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Metta E, Unkels R, Mselle LT, Hanson C, Alvesson HM, Al-Beity FMA. Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study. BMC Pregnancy Childbirth 2024; 24:290. [PMID: 38641769 PMCID: PMC11027221 DOI: 10.1186/s12884-024-06396-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/07/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Women's childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women's childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user's needs. AIM This study aimed to explore women's childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania. METHODS This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization's Quality of Care framework on experiences of care domains. RESULTS Three themes emerged from the data: (1) Women's experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were. CONCLUSION The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women's needs.
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Affiliation(s)
- Emmy Metta
- Department of Behavioural Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Regine Unkels
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lilian Teddy Mselle
- Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Fadhlun M Alwy Al-Beity
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Department of Obstetrics/Gynaecology, School of Clinical Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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Merner B, Schonfeld L, Virgona A, Lowe D, Walsh L, Wardrope C, Graham-Wisener L, Xafis V, Colombo C, Refahi N, Bryden P, Chmielewski R, Martin F, Messino NM, Mussared A, Smith L, Biggar S, Gill M, Menzies D, Gaulden CM, Earnshaw L, Arnott L, Poole N, Ryan RE, Hill S. Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 3:CD013274. [PMID: 36917094 PMCID: PMC10065807 DOI: 10.1002/14651858.cd013274.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. OBJECTIVES 1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences. SEARCH METHODS We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care. SELECTION CRITERIA We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services. DATA COLLECTION AND ANALYSIS Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles. MAIN RESULTS We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability. AUTHORS' CONCLUSIONS Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.
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Affiliation(s)
- Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Ariane Virgona
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
- Child and Family Evidence, Australian Institute of Family Studies, Melbourne, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Cheryl Wardrope
- Clinical Governance, Metro South Hospital and Health Service, Eight Mile Plains, Australia
| | | | - Vicki Xafis
- The Sydney Children's Hospitals Network, Sydney, Australia
| | - Cinzia Colombo
- Laboratory for medical research and consumer involvement, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Nora Refahi
- Consumer Representative, Melbourne, Australia
| | - Paul Bryden
- Consumer Representative, Caboolture, Australia
| | - Renee Chmielewski
- Planning and Patient Experience, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | | | | | | | - Lorraine Smith
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Susan Biggar
- Consumer Representative, Melbourne, Australia
- Australian Health Practitioner Regulation Agency (AHPRA), Melbourne, Australia
| | - Marie Gill
- Gill and Wilcox Consultancy, Melbourne, Australia
| | - David Menzies
- Chronic Disease Programs, South Eastern Melbourne Primary Health Network, Heatherton, Australia
| | - Carolyn M Gaulden
- Detroit Wayne County Authority Health Residency Program, Michigan State University, Providence Hospital, Southfield, Michigan, USA
| | | | | | - Naomi Poole
- Strategy and Innovation, Australian Commission on Safety and Quality in Health Care, Sydney, Australia
| | - Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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Bewket T, Ensieh F, Virginia P, Gayle M. Barriers to effective management of primary postpartum haemorrhage following in-hospital births in northwest Ethiopia: healthcare providers' views using a qualitative approach. BMC Pregnancy Childbirth 2022; 22:755. [PMID: 36209045 PMCID: PMC9548148 DOI: 10.1186/s12884-022-05071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Data showed that postpartum haemorrhage contributed to over 40% of in-hospital deaths of Ethiopian women. However, little is known about the barriers to effective management of primary postpartum haemorrhage. This study aims to explore the views and experiences of maternity healthcare professionals about the barriers to managing primary postpartum haemorrhage following in-hospital births in northwest Ethiopia using the ‘Three Delays’ model as a conceptual framework. Methods A qualitative descriptive study was employed at two tertiary referral hospitals between December 2018 and May 2019. Forty-one maternal healthcare providers, including midwives, midwifery unit managers, and obstetricians, participated in this study. Individual face-to-face interviews, focus group discussions, and self-administered open-ended questionnaires were used to collect data. A framework analysis approach was used for the qualitative data analysis. Themes were identified based on the Three Delays model of ‘delay the decision to seek care’, ‘delay arrival at a health facility’, and ‘delay the provision of appropriate and quality care’. Results Participants reported several modifiable issues when managing primary postpartum haemorrhage, and all were linked to a delay in receiving appropriate and quality care due to limited resources. Five sub-themes were identified: ‘workforce’, ‘communication issues between healthcare providers’, ‘systemic issues’, ‘education, training, and resourcing issues’, and ‘lack of identification and referral’. Conclusion Maternal healthcare providers in these hospitals require training in managing a birthing emergency. In addition, the birth units need adequate supplies and continuous essential services. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05071-6.
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Affiliation(s)
- Tiruneh Bewket
- School of Nursing and Midwifery, Monash University, Wellington Rd, 3800, Clayton, Melbourne, VIC, Australia. .,School of Nursing, University of Gondar, Gondar, Ethiopia.
| | - Fooladi Ensieh
- School of Nursing and Midwifery, Monash University, Wellington Rd, 3800, Clayton, Melbourne, VIC, Australia
| | - Plummer Virginia
- School of Nursing and Midwifery, Monash University, Wellington Rd, 3800, Clayton, Melbourne, VIC, Australia.,School of Health, Federation University, Berwick, Melbourne, Australia
| | - McLelland Gayle
- School of Nursing and Midwifery, Monash University, Wellington Rd, 3800, Clayton, Melbourne, VIC, Australia
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Breneol S, Curran JA, Marten R, Minocha K, Johnson C, Wong H, Langlois EV, Wozney L, Vélez CM, Cassidy C, Juvekar S, Rothfus M, Aziato L, Keeping-Burke L, Adjorlolo S, Patiño-Lugo DF. Strategies to adapt and implement health system guidelines and recommendations: a scoping review. Health Res Policy Syst 2022; 20:64. [PMID: 35706039 PMCID: PMC9202131 DOI: 10.1186/s12961-022-00865-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries. METHODS We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level. CONCLUSIONS The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.
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Affiliation(s)
- Sydney Breneol
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada
- Strengthening Transitions in Care Lab, IWK Health Centre, 8th Floor Children's Site, 5850/5980 University Ave, Halifax, NS, B3K 6R8, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada.
- Strengthening Transitions in Care Lab, IWK Health Centre, 8th Floor Children's Site, 5850/5980 University Ave, Halifax, NS, B3K 6R8, Canada.
| | - Robert Marten
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Kirti Minocha
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Catie Johnson
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada
- Strengthening Transitions in Care Lab, IWK Health Centre, 8th Floor Children's Site, 5850/5980 University Ave, Halifax, NS, B3K 6R8, Canada
| | - Helen Wong
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada
- Faculty of Health, Dalhousie University, Halifax, Canada
| | - Etienne V Langlois
- Partnership for Maternal, Newborn & Child Health (PMNCH), World Health Organization, Geneva, Switzerland
| | - Lori Wozney
- Nova Scotia Health Authority Policy and Planning, Dartmouth, Canada
| | - C Marcela Vélez
- Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Christine Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada
- Strengthening Transitions in Care Lab, IWK Health Centre, 8th Floor Children's Site, 5850/5980 University Ave, Halifax, NS, B3K 6R8, Canada
| | - Sanjay Juvekar
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Melissa Rothfus
- W.K. Kellogg Health Science Library, Dalhousie University, Halifax, Canada
| | - Lydia Aziato
- School of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana
| | - Lisa Keeping-Burke
- Department of Nursing & Health Sciences, University of New Brunswick, St. John, Canada
| | - Samuel Adjorlolo
- Department of Mental Health Nursing, University of Ghana, Legon, Accra, Ghana
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Ugwu SN, Adewusi OJ. Pattern of implementation of Emergency Obstetric Life-Saving Skills in public health facilities in Nsukka Local Government Area of Enugu State, Nigeria. J OBSTET GYNAECOL 2021; 42:1065-1071. [PMID: 34951332 DOI: 10.1080/01443615.2021.1999910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Maternal mortality and morbidity can be minimised if adequate timely emergency obstetric life-saving care is provided especially at the primary health level. We conducted a descriptive cross-sectional study among 167 community health workers to investigate the pattern of performance of implementation of emergency obstetric life-saving skills (EmOLSS) in health facilities in Nsukka Local Government Area (LGA) of Enugu State. A pre-tested, paper-based questionnaire was utilised and data was analysed using descriptive and Chi-square statistics. Almost all were female (99.4%) and mean age was 39.5 ± 8.17 years. The pattern of core EmOLSS showed that 8.4% always use partograph and 60.8% use oxytocin for active management of third stage of labour. Only 15% had high level of confidence to carry out intrapartum and postpartum EmOLSS activities. Increased workload (66.3%), lack of supportive supervision (91.0%) and lack of infrastructure to work with (81.3%) influenced the pattern of implementation while poor basic knowledge of EmOLSS and lack of time influenced the level of confidence of the health workers. Health workers displayed poor pattern of EmOLSS implementation and low level of confidence. Regular training with supervision and provision of infrastructure will be beneficial to ensure improvement in the quality of care and reduction in maternal mortality.IMPACT STATEMENTWhat is already known on this subject? Emergency obstetric life-saving care is a key interventional strategy in the reduction of maternal mortality and morbidity. Reports showed that effective coordination and implementation of this care especially at the primary care level could reduce birth complications. Yet, there are gaps in the implementation of this essential care in the low and middle income countries.What do the results of this study add? This study revealed poor pattern of implementation of emergency obstetric life-saving care and low level of confidence among frontline health workers in public primary healthcare facilities in Nsukka Local Government Area of Enugu State, Nigeria. While there are efforts geared towards training of these health workers, the pattern of implementation of emergency obstetric life-saving care was affected by other health workers' intrapersonal, client-related and institutional factors.What are the implications of these findings for clinical practice and/or further research? Information from this study is useful to the government and other maternal health stakeholders to formulate policies, and design ecological programs that target the clients, health workers and institutions.
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Affiliation(s)
- Scholastica N Ugwu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oluwafemi J Adewusi
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Ramsey K. Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth. Health Policy Plan 2021; 37:400-415. [PMID: 34755181 DOI: 10.1093/heapol/czab135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Kate Ramsey
- Columbia University Mailman School of Public Health, Department of Population and Family Health, 60 Haven Avenue, New York, NY 10032, USA
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Pare Toe L, Samuelsen H. Balancing professional autonomy and authority at the margins of a fragile state: Front-line health workers' experiences in Burkina Faso. Glob Public Health 2020; 16:1099-1110. [PMID: 33028153 DOI: 10.1080/17441692.2020.1825768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The availability of diagnostic equipment, medical products and basic infrastructure is limited in most low-income societies. Poor motivation among health workers as well as recruitment and retention problems are key factors contributing to poor health care services in developing countries. The current paper describes how the front line cope with these difficult working conditions. Data for this study come from anthropological fieldwork in two districts of Burkina Faso and include a total of 27 unstructured and 40 semi-structured interviews with staff at dispensaries and medical centres in the two districts. Analytically, we make a distinction between their professional autonomy and their professional authority. We find that while the health workers experience a certain degree of professional autonomy, in the sense that they rely on their own clinical judgement and their discretion as decision makers and gatekeepers, their professional authority is constantly challenged when working at the margins of the state. Through improvisations and bricolaging, they compensate for the many shortcomings, but many of them feel that their skills are waning and that their professional identity threatened. Thus, massive strengthening of the front-line health worker's capacity is imperative for future improvement of health care services in Burkina Faso.
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Affiliation(s)
- Lea Pare Toe
- Institut de Recherche en Sciences de la Santé, Unite Biomedicale, Ouagadougou, Burkina Faso
| | - Helle Samuelsen
- Department of Anthropology, University of Copenhagen, Denmark
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8
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Masefield SC, Megaw A, Barlow M, White PCL, Altink H, Grugel J. Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research. Health Res Policy Syst 2020; 18:63. [PMID: 32513183 PMCID: PMC7278191 DOI: 10.1186/s12961-020-00577-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/19/2020] [Indexed: 11/26/2022] Open
Abstract
Background Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes. Methods A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data. Results Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data. Conclusion We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.
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Affiliation(s)
- Sarah C Masefield
- Department of Health Sciences, University of York, York, YO10 5DD, United Kingdom. .,Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom.
| | - Alice Megaw
- Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom
| | - Matt Barlow
- Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom.,Department of Politics, University of York, York, YO10 5DD, United Kingdom
| | - Piran C L White
- Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom.,Department of Environment and Geography, University of York, York, YO10 5NG, United Kingdom
| | - Henrice Altink
- Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom.,Department of History, University of York, York, YO10 5NH, United Kingdom
| | - Jean Grugel
- Interdisciplinary Global Development Centre, University of York, York, YO10 5DD, United Kingdom.,Department of Politics, University of York, York, YO10 5DD, United Kingdom
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Haley CA, Brault MA, Mwinga K, Desta T, Ngure K, Kennedy SB, Maimbolwa M, Moyo P, Vermund SH, Kipp AM. Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health. Health Policy Plan 2019; 34:24-36. [PMID: 30698696 PMCID: PMC6479825 DOI: 10.1093/heapol/czy105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2018] [Indexed: 11/12/2022] Open
Abstract
Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.
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Affiliation(s)
- Connie A Haley
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Marie A Brault
- Department of Anthropology, University of Connecticut, 354 Mansfield Road, Storrs, CT, USA
| | - Kasonde Mwinga
- World Health Organization, Regional Office for Africa, Cite du Djoue, Brazzaville, Congo
| | - Teshome Desta
- World Health Organization, Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research & Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | | | - Precious Moyo
- Collaborative Research Program, University of Zimbabwe/University of California, San Francisco, Harare, Zimbabwe
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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Yasin C, Geleto A, Berhane Y. Referral linkage among public health facilities in Ethiopia: A qualitative explanatory study of facilitators and barriers for emergency obstetric referral in Addis Ababa city administration. Midwifery 2019; 79:102528. [PMID: 31442877 DOI: 10.1016/j.midw.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/11/2019] [Accepted: 08/11/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND In developing countries including Ethiopia, maternal mortality ratio remains unacceptably high. During pregnancy and childbirth, a woman may acquire one or more of obstetric complications including hemorrhage, sepsis, hypertension and obstructed labor. Early diagnosed and referral of women who experienced obstetric complications to a specialty center can save the life of women and babies. However, several factors might affect the referral procedures of these women. Therefore, this study was aimed at assessing the facilitators and barriers of obstetric referral in selected public health facilities of Addis Ababa city administration, Ethiopia. METHODS A qualitative study design was employed to obtain the narratives of 12 healthcare workers and three recently referred mothers. The study included a regional health bureau, a lead hospital and a health center. Thematic analysis was employed to present to present the findings of the study and open code software was used to code and generate the themes. RESULTS This study revealed several barriers and some facilitators of obstetric referral. Early identification of complications, exercising teamwork, availability of referral protocol, availability of ambulance and effective communication system were the major reported factors which enhanced obstetric referral. Several themes including poor perception of clients, poor supportive supervision, lack of staff motivation and shortage of beds and medical equipment, lack of competence among the staffs and shortage of ambulance at health center were emerged as barriers of obstetric referral. CONCLUSIONS This study revealed several barriers of obstetric referral in the Addis Ababa city administration although a number of facilitators of obstetric referral exist. All of the reported barriers are related to the existing health system that need a collective action of all the actors to eliminate the barriers while enhancing the facilitators of obstetric referral.
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Affiliation(s)
- Chaltu Yasin
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia.
| | - Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Ethiopia.
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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11
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Shelley KD, Mpembeni R, Frumence G, Stuart EA, Killewo J, Baqui AH, Peters DH. Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis. Matern Child Health J 2019; 23:1327-1338. [PMID: 31228143 DOI: 10.1007/s10995-019-02783-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth A Stuart
- Department of Mental Health, Department of Biostatistics, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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12
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Bintabara D, Ernest A, Mpondo B. Health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a Tanzania National Survey. BMJ Open 2019; 9:e020608. [PMID: 30782861 PMCID: PMC6398731 DOI: 10.1136/bmjopen-2017-020608] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study used a nationally representative sample from Tanzania as an example of low-resource setting with a high burden of maternal and newborn deaths, to assess the availability and readiness of health facilities to provide basic emergency obstetric and newborn care (BEmONC) and its associated factors. DESIGN Health facility-based cross-sectional survey. SETTING We analysed data for obstetric and newborn care services obtained from the 2014-2015 Tanzania Service Provision Assessment survey, using WHO-Service Availability and Readiness Assessment tool. PRIMARY AND SECONDARY OUTCOME MEASURES Availability of seven signal functions was measured based on the provision of 'parental administration of antibiotic', 'parental administration of oxytocic', 'parental administration of anticonvulsants', 'assisted vaginal delivery', 'manual removal of placenta', 'manual removal of retained products of conception' and 'neonatal resuscitation'. Readiness was a composite variable measured based on the availability of supportive items categorised into three domains: staff training, diagnostic equipment and basic medicines. RESULTS Out of 1188 facilities, 905 (76.2%) were reported to provide obstetric and newborn care services and therefore were included in the analysis of the current study. Overall availability of seven signal functions and average readiness score were consistently higher among hospitals than health centres and dispensaries (p<0.001). Furthermore, the type of facility, performing quality assurance, regular reviewing of maternal and newborn deaths, reviewing clients' opinion and number of delivery beds per facility were significantly associated with readiness to provide BEmONC. CONCLUSION The study findings show disparities in the availability and readiness to provide BEmONC among health facilities in Tanzania. The Tanzanian Ministry of Health should emphasise quality assurance efforts and systematic maternal and newborn death audits. Health leadership should fairly distribute clinical guidelines, essential medicines, equipment and refresher trainings to improve availability and quality BEmONC.
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Affiliation(s)
- Deogratius Bintabara
- Department of Public Health, College of Health Sciences, The University of Dodoma, Dodoma, United Republic of Tanzania
| | - Alex Ernest
- Department of Obstetrics and Gynecology, College of Health Sciences, The University of Dodoma, Dodoma, United Republic of Tanzania
| | - Bonaventura Mpondo
- Department of Internal Medicine, College of Health Sciences, The University of Dodoma, Dodoma, United Republic of Tanzania
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Baker U, Petro A, Marchant T, Peterson S, Manzi F, Bergström A, Hanson C. Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework. PLoS One 2018; 13:e0209092. [PMID: 30566511 PMCID: PMC6300247 DOI: 10.1371/journal.pone.0209092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Quality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect. Materials and methods A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes. Results Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention’s comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge. Conclusion Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.
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Affiliation(s)
- Ulrika Baker
- Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
- * E-mail: ,
| | - Arafumin Petro
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Stefan Peterson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Makerere School of Public Health, Kampala, Uganda
- UNICEF, Health Section, Programme Division, New York, United States of America
| | - Fatuma Manzi
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Anna Bergström
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Institute for Global Health, University College London, London, United Kingdom
| | - Claudia Hanson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
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14
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Geleto A, Chojenta C, Musa A, Loxton D. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature. Syst Rev 2018; 7:183. [PMID: 30424808 PMCID: PMC6234634 DOI: 10.1186/s13643-018-0842-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa. METHODS Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings. RESULT The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff. CONCLUSIONS A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017074102.
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Affiliation(s)
- Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia. .,Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia.
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
| | - Abdulbasit Musa
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia.,School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
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Cichowitz C, Watt MH, Mchome B, Masenga GG. Delays contributing to the development and repair of obstetric fistula in northern Tanzania. Int Urogynecol J 2017; 29:397-405. [PMID: 28836060 DOI: 10.1007/s00192-017-3416-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Cody Cichowitz
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bariki Mchome
- Kilimanjaro Christian Medical Center, P.O. Box 3010, Moshi, Tanzania
| | - Gileard G Masenga
- Kilimanjaro Christian Medical Center, P.O. Box 3010, Moshi, Tanzania.
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16
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Kanté AM, Exavery A, Phillips JF, Jackson EF. Why women bypass front-line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania. Trop Med Int Health 2016; 21:504-14. [PMID: 26806479 DOI: 10.1111/tmi.12672] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In the Tanzanian health system, women are expected to first visit their nearest front-line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behaviour. METHODS Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered 'bypassers'. Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited, among 521 women with no previous complications, and among 407 women not primigravida and without previous complications. RESULTS More than 75.4% of women bypassed. In the fully adjusted model of all 597 women those who had experienced complications were more likely to bypass for delivery [OR = 6.31 (2.36, 16.86)]. In the fully adjusted model excluding women with previous complications, primigravida women were more likely to bypass [OR = 3.70 (1.71, 8.01)]. Fully adjusted models for each set of analysis found that, for each additional emergency obstetric and newborn care signal function (EmONC SF) available at the nearest FLF, women's odds of bypassing almost halved. CONCLUSIONS Bypassing is highly associated with EmONC SF score at nearest FLF, controlling for individual and community-level factors.
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Affiliation(s)
- A M Kanté
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.,Ifakara Health Institute, Dar-Es-Salaam, Tanzania
| | - A Exavery
- Ifakara Health Institute, Dar-Es-Salaam, Tanzania
| | - J F Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - E F Jackson
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
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17
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Mahiti GR, Mkoka DA, Kiwara AD, Mbekenga CK, Hurtig AK, Goicolea I. Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania. Glob Health Action 2015; 8:28567. [PMID: 26498576 PMCID: PMC4617868 DOI: 10.3402/gha.v8.28567] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/17/2015] [Accepted: 09/26/2015] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Gladys Reuben Mahiti
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;
| | - Dickson Ally Mkoka
- School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Angwara Dennis Kiwara
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Anna-Karin Hurtig
- Division of Epidemiology and Global Health, Umea University, Umea, Sweden
| | - Isabel Goicolea
- Division of Epidemiology and Global Health, Umea University, Umea, Sweden
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Mkoka DA, Mahiti GR, Kiwara A, Mwangu M, Goicolea I, Hurtig AK. "Once the government employs you, it forgets you": Health workers' and managers' perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania. HUMAN RESOURCES FOR HEALTH 2015; 13:77. [PMID: 26369663 PMCID: PMC4570215 DOI: 10.1186/s12960-015-0076-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 09/08/2015] [Indexed: 05/31/2023]
Abstract
BACKGROUND In many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems' function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention. METHODS In-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director's office). An interview guide was used with questions pertaining to informants' perspective on provision of maternal health care service, working environment, living conditions, handling of staff's financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers' role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach. RESULTS Overall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers' role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers' claims timely and that there is no transparency and fairness in dealing with health workers' financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers' concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers' knowledge and skills necessary for providing quality maternal health care. CONCLUSION Health workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers' financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.
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Affiliation(s)
- Dickson Ally Mkoka
- Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Gladys Reuben Mahiti
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Angwara Kiwara
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Mughwira Mwangu
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Isabel Goicolea
- Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health, Umeå University, 901 85, Umeå, Sweden.
| | - Anna-Karin Hurtig
- Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health, Umeå University, 901 85, Umeå, Sweden.
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Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts. PLoS One 2015; 10:e0130633. [PMID: 26068907 PMCID: PMC4465977 DOI: 10.1371/journal.pone.0130633] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ineffective district health management potentially impacts on health system performance and service delivery. However, little is known about district health managing practices and time allocation in resource-constrained health systems. Therefore, a time use study was conducted in order to understand current time use practices of district health managers in Ghana. METHODS All 21 district health managers working in three districts of the Eastern Region were included in the study and followed for a period of three months. Daily retrospective interviews about their time use were conducted, covering 1182 person-days of observation. Total time use of the sample population was assessed as well as time use stratified by managerial position. Differences of time use over time were also evaluated. RESULTS District health managers used most of their working time for data management (16.6%), attending workshops (12.3%), financial management (8.7%), training of staff (7.1%), drug and supply management (5.0%), and travelling (9.6%). The study found significant variations of time use across the managerial cadres as well as high weekly variations of time use impulsed mainly by a national vertical program. CONCLUSIONS District health managers in Ghana use substantial amounts of their working time in only few activities and vertical programs greatly influence their time use. Our findings suggest that efficiency gains are possible for district health managers. However, these are unlikely to be achieved without improvements within the general health system, as inefficiencies seem to be largely caused by external factors.
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Affiliation(s)
- Marc Bonenberger
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
| | - Moses Aikins
- School of Public Health, University of Ghana, Legon, Ghana
| | | | - Xavier Bosch-Capblanch
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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