Association between decision-making during pregnancy and woman-centred care among Tanzanian pregnant women: A cross-sectional survey

BACKGROUND

Many women in Tanzania lack autonomy in decision-making for their pregnancy and childbirth. Woman-centred care (WCC) seeks to provide each woman with the appropriate information that promotes participation and highlights their informed decision-making. Thus, decision-making has been proposed as an essential determinant of WCC. This study aimed to assess the association between decision-making and WCC among Tanzanian pregnant women.

METHODS

We conducted a cross-sectional study among 710 pregnant women in Tanzania. The 23-item Woman-Centred Care English version questionnaire was used to assess how women perceived the care provided by midwives. Participants were categorized into two decision-making groups: decision-making for the birthing place by pregnant women themselves and by others. The pre-defined cut-off point of the top 20 percentile was used to indicate a high level of WCC. Binary logistic regression models were used to determine the association between decision-making and WCC.

RESULTS

The median score (interquartile range) of WCC was 97 (92-103) points when decisions were made by pregnant women, compared to 92 (88-96) points when decisions were made by others (p<0.001). There was a significant association between decision-maker and WCC in both unadjusted (p<0.001) and multivariable-adjusted (p=0.006) analyses. The unadjusted odds were approximately 5 times higher in the pregnant women decision-making group (OR: 4.80, 95% CI: 2.74-8.43) and 3 times higher (OR:2.90, 95% CI: 1.36-6.07) after the adjustment for covariates. We observed no significant interaction between decision-making and parity on the level of WCC (p for interaction=0.52).

CONCLUSION

Pregnant women who made decisions for the birthing place had a higher likelihood of having a high level of WCC compared with their counterparts. Our findings suggest that women should be empowered to be involved in decision-making to increase their satisfaction with the care provided by healthcare providers and foster a positive childbirth experience.

Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda

Evidence-based quality care is essential for reducing sub-Saharan Africa's high burden of maternal and newborn mortality and morbidity. Provision of quality care results from interaction between several components of the health system including competent midwifery care providers and the working environment. We assessed midwifery care providers' ability to provide quality intrapartum and newborn care and selected aspects of the working environment as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) project in Benin, Malawi, Tanzania, and Uganda. We used a self-administered questionnaire to assess provider knowledge and their working environment and skills drills simulations to assess skills and behaviours. All midwifery care providers including doctors providing midwifery care in the maternity units were invited to take part in the knowledge assessment and one third of the midwifery care providers who took part in the knowledge assessment were randomly selected and invited to take part in the skills and behaviour simulation assessment. Descriptive statistics of interest were calculated. A total of 302 participants took part in the knowledge assessment and 113 skills drills simulations were conducted. The assessments revealed knowledge gaps in frequency of fetal heart rate monitoring and timing of umbilical cord clamping. Over half of the participants scored poorly on aspects related to routine admission tasks, clinical history-taking and rapid and initial assessment of the newborn, while higher scores were achieved in active management of the third stage of labour. The assessment also identified a lack of involvement of women in clinical decision-making. Inadequate competency level of the midwifery care providers may be due to gaps in pre-service training but possibly related to the structural and operational facility characteristics including continuing professional development. Investment and action on these findings are needed when developing and designing pre-service and in-service training. Trial registration: PACTR202006793783148-June 17th, 2020.

Effectiveness of an Early Skin-to-Skin Contact Program for Pregnant Women with Cesarean Section: A Quasi-Experimental Trial

OBJECTIVE

This study aimed to clarify the effectiveness of early skin-to-skin contact (SSC) after a cesarean section (CS) program.

METHODS

An "early SSC after CS" program was implemented at a tertiary care hospital in Tanzania. A non-equivalent group design was used. A questionnaire was used to collect data on exclusive breastfeeding, breastfeeding intention, Birth Satisfaction Scale-Revised Indicator (BSS-RI) score, perioperative pain with a visual analogue scale, and infant hospitalization for infectious diseases and diarrhea at 2-3 days postpartum. Follow-up surveys were conducted until 4 months postpartum regarding exclusive breastfeeding, breastfeeding intention, and hospitalization of the infants.

RESULTS

This study involved 172 parturient women who underwent CS, with 86 in the intervention group and 86 in the control group. The exclusive breastfeeding rates at 4 months postpartum were 57 (76.0%) in the intervention group and 58 (76.3%) in the control group, with no significant difference. The BSS-RI score was higher in the intervention group (7.91, range 4-12, SD 2.42) than in the control group (7.18, range 3-12, SD 2.02) (p = 0.007) for women who underwent emergency CS. The survival probability for infants hospitalized owing to infectious diseases, and diarrhea was significantly higher in the intervention group (98.5%) than in the control group (88.3%) (χ² = 5.231, p = 0.022) for multiparas.

CONCLUSION

The early SSC after CS program showed a positive effect on the birth satisfaction of women undergoing emergency CS. It also reduced the incidence of infants hospitalized owing to infectious diseases and diarrhea for multiparas.

Development and pilot test of a smartphone app for midwifery care in Tanzania: A comparative cross-sectional study

To address Tanzania's high maternal mortality ratio, it is crucial to increase women's access to healthcare. To improve access, the quality of antenatal care needs to be improved. Therefore, we conducted a pilot study of a smartphone app for midwives and examined its potential effects on the learning outcomes of midwives and birth preparedness of pregnant women in Tanzania. This mixed-methods, pilot study provided an educational app for midwives in the intervention group, obtained data about the continuous use of the app, measured midwives' learning outcomes, directed focus group discussions on the usability of the app, and conducted surveys among pregnant women about birth preparedness in the intervention and control groups to evaluate if midwives provided proper information to them. The control group received regular antenatal care and answered the same survey. Participants were 23 midwives who participated in the testing and provided learning outcome data. Twenty-one participated in focus group discussions. Results showed that 87.5% of midwives continued to study with the app two months post-intervention. A mini-quiz conducted after using the app showed a significant increase in mean scores (6.9 and 8.4 points, respectively) and a non-significant increase on the questionnaire on women-centered care (98.6 and 102.2 points, respectively). In the focus group discussions, all midwives expressed satisfaction with the app for several reasons, including comprehensive content, feelings of confidence, and reciprocal communication. There were 207 pregnant women included in the analysis. The intervention group had significantly higher knowledge scores and home-based value scores than did controls. The total scores and other subscales did not show statistical significance for group differences. The results indicate the potential impact of the midwifery education app when it is implemented on a larger scale, especially considering that the results show a potential effect on midwives' learning outcomes.

Women's experiences with hypertensive disorders of pregnancy from a national referral hospital in Tanzania: A qualitative study

AIM

This study aimed to explore the experiences among postpartum women with hypertensive disorders of pregnancy, from pregnancy to admission at a referral hospital in Tanzania.

METHODS

This was a descriptive cross-sectional design with purposive sampling. Data were collected from semi-structured in-depth interviews with postpartum women diagnosed with hypertensive disorders and who were admitted to the maternity ward of Muhimbili National Hospital. Data were analyzed using NVivo software for qualitative content analysis.

RESULTS

Fourteen women participated in interviews. Half were primipara and two-thirds had over four antenatal visits. Data analysis yielded four categories and 27 sub-categories. The four categories were: "I'm shocked; I thought I was normal," "The treatment journey," "What health care providers did and did not teach me," "I have a risky future; I hope health care providers can help me."

CONCLUSION

Women regarded themselves going from being normal to having a risk through the process of experiencing their treatments. They did not expect to be admitted or referred to a major hospital and while they demanded more information and education, they also expressed appreciation for their health care providers. Education during pregnancy addressing their needs and level of understanding is recommended for improvement of early detection and access to the health service.

Local knowledge and derived practices of safety during pregnancy, childbirth and postpartum: a qualitative study among nurse-midwives in urban eastern Tanzania

BACKGROUND

Maternal and newborn mortality are still high in low-income and middle-income countries despite global efforts to improve the quality of care by prioritising evidence-based practices and increasing the number of births attended by skilled personnel. During childbirth, women are hesitant to use the health facility services. Concerns about safety and risks during pregnancy, childbirth and postpartum period are deeply rooted in local health practices and beliefs.

OBJECTIVE

The aim of this study was to explore the perceptions of local health knowledge and derived practices among nurse-midwives in urban eastern Tanzania.

METHODS

An exploratory qualitative study design was carried out in a district hospital in eastern Tanzania. Twenty-one nurse-midwives participated in two focus group discussions. The data were analysed using qualitative content analysis.

RESULTS

Based on existing scientific data, local knowledge and derived practices were categorised as potentially beneficial, neither beneficial nor harmful and potentially harmful. Our study identified a wide range of local knowledge and derived practices used by women. These include to refrain from shouting or crying to prevent exhaustion during labour, drinks and foods restrictions during labour and after birth, and use of local herbs to stimulate labour. In addition, midwives reinforced the importance of integrating local knowledge and practices with potential benefits with evidence-based practices. Encouraging and listening to women would offer an opportunity to reduce harmful practices.

CONCLUSIONS

While non-harmful and beneficial practices for ensuring safety during pregnancy, childbirth and postpartum period should be accepted and supported as a part of our cultural richness, harmful practices should be discouraged. This can be achieved through antenatal health education and afterbirth health messages on hospital discharge to promote positive childbirth health outcomes.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare.

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

Are midwives ready to provide quality evidence-based care after pre-service training? Curricula assessment in four countries-Benin, Malawi, Tanzania, and Uganda

This research sought to map midwifery pre-service training curricula as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project conducted in Benin, Malawi, Tanzania, and Uganda. We conducted the review in two phases. In the first phase, online interviews were performed with the lead project midwives in all four study countries to get an overview of midwifery care providers' pre-service training courses, registration, and licensing requirements. We performed a mapping review of midwifery care providers' pre-service training curricula from different training institutions in the four study countries during the second phase. Curricula were reviewed and mapped against the International Confederation of Midwives (ICM) Essential Competencies framework to assess whether these curricula included the minimum essential training components described in the ICM framework. We identified 10 different professional titles for midwifery care providers. The number of years spent in pre-service training varied from one and a half to four years. Ten pre-service curricula were obtained and the assessment revealed that none of the curricula included all ICM competencies. Main gaps identified in all curricula related to women-centred care, inclusion of women in decision making, provision of care to women with unintended or mistimed pregnancy, fundamental human rights of individuals and evidence-based learning. This review suggests that there are skills, knowledge and behaviour gaps in pre-service training curricula for midwifery care providers when mapped to the ICM Essential Competencies framework. These gaps are similar among the different training courses in participating countries. The review also draws attention to the plethora of professional titles and different pre-service training curricula within countries. Trial registration: PACTR202006793783148-June 17th, 2020.

Birth preparedness and related factors: a cross-sectional study in Tanzania City area

Background

Birth preparedness could be the key factor that influences the choice of birthplace with skilled birth attendants. To reduce the high maternal mortality of Tanzania, a large study was planned to develop a smartphone app to promote birth preparedness in a city area of Tanzania. This study aimed to identify factors that influence birth preparedness in the city area of Tanzania.

Methods

Pregnant women were asked to complete the Birth Preparedness Questionnaire during antenatal visits using tablets. Multiple linear regression analyses were performed to determine the sociodemographic and obstetric characteristics that influenced the factors.

Results

A total of 211 participants were included in the analysis. Distance from the nearest health facility negatively influenced the total score of the Birth Preparedness Assessment (β= 0.7, p = 0.02). Education higher than college positively influenced the total score (β = 4.76, p = 0.01). Decision-making of birthplace by other people (not women) negatively influenced Family Support (β=1.18, p = 0.03). Having jobs negatively influenced Preparation of Money and Food (β=-1.02, p < 0.01) and positively influenced the knowledge (β = 0.75, p = 0.03). Being single positively influenced Preparation of Money and Food (β = 0.35, p = 0.19) and Preference of Skilled Birth Attendants (β = 0.42, p = 0.04). Experience of losing a baby negatively influenced the knowledge (β=0.80, p < 0.01) and Preference of Skilled Birth Attendants (β=0.38, p = 0.02).

Conclusions

The findings showed an updated information on pregnant Tanzanian women living in an urban area where rapid environmental development was observed. Birth preparedness was negatively affected when women reside far from the health facilities, the birthplace decision-making was taken by others beside the women, women have jobs, and when women have experienced the loss of a baby. We hope to use the information from this study as content in our future study, in which we will be applying a smartphone app intervention for healthy pregnancy and birth preparedness. This information will also help in guiding the analysis of this future study. Although generalization of the study needs careful consideration, it is important to reconsider issues surrounding birth preparedness as women’s roles both in the family and society, are more, especially in urban settings.

Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol

BACKGROUND

We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care.

METHODS

Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs.

DISCUSSION

We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project.

TRIAL REGISTRATION

PACTR202006793783148-June 17th, 2020.

Perceived differences on the role of traditional birth attendants in rural Tanzania: a qualitative study

Background

In many low to middle income countries, traditional birth attendants (TBAs) play various roles (e.g., provision of health education, referral to hospitals, and delivery support) that can potentially improve women’s access to healthcare. In Tanzania, however, the formal healthcare systems have not acknowleded the role of the TBAs. TBAs’ contributions are limited and are not well described in policy documents. This study aimed to examine the perspectives of both TBAs and skilled birth attendants (SBAs) to clarify the role of TBAs and issues impacting their inclusion in rural Tanzania.

Methods

We used a qualitative descriptive design with triangulation of investigators, methods, and data sources. We conducted semi-structured interviews with 15 TBAs and focus group discussions with 21 SBAs in Kiswahili language to ask about TBAs’ activities and needs. The data obtained were recorded, transcribed, and translated into English. Two researchers conducted the content analysis.

Results

Content analysis of data from both groups revealed TBAs’ three primary roles: emergency delivery assistance, health education for the community, and referrals. Both TBAs and SBAs mentioned that one strength that the TBAs had was that they supported women based on the development of a close relationship with them. TBAs mentioned that, while they do not receive substantial remuneration, they experience joy/happiness in their role. SBAs indicated that TBAs sometimes did not refer women to the hospital for their own benefit. TBAs explained that the work issues they faced were mainly due to insufficient resources and unfavorable relationships with hospitals. SBAs were concerned that TBAs’ lacked formal medical training and their actions could interfere with SBAs’ professional work. Although there were no between-group interactions at the time of this study, both groups expressed willingness to collaborate/communicate to ensure the health and lives of mothers and babies.

Conclusions

TBAs and SBAs have different perceptions of TBAs’ knowledge and skills, but agreed that TBAs need further training/inclusion. Such collaboration could help build trust, improve positive birth experiences of mothers in rural Tanzania, and promote nationwide universal access to maternal healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03611-0.

Knowledge of danger signs during pregnancy and subsequent healthcare seeking actions among women in Urban Tanzania: a cross-sectional study

BACKGROUND

Tanzania is among the countries with a high maternal mortality ratio. However, it remains unclear how information and education on danger signs of pregnancy translate into appropriate actions when a woman recognizes danger signs. This study aimed to determine women's knowledge of obstetric danger signs during pregnancy and their subsequent healthcare seeking actions.

METHODS

The study design was a health facility-based cross-sectional study. Quantitative data were collected through interviewer-administered questionnaires. Descriptive and inferential statistics were used to analyze the data. The study enrolled 384 women from two health centers in Kinondoni Municipality, Dar es Salaam, Tanzania. A woman who had not mentioned any danger sign was categorized as having no knowledge, mentioned one to three danger signs as having low knowledge, and mentioned four or more danger signs as having sufficient knowledge.

RESULTS

Among the 384 participants, 67 (17.4%) had experienced danger signs during their pregnancy and reported their healthcare seeking actions after recognizing the danger signs. Among those who recognized danger signs, 61 (91%) visited a healthcare facility. Among the 384 participants, five (1.3%) had no education, 175 (45.6%) had primary education, 172 (44.8%) had secondary education, and 32 (8.3%) had post-secondary education as their highest educational levels. When asked to spontaneously mention the danger signs, more than half of the participants (n = 222, 57.8%) were able to mention only one to three danger signs. Only 104 (31%) had correct knowledge of at least four danger signs and nine (2.7%) were not able to mention any item. The most commonly known pregnancy danger signs were vaginal bleeding (81%); swelling of the fingers, face, and legs (46%); and severe headache (44%). Older women were 1.6 times more likely to have knowledge of danger signs than young women (OR 1.61; 95% CI 1.05-2.46)".

CONCLUSION

Women took appropriate healthcare seeking action after recognizing danger signs during pregnancy. However, the majority had low knowledge of pregnancy danger signs. Additional studies are warranted to address the knowledge gap and to plan interventions for improving health education under limited resource settings.