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Background: The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers’ performance have not yet been fully understood. This paper uses ethnographic methods to document health workers’ antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers’ performance. Potential implications for improving antenatal care provision in Tanzania are discussed.Methods: Combining different qualitative techniques, we studied health workers’ antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers’ practices and contextual factors influencing antenatal care provision.Results: The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers’ practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or “street-level bureaucracy”.Conclusions: Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to the identification of informal practices resulting from individual coping strategies and “street-level bureaucracy” in order to tackle problems before they become part of the organizational culture. © 2011 Gross et al; licensee BioMed Central Ltd.
Data for this study were collected in health facilities during research visits of one week per facility in July 2008 and during short one-day follow-up visits in April 2009 in the Kilombero and Ulanga Districts, Morogoro Region in south-eastern Tanzania. The study area comprised the 25 villages of the ‘Health and Demographic Surveillance System’ that has been described extensively by other authors [31-34]. The Tanzanian public health system consists of a dense network of dispensaries, health centres and hospitals. At the time of the study, two public health centres and ten dispensaries (7 public and 3 private not-for-profit) provided Reproductive-and-Child-Health (RCH) care services in the research area on a weekly or daily basis from Monday to Friday. Two district hospitals served as referral hospitals. The local health system runs a cost-sharing scheme from which pregnant women and children under five years of age are exempted. Four public health facilities were selected in the study area: both of the health centres (HC) and one selected dispensary (D) from each district. The selection of the dispensaries was based on the criteria of 1) daily RCH service provision and 2) high numbers of pregnant women attending the RCH clinic based on patient registers. The present study used qualitative methodology including 4 elements: 1) participant observation of daily RCH clinic procedures, 2) structured observation of ANC consultations, 3) informal conversations with pregnant women and health workers and 4) in-depth interviews with the five health workers available at the RCH clinics at the time of the study. Data collection was carried out in Swahili at each health facility over a one-week period by one of the investigators (KG). She was supported by a research assistant who could help with nuances of the language. In the four health facilities, 39 ANC consultations were selected for observation by convenience sampling. ANC consultations were spread over the whole week and included consultations of women attending for the first time as well as return visits. The number of observed consultations per health worker ranged from 3 to 21, depending on the number of women attending per facility. Three women were excluded from the sample since they did not receive any services, and thus their consultations could not be observed. Two of them attended on the “wrong” day and one woman came with an early pregnancy that could not be confirmed. The three women were sent home and told to come again another day. This led to a final sample of 36 observed ANC consultations. Structured observation was used to record services delivered during the ANC consultations. A checklist including 41 recommended services was developed on the basis of the Tanzanian FANC guidelines [11]. Three services delivered at the laboratory facilities were later excluded because they could not be directly observed. This led to a final list of 38 recommended services on which data were collected (see Figure Figure11). Proportion of pregnant women receiving each of the 38 services recommended by the guidelines. Because of the health workers’ high work load, the participant observers became involved in administrative work and registering clients. Informal conversations with the health workers during and after work helped to understand clinic procedures and to clarify questions that had arisen during the observations. Notes were taken during the observations and conversations and were elaborated the same day in descriptive field notes [35] in collaboration with the research assistant. Towards the end of the week, in-depth interviews were conducted with the five health workers who had been present at the time of the study. The interview guidelines explored contextual factors influencing health workers’ ANC practices such as health workers’ training and position, their perceived work problems, work expectations and interaction with their patients, colleagues and supervisors. All in-depth interviews were tape-recorded with health workers’ permission. The in-depth interviews were transcribed and translated into English by two research assistants fluent in English and Swahili. One of us (KG) reviewed the transcripts and original recordings and discussed ambiguities with the research assistants. For data analysis, data from the structured observation of 36 ANC consultations were compared with the FANC guidelines [11] and the ANC card. For each of the 38 services it was determined whether according to the FANC guidelines the women should have received the specific service considering her gestational age and/or number of ANC visits. This was then compared with the structured observations of ANC consultations. Data from the in-depth interviews, the participant observations and informal conversations were used to contextualize and validate the findings from the structured observations. Data analysis was guided by a mix of inductive and deductive category building and was completed using MAXqda2 (VERBI Software, Marburg, Germany). In the in-depth interviews, the most prevalent themes raised by the health workers were coded into categories using qualitative content analysis [36] and tested in the further analysis of the interviews. The same categories were applied to the field notes of the observations and informal conversations in order to check their validity. Additionally, analysis of all data sources was guided by the researchers’ interest in how rules and regulations determine health workers’ practices. In order to explore differences in service delivery between and within health facilities, information on the identified themes was cross-tabulated for comparison between and within the health facilities. Questions arising during data analysis were addressed in follow-up and feedback visits at the four health facilities in April 2009. In conformity with the Helsinki Declaration, this study was discussed and approved by the district coordinators for Reproductive and Child Health (RCH) and staff in -charge were asked for permission to conduct the study at their facilities. Oral or written consent was obtained from all pregnant women and health workers participating in the study after explaining the purpose of the study to them and informing them of their right to withdraw at any time. The study received clearance from the Tanzanian National Institution for Medical Research as part of the ACCESS Programme (NIMR/HQ/R.8c/Vol. I/66). The study was also approved by the two review boards of the Swiss Tropical and Public Health Institute (STPH), formerly known as Swiss Tropical Institute (STI), and the Ifakara Health Institute (IHI), formerly known as Ifakara Health Research and Development Centre (IHRDC).
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