Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour

Supply-side factors influencing demand for facility-based delivery in Tanzania: a multilevel analysis

BACKGROUND

Improving access to facility-based delivery care has the potential to reduce maternal and newborn deaths across settings. Yet, the access to a health facility for childbirth remains low especially in low-income settings. To inform evidence-based interventions, more evidence is needed especially accounting for demand- and supply-side factors influencing access to facility-based delivery care. We aimed to fill this knowledge gap using data from Tanzania.

METHODS

We used data from a cross-sectional survey (conducted in January 2012) of 150 health facilities, 1494 patients and 2846 households with women who had given births in the last 12 months before the survey across 11 districts in three regions in Tanzania. The main outcome was the place of delivery (giving birth in a health facility or otherwise), while explanatory variables were measured at the individual woman and facility level. Given the hierarchical structure of the data and variance in demand across facilities, we used a multilevel mixed-effect logistic regression to explore the determinants of facility-based delivery care.

RESULTS

Eighty-six percent of 2846 women gave birth in a health facility. Demand for facility-based delivery care was influenced more by demand-side factors (76%) than supply-side factors (24%). On demand-side factors, facility births were more common among women who were educated, Muslim, wealthier, with their first childbirth, and those who had at least four antenatal care visits. On supply-side factors, facility births were more common in facilities offering outreach services, longer consultation times and higher interpersonal quality. In contrast, facilities with longer average waiting times, longer travel times and higher chances of charging delivery fees had few facility births.

CONCLUSIONS

Policy responses should aim for strategies to improve demand like health education to raise awareness towards care seeking among less educated groups and those with higher parity, reduce financial barriers to access (including time costs to reach and access care), and policy interventions to enhance interpersonal quality in service provision.

Understanding Healthcare-Seeking Pathways and Dilemmas Among Women with Obstetric Fistulas in Ethiopia: A Qualitative Inquiry

Background

Obstetric fistula is a public health problem with a damaging effect on the health of women around the world. The path to medical care is an integral part of women's experience of illness that may have an impact on their health. Studies have addressed the experiences of patients after fistula repair, but fistula victims' care-seeking pathways and dilemmas are still poorly understood in low-income countries, particularly Ethiopia.

Objective

This study aimed to explore the care-seeking pathways and dilemmas among women with fistulas in Ethiopia.

Methods

An exploratory phenomenological study was carried out from April 1 to August 1, 2019, through in-depth interviews and supplementary informant interviews. Data were obtained from 21 purposively selected women with fistulas who survived with morbidity for one and more years and 12 supplementary interviewees at fistula treatment centers in Oromia Region and Addis Ababa. Data were analyzed assisted by ATLAS. ti 8.4 software.

Results

Respondents gave their testimony that most of the women with fistulas first sought care from traditional care places and finally from fistula treatment centers. The reasons for care-seeking path dilemmas were a wrong perception about fistula, its causes, and treatment; families' pressure and lack of decision-making power on where to seek treatment, and a lack of knowledge on where modern treatments are available for fistula. They received psychological, companionship, and transport support from a family and a community; referral and counseling support from health care providers during their care-seeking pathways.

Conclusion

A myriad of reasons inhibits the right care-seeking pathways among women with fistulas. Communities and women with fistula awareness creation on the right places for fistula treatment and psychological support programs are required. Additionally, developing and implementing tactics for community-level screening programs for targeted victims and early admission to treatment centers can minimize the tragic sequela of the fistula.

The Predictors of Intent to Prevent Obstetric Fistula Recurrence Among Women with Fistula in Ethiopia: A Facility-Based Cross-Sectional Study

Background

Obstetric fistula recurrence predisposes to a decreasing success rate of fistula repair and accounts for the continued incidence of obstetric fistulas in low-income countries. Evidence has revealed that there are women’s intent gaps in the prevention of obstetric fistula recurrence. Assessments of predictors of intent to prevent obstetric fistula recurrence among women with fistula are scarce.

Objective

This study assessed the intent to prevent obstetric fistula recurrence and its predictive factors among women with obstetric fistula in Ethiopia.

Methods

Facility-based cross-sectional study was conducted from April 01, 2019, to August 01, 2019, with consecutively selected 478 women with fistulas in five fistula treatment centers in Addis Ababa and Oromia regions. Data were collected using an interviewer-administered structured questionnaire and analyzed using SPSS 23 software. Simple and multiple linear regression models were fitted for data analysis.

Results

Mean score of intent to prevent obstetric fistula recurrence among women with obstetric fistula was 27.72 ± 5.06. Living in a rural setting (β =−2.27; 95% CI: −3.62, −0.93), being married (β =1.71, 95% CI: 0.56, 2.85), having one previous repair (β =2.14, 95% CI: 0.19, 4.08), high self-esteem (β =1.42, 95% CI: 0.09, 2.74), psychological health (β =0.05, 95% CI: 0.26, 3.79), living with fistula ≥5 years (β =1.82, 95% CI: 0.44, 3.21), high knowledge of risk factors (β =3.12, 95% CI: 1.99, 4.25), and a positive attitude (β =2.33, 95% CI: 1.12, 3.54) were significant predictors of the intent to prevent obstetric fistula recurrence.

Conclusion

Intent to prevent obstetric fistula recurrence among women with obstetric fistula was low. This indicates an urgent need to create awareness among women with an obstetric fistula on the risk factors of obstetric fistula recurrence, attitudinal changes towards prevention of obstetric fistula recurrence, and the availability of prevention measures.

Sub-Saharan African women's views and experiences of risk factors for obstetric fistula: a qualitative systematic review

Background

Obstetric fistula used as synonymous with VVF in this study, is an abnormal communication/hole between the urinary tract and the genital tract or the gastrointestinal tract and the genital tract, resulting from prolonged obstructed labour. VVF may cause sufferers to experience chronic urinary/faecal incontinence, and the stigma of continuing foul odour. VVF is primarily caused by prolonged obstructed labour, which is brought about by a range of causes. Recently, it has been proposed that women’s groups and fistula survivors should suggest interventions to reduce or prevent the incidence of obstetric fistula.

Objective

The objective of this review was to synthesise what is reported about women’s views and experiences of the risk factors underlying the causes of VVF.

Methods

A systematic approach outlined in the Joanna Briggs Institute Manual for Evidence synthesis was followed for this review, articles published since the last 11 years from 2011 to 2021 were selected against several criteria and critically appraised using JBI Critical Appraisal Checklist for qualitative studies.

Results

Nine studies were retained for inclusion in this review and the data were then synthesised into five themes: (1) Cultural beliefs and practices impeding safe childbirth, (2) Lack of woman’s autonomy in choices of place to birth safely, (3) Lack of accessibility and social support to safe childbirth, (4) Inexperienced birth attendants and, (5) Delayed emergency maternal care (childbirth).

Conclusions

This review highlights the complexity of risk factors predisposing women to the known causes of VVF. It also illuminates the absence of women’s voices in the identification of solutions to these risks. Women are most directly affected by VVF. Therefore, their knowledge, views, and experiences should be considered in the development and implementation of strategies to address the issue. Exploring women’s views on this issue would enable the identification of gaps in maternity care provision, which would be of interest to community and health service leaders as well as policymakers in Sub-Saharan Africa.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05013-2.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

Self-reported disrespect and abuse by nurses and midwives during childbirth in Tanzania: a cross-sectional study

Background

Facility-based childbirth has increased globally. Unfortunately, there have also been reports of women experiencing disrespect and abuse by healthcare providers during childbirth. This study aimed to measure the prevalence of self-reported disrespect and abuse (D&A) by healthcare providers of women during childbirth in health facilities in Tanzania, and to clarify the factors related to D&A.

Methods

A cross-sectional survey was conducted in public health facilities of three regions in Tanzania from September 2016 to October 2016. Nurses and midwives who had ever conducted deliveries completed a 22-item section about D&A and three sections about working conditions and environment. A model for predicting D&A based on several factors such as their characteristics, working conditions, and working environment was developed by conducting multiple regression analysis.

Results

Thirty public health facilities in three regions within Tanzania were selected to reflect different levels of hospitals. Among 456 participants (nurses, midwives, and nursing assistants), 439 were included in the analysis. Average number of self-reported D&A out of 22 items was five, and nearly all participants (96.1%) reported enacting one form of D&A at the least and two forms of D&A at the most. About 25–44% of D&A items were in the forms related to women’s experiences with childbirth psychologically. Moreover, at least 10–30% of the participants enacted some form of D&A which could directly affect the well-being of mothers and babies. D&A scores increased with an increase in ‘working hours per week’ and ‘taking a break during evening shifts’. D&A scores decreased with an increase in the scores of the ‘two components of the Index of Working Satisfaction (professional status and interaction between nurses)’, and ‘any type of supervision for new nurse-midwives’.

Conclusion

Most studies about D&A of healthcare providers previously focused on the reports of women. To our knowledge, this is the first report that focused on D&A reported by healthcare providers. Working conditions and systems including personal relationships with colleagues were both positively and negatively related to D&A of healthcare providers rather than the provider’s individual and facility structural characteristics.

Quality of Life among Obstetric Fistula Patients at Kitovu Mission Hospital: A Health Facility-Based Cross-Sectional Study in Masaka District, Uganda

Background

Obstetric fistula (OF) remains a silent neglected maternal challenge associated with devastating life consequences. Living with OF presents far-reaching physical, social, psychosocial, and emotional concerns, which negatively impact a woman's quality of life. This study evaluated the quality of life among obstetric fistula patients in Masaka district, Uganda.

Method

A cross-sectional study was conducted among 63 women diagnosed with OF at Kitovu Mission Hospital. Data were collected using a questionnaire, observation, in-depth interviews, and focus group discussions. Data were analyzed at univariate, bivariate, and multivariate levels, where the ordinal logistic regression model was applied. The qualitative data was transcribed and analyzed using qualitative content analysis.

Results

Majority (87%) of the women diagnosed with OF reportedly had a poor quality of life. Bivariate analysis indicated that level of education (P < 0.001), employment status (P < 0.001), energy for everyday life (P < 0.001), capacity to work (P < 0.001), satisfaction with personal relationships (P < 0.001), feelings of loneliness (P < 0.001), negative feelings (P = 0.002), and self-confidence (P < 0.001) were significantly associated with good QoL. Multivariate analysis showed increased odds of good QoL increased among women with self-confidence (OR = 32.320; CI = 2.019–517.467), formal education (OR = 9.9497; CI = 1.075–92.048), women who did not experience difficulties in mobility (OR = 19.144; CI = 0.149–2456.770), and women who were satisfied with their personal relationships (OR = 5.785; CI = 0.447–74.824).

Conclusion

A holistic fistula treatment approach is required that takes into consideration all aspects of life to address the consequences of obstetric fistula to realize improved quality of life among patients.

Childbirth experiences of Sudanese women living with obstetric fistula - A qualitative study

BACKGROUND

Obstetric Fistula results from failure to manage obstructed labor in a timely manner; the failure can be attributed to many factors. Therefore, the study seeks to provide a better understanding of the circumstances surrounding the occurrence of Obstetric Fistula using the Three-Delays model.

METHODS

Semi-structured interviews were conducted with 19 women living with OF. Study participants were recruited from the Dr. Abbu Fistula Center and the Fistula Re-integration Center in Khartoum, Sudan. Thematic analysis was used to analyze the study findings. The Three-Delays Model guided the analysis and discussion of these findings.

RESULTS

The majority (11 out of 19) experienced more than one delay and six of the participants had all the three delays. Women were kept at home by midwives or family members for days until the baby was dead or the woman showed severe signs of complications. Many of the participants went through injurious vaginal labor which could have been prevented if they had had timely access to a caesarian section.

CONCLUSION

In order to reduce the delays in seeking care, special attention must be paid to raising women's, husbands' and the community's awareness about danger signs that may arise before and during childbirth, the benefits of skilled birth attendance, and where and when to seek help. In addition, the provision of information regarding where to find Emergency Obstetric Care services and a birth preparedness plan would facilitate prompt care-seeking behavior. More resources must be allocated to strengthen the quality and coverage of reproductive health services.

Experiences of care in the context of payment for performance (P4P) in Tanzania

BACKGROUND

Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members.

METHODS

A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis.

RESULTS

Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P.

CONCLUSION

Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.

Knowledge of front-line health workers on the role of urethral catheterization for primary prevention of obstetric fistula in Ibadan, Nigeria

Background

Obstetric fistula (OF), a preventable debilitating condition is mostly caused by prolonged obstructed labour (POL). The aim of bladder catheterization is to allow for healing process by preventing tension to adjoining tissues and improve blood supply. This study assessed the knowledge of catheterization in the prevention of OF among health workers in Ibadan, Nigeria.

Methods

A cross sectional study among 147 health workers providing obstetric care in the labour and post-delivery wards using a self-administered questionnaire in 10 selected primary health centres was conducted. The knowledge of catheterization for primary prevention of OF was assessed on a three-point scale. Data was analysed using SPSS version 20. Logistic regression was used to determine the association between health workers socio-demographics and professional characteristics and their knowledge of catheterization for OF prevention.

Results

The mean age of participants was 41.6 (SD =8.9) years. Fifty-six (38.1%) of the participants had good knowledge of catheterization for OF prevention. Higher proportion (41.3%) of registered nurses and/or midwives had good knowledge of catheterization for OF prevention compared to those who attended school of hygiene. Health workers who had practiced for between 7-9 years were about seven times more likely to have good knowledge of catheterization compared to those who had worked for less than 3 years (OR =6.929, 95% CI, 1.755-27.357).

Conclusions

Majority of health workers had poor knowledge of catheterization in OF prevention. There is need for training and re-training of health workers in primary health care centres (PHC) on the vital role of bladder catheterization following prolonged/obstructed labour so as to reduce the burden of OF.

Humanizing birth in Tanzania: a qualitative study on the (mis) treatment of women during childbirth from the perspective of mothers and fathers

BACKGROUND

While there has been a trend for greater number of women to deliver at health facilities across Tanzania, mothers and their family members continue to face mistreatment with respectful maternity care during childbirth being violated. The objective of this study was to describe the experience of mothers and fathers in relation to (mis) treatment during childbirth in Tanzania.

METHODS

Using a qualitative descriptive design, 12 semi-structured interviews and four focus group discussions were held with mothers and fathers who were attending a postnatal clinic in the Lake Zone region of Tanzania. Mothers' age ranged from 20 to 45 years whereas fathers' age ranged from 25 to 60 years. Data were analyzed using a priori coding based on Bohren's et al. typology of the mistreatment of women during childbirth.

RESULTS

Mothers reported facing mistreatment and disrespectful maternity care through verbal abuse (harsh or rude language and judgmental or accusatory comments), failure to meet professional standards of care (refused pain relief, unconsented surgical operations, neglect, abandonment or long delays, and skilled attendant absent at time of delivery), poor rapport between women and providers (poor communication, lack of supportive care, denied husbands presence at birth, denied mobility, denied safe traditional practices, no respect for their preferred birth positions), and health system conditions and constraints (poor physical condition of facilities, supply constraints, bribery and extortion, unclear fee structures). Despite some poor care, some mothers also reported positive birthing experiences and respectful maternity care by having a skilled attendant assistance at delivery, having good communication from nurses, receiving supportive care from nurses and privacy during delivery.

CONCLUSION

Despite the increasing number of deliveries occurring in the hospital, there continue to be challenges in providing respectful maternity care. Humanizing birth care in Tanzania continues to have a long way to go, however, there is evidence that changes are occurring as mothers notice and report positive changes in delivery care practices.

Post - effects of obstetric fistula in Uganda; a case study of fistula survivors in KITOVU mission hospital (MASAKA), Uganda

Background

Obstetrical fistula (OF) is a public health challenge that is among the previously neglected components of maternal health in the developing world. The condition, which in the recent past has increasingly drawn more attention from the public, has a devastating impact on the health and wellbeing of both women and girls worldwide. The most common cause of obstetric fistula in developing countries is prolonged obstructed labor affecting approximately 2 million women and girls across Africa and Asia.

The objective of this study was to examine the post-effects of fistula and reintegration strategies of fistula survivors in Uganda.

Methods

A descriptive case study design was used to collect data from women aged 15–49 years who had experienced OF and been successfully treated/repaired. Data collection was aided by in-depth interview guides designed for collecting qualitative data which was analyzed using thematic and content analysis.

Results

The study results showed that 45.6% were aged 18–24 years, 43% had only primary level education and 55.7% of the women were married. Fistula survivors continue to suffer from shame, rejection, isolation and stigma, trauma and disgrace among other effects even after successful repair/surgery. Some of the reintegration strategies for fistula survivors include; seeking for successful repair, remarriage and relocation from their parent communities to new environments.

Conclusion

In addition to capacity building, changing attitudes and strengthening the health system, a comprehensive and holistic fistula care approach is required to facilitate the reintegration process and restoration of women dignity.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7023-7) contains supplementary material, which is available to authorized users.

Policy, law and post-abortion care services in Kenya

BACKGROUND

Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy.

METHODS

A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality.

RESULTS

The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge.

DISCUSSION

Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination.

CONCLUSION

Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.

Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members

Background: In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice.

Objective: To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community.

Methods: Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process.

Results: In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives’ advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral.

Conclusions: Declining maternal referral advice centred around the pregnant women’s position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals.

Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti

Background

The primary objective of this comparative, cross-sectional study was to identify factors affecting delays in accessing emergency obstetric care and clinical consequences of delays among preeclamptic and non-preeclamptic women in Port-au-Prince, Haiti.

Methods

We administered 524 surveys to women admitted to the Médecins Sans Frontières Centre de Référence en Urgences Obstétricales (CRUO) obstetric emergency hospital. Survey questions addressed first (at home), second (transport) and third (health facility) delays; demographic, clinical, and behavioral risk factors for delay; and clinical outcomes for women and infants. Bivariate statistics assessed relationships between preeclampsia status and delay, and between risk factors and delay.

Results

We found longer delays to care for preeclamptic women (mean 14.6 h, SD 27.9 versus non-preeclamptic mean 6.8 h, SD 10.5, p < 0.01), primarily attributable to delays before leaving for hospital (mean 13.4 h, SD 30.0 versus non-preeclamptic mean 5.5 h, SD 10.5). Few demographic, clinical, or behavioral factors were associated with care access. Poor outcomes were more likely among preeclamptic women and infants, including intensive care unit admission (10.7%, vs. 0.5% among non-preeclamptic women, p < 0.01) and eclampsia (10.7% vs. no cases, p < 0.01) for women, and neonatal care unit admission (45.6% vs. 15.4%, p < 0.01) and stillbirth (9.9% vs. 0.5%, p < 0.01). Longer delays among both groups were not associated with poorer clinical outcomes.

Conclusion

Pregnant women with preeclampsia in Port-au-Prince reported significant delays in accessing emergency obstetric care. This study provides clear evidence that hospital proximity alone does not mitigate the long delays in accessing emergency obstetrical care for Haitian urban, poor women.

When, where and who? Accessing health facility delivery care from the perspective of women and men in Tanzania: a qualitative study

BACKGROUND

Childbirth is a momentous event for women and their partners, yet women continue to die in childbirth worldwide, particularly in sub-Saharan Africa. To reduce maternal mortality and increase the number of women delivering at health facilities, it is important to understand reasons why women who do deliver at health facilities chose to do so. Therefore, the objective of this qualitative study was to explore the perceptions of women and men on (i) when women go to the hospital; (ii) where women deliver; and (iii) who is involved in the delivery process related to accessing health facilities for delivery care in Tanzania.

METHODS

Using a qualitative design, four focus group discussions (n = 23) and semi-structured interviewers (n = 12) were held with postnatal women and men who were attending a postnatal clinic in the Lake Zone region of Tanzania. Data was analyzed using thematic coding.

RESULTS

Women and men expressed factors that influenced when, where, and with whom they accessed health facilities for delivery care, with the quality of care received providing a significant influence. When decisions were made about going to the hospital, there were challenges that resulted in delayed treatment seeking; however, couples recognized the need to seek care earlier to prevent complications. Private hospitals were the preferred location for delivery with public hospitals and home deliveries with traditional birth attendants being less desirable. Both when and where delivery took place was influenced by the desire for better quality of care received as well as financial costs. Finally, there was mixed evidence on who was involved in decision making around delivery location from the perspective of women and men, but both groups expressed a preference for more male involvement during the delivery.

CONCLUSION

Men and women show desire for women to delivery at health facilities; however, improvements are needed with respect to maternal care and humanizing the birth process in Tanzania. Greater emphasis needs to be placed on including men during the birth process, improving the quality of care received in public hospitals, and reducing the barriers to accessing health facilities for delivery care.

Obstetric fistula policy in Nigeria: a critical discourse analysis

BACKGROUND

In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing.

METHODS

A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice.

RESULTS

The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development."

CONCLUSION

This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

Factors affecting effective ventilation during newborn resuscitation: a qualitative study among midwives in rural Tanzania

BACKGROUND

Intrapartum-related hypoxia accounts for 30% of neonatal deaths in Tanzania. This has led to the introduction and scaling-up of the Helping Babies Breathe (HBB) programme, which is a simulation-based learning programme in newborn resuscitation skills. Studies have documented ineffective ventilation of non-breathing newborns and the inability to follow the HBB algorithm among providers.

OBJECTIVE

This study aimed at exploring barriers and facilitators to effective bag mask ventilation, an essential component of the HBB algorithm, during actual newborn resuscitation in rural Tanzania.

METHODS

Eight midwives, each with more than one year's working experience in the labour ward, were interviewed individually at Haydom Lutheran Hospital, Tanzania. The audio recordings were transcribed and translated into English and analysed using qualitative content analysis.

RESULTS

Midwives reported the ability to monitor labour properly, preparing resuscitation equipment before delivery, teamwork and frequent ventilation training as the most effective factors in improving actual ventilation practices and promoting the survival of newborns. They thought that their anxiety and fear due to stress of ventilating a non-breathing baby often led to poor resuscitation performance. Additionally, they experienced difficulties assessing the baby's condition and providing appropriate clinical responses to initial interventions at birth; hence, further necessary actions and timely initiation of ventilation were delayed.

CONCLUSIONS

Efforts should be focused on improving labour monitoring, birth preparedness and accurate assessment immediately after birth, to decrease intrapartum-related hypoxia. Midwives should be well prepared to treat a non-breathing baby through high-quality and frequent simulation training with an emphasis on teamwork training.

Healthcare Provider Views on Transitioning From Task Shifting to Advanced Practice Nursing in Tanzania

BACKGROUND

The Tanzanian health sector suffers from shortages of healthcare workers as well as uneven distribution of healthcare workers in urban and rural areas. Task shifting-delegation of tasks from professionals to other healthcare team members with less training, such as medical attendants-is practiced, compromising quality of care. Advanced practice nursing is underutilized.

OBJECTIVE

The purpose of this study was to explore the views of nurses and physicians on current responses to shortages of healthcare workers and the potential for utilization of advanced practice nurses.

METHODS

A descriptive, qualitative design was used. Purposeful sampling was used to select 20 participants. An in-depth interview guide was used to obtain information. Interviews were conducted in Swahili or English. Content analysis was used to identify themes.

RESULTS

Shortage of human resources in rural primary healthcare facilities was identified as a major rationale for implementation of the advanced practice nurse practitioner role because the current health providers in rural health facilities are less trained and doctors are not ready to work in these settings. Opposition from physicians is expected during the course of implementing the nurse practitioner role. Professional bodies and government should reach consensus before the implementation of this role in such a way that they should agree on scope and standards of practice of nurse practitioners in Tanzania.

CONCLUSION

Shortage of human resources for health is greater in rural primary healthcare facilities. Task shifting in Tanzania is neither effective nor legally recognized. Transition to advanced practice nursing roles-particularly the nurse practitioner role-can facilitate provision of optimal care. Nurse practitioners should be prepared to work in rural primary healthcare facilities.

Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment

BACKGROUND

Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair.

METHODS

We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software.

RESULTS

Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed.

CONCLUSION

This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

Saving lives with caring assessments: How Tanzanian nurse-midwives and obstetricians negotiate postpartum practices

AIMS AND OBJECTIVES

To explore the nurse-midwives' and obstetricians' experiences delivering postpartum care assessments and how it was constructed through personal, social and institutional discourses.

INTRODUCTION

The Tanzanian Government has prioritised maternal and child health as an urgent healthcare issue. Nurse-midwives and obstetricians are the two main providers of care throughout the prenatal and postpartum periods.

DESIGN

A qualitative design guided by a feminist poststructuralist methodology.

METHODS

Ten nurse-midwives and three obstetricians from three Regional Hospitals in Dar es Salaam participated in individual semi-structured in-depth interviews.

RESULTS

Assessment emerged as a significant theme with three subthemes. Nurse-midwives shared their beliefs and values about assessments that focused on the safety of mothers and babies. They felt proud working with mothers and babies and shared their frustrations having to deal with inadequate working conditions. Guidelines and practices were part of the institutional discourse that impacted the day-to-day experiences of nurse-midwives and obstetricians. The nurse-midwives held the belief that it was vital to complete a comprehensive assessment to identify danger signs, keep mothers and babies safe and look for any abnormalities. They were concerned that mothers were being sent home too early.

CONCLUSIONS

Nurse-midwives' experiences in the provision of postpartum care portray that these health providers work heartedly to make sure that the mothers and their newborns receive the best care they can provide. The health system is challenged to address the needed supplies and equipment for reproductive health in particular postpartum care services.

RELEVANCE TO CLINICAL PRACTICE

Institutional health discourses significantly affect the practice of nurse-midwives and obstetricians to deliver timely and effective postpartum assessments. Immediate and ongoing postpartum assessments conducted by nurse-midwives and obstetricians can save lives. This study presents the first theme of the study: Caring assessments save lives.

Perceptions and experiences of women seeking treatment for obstetric fistula

OBJECTIVE

To understand patients' perspectives on the causative factors and preventive measures of obstetric fistula; and the effect of fistula on the victims' psycho-social, sexual, and economic well being.

METHODS

A questionnaire-based interview of 215 women with obstetric fistula admitted for treatment in 17 hospitals in India was carried out during 2010-2011. Responses of participants from poor, medium, and better performing states were categorized into pre-coded themes and compared.

RESULTS

The majority of the women were from rural areas (75.3%), multiparous (68.8%), and with less than high school education (82.2%). The majority (70.7%) of the women reported attempt at home delivery by untrained persons. Poor awareness of where and when to seek care when faced with a difficult delivery, and poor quality of care in facilities were perceived as important causative factors. Delivery by trained providers and early referral of women with problems during labor were identified as important preventive factors. Spouses and families were supportive of treatment in spite of economic hardships, but most (79.5%) patients felt socially isolated after developing fistula.

CONCLUSION

Poor awareness regarding delivery care among the women indicates a need for increasing birth preparedness in the community. Patients' perceptions of poor quality of care in facilities need to be addressed urgently. Psychological evaluation and counseling should be offered to fistula patients, to help them cope with adverse psycho-social and economic circumstances. The results of this study may provide insights for prevention and management of fistula, and may help to improve patient care and services.

Delays contributing to the development and repair of obstetric fistula in northern Tanzania

INTRODUCTION AND HYPOTHESIS

Delays in receiving obstetric care during labor contribute to high rates of maternal morbidity in sub-Saharan Africa. This exploratory study was conducted to identify important delays experienced during the development and subsequent repair of obstetric fistula in northern Tanzania.

METHODS

Sixty women presenting to a tertiary hospital with obstetric fistula completed structured surveys about the birth experience that led to fistula development and their experiences seeking surgical repair. A subset of 30 provided qualitative accounts. Clinical data were collected postsurgery. Data were analyzed according to a four-delay model, with iterative analysis allowing for triangulation of all sources.

RESULTS

During the index pregnancy, women labored for a median of 48 h. Most women (53/60; 88.3%) delivered in a facility but labored for a median of 12.4 h before deciding to seek care (Delay 1). Women spent a median of 1.25 h traveling to a facility (Delay 2). After presenting to care, 15/51 (29.4%) waited at least an hour to see a medical provider, and 35/53 (66.0%) required transfer to another facility (Delay 3). Women lived with fistula for a median of 10 years (Delay 4). Qualitative data provided context and a deeper understanding of the factors contributing to each delay.

CONCLUSIONS

Critical delays exist both outside and within the healthcare system that contribute to the development and timely repair of obstetric fistula. Healthcare system strengthening, particularly with regard to emergency obstetric care, is critical to reduce the burden of obstetric fistula in women in Tanzania.

Relying on Visiting Foreign Doctors for Fistula Repair: The Profile of Women Attending Fistula Repair Surgery in Somalia

Obstetric fistula is treatable by surgery, although access is usually limited, particularly in the context of conflict. This study examines the profile of women attending fistula repair surgery in three hospitals in Somalia. A cross-sectional study was conducted in Somalia from August to September 2016. Structured questionnaires were administered to 81 women who registered for fistula repair surgery in the Garowe, Daynile, and Kismayo General Hospitals in Somalia. Findings revealed that 70.4% of the study participants reported obstetric labor as the cause of their fistula, and 29.6% reported iatrogenic causes. Regarding the waiting time for the repair surgery, 45% waited for the surgery for over one year, while the rest received the surgery within a year. The study suggests that training for fistula surgery has to be provided for healthcare professionals in Somalia, fistula centers should be established, and access to these facilities has to be guaranteed for all patients who need these services.

Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review

BACKGROUND

Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.

RESULTS

One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.

CONCLUSION

Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2014 CRD42014015549.

Ambiguous subjects: Obstetric violence, assemblage and South African birth narratives

Obstetric violence is gaining recognition as a worldwide problem manifesting in a range of geopolitical contexts. While global public health attention is turning to this issue, there has been a lack of theoretical engagement by feminist psychologists with the phenomenon of obstetric violence. This paper contributes to the literature on obstetric violence via a feminist social constructionist analysis of “marginalized” and low-income South African women’s narratives of giving birth in public sector obstetric contexts. Drawing on interviews conducted in 2012 with 35 black, low-income women living in Cape Town, South Africa, the analysis focuses on obstetric violence as a relational, disciplinary, and productive process that has implications for the construction of women’s subjectivities and agency during childbirth. The findings focus on relational constructions of violence and agency in women’s narratives, including (a) the performance of docility as an act of ambiguous agency and (2) resistant bodies and modes of discipline. Framed within a Foucauldian approach to power and using the concept of assemblage, I argue that obstetric violence needs to be conceptualized as more than isolated acts involving individual perpetrators and victims. Instead, the analysis shows that obstetric violence functions as a mode of discipline embedded in normative relations of class, gender, race, and medical power.

International Human Rights and the Mistreatment of Women During Childbirth

International human rights bodies have played a critical role in codifying, setting standards, and monitoring human rights violations in the context of sexual and reproductive health and rights. In recent years, these institutions have developed and applied human rights standards in the more particular context of maternal mortality and morbidity, and have increasingly recognized a critical human rights issue in the provision and experience of care during and after pregnancy, including during childbirth. However, the international human rights standards on mistreatment during facility-based childbirth remain, in an early stage of development, focused largely on a discrete subset of experiences, such as forced sterilization and lack of access to emergency obstetric care. As a consequence, the range of mistreatment that women may experience has not been adequately addressed or analyzed under international human rights law. Identifying human rights norms and standards related to the full range of documented mistreatment is thus a first step towards addressing violations of human rights during facility-based childbirth, ensuring respectful and humane treatment, and developing a program of work to improve the overall quality of maternal care. This article reviews international human rights standards related to the mistreatment of women during childbirth in facility settings under regional and international human rights law and lays out an agenda for further research and action.

"By slapping their laps, the patient will know that you truly care for her": A qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria

BACKGROUND

Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth.

METHODS

Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth.

RESULTS

Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's "disobedience" and "uncooperativeness" during labor for her experience of mistreatment.

CONCLUSIONS

Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.

Healthcare access and quality of birth care: narratives of women living with obstetric fistula in rural Tanzania

BACKGROUND

Increasing births with skilled attendants and increasing health facilities with Emergency Obstetric Care (EmOC) can reduce maternal mortality and are considered critical interventions for ensuring safe motherhood. Despite Tanzania's policy to support women to give birth with the assistance of skilled personnel, some women do not access this care. This article uses women's stories to illustrate the challenges that caused them to fail to access adequate obstetric care in a timely manner, hence causing the development of fistulas.

METHODS

This paper presents the narratives of 16 women who were conveniently selected based on their experiences of not being able to access adequate obstetric care in timely manner. The analysis was guided by recommendations for the identification and interpretation of narratives, and identified important components of women's experiences, paying attention to commonalities, differences and areas of emphasis. Semi-structured interviews were carried out at CCBRT hospital in Dar es Salaam.

RESULTS

Four (4) general story lines were identified from women description of their inability to access quality obstetric care in a timely manner. These were; failing to decide on a health care facility for delivery, lacking money to get to a health care facility, lacking transportation to a health care facility and lacking quality birth care at the health care facility.

CONCLUSION

Women were unable to reach to the health care facilities providing comprehensive emergency obstetric care (CEmOC) in time because of their lack of decision-making power, money and transportation, and those who did reach the facilities received low quality birth care. Empowering women socially and financially, upgrading primary health care facilities to provide CEmOC and increased numbers of skilled personnel would promote health care facility deliveries.

Characteristics and repair outcome of patients with Vesicovaginal fistula managed in Jimma University teaching Hospital, Ethiopia

Background

In Ethiopia, about 9000 fistula cases are estimated to occur every year with an incidence of 2.2/1000 women. This study was aimed to determine obstetric fistula characteristics and surgical repair outcomes among patients with fistula surgical repair.

Methods

A Hospital based cross sectional study design was conducted on all patients with Obstetric vesicovaginal Fistula, who were admitted to Gynecology ward, and had surgical repair from January 2011 to December 2014. Data was collected from patients’ chart, operation logbook and discharge logbook which were filled up from the entry of the patient to the hospital till her discharge. At discharge, a dye test was done to determine the outcome of repair.

Results

One hundred sixty eight patients with obstetric vesicovaginal fistula were repaired during the study period. The age of the women ranged from 12 to 45 years with mean of 25 (±6) years and 10.1 % were younger than 18 years. Eighty percent of patients were laboring for two or more days, 46.4 % delivered abdominally (cesarean section 24.4 %, hysterectomy for uterine rupture 22 %), and 85.7 % ended up in stillbirth. Most patients (56 %) had mid-vaginal vesicovaginal fistula. Route of repair was vaginal among 95.8 % of patients, and spinal anesthesia was applied among 70.8 % of patients. Out of 93.4 % patients who had successful closure of their fistula, 84.5 % of patients had their fistula healed and continent, 8.9 % of them developed urinary incontinence while 6.5 % of fistula repair had failed at the time of discharge.

Conclusions

Most fistula patients in this study are older than 18 years, referred from health centers either for cephalopelvic disproportion or obstructed labor after prolonged labor at home. In this study, Spinal anesthesia as well as vaginal route was widely employed and high success rates were achieved with surgical repair. Therefore, increasing access to comprehensive emergency obstetric and new born care is essential to minimize the delay contributing to perinatal mortality and obstetric fistula. In addition use of spinal anesthesia and vaginal route of repair is essential for the high success of repair outcome and low postoperative morbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-016-0152-8) contains supplementary material, which is available to authorized users.

Risk factors for vaginal fistula symptoms in Sub-Saharan Africa: a pooled analysis of national household survey data

BACKGROUND

Vaginal fistula (VF) is one of the most severe maternal morbidities with the immediate consequence of chronic urinary and/or fecal incontinence. The epidemiological evidence regarding risk factors for VF is dominated by facility-based studies. Our aim is to estimate the effect size of selected risk factors for VF using population-based survey data.

METHODS

We pooled all available Demographic and Health Surveys and Multiple Indicators Cluster Surveys carried out in sub-Saharan Africa that collected information on VF symptoms. Bayesian matched logistic regression models that accounted for the imperfect sensitivity and specificity of self-reports of VF symptoms were used for effect size estimation.

RESULTS

Up to 27 surveys were pooled, including responses from 332,889 women. Being able to read decreased the odds of VF by 13% (95% Credible Intervals (CrI): 1% to 23%), while higher odds of VF symptoms were observed for women of short stature (<150 cm) (Odds Ratio (OR) = 1.31; 95% CrI: 1.02-1.68), those that had experienced intimate partner sexual violence (OR = 2.13; 95% CrI: 1.60-2.86), those that reported sexual debut before the age of 14 (OR = 1.41; 95% CrI: 1.16-1.71), and those that reported a first birth before the age of 14 (OR = 1.39; 95% CrI: 1.04-1.82). The effect of post-primary education, female genital mutilation, and having problems obtaining permission to seek health care were not statistically significant.

CONCLUSIONS

Increasing literacy, delaying age at first sex/birth, and preventing sexual violence could contribute to the elimination of obstetric fistula. Concomitant improvements in access to quality sexual and reproductive healthcare are, however, required to end fistula in sub-Saharan Africa.

Barriers to access reproductive health care for pregnant adolescent girls: a qualitative study in Tanzania

AIMS

In Tanzania, approximately 25% of adolescents give birth and 50% more become sexually active during adolescence. We hypothesised that reproductive health education and services for adolescent girls are inaccessible and conducted this study to gain insights into their perceptions of sexually transmitted infections (STIs) and barriers to reproductive health service utilisation in rural Mwanza, Tanzania.

METHODS

We conducted nine focus groups among pregnant adolescents aged 15-20 years. Data were transcribed, translated and coded for relevant themes using NVivo10 software for qualitative data analysis.

RESULTS

Most participants were aware of the dangers of STIs to themselves and their unborn babies, but did not perceive themselves as at risk of acquiring STIs. They viewed condoms as ineffective for preventing STIs and pregnancies and unnecessary for those in committed relationships. Stigma, long waiting times, and lack of privacy in the clinics discouraged adolescent girls from seeking reproductive health care.

CONCLUSION

Reproductive health care for adolescent girls who are not pregnant is practically nonexistent in Tanzania. Healthcare access for pregnant young women is also limited. Targeted changes to increase clinic accessibility and to provide reproductive health education to all rather than only pregnant women have the potential to address these gaps.

Living with constant leaking of urine and odour: thematic analysis of socio-cultural experiences of women affected by obstetric fistula in rural Tanzania

Background

Obstetric fistula is a worldwide problem that affects women and girls mostly in Sub Saharan Africa. It is a devastating medical condition consisting of an abnormal opening between the vagina and the bladder or rectum, resulting from unrelieved obstructed labour. Obstetric fistula has devastating social, economic and psychological effect on the health and wellbeing of the women living with it. This study aimed at exploring social-cultural experiences of women living with obstetric fistula in rural Tanzania.

Methods

Women living with obstetric fistula were identified from the fistula ward at CCBRT hospital. Sixteen individual semi structured interviews and two (2) focus group discussions were conducted among consenting women. Interviews were transcribed verbatim and transcripts analysed independently by two researchers using a thematic analysis approach. Themes related to the experiences of living with obstetric fistula were identified.

Results

Four themes illustrating the socio-cultural experiences of women living with obstetric fistula emerged from the analysis of women experiences of living with incontinence and odour. These were keeping clean and neat, earning an income, maintaining marriage, and keeping association. Women experiences of living with fistula were largely influenced by perceptions of people around them basing on their cultural understanding of a woman.

Conclusion

Living with fistula reveals women’s day-to-day experiences of social discrimination and loss of control due to incontinence and odour. They cannot work and contribute to the family income, cannot satisfy their husband’s sexual needs and or bear children, and cannot interact with members of the community in social activities. Women experience of living with fistula was influenced by perceptions of people around them. In the eyes of these people, women who leak urine were of less value since they were not capable of carrying out ascribed social roles.

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

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.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review

Background

High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care.

Methods

Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded.

Findings

Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients’ attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being.

Conclusions

The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-015-0117-9) contains supplementary material, which is available to authorized users.

The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review

BACKGROUND

Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.

METHODS AND FINDINGS

We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.

CONCLUSIONS

This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia

Research on obstetric fistula has paid limited attention to the lived experiences of survivors. This qualitative study explored the evolution of survivors' perceptions of their social relationships and health since developing this obstetric complication. In-depth interviews were conducted with eight survivors who were selected based on purposive and snowball sampling techniques. Thematic categorization and content analysis was used to analyze the data. The resultant themes included participants' understanding of factors predisposing to fistula, challenges they encounter, their coping responses, and the meaning of their experiences. First, the participants had a common understanding of the factors that predisposed them to obstetric fistula. They mentioned poor knowledge about pregnancy, early marriage, cultural practices, and a delay in or lack of access to emergency obstetric care. Second, the participants suffered from powerlessness experienced during their childhood and married lives. They also faced prolonged obstructed labor, physical injury, emotional breakdown, depression, erosion of social capital, and loss of healthy years. Third, to control their negative emotions, participants reported isolating themselves, having suicidal thoughts, positive interpretation about the future, and avoidance. To obtain relief from their disease, the women used their family support, sold their properties, and oriented to reality. Fourth, the participants were struggling to keep going, to accept their changed reality, and to change their perspectives on life. In conclusion, obstetric fistula has significant physical, psychosocial, and emotional consequences. The study participants were not passive victims but rather active survivors of these challenges. Adequate support was not provided by their formal or informal support systems. To prevent and manage obstetric fistula successfully, there should be family-based interventions that improve access to and provision of emergency obstetric care. These initiatives should also ensure men's participation, women's empowerment, and the utilization of community-based institutions.

"Hoping for a normal life again": reintegration after fistula repair in rural Tanzania

OBJECTIVE

To explore women's expectations, worries, and hopes related to returning to their family and community after fistula repair.

METHODS

We used a concurrent mixed methods design with a hospital survey and qualitative interviews. One hundred fifty-one women completed a questionnaire, eight were interviewed in hospital after fistula repair, and one woman was followed up at home for six months during the reintegration phase.

RESULTS

Women were concerned about where they could live and about not being accepted by their husbands and in-laws. While 51% feared that their husbands would not accept them despite full recovery, 53% said their parents would accept them. In the qualitative study women wished to live with their parents, whereas almost one half (49.7%) of the women in the quantitative study, who had lived with fistula for a shorter time, wished to live with their husbands. All women hoped to have children in the future, although many women, especially those with no children, were worried about whether they could bear children in the future. Despite fears related to economic survival and social acceptance, women were optimistic about regaining a normal social life.

CONCLUSION

Women's expectations of going home after fistula repair are linked to their history of living with obstetric fistula. For women who have lived with a fistula for many years, reintegration involves re-establishing an identity that is clean and respected. To facilitate this transition, fistula repair needs to be accompanied by psychological and social rehabilitation and assistance in returning to reproductive capabilities.

Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda

Background

Obstetric fistula is a worldwide problem that is devastating for women in developing countries. The cardinal cause of obstetric fistula is prolonged obstructed labour and delay in seeking emergency obstetric care. Awareness about obstetric fistula is still low in developing countries. The objective was to assess the awareness about risk factors of obstetric fistulae in rural communities of Nabitovu village, Iganga district, Eastern Uganda.

Methods

A qualitative study using focus group discussion for males and females aged 18-49 years, to explore and gain deeper understanding of their awareness of existence, causes, clinical presentation and preventive measures for obstetric fistula. Data was analyzed by thematic analysis.

Results

The majority of the women and a few men were aware about obstetric fistula, though many had misconceptions regarding its causes, clinical presentation and prevention. Some wrongly attributed fistula to misuse of family planning, having sex during the menstruation period, curses by relatives, sexually transmitted infections, rape and gender-based violence. However, others attributed the fistula to delays to access medical care, induced abortions, conception at an early age, utilization of traditional birth attendants at delivery, and some complications that could occur during surgical operations for difficult deliveries.

Conclusion

Most of the community members interviewed were aware of the risk factors of obstetric fistula. Some respondents, predominantly men, had misconceptions/myths about risk factors of obstetric fistula as being caused by having sex during menstrual periods, poor usage of family planning, being a curse.

Profiles and experiences of women undergoing genital fistula repair: findings from five countries

This article presents data from 1354 women from five countries who participated in a prospective cohort study conducted between 2007 and 2010. Women undergoing surgery for fistula repair were interviewed at the time of admission, discharge, and at a 3-month follow-up visit. While women's experiences differed across countries, a similar picture emerges across countries: women married young, most were married at the time of admission, had little education, and for many, the fistula occurred after the first pregnancy. Median age at the time of fistula occurrence was 20.0 years (interquartile range 17.3–26.8). Half of the women attended some antenatal care (ANC); among those who attended ANC, less than 50% recalled being told about signs of pregnancy complications. At follow-up, most women (even those who were not dry) reported improvements in many aspects of social life, however, reported improvements varied by repair outcome. Prevention and treatment programmes need to recognise the supportive role that husbands, partners, and families play as women prepare for safe delivery. Effective treatment and support programmes are needed for women who remain incontinent after surgery.

Characterising women with obstetric fistula and urogenital tract injuries in Tanzania

INTRODUCTION AND HYPOTHESIS

World Health Organisation (WHO) data suggest that more than two million women and girls live with fistula and that an additional 50-100,000 are newly affected each year. In Tanzania, it has been estimated that there are between 1,200 and 3,000 new cases of obstetric fistula annually.

METHODS

To characterize women undergoing surgery in 2011 for obstetric fistula repair at a disability hospital associated with Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), we identified routinely collected data and input into an Access database.

RESULTS

Women affected by obstetric fistulae in Tanzania are frequently young, poorly educated, primiparous, subsistence farmers or housewives and have experienced obstructed labour as a result of delays occurring at home and/or after reaching a health facility. The majority experienced stillbirth, particularly in cases of assisted or operative delivery. Success rates for fistula closure were high, at 91 %, but residual incontinence on discharge from hospital was seen in 39 %.

CONCLUSIONS

Longer-term follow-up is required to determine rates of disabling residual incontinence and to examine demographics in greater depth, including variation between regions and in urban, periurban and rural settings in Tanzania.

Why give birth in health facility? Users' and providers' accounts of poor quality of birth care in Tanzania

Background

In Tanzania, half of all pregnant women access a health facility for delivery. The proportion receiving skilled care at birth is even lower. In order to reduce maternal mortality and morbidity, the government has set out to increase health facility deliveries by skilled care. The aim of this study was to describe the weaknesses in the provision of acceptable and adequate quality care through the accounts of women who have suffered obstetric fistula, nurse-midwives at both BEmOC and CEmOC health facilities and local community members.

Methods

Semi-structured interviews involving 16 women affected by obstetric fistula and five nurse-midwives at maternity wards at both BEmOC and CEmOC health facilities, and Focus Group Discussions with husbands and community members were conducted between October 2008 and February 2010 at Comprehensive Community Based Rehabilitation in Tanzania and Temeke hospitals in Dar es Salaam, and Mpwapwa district in Dodoma region.

Results

Health care users and health providers experienced poor quality caring and working environments in the health facilities. Women in labour lacked support, experienced neglect, as well as physical and verbal abuse. Nurse-midwives lacked supportive supervision, supplies and also seemed to lack motivation.

Conclusions

There was a consensus among women who have suffered serious birth injuries and nurse midwives staffing both BEmOC and CEmOC maternity wards that the quality of care offered to women in birth was inadequate. While the birth accounts of women pointed to failure of care, the nurses described a situation of disempowerment. The bad birth care experiences of women undermine the reputation of the health care system, lower community expectations of facility birth, and sustain high rates of home deliveries. The only way to increase the rate of skilled attendance at birth in the current Tanzanian context is to make facility birth a safer alternative than home birth. The findings from this study indicate that there is a long way to go.

Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi

BACKGROUND

Despite Malawi government's policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care.

OBJECTIVE

The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care.

METHODS

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women's perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis.

RESULTS

Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers' attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery.

CONCLUSIONS

This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.