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Background: Increasing births with skilled attendants and increasing health facilities with Emergency Obstetric Care (EmOC) can reduce maternal mortality and are considered critical interventions for ensuring safe motherhood. Despite Tanzania’s policy to support women to give birth with the assistance of skilled personnel, some women do not access this care. This article uses women’s stories to illustrate the challenges that caused them to fail to access adequate obstetric care in a timely manner, hence causing the development of fistulas. Methods: This paper presents the narratives of 16 women who were conveniently selected based on their experiences of not being able to access adequate obstetric care in timely manner. The analysis was guided by recommendations for the identification and interpretation of narratives, and identified important components of women’s experiences, paying attention to commonalities, differences and areas of emphasis. Semi-structured interviews were carried out at CCBRT hospital in Dar es Salaam. Results: Four (4) general story lines were identified from women description of their inability to access quality obstetric care in a timely manner. These were; failing to decide on a health care facility for delivery, lacking money to get to a health care facility, lacking transportation to a health care facility and lacking quality birth care at the health care facility. Conclusion: Women were unable to reach to the health care facilities providing comprehensive emergency obstetric care (CEmOC) in time because of their lack of decision-making power, money and transportation, and those who did reach the facilities received low quality birth care. Empowering women socially and financially, upgrading primary health care facilities to provide CEmOC and increased numbers of skilled personnel would promote health care facility deliveries.
This study uses narrative research, a qualitative approach on the propensity of humans to narrate experiences, and draws on data from a previous study on access to and quality of birth care in Tanzania: The problem of obstetric fistula and its implication conducted between 2010 and 2012 [30]. Stories provide a way for individuals to reflect on their experiences, create meaning, and imagine life’s possibilities [31]. They are concrete, personal and temporal accounts in which the narrator sets the scene and describes the main event and their resolution, including the central point of the story. In this study, stories from an in-depth analysis of women’s experience of labour and delivery provide a way to understand the complexities inherent in how women who live in rural settings of Tanzania access adequate obstetric care. By identifying the main story lines, a rich description of labour and delivery in the context of women’s lived experience of delays in accessing adequate obstetric care is provided [32]. The usefulness of stories in enriching our understanding of health and illness experiences has been recognised [31]. As described elsewhere [25], the study was conducted at the Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) hospital. CCBRT is a private, non-governmental organisation (NGO) in Dar es Salaam that serves as a major service delivery point for obstetric fistula repair in the Coastal region. It also receives patients from the central and eastern part of the country. The hospital has a 21-bed fistula ward, and a hostel where fistula patients live while awaiting fistula repair. It performs approximately 400 vesico-vaginal fistula (VVF) and recto-vaginal fistula (RVF) surgeries each year. The hospital has an active case finding program that traces patients in rural areas and brings them to the hospital for surgical treatment free of charge. This is done using a mobile phone based money transfer service to send cash to obstetric fistula patients for transportation costs to come to CCBRT. The program is facilitated by health care providers working in the primary health care facilities, who identify, communicate and facilitate transportation of women with obstetric fistula to CCBRT for treatment. The hospital also implements an incentive scheme for the identification of obstetric fistula cases. A convenience sample of 16 women affected by obstetric fistula was recruited for semi-structured interviews. It was essential to use convenience sampling because women were recruited from the fistula ward, and some were recruited after fistula repair. Therefore, their recruitment depended on their health condition. The inclusion criteria were women with fistula admitted to CCBRT for surgical repair (before or after fistula repair), ability to speak Kiswahili and willing to participate in the study. A senior nurse-midwife in the fistula ward aided in identifying women who met the inclusion criteria, explained the purpose and the method of the study, including principles of confidentiality, and arranged for a suitable time for an interview. All participants provided written informed consent. Each woman participated in an audio recorded, semi-structured interview [33] that lasted about 1 h. During the interviews, women were encouraged to tell their stories of labour and delivery before they developed fistula. These interviews were conducted by the first author in the room adjacent to fistula ward. The interview room was quiet and out of sight and hearing range of other fistula patients and staff; this ensured the women’s privacy. The principle of saturation guided the sampling process. Saturation was achieved after 16 interviews, at which point answers from the women seemed to repeat information gained earlier and little new information was attained [34]. The semi-structured interview guide included topics and probing questions focussing on women’s experiences of labour and delivery (see Table 1). The interviewer used additional probing questions to clarify aspects of stories where necessary. Prompts and probes were used to encourage women to extend their responses and to provide stories that are more complete. Most of the participants spoke openly during all interviews. Semi-structured interview guide for women affected by fistula Data analysis was guided by recommendations for the identification and interpretation of narratives [35]. The audio recorded interviews were transcribed and read several times to identify the parts of the interview that made up each woman’s story. In this stage, the audio recorded interviews were reviewed to verify the written/transcribed interviews. Relevant sections of the interview were marked accordingly. These were all texts that described women experiences of delay in accessing obstetric care. The interviews were re-read to capture the universal impression of each woman’s story. To facilitate this, the author prepared brief summaries of each woman’s narrative, highlighting general impressions, as well as unusual features, of each story. The authors systematically reviewed summaries of the stories to identify the central narrative or story lines that women used to explain their experiences of being unable to access obstetric care during labour and delivery (See Table 2). Decisions were made through consensus and in cases of disagreements, the authors returned to the transcript to ensure interpretations were grounded in the data. Using these central narratives, the interviews were re-read and coded. Example of the process of analysis The authors then probed each central narrative [35], whereby the process began by reading all relevant coded segments. Attention was given to the identification of important components of the stories, what was emphasized and the similarities and differences in the way the stories were told. All texts from the interviews were first analysed for identification of delay patterns in accessing obstetric care. Women’s narratives were organised according to the “three delays” model [29]. The research team crosschecked analysis and discussed and agreed on the sorting of codes and naming of categories.
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