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Background: In Tanzania, half of all pregnant women access a health facility for delivery. The proportion receiving skilled care at birth is even lower. In order to reduce maternal mortality and morbidity, the government has set out to increase health facility deliveries by skilled care. The aim of this study was to describe the weaknesses in the provision of acceptable and adequate quality care through the accounts of women who have suffered obstetric fistula, nurse-midwives at both BEmOC and CEmOC health facilities and local community members. Methods. Semi-structured interviews involving 16 women affected by obstetric fistula and five nurse-midwives at maternity wards at both BEmOC and CEmOC health facilities, and Focus Group Discussions with husbands and community members were conducted between October 2008 and February 2010 at Comprehensive Community Based Rehabilitation in Tanzania and Temeke hospitals in Dar es Salaam, and Mpwapwa district in Dodoma region. Results: Health care users and health providers experienced poor quality caring and working environments in the health facilities. Women in labour lacked support, experienced neglect, as well as physical and verbal abuse. Nurse-midwives lacked supportive supervision, supplies and also seemed to lack motivation. Conclusions: There was a consensus among women who have suffered serious birth injuries and nurse midwives staffing both BEmOC and CEmOC maternity wards that the quality of care offered to women in birth was inadequate. While the birth accounts of women pointed to failure of care, the nurses described a situation of disempowerment. The bad birth care experiences of women undermine the reputation of the health care system, lower community expectations of facility birth, and sustain high rates of home deliveries. The only way to increase the rate of skilled attendance at birth in the current Tanzanian context is to make facility birth a safer alternative than home birth. The findings from this study indicate that there is a long way to go. © 2013 Mselle et al.; licensee BioMed Central Ltd.
The qualitative research was carried out between August 2008 and August 2010, at Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) [5], Temeke district hospital in Dar es Salaam, and Mpwapwa district in Dodoma region. Temeke hospital operates as a municipal and district hospital in Dar es Salaam city, and has 26,568 annual numbers of deliveries, calculated out of total annual expected deliveries [22]. The CCBRT hospital was chosen because it was among the two major service points for fistula surgery, with higher fistula repair rates [23]. Mpwapwa district on the other hand, was chosen because many women affected by obstetric fistula who were admitted at CCBRT during the study period were from this district. Selection of these settings ensured access to an adequate number of women affected by fistula. The focus of this study was experiences related to obstetric fistula. Therefore 16 women affected by obstetric fistula (see Table 1) were conveniently selected from CCBRT hospital. The inclusion criteria were that the woman was admitted at the hospital for obstetric fistula repair before or after surgery, was able to speak Swahili, and agreed to participate in the study. A senior nurse-midwife (not part of the interviewed nurse- midwives) identified women affected by obstetric fistula at CCBRT during the data collection period. The purpose of the study and principles of confidentiality were explained, and thereafter, a convenient time for an interview was arranged. This study also involved six husbands of the affected women, six community members and five nurse-midwives staffing labour wards at both BEmOC and CEmOC health facilities. Community members were purposefully selected from different locations in Mpwapwa district, based on gender and occupation, whereby husbands and nurse-midwives were conveniently selected. Husbands and community members were recruited from Mpwapwa district in Dodoma region, with assistance of the Anti-Female Genital Mutilation Network project (AFNET) [24], whereas nurse-midwives were selected from Mboli dispensary and, Mpwapwa, and Temeke district hospitals. Characteristics of women affected by obstetric fistula who were interviewed at CCBRT hospital, Tanzania, 2008–2010 Semi structured interviews [25] with women affected by obstetric fistula, which lasted between 45 minutes and 2 hours, were conducted in person by the first author (LTM), a registered nurse with a background in social sciences and health promotion, and a fluent Swahili speaker. The sample size of the women affected by obstetric fistula was not predetermined. However, saturation [26] was achieved after 16 interviews, where answers from women seemed to repeat information gained earlier and little new information was attained. Interviews were done at CCBRT hospital, in a private room adjacent to the fistula ward. Five individual face-to-face interviews were conducted with nurse-midwives who were on duty during the data collection period. Of these, three were from the district hospital in Dar es Salaam, two from Mpwapwa district; one from a rural dispensary and another from the district hospital. It was important to interview nurse-midwives employed at different levels of health care, since the women who had suffered obstetric fistula were referred from lower (BEmOC) to higher (CEmOC) levels of care during labour. The interview with nurse-midwives lasted between 30 and 40 minutes and were held in their respective health facilities, after duty, when they were about to go home. The interview guide had only one question with few probing questions focusing on the nurse- midwives’ experiences of providing birth care. Interview guides with open-ended questions and probes used were not rigidly adhered to, allowing the interviewer to explore issues as they emerged [27], and they were revised during the course of data collection. All interviews were audio-recorded with permission from informants. Notation of nonverbal expressions of the informants during the interview was taken during and immediately after the interview. Two FGDs each with 6 participants were held at Mpwapwa district in Dodoma region by the first author using the FGD guides. The FGD with community members was conducted at the AFNET office, Mpwapwa branch. The discussion begun by reading aloud a hypothetical scenario describing potential challenges women face in relation to seeking adequate birth care. This was done to stimulate and guide the discussions. The group included a teacher, a farmer, a homemaker, a volunteer at AFNET, an accountant and a traditional birth attendant who had also suffered obstetric fistula. The other FGD with husbands of women affected by fistula was held at Tambi village. Ten husbands were approached and all agreed to take part in the study, however, only six husbands who came from different places of Mpwapwa district turned up on the day of discussion. The group was comprised of husbands of different ages and ethnicity. Discussions were conducted in Swahili, lasted for 1–2 hours and were audio-recorded. Analysis of the interviews was done concurrently with the data collection process. All interviews and FGDs were transcribed verbatim, and translated from Swahili to English by a linguistic teacher with the first author doing the final editing and ensuring accurate translation. The English transcripts were used for analysis, and the original transcripts were crosschecked to ensure a correct interpretation throughout the process. The analysis was guided by a thematic analysis approach [28]. All transcripts were carefully read sentence by sentence to obtain a sense of the content as narrated by informants. Phrases and sentences related to experiences and perspectives related to institutional maternal care were coded in the margin of the transcript sheets by the first author, and codes with similar content were brought together into themes (see example, Table 2). Several rounds of coding and discussions among the co-authors were necessary for content validity [29]. To ensure confirmability, all the co-authors reflected, discussed differences in interpretation of data, and agreed on the categorisation [30]. An initial attempt to codify “missing attention, care, and support” theme from accounts of health care users, by means of inductive thematic Ethical clearance was obtained from the Muhimbili University of Health and Allied Health Sciences (MUHAS) Research and Ethical Review Board. Permission to conduct the study was thereafter obtained from CCBRT hospital and the Municipal director, Temeke municipality; Dar es Salaam. All informants provided written consent after discussing the purpose of the study and issues of confidentiality.
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