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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.
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