Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania

BACKGROUND: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania. METHODS: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10). RESULTS: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment. CONCLUSIONS: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged

Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania

<p>Abstract</p> <p>Background</p> <p>In Tanzania, and many sub-Saharan African countries, postpartum health programs have received less attention compared to other maternity care programs and therefore new parents rely on informal support. Knowledge on how informal support is understood by its stakeholders to be able to improve the health in families after childbirth is required. This study aimed to explore discourses on health related informal support to first-time parents after childbirth in low-income suburbs of Dar es Salaam, Tanzania.</p> <p>Methods</p> <p>Thirteen focus group discussions with first-time parents and female and male informal supporters were analysed by discourse analysis.</p> <p>Results</p> <p>The dominant discourse was that after childbirth a first time mother needed and should be provided with support for care of the infant, herself and the household work by the maternal or paternal mother or other close and extended family members. In their absence, neighbours and friends were described as reconstructing informal support. Informal support was provided conditionally, where poor socio-economic status and non-adherence to social norms risked poor support. Support to new fathers was constructed as less prominent, provided mainly by older men and focused on economy and sexual matters. The discourse conveyed stereotypic gender roles with women described as family caretakers and men as final decision-makers and financial providers. The informal supporters regulated the first-time parents' contacts with other sources of support.</p> <p>Conclusions</p> <p>Strong and authoritative informal support networks appear to persist. However, poverty and non-adherence to social norms was understood as resulting in less support. Family health in this context would be improved by capitalising on existing informal support networks while discouraging norms promoting harmful practices and attending to the poorest. Upholding stereotypic notions of femininity and masculinity implies great burden of care for the women and delimited male involvement. Men's involvement in reproductive and child health programmes has the potential for improving family health after childbirth. The discourses conveyed contradicting messages that may be a source of worry and confusion for the new parents. Recognition, respect and raising awareness for different social actors' competencies and limitations can potentially create a health-promoting environment among families after childbirth.</p

“We have been working overnight without sleeping”: traditional birth attendants’ practices and perceptions of post-partum care services in rural Tanzania

Background: In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs’ practices and perceptions in post-partum care in rural Tanzania. Methods: Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data. Results: Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system. Conclusions: This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA servic

Perceptions about the cultural practices of male partners during postpartum care in rural Tanzania: a qualitative study

Background: Men play an important role in maternal health. The postpartum period is a critical stage, yet there is a scarcity of research that explores men’s involvement during this stage. Objective: The aim of the study was to explore male partners’ perceptions of the cultural practices during postpartum care in rural Tanzania. Methods: Fourteen focus group discussions were conducted with 93 men, with an age range of 19–65 years, in August 2013. The study was conducted in the Kongwa District, located in the Dodoma region in central Tanzania. Qualitative data were digitally recorded, transcribed verbatim and analyzed using content analysis. Results: Four categories emerged, namely: ‘Men as providers and, occasionally, care takers’, ‘Men as decision makers’, ‘Diverse perceptions of sexual abstinence’ and ‘Barriers for men in using/accompanying partners to use reproductive and child healthcare services’. The cross-category theme ‘Men during postpartum: remaining powerful but excluded’ refers to how men are in a powerful position above women in different aspects of life. Elderly women played an important role in caring for postpartum mothers and their newborns, but men were the ones making the final decision about where to seek care. Traditional practices isolated men from their partners for a certain period, and enforced sexual abstinence for the women during the postpartum period. However, cultural norms permitted men to engage in extramarital relations. Reproductive and child healthcare services were perceived by men as not welcoming the male partners, and local gender norms discouraged men from accompanying their partners to seek services. Conclusions: In this study, we found that men perceived their role during the postpartum period as financial providers, decision makers and, occasionally, care givers. Men also held diverse perceptions with regard to sexual abstinence and felt excluded from participating in maternal healthcare services

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

Background: In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice. Objective: To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community. Methods: Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process. Results: In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives’ advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral. Conclusions: Declining maternal referral advice centred around the pregnant women’s position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals

Sexual life and dysfunction after maternal morbidity: a systematic review

Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women´s sexual life and function we conducted a systematic review with the purpose of identifying the available evidence on any sexual impairment associated with complications from pregnancy and childbirth