The use of antenatal and postnatal care: Perspectives and experiences of women and health care providers in rural southern Tanzania

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Study Justification:
– Antenatal care coverage in Tanzania is high, but there are gaps in terms of quality and ability to prevent, diagnose, or treat complications.
– Utilization of postnatal care is not well understood.
– This study aims to explore the perspectives and experiences of women and healthcare providers regarding antenatal and postnatal care.
Highlights:
– Women generally have positive views about antenatal and postnatal care.
– Late initiation of antenatal care is often due to concerns about multiple clinic visits, fear of encountering wild animals, and lack of money.
– Fear of caesarean section hinders intrapartum care-seeking from hospitals.
– Postnatal care for mothers is lacking, and there are shortages of staff, equipment, and supplies.
Recommendations:
– Improve geographical and economic access to antenatal and postnatal care.
– Make services more culturally sensitive.
– Encourage women to deliver with a skilled attendant.
– Address staff shortages through training opportunities and incentives.
– Develop postnatal care guidelines.
Key Role Players:
– Health care providers
– Village based informants
– Women and mothers
– Policy makers
– Community leaders
Cost Items for Planning Recommendations:
– Training programs for healthcare providers
– Incentives for healthcare providers
– Development of postnatal care guidelines
– Equipment and supplies for healthcare facilities
– Outreach programs to improve geographical access
– Community education and awareness campaigns

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on in-depth interviews and focus group discussions conducted with health care providers and women in rural southern Tanzania. The study provides insights into the perspectives and experiences of women and health care providers regarding antenatal and postnatal care. However, the evidence is limited to a specific region and may not be generalizable to other settings. To improve the strength of the evidence, future studies could include a larger sample size and a more diverse population. Additionally, incorporating quantitative data could provide a more comprehensive understanding of the utilization of antenatal and postnatal care services.

Background: Although antenatal care coverage in Tanzania is high, worrying gaps exist in terms of its quality and ability to prevent, diagnose or treat complications. Moreover, much less is known about the utilisation of postnatal care, by which we mean the care of mother and baby that begins one hour after the delivery until six weeks after childbirth. We describe the perspectives and experiences of women and health care providers on the use of antenatal and postnatal services. Methods: From March 2007 to January 2008, we conducted in-depth interviews with health care providers and village based informants in 8 villages of Lindi Rural and Tandahimba districts in southern Tanzania. Eight focus group discussions were also conducted with women who had babies younger than one year and pregnant women. The discussion guide included information about timing of antenatal and postnatal services, perceptions of the rationale and importance of antenatal and postnatal care, barriers to utilisation and suggestions for improvement. Results: Women were generally positive about both antenatal and postnatal care. Among common reasons mentioned for late initiation of antenatal care was to avoid having to make several visits to the clinic. Other concerns included fear of encountering wild animals on the way to the clinic as well as lack of money. Fear of caesarean section was reported as a factor hindering intrapartum care-seeking from hospitals. Despite the perceived benefits of postnatal care for children, there was a total lack of postnatal care for the mothers. Shortages of staff, equipment and supplies were common complaints in the community. Conclusion: Efforts to improve antenatal and postnatal care should focus on addressing geographical and economic access while striving to make services more culturally sensitive. Antenatal and postnatal care can offer important opportunities for linking the health system and the community by encouraging women to deliver with a skilled attendant. Addressing staff shortages through expanding training opportunities and incentives to health care providers and developing postnatal care guidelines are key steps to improve maternal and newborn health. © 2009 Mrisho et al; licensee BioMed Central Ltd.

The study was conducted in Lindi Rural and Tandahimba Districts in southern Tanzania, a study area that has been described in detail elsewhere ([30,31]). In brief, these areas have a total population of about 300,000 people [32]. Lindi Rural has highland areas as well as low-lying plains with major permanent rivers (Lukuledi, Matandu and Mavuji). There are two main rainy seasons, November to December and February to May. The area has a wide mix of ethnic groups, most common being Yao, Makonde, Mwera and Matumbi. These groups frequently intermarry and are predominantly Muslim. Health services are delivered by the public health system. These consist of a network of dispensaries, health centers and hospitals that offer varying quality of care. There are also a few private not-for-profit dispensaries and hospitals run by Christian mission organisations. Three-quarters of the population live within about 5 km of their nearest facility [29]. Routine immunisation is the basis of the EPI activities. On a regular basis vaccines for measles, diphtheria, pertussis, tetanus, polio and tuberculosis, are provided in health facilities all over the country. Vaccinations are given in static, out-reach, and mobile health facilities. The immunisation schedule including the above vaccines stretches over the child’s first year and tetanus vaccination is given to women of childbearing age [33]. In Lindi and Mtwara regions, the proportion of heads of household and women of reproductive age (15–49 years) with no education was 35% and 27% respectively. Thirty-eight percent of a representative sample of 19,007 women aged 15–49 years interviewed in July and August 2004 had experienced the loss of at least one child [29]. Data was collected within a framework of ethnographic fieldwork for a larger project assessing community acceptability of intermittent preventive treatment for malaria in infants during March and April 2007. Follow-up data collection was carried out during January 2008. Using a network of female village based informants (VBI) in 8 villages of Lindi Rural and Tandahimba districts ([30,31]), we conducted a series of in-depth interviews (N = 16; N = 8 with VBI, N = 8 with health care providers (HCP)) and focus group discussions (FGD; N = 8). Each FGD was conducted in groups of 6 to 8 women with babies aged less than one year of age as well as pregnant women with similar backgrounds and experiences [34]. In total, 74 respondents participated in FGD and in-depth interviews. Participants in FGDs included 58 women of whom, 39 had young child less than one year old and 19 were pregnant. Almost all women who participated in FGD and in-depth interviews were aged between 15–42 years and had completed primary school education. Both in-depth interviews and FGD were intended to gather information about the timing and perceived reasons for ANC and PNC; services available in ANC and PNC; perceptions about the importance of ANC and PNC; home births and barriers to ANC and PNC; and lastly, suggestions on how to improve ANC and PNC (see Table ​Table2).2). The FGD generally took place at the VBI’s home. Before the FGD, the moderator introduced all participants, explained the general topics of discussion and encouraged all participants to contribute their ideas. An experienced moderator led the discussions with support from a note-taker, with both taking notes. The FGDs were recorded using an MP3 voice recorder. After the FGD, the note-taker and the moderator reviewed their handwritten notes. After revision of notes, the transcripts were typed and exported to NVivo 2 [35] qualitative data analysis software. Data analysis compared responses from both the in-depth interviews and FGDs. We triangulated responses from in-depth interviews with VBIs and HCPs as well as FGDs with mothers of infants and pregnant women. We found that the responses were in accordance with each other for most of the results. The only exception to this was for barriers to births and suggestions for improvement of ANC and PNC services. For these results we have shown the differences among the sources. Our major key themes emerged as a result of the interview guide (shown in Table ​Table22 below) and the coded transcripts from the FGDs and in-depth interview. Questions included in the topic guide used during FGDs and in-depth interviews We obtained informed consent verbally at the start of each interview or FGD. Most health care providers were not willing to be recorded, but gave their consent to be interviewed. Interviews with health care providers were done at their workplace and at a time that was convenient for them, particularly when there were few or no clients. In these cases, the analysis was done from written notes. Confidentiality of all study participants was assured and village names have been encoded in this manuscript. We chose a qualitative approach in order to improve our understanding of community views and perceptions regarding ANC and PNC services. The study was undertaken within the framework of the assessment of the community effectiveness of Intermittent Preventive Treatment for malaria in infants (IPTi). We received ethical approval from the local and national institutional review boards (Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee) through the Tanzania Commission for Science and Technology. In addition ethical and research clearance was also obtained from institutional review board of the London School of Hygiene and Tropical Medicine, UK, and Ethics Commission of the Cantons of Basel-Stadt and Basel-Land, Switzerland.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile clinics: Implementing mobile clinics that can travel to remote areas and provide antenatal and postnatal care services. This would address the geographical barriers faced by women in accessing healthcare.

2. Telemedicine: Introducing telemedicine services that allow women to consult with healthcare providers remotely. This would help overcome the lack of healthcare facilities in certain areas and improve access to antenatal and postnatal care.

3. Community health workers: Training and deploying community health workers who can provide basic antenatal and postnatal care services in rural areas. This would increase the availability of healthcare providers and reduce the need for women to travel long distances to access care.

4. Financial incentives: Introducing financial incentives for women to seek antenatal and postnatal care. This could include providing transportation allowances or cash transfers to cover the costs associated with accessing healthcare.

5. Awareness campaigns: Conducting awareness campaigns to educate women and their families about the importance of antenatal and postnatal care. This would help address cultural barriers and misconceptions that may prevent women from seeking care.

6. Improving healthcare infrastructure: Investing in improving healthcare infrastructure, including the construction and renovation of healthcare facilities in underserved areas. This would ensure that women have access to quality antenatal and postnatal care services.

7. Strengthening supply chains: Addressing shortages of staff, equipment, and supplies by strengthening supply chains. This would ensure that healthcare facilities have the necessary resources to provide antenatal and postnatal care.

These are just a few potential innovations that could be considered to improve access to maternal health based on the information provided. Each innovation would need to be carefully evaluated and tailored to the specific context and needs of the communities in Lindi Rural and Tandahimba Districts in southern Tanzania.
AI Innovations Description
Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve the quality and availability of antenatal and postnatal care: Address the gaps in the quality of care provided during antenatal and postnatal visits. This can be done by ensuring that healthcare providers are adequately trained and equipped to provide comprehensive care to pregnant women and new mothers. Additionally, efforts should be made to increase the availability of antenatal and postnatal services in rural areas, where access to healthcare facilities may be limited.

2. Address barriers to utilization of antenatal and postnatal care: Identify and address the barriers that prevent women from seeking antenatal and postnatal care. This may include addressing concerns about multiple clinic visits, fear of encountering wild animals on the way to the clinic, and lack of financial resources. Strategies such as mobile clinics or outreach programs can be implemented to bring healthcare services closer to the communities, making it easier for women to access care.

3. Promote culturally sensitive care: Recognize and respect the cultural beliefs and practices of the community when providing antenatal and postnatal care. This can be achieved by training healthcare providers to be culturally sensitive and by involving community members in the planning and implementation of maternal health programs. By incorporating local customs and traditions into the care provided, women may feel more comfortable and more likely to seek care.

4. Address staff shortages: Take steps to address the shortage of healthcare providers in rural areas. This may involve expanding training opportunities for healthcare professionals, providing incentives to attract and retain healthcare providers in rural areas, and improving working conditions in healthcare facilities. By ensuring an adequate number of skilled healthcare providers, the quality and availability of antenatal and postnatal care can be improved.

5. Develop guidelines for postnatal care: Establish clear guidelines for postnatal care to ensure that mothers receive the necessary care and support after childbirth. These guidelines should outline the recommended frequency and content of postnatal visits, as well as the roles and responsibilities of healthcare providers in providing postnatal care. By standardizing postnatal care practices, the quality and consistency of care can be improved.

Overall, the recommendation is to focus on improving the quality and availability of antenatal and postnatal care, addressing barriers to utilization, promoting culturally sensitive care, addressing staff shortages, and developing guidelines for postnatal care. By implementing these recommendations, access to maternal health can be improved, leading to better health outcomes for both mothers and babies.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Improve transportation: Address the fear of encountering wild animals on the way to the clinic by implementing safe and reliable transportation options for pregnant women in rural areas.

2. Increase clinic availability: Address the concern of having to make several visits to the clinic by increasing the number of clinics and extending their operating hours. This will make it more convenient for women to access antenatal and postnatal care.

3. Financial support: Address the lack of money as a barrier to accessing care by providing financial support or subsidies for antenatal and postnatal services. This can help alleviate the financial burden on women and encourage them to seek care.

4. Staffing and resource allocation: Address shortages of staff, equipment, and supplies by investing in training opportunities for healthcare providers and ensuring that clinics are adequately staffed and equipped. This will improve the quality of care and increase the availability of services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the number of women receiving antenatal and postnatal care, the distance to the nearest clinic, or the percentage of women who face financial barriers.

2. Collect baseline data: Gather data on the current state of access to maternal health in the study area. This can be done through surveys, interviews, or existing data sources.

3. Model the impact: Use mathematical or statistical models to simulate the impact of the recommendations on the identified indicators. This can involve estimating the potential increase in the number of women accessing care, the reduction in travel distance, or the decrease in financial barriers.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the results. This involves testing the impact of different assumptions or scenarios on the outcomes to understand the range of potential impacts.

5. Interpret and communicate the results: Analyze the simulated results and interpret the findings. Communicate the potential impact of the recommendations to stakeholders, policymakers, and healthcare providers to inform decision-making and prioritize interventions.

6. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations to assess their effectiveness and make adjustments as needed. This can involve collecting data on the indicators identified in step 1 and comparing them to the baseline data to measure progress.

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