviews would be recorded and agreed for their anonymous quotes to be used.

AI Digest

Study Justification:

– The study aims to explore the perceptions and practices of skilled health personnel on humanizing birth care in Tanzania.
– Previous reviews have identified systematic failures and provider attitudes as barriers to humanized care.
– The study is part of a larger project exploring community and skilled health personnel perceptions and practices on humanizing birth care in Tanzania.
– The Lake Zone in Tanzania was chosen as it has high maternal mortality rates.

Study Highlights:

– Skilled health personnel identified systematic barriers to providing humanizing birth care, including lack of space and limited facilities.
– Institutional norms and practices prohibited family involvement during the birth process.
– Four facilitators were identified to improve humanized care: ongoing education of skilled health personnel, institutional norms for continuous clinic support, belief in the benefit of family involvement, and respecting maternal wishes.

Study Recommendations:

– Address systematic barriers to humanizing birth care in Tanzania.
– Change the mindset of personnel towards respectful maternal care.
– Increase space and staff allocation in labor wards to enhance family-integrated care.
– Provide in-service training and incorporate respectful maternal care in pre-service training.

Key Role Players:

– Government officials responsible for healthcare policy and funding.
– Private hospital administrators and managers.
– Skilled health personnel, including midwives and obstetricians.
– Training institutions for healthcare professionals.

Cost Items for Planning Recommendations:

– Renovation and expansion of labor wards to increase space.
– Hiring additional staff to support family-integrated care.
– Development and implementation of in-service training programs.
– Incorporation of respectful maternal care in pre-service training curriculum.
– Ongoing education and training for skilled health personnel.
– Monitoring and evaluation of the implementation of humanizing birth care practices.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides insights into the perceptions and practices of skilled health personnel on humanizing birth care in Tanzania. The use of semi-structured interviews with midwives and obstetricians adds depth to the findings. The study also identifies both barriers and facilitators to humanized care during childbirth. However, the sample size is small, with only eight skilled health personnel interviewed. To improve the strength of the evidence, it would be beneficial to increase the sample size and include a more diverse range of participants. Additionally, the study could benefit from including a control group or comparative analysis to further support the findings.

Abstract

This study is part of a larger project exploring community and skilled health personnel perceptions and practices on humanizing birth care in Tanzania. The study was conducted in the two District hospitals in the Mwanza and Mara regions in the Lake Zone, Tanzania. Districts hospitals in Tanzania are the first referral level in the health system referral pyramid where necessary drugs, equipment, and skilled staff are supposed to be available to provide comprehensive EmOC. Further up in the health pyramid, there are regional hospitals, followed by zonal referral hospitals, and at the highest level are the national hospitals. The Lake Zone was chosen as it is one of the regions of Tanzania with the highest maternal mortality rates, with Mara having a maternal mortality ratio of 362 per 1000 births and 305 per 1000 births in Mwanza according to the 2012 census [23]. The aim of this study was to explore the perceptions and experiences of humanizing birth care in Tanzania. Therefore, eight skilled health personnel including six midwives and two obstetricians were conveniently selected from two hospitals in the Lake Zone. Only eight skilled health personnel were interviewed, however qualitative sample size has no rule it depends on what the researcher wants to know, the purpose of the research study, and what can be done with available time and resources. It is further recommended that the minimum samples for qualitative research should be based on expected reasonable coverage of the phenomenon given the purpose of the study and interest [24]. The inclusion criteria were midwives or obstetricians working in the labour ward for a minimum of two years providing birth care and agreed to participate in the study. A midwife in charge of the labour ward (not part of the interviewed midwives) identified midwives and obstetrician who met the inclusion criteria. Throughout this paper, the term “skilled health personnel”, as defined by the 2018 WHO [25], is used to include both nurse midwives and obstetricians because of the desire not to separate out the nurse midwives and obstetricians specific findings. The purpose of the study and principles of confidentiality were explained to participants, and thereafter, a convenient time for an interview was arranged. Semi structured interviews [26] with midwives and obstetricians who were on duty during the data collection period were conducted. A semi-structured interview guide was used focusing on skilled health personnels’perceptions and experiences of humanizing birth care (see Table 1). The guide with open-ended questions and probes used was flexible to allow the interviewer to explore issues of relevance as they emerged [27]. Interviews were conducted in aprivate, quiet room within the hospital premise at the end of the participants shift. In each interview, the participant was a major speaker and the researcher served as a guide and facilitator. The level of openness of the interviewees varied but seemed to be generally good. All interviewees agreed to the use of an audio-recorder and interviews lasted between 30–45 min. Notation of nonverbal expressions of the informants during the interview was taken during and immediately after the interview. Interview guide for Midwives and Obstetricians Semi-structured interviews were transcribed verbatim into Kiswahili, and then translated into English by hired research assistants fluent in both languages. It was essential to translate transcripts into English to ensure access of data to non-Kiswahili speaking members of the research team. Data were analyzed using thematic coding using the English transcripts with initial codes collected and reviewed, duplicates removed, and similar codes grouped together [28, 29]. Codes and corresponding quotes were reviewed and re-labeled if necessary [30]. The semi-structured interviews yielded significantly rich data whereby no additional themes seemed to emerge, suggesting sufficient data to develop themes [30]. This study was approved by the National Institute of Medical Research in Tanzania (Ref. no. NIMR/HQ/R.8a/Vol.IX/2143). All participants gave informed written consent to be interviewed. Participants were informed that their interviews would be recorded and agreed for their anonymous quotes to be used.

Materials

N/A

Innovations

Based on the findings of the study, the following recommendations can be made to develop innovations to improve access to maternal health in Tanzania:

1. Increase space and facilities: The government and private hospitals should revalue their labor wards and allocate more space and staff to each mother. This will enhance family-integrated care and allow for a more comfortable and respectful birthing environment.

2. Ongoing education: Skilled health personnel should receive continuous education on respectful maternal care. This will help change their mindset and ensure that they provide humanized care during childbirth.

3. Institutional norms: Hospitals should establish norms that support continuous clinic support during childbirth. This includes allowing family involvement and respecting maternal wishes when appropriate. These norms should be designed to promote a culture of respect and dignity for mothers.

4. Training: In-service training for skilled health personnel should incorporate modules on respectful maternal care. Additionally, respectful maternal care should be included in pre-service training for midwives and obstetricians. This will help change the culture in the labor ward and ensure that all health personnel are equipped with the necessary skills and knowledge to provide humanized care.

By implementing these recommendations, it is hoped that access to maternal health will be improved in Tanzania, leading to better outcomes for mothers and their babies.

AI Innovations Description

Based on the findings of the study, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

To improve access to maternal health and humanize the birth process in Tanzania, it is recommended to address the systematic barriers identified by skilled health personnel. This can be achieved through the following steps:

1. Increase space and facilities: The government and private hospitals should revalue their labor wards and allocate more space and staff to each mother. This will enhance family-integrated care and allow for a more comfortable and respectful birthing environment.

2. Ongoing education: Skilled health personnel should receive continuous education on respectful maternal care. This will help change their mindset and ensure that they provide humanized care during childbirth.

3. Institutional norms: Hospitals should establish norms that support continuous clinic support during childbirth. This includes allowing family involvement and respecting maternal wishes when appropriate. These norms should be designed to promote a culture of respect and dignity for mothers.

4. Training: In-service training for skilled health personnel should incorporate modules on respectful maternal care. Additionally, respectful maternal care should be included in pre-service training for midwives and obstetricians. This will help change the culture in the labor ward and ensure that all health personnel are equipped with the necessary skills and knowledge to provide humanized care.

By implementing these recommendations, it is hoped that access to maternal health will be improved in Tanzania, leading to better outcomes for mothers and their babies.

AI Innovations Methodology

The methodology used in this study to simulate the impact of the main recommendations on improving access to maternal health is not explicitly described in the provided information. However, based on the information provided, it appears that the study utilized semi-structured interviews with skilled health personnel, including midwives and obstetricians, working in two district hospitals in Tanzania. The interviews were conducted using a semi-structured interview guide that focused on the perceptions and experiences of humanizing birth care.

The interviews were transcribed verbatim in Kiswahili and then translated into English. Thematic coding was used to analyze the data, with initial codes collected, reviewed, and duplicates removed. Similar codes were grouped together, and codes and corresponding quotes were reviewed and re-labeled if necessary.

It is important to note that the study did not explicitly mention the use of simulation or provide details on how the impact of the recommendations was simulated. The study primarily focused on exploring the perceptions and experiences of skilled health personnel regarding humanizing birth care in Tanzania.

For a more comprehensive understanding of the methodology used to simulate the impact of the recommendations, it would be necessary to refer to the full publication in the Reproductive Health journal, Volume 15, No. 1, Year 2018.

Author

Dima Health

Statistics:

Citations: 19

Identifiers:

DOI: 10.1186/s12978-018-0583-7

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Social Determinants, Workforce

Study Countries:

Tanzania

Study Design:

Grounded Theory

Study Approach:

Qualitative