Background: In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania. Methods: A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required. Results: Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a “normal” process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery. Conclusion: Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.
The study was conducted in Geita, a rural district located in Northwest Tanzania. The district has a hospital, five health centers, and 38 health dispensaries. Pregnant women in their third trimester were recruited in 11 of 35 wards. Details on this sample and the recruitment process have been published previously [16]. Geita district is a primarily rural area located in the Lake Zone in Tanzania. The total fertility rate in the Lake Zone is high at 6.4 children per woman [4]. However, utilization of maternal health services is generally poor; modern contraceptive use (13%), health facilities for delivery (48%), postnatal care service utilization (14%). Eleven wards that were primarily rural were purposely selected for this study: Lwamgasa, Nyaruyeye, Bukoli, Nyarugusu, Nyakamwaga, Butundwe, Chigunga, Nyamiluluma, Bukondo, Nzera, and Lwenzera. This study used a qualitative case study approach to gain a deeper understanding of the issues related to low utilization of health facilities for childbirth [17]. This methodology was used to gain deeper understanding of home delivery as an event in these communities and to explore community processes, activities, and perceptions surrounding this event [17]. Data was collected from different sources; women who recently delivered at home or at a health facility, men whose wives had recently delivered at home or at a health facility, traditional birth attendants (TBAs), and community health workers (CHWs). This allowed us to capture contextual variability among various groups of individuals in the local community who had an important stake in obstetric and childbirth outcomes. Data collection approaches included focus group discussions (FGD) and key informant interviews (KII). The women were part of a large cohort study investigating maternal and child mortality and morbidity in relation to place of delivery [16]. Women were selected purposively based on the place of delivery and invited for interviews by CHWs. Convenience sampling was used to select the men who participated in the focus group discussions. All available CHWs from the study wards were invited to participate in FGDs. This method provided a dynamic environment to capture social interactions and the shared experiences of the women, men whose wives had recently delivered, and the CHWs [17]. Key informant interviews were conducted with TBAs who were considered knowledgeable with regard to issues related to home deliveries [17]. These FDGs and interviews provided us with the opportunity to better understanding the diversity of social and cultural meanings associated with childbirth within the same community and the influence that these had on whether or not women delivered at health facilities. Sixty-eight participants took part in the study; 33 women, 28 CHWs, five men and two TBAs. We conducted 11 FGDs over a 4-month period (Sept – Dec 2017): five with women, five with CHWs, and one with men who were husbands of women who recently delivered. Each FGD consisted of 5–7 participants and lasted between 60 and 90 min. Each person participated only once in a FGD. The TBAs participated in individual KIIs. All individuals approached agreed to participate except one TBA. To ensure a comfortable and non-threatening atmosphere, we conducted nine FGDs at primary schools, village offices or in open spaces. However, two FGDs were conducted within health facility premises, in separate rooms to ensure privacy and confidentiality. Health care providers were restricted from entering the rooms during the interviews and only research team members and participants were involved in the discussions. The individual interviews with the TBAs were conducted at their homes. Throughout the FGDs and KIIs, the presence of non-participants was strongly discouraged in order to promote free and open discussion. A pilot test was conducted to ensure that the semi-structured questionnaire that would be used to direct interviews was comprehensive and appropriate for the purpose of this study. This questionnaire was used to guide the discussions and interviews. To obtain a clearer understanding of participants’ experiences and views, follow up questions were included. FDGs and KIIs were conducted in Swahili, the first language of the participants. As the FGDs progressed, additional questions were included based on issues identified in previous FGDs in order to shed light on emerging themes. The research team who conducted the discussions and interviews consisted of two females (PI & a nurse) and two males (a nurse & intern doctor). The team members were not involved in providing health care services in the study area; however, their medical knowledge assisted in better understanding participants’ experiences and views. The FGDs and KIIs were recorded and field notes were written during the discussions. Reflections on the process, group interactions, and disagreements amongst group members were captured in the field notes. The field notes were used during interpretation of the study findings to facilitate understanding of the group dynamics and the local context of childbirth care. Data collection was suspended when saturation was achieved. Triangulation of different data sources and data collection approaches were used as strategies to maintain trustworthiness in this study [18, 19]. We involved women, men whose wives had recently delivered, CHWs, and TBAs who are involved during childbirth in the community. The use of these different data sources allowed us to gain deeper understanding of the general community perspective related to home delivery and also to validate the themes across our different participant groups. The use of FGDs and individual interviews complemented each other in terms of their individual strengths. Further, although the transcripts of the FGIs and KIIs were not returned to the participants, debriefing meetings with village leaders, health providers, and CHWs who did not participate in the FGDs were held to consolidate and validate the themes identified by the participants. Two research assistants who were fluent in Swahili and English transcribed and translated the FDGs and KIIs. The PI and a co-author reviewed the English versions of all of the transcripts for consistency. The PI randomly cross-checked six transcriptions with the original recordings for verification purposes. The qualitative data process was done using NVIVO 12 after manual familiarization of the data. Themes were derived from the data based on what participants said. Frameworks developed by Thaddeus and Maine related to decisions to seek care, access to care, and receive care, and Behruzi et al. on cultural issues associated with childbirth were used to facilitate the process of theme development [14, 20]. Using thematic analysis, initial coding was done to develop a general description of the themes present. Descriptions were used to guide the iterative approach to derive main themes, sub-themes, and sub sub-themes [21]. Table Table11 shows the general description of the coding process that was used to develop the themes during the analysis. In order to identify themes, the following six steps were undertaken in a systematic manner: 1) a verbatim transcription was made of the transcript, followed by familiarization of all records, 2) the transcription was carefully read line by line to apply the labels/codes, 3) main and sub themes were developed, 4) subsequent transcripts were indexed based on existing themes, 5) data was summarized by category and tagged to relevant quotations (i.e. charting), and 6) lastly, interpretation [21, 22]. Analytic framework for the description of the key themes
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