Women’s perceptions of antenatal, delivery, and postpartum services in rural Tanzania

Global Health Action, Volume 8, No. 1, Year 2015

Interpretation

Background: Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women’s views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. Design: We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. Results: ‘Three categories emerged that reflected women’s perceptions of maternal health care services: “mothers perceive that maternal health services are beneficial,” “barriers to accessing maternal health services” such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and “ambivalence regarding the quality of maternal health services” reflecting that women had both positive and negative perceptions in relation to quality of health care services offered’. Conclusions: Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals’ attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women. The study was conducted in Kongwa district, one of the five districts in the Dodoma region. The district has a population of 248,656 (23), 90% living in rural parts of the district. It is an agricultural district where people mainly engage in cultivation, livestock keeping, and trade (23). The region was purposely selected because of its rural characteristics. The study is part of a larger ongoing research project on health systems in the Dodoma region. The area has a poor transport network which presents difficulties for women from rural and remote parts of the district seeking health care services. There are in total 46 health facilities in Kongwa district: one district hospital, four health centres, and 41 dispensaries. At the dispensary level, they offer Antenatal Care services where immunisations and PMTCT services are included, and they assist normal deliveries; when they are faced with obstetric complications, they refer the mother to the higher level. They also offer postnatal check-ups that include contraceptive provision and detection of complications. At the health centre level, they offer basic emergency obstetric care services. At the district hospital, they offer comprehensive emergency obstetric care (EOC). Nearby the district hospital, there is also a maternity waiting home (Chigonela). In the Dodoma region, 97.8% of pregnant women receive at least one antenatal check-up. The WHO recommends four antenatal care visits (24). There are no disaggregated data by regions showing women utilisation of ANC services per number of visits. At the national level, 3.8% of rural women receive only one visit, 54.5% receive 2–3 visits, and 39.5% receive 4 or more visits. Institutional delivery is estimated to be 45.9%, and only 33.8% of mothers receive postnatal check-ups (15). A number of interventions were reported to be implemented in the district to improve maternal health, such as 1) training service providers in EMOC; 2) introducing a waiting maternity home (Chigonela) to the district hospital, where women who live far away or have complicated pregnancies can stay until delivery; 3) equipping facilities with help from non-governmental organisations (NGOs); 4) motivating TBAs by paying them to bring mothers to give birth at the facilities (currently stopped due to unavailability of funds from the government); and 5) implementing community sensitisation to delivery in health facilities. A study conducted in Kongwa by Mahiti et al. (25) revealed that women were attended after child birth by TBAs who performed certain rituals (bathing, cooking, etc.) that were appreciated by the women. In that study, TBAs also reported that they lacked training in postpartum care and the links between them and formal health care facilities were perceived to be poor (25). Fifteen focus group discussions (FGDs) were conducted between April and August 2012, involving a total of 105 women after child birth, at Kongwa District Hospital and Ugogoni Health Centre. These facilities were purposively selected to include both a larger hospital and a smaller health centre. Women were recruited when they came to vaccinate their children; since vaccination coverage is quite high in the area we expected that women coming to vaccinate their children encompass a diversity in terms of educational level, age, and other characteristics. The participants were aged between 14 and 45 years. The majority of women had no formal education (43%) and most were engaged in farming activities (91%). FGD guides were prepared in English and later translated into Kiswahili, the mother tongue of the participants and the moderator of the FGD. The guide was composed of broad themes including the participants’ perceptions of the health facility services offered for pregnancy, child birth, and postpartum care; their experiences of consultations at health facilities during pregnancy, delivery, and postpartum; and their interactions with health care providers. Five FGDs were conducted in the under-five monitoring rooms and the remaining nine groups were conducted outside the health facility, under the trees. Participants themselves chose the place for the discussions. Verbal consent was obtained from all the women before starting the FGDs; all the women approached were informed of the aim of the project, and the researcher read the consent form to them and they were informed that their participation was voluntary. The researcher asked the participants not to disclose any personal issues that they were not comfortable sharing with the group; also the participants were not to disclose issues that were discussed outside the group. Participants were free to withdraw from the study at any point, and could refuse to answer any question they felt uncomfortable sharing with the group. Their consent to participation in the FGDs was recorded and was part of the transcripts. At the start of each FGD, the participants also agreed on a suitable place to conduct the FGDs. The FGDs lasted between 50 and 60 min and were audio-recorded. The first author moderated the discussion, and an assistant took notes and managed the recording equipment. The groups’ size ranged from 6 to 10 women. After the 15th group, it was felt that saturation point had been reached – that is, no new information was emerging to answer our research questions (26). Based on continuous reflections and preliminary analysis shared within the research team, we finished data collection at that point. Non-participant observation was also used, where the researcher observed waiting times, postpartum mothers’ interactions with service providers, and the environment at the health facilities: amenities, cleanliness, and bedding. The observation took 30–60 min, and it was conducted before or after the FDGs. The researcher did not observe clinical procedures, that is, observing women giving birth, check-ups at antenatal clinics, and postpartum check-ups, to respect the privacy of the mothers in the health workers’ rooms. The observations were recorded in a field book for proper analysis in order to triangulate the information obtained from the FGDs. All data from the FGDs on the women’s perceptions, after child birth, of the maternal health services offered to them were transcribed verbatim and later translated into English to facilitate analysis by the research group. We did not consider segregation of participants based on characteristics such as educated and non-educated, or employment, since the majority of women in this setting have incomplete primary education and work at home and in subsistence agriculture; therefore, it would have been logistically complicated to identify and enroll a sufficient number of women with secondary or high education or working in other occupations. Qualitative content analysis was used to analyse the data, as described by Graneheim and Lundman (27). The FGDs were read several times to obtain a sense of the whole. The texts containing information on antenatal, delivery, and postpartum care were selected into ‘meaning units’. A process of condensation then identified condensed meaning units from the original meaning units. The condensed meaning units were then abstracted and labelled with codes using the Open Code software programme (28). The codes were later grouped into categories reflecting the manifest content of the text (see Table 2). Example of process of analysis Several criteria are used in evaluating trustworthiness: credibility, transferability, dependability, and confirmability (27, 29). In this study credibility – that is, how well the data addressed the intended focus – was covered in several ways. The use of purposive sampling enabled the selection of participants who fulfilled the criteria for participation. Confidentiality was encouraged and the participants agreed not to share the discussion outside the group. This increased the credibility of the information produced. The involvement of more than one researcher in the process enhanced dependability by ensuring that the interpretations emerged in data through researchers’ triangulation. In addition, the first author, a native speaker with expertise in rural development, collected data. The description of the study context, selection criteria, and data collection and analysis process was complemented with quotes to allow readers to assess the transferability of the findings. All the FGDs followed an FGD guide and allowed openness to new insights through open-ended questions. New issues that emerged were considered in subsequent data collection and the analysis process followed an emergent design that enhanced dependability. The translation of FGD guides from English to Kiswahili was intended to increase the free expression of participants, as the participants were more conversant in Kiswahili than in English. Before administering the instruments, there was back-translation from Kiswahili to English in order to check the accuracy of translation and to meet the criterion of confirmability. The necessary ethical approval for conducting this study was granted from the Senate Research and Publication Committee, Muhimbili University of Health and Allied Sciences. Further, permission to conduct the study was obtained from the Kongwa district executive director and district medical officer. Informed consent was obtained from each potential participant. The discussions were anonymous because despite being reproduced in the paper the identities of the participants are protected.

AI Digest

Study Justification:

– Maternal health care provision is a major challenge in developing countries.
– Quality clinical services are essential to reduce maternal death rates.
– Despite efforts to improve access, many women in Tanzania do not access maternal health services.
– This study aims to explore women’s views on the maternal health services they received in rural Tanzania to identify gaps in service provision.

Highlights:

– Women perceive maternal health services as beneficial during pregnancy and delivery.
– Awareness of postpartum complications and the role of medical services is poor.
– Women have ambivalent perceptions of the quality of health care services offered.
– Barriers to accessing maternal health care services include cost of transport and use of traditional birth attendants.
– Improvements should address accessibility of services, professionals’ attitudes, and promotion of postpartum check-ups.

Recommendations:

– Improve accessibility of maternal health care services.
– Address professionals’ attitudes towards maternal health care.
– Promote the importance of postpartum check-ups among health care professionals and women.

Key Role Players:

– Health care professionals
– Traditional birth attendants
– Non-governmental organizations
– Government officials
– Community leaders

Cost Items for Planning Recommendations:

– Training service providers in emergency obstetric care
– Equipping health facilities with necessary resources
– Motivating traditional birth attendants to bring mothers to health facilities
– Implementing community sensitization programs
– Improving transport network for better access to health care services

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on qualitative data from focus group discussions, which provides valuable insights into women’s perceptions of maternal health services. However, the study does not provide information on the representativeness of the sample or the specific methodology used for data analysis. To improve the strength of the evidence, the study could include a larger and more diverse sample of women, provide more details on the data analysis process, and consider triangulating the findings with quantitative data.

Abstract

The study was conducted in Kongwa district, one of the five districts in the Dodoma region. The district has a population of 248,656 (23), 90% living in rural parts of the district. It is an agricultural district where people mainly engage in cultivation, livestock keeping, and trade (23). The region was purposely selected because of its rural characteristics. The study is part of a larger ongoing research project on health systems in the Dodoma region. The area has a poor transport network which presents difficulties for women from rural and remote parts of the district seeking health care services. There are in total 46 health facilities in Kongwa district: one district hospital, four health centres, and 41 dispensaries. At the dispensary level, they offer Antenatal Care services where immunisations and PMTCT services are included, and they assist normal deliveries; when they are faced with obstetric complications, they refer the mother to the higher level. They also offer postnatal check-ups that include contraceptive provision and detection of complications. At the health centre level, they offer basic emergency obstetric care services. At the district hospital, they offer comprehensive emergency obstetric care (EOC). Nearby the district hospital, there is also a maternity waiting home (Chigonela). In the Dodoma region, 97.8% of pregnant women receive at least one antenatal check-up. The WHO recommends four antenatal care visits (24). There are no disaggregated data by regions showing women utilisation of ANC services per number of visits. At the national level, 3.8% of rural women receive only one visit, 54.5% receive 2–3 visits, and 39.5% receive 4 or more visits. Institutional delivery is estimated to be 45.9%, and only 33.8% of mothers receive postnatal check-ups (15). A number of interventions were reported to be implemented in the district to improve maternal health, such as 1) training service providers in EMOC; 2) introducing a waiting maternity home (Chigonela) to the district hospital, where women who live far away or have complicated pregnancies can stay until delivery; 3) equipping facilities with help from non-governmental organisations (NGOs); 4) motivating TBAs by paying them to bring mothers to give birth at the facilities (currently stopped due to unavailability of funds from the government); and 5) implementing community sensitisation to delivery in health facilities. A study conducted in Kongwa by Mahiti et al. (25) revealed that women were attended after child birth by TBAs who performed certain rituals (bathing, cooking, etc.) that were appreciated by the women. In that study, TBAs also reported that they lacked training in postpartum care and the links between them and formal health care facilities were perceived to be poor (25). Fifteen focus group discussions (FGDs) were conducted between April and August 2012, involving a total of 105 women after child birth, at Kongwa District Hospital and Ugogoni Health Centre. These facilities were purposively selected to include both a larger hospital and a smaller health centre. Women were recruited when they came to vaccinate their children; since vaccination coverage is quite high in the area we expected that women coming to vaccinate their children encompass a diversity in terms of educational level, age, and other characteristics. The participants were aged between 14 and 45 years. The majority of women had no formal education (43%) and most were engaged in farming activities (91%). FGD guides were prepared in English and later translated into Kiswahili, the mother tongue of the participants and the moderator of the FGD. The guide was composed of broad themes including the participants’ perceptions of the health facility services offered for pregnancy, child birth, and postpartum care; their experiences of consultations at health facilities during pregnancy, delivery, and postpartum; and their interactions with health care providers. Five FGDs were conducted in the under-five monitoring rooms and the remaining nine groups were conducted outside the health facility, under the trees. Participants themselves chose the place for the discussions. Verbal consent was obtained from all the women before starting the FGDs; all the women approached were informed of the aim of the project, and the researcher read the consent form to them and they were informed that their participation was voluntary. The researcher asked the participants not to disclose any personal issues that they were not comfortable sharing with the group; also the participants were not to disclose issues that were discussed outside the group. Participants were free to withdraw from the study at any point, and could refuse to answer any question they felt uncomfortable sharing with the group. Their consent to participation in the FGDs was recorded and was part of the transcripts. At the start of each FGD, the participants also agreed on a suitable place to conduct the FGDs. The FGDs lasted between 50 and 60 min and were audio-recorded. The first author moderated the discussion, and an assistant took notes and managed the recording equipment. The groups’ size ranged from 6 to 10 women. After the 15th group, it was felt that saturation point had been reached – that is, no new information was emerging to answer our research questions (26). Based on continuous reflections and preliminary analysis shared within the research team, we finished data collection at that point. Non-participant observation was also used, where the researcher observed waiting times, postpartum mothers’ interactions with service providers, and the environment at the health facilities: amenities, cleanliness, and bedding. The observation took 30–60 min, and it was conducted before or after the FDGs. The researcher did not observe clinical procedures, that is, observing women giving birth, check-ups at antenatal clinics, and postpartum check-ups, to respect the privacy of the mothers in the health workers’ rooms. The observations were recorded in a field book for proper analysis in order to triangulate the information obtained from the FGDs. All data from the FGDs on the women’s perceptions, after child birth, of the maternal health services offered to them were transcribed verbatim and later translated into English to facilitate analysis by the research group. We did not consider segregation of participants based on characteristics such as educated and non-educated, or employment, since the majority of women in this setting have incomplete primary education and work at home and in subsistence agriculture; therefore, it would have been logistically complicated to identify and enroll a sufficient number of women with secondary or high education or working in other occupations. Qualitative content analysis was used to analyse the data, as described by Graneheim and Lundman (27). The FGDs were read several times to obtain a sense of the whole. The texts containing information on antenatal, delivery, and postpartum care were selected into ‘meaning units’. A process of condensation then identified condensed meaning units from the original meaning units. The condensed meaning units were then abstracted and labelled with codes using the Open Code software programme (28). The codes were later grouped into categories reflecting the manifest content of the text (see Table 2). Example of process of analysis Several criteria are used in evaluating trustworthiness: credibility, transferability, dependability, and confirmability (27, 29). In this study credibility – that is, how well the data addressed the intended focus – was covered in several ways. The use of purposive sampling enabled the selection of participants who fulfilled the criteria for participation. Confidentiality was encouraged and the participants agreed not to share the discussion outside the group. This increased the credibility of the information produced. The involvement of more than one researcher in the process enhanced dependability by ensuring that the interpretations emerged in data through researchers’ triangulation. In addition, the first author, a native speaker with expertise in rural development, collected data. The description of the study context, selection criteria, and data collection and analysis process was complemented with quotes to allow readers to assess the transferability of the findings. All the FGDs followed an FGD guide and allowed openness to new insights through open-ended questions. New issues that emerged were considered in subsequent data collection and the analysis process followed an emergent design that enhanced dependability. The translation of FGD guides from English to Kiswahili was intended to increase the free expression of participants, as the participants were more conversant in Kiswahili than in English. Before administering the instruments, there was back-translation from Kiswahili to English in order to check the accuracy of translation and to meet the criterion of confirmability. The necessary ethical approval for conducting this study was granted from the Senate Research and Publication Committee, Muhimbili University of Health and Allied Sciences. Further, permission to conduct the study was obtained from the Kongwa district executive director and district medical officer. Informed consent was obtained from each potential participant. The discussions were anonymous because despite being reproduced in the paper the identities of the participants are protected.

Materials

N/A

Innovations

Based on the findings of the study, here are some innovations that can be developed to improve access to maternal health:

1. Strengthening the referral system: Develop a mobile application or SMS-based system that allows health workers at lower-level facilities to easily refer pregnant women to higher-level facilities in case of complications. This can improve communication and ensure timely transfer of patients.

2. Enhancing community sensitization: Create a mobile app or online platform that provides information on the importance of maternal health services and allows women to easily access educational materials and resources. This can help raise awareness and empower women to make informed decisions about their healthcare.

3. Improving availability and accessibility of services: Develop a telemedicine program that allows women in remote areas to consult with healthcare professionals through video calls or phone consultations. This can help bridge the gap between rural communities and healthcare facilities, ensuring that women receive timely and appropriate care.

4. Addressing financial barriers: Implement a mobile banking system that allows women to save money specifically for maternal health expenses. This can help them overcome financial barriers by providing a convenient and secure way to save and access funds when needed.

5. Strengthening the role of traditional birth attendants (TBAs): Develop a training program for TBAs that includes modules on postpartum care and the importance of seeking medical help in case of complications. This can help improve the knowledge and skills of TBAs and ensure that they are able to provide safe and appropriate care to women in their communities.

These innovations should be implemented in collaboration with local stakeholders and continuously evaluated to ensure their effectiveness and sustainability.

AI Innovations Description

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

1. Strengthening the referral system: Develop a comprehensive and efficient referral system that ensures timely and appropriate transfer of pregnant women from lower-level health facilities to higher-level facilities in case of obstetric complications. This can include improving communication channels, providing training to health workers on recognizing and managing complications, and ensuring availability of transportation for emergency referrals.

2. Enhancing community sensitization: Implement community-based awareness campaigns to educate women and their families about the importance of accessing maternal health services, including antenatal care, delivery in health facilities, and postpartum check-ups. This can be done through community meetings, radio programs, and the use of local influencers to disseminate information.

3. Improving availability and accessibility of services: Increase the number of health facilities in rural areas and ensure they are adequately staffed and equipped to provide quality maternal health services. This can involve recruiting and training more healthcare professionals, providing necessary medical supplies and equipment, and addressing infrastructure challenges such as poor transport networks.

4. Addressing financial barriers: Develop innovative financing mechanisms, such as community-based health insurance schemes or conditional cash transfer programs, to reduce the financial burden on women seeking maternal health services. This can help overcome barriers related to the cost of transportation, user fees, and other out-of-pocket expenses.

5. Strengthening the role of traditional birth attendants (TBAs): Collaborate with TBAs and provide them with training and support to ensure they are equipped with the necessary knowledge and skills to provide safe and appropriate care during pregnancy, delivery, and the postpartum period. This can help bridge the gap between traditional and formal healthcare systems and improve access to maternal health services in remote areas.

It is important to note that these recommendations should be tailored to the specific context and needs of the community. Continuous monitoring and evaluation of the implemented interventions are essential to assess their effectiveness and make necessary adjustments for sustained improvement in access to maternal health.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a mixed-methods approach can be used. Here is a suggested methodology:

1. Quantitative data collection: Conduct a survey among women in the Kongwa district to gather quantitative data on their access to maternal health services. The survey should include questions on the number of antenatal care visits, place of delivery, postnatal check-ups, and barriers faced in accessing these services. This data will provide baseline information on the current state of access to maternal health services in the district.

2. Qualitative data collection: Conduct focus group discussions with women in the Kongwa district to gather qualitative data on their perceptions and experiences of maternal health services. The discussions should explore their views on the barriers they face in accessing these services and their opinions on the proposed recommendations. This data will provide insights into the factors influencing access to maternal health services and the potential impact of the recommendations.

3. Data analysis: Analyze the quantitative data using statistical methods to determine the current levels of access to maternal health services in the district. Calculate indicators such as the percentage of women receiving the recommended number of antenatal care visits, the percentage of institutional deliveries, and the percentage of women receiving postnatal check-ups. Analyze the qualitative data using thematic analysis to identify common themes and patterns related to access to maternal health services and the potential impact of the recommendations.

4. Simulate the impact: Use the quantitative and qualitative findings to simulate the potential impact of the recommendations on improving access to maternal health services. This can be done by comparing the current levels of access with the projected levels of access if the recommendations are implemented. Calculate indicators such as the expected increase in the percentage of women receiving the recommended number of antenatal care visits, the expected increase in institutional deliveries, and the expected increase in the percentage of women receiving postnatal check-ups.

5. Sensitivity analysis: Conduct a sensitivity analysis to assess the robustness of the findings. This can involve varying the assumptions used in the simulation, such as the effectiveness of the interventions or the coverage of the interventions, to see how sensitive the results are to these changes.

6. Policy implications: Based on the simulated impact, provide recommendations for policy and programmatic interventions to improve access to maternal health services in the Kongwa district. These recommendations should be informed by the findings of the study and take into account the specific context and needs of the community.

By following this methodology, researchers can gain insights into the potential impact of the recommendations on improving access to maternal health services in the Kongwa district. This information can inform decision-making and guide the development of interventions to address the identified barriers and improve maternal health outcomes.

Author

Dima Health

Statistics:

Citations: 47

Identifiers:

DOI: 10.3402/gha.v8.28567

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Tanzania

Study Design:

Cross Sectional Study, Ethnographic Study, Grounded Theory, Phenomenological Study

Study Approach:

Mixed-methods, Qualitative

Participants Gender:

Female