Factors affecting effective community participation in maternal and newborn health programme planning, implementation and quality of care interventions.

BACKGROUND: Community participation in in health programme planning, implementation and quality improvement was recently recommended in guidelines to improve use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns. How to implement community participation effectively remains unclear. In this article we explore different factors. METHODS: We conducted a secondary analysis, using the Supporting the Use of Research Evidence framework, of effectiveness studies identified through systematic literature reviews of two community participation interventions; quality improvement of maternity care services; and maternal and newborn health programme planning and implementation. RESULTS: Community participation ranged from outreach educational activities to communities being full partners in decision-making. In general, implementation considerations were underreported. Key facilitators of community participation included supportive policy and funding environments where communities see women's health as a collective responsibility; linkages with a functioning health system e.g. via stakeholder committees; intercultural sensitivity; and a focus on interventions to strengthen community capacity to support health. Levels of participation and participatory approaches often changed over the life of programmes as community and health services capacity to interact developed. CONCLUSION: Implementation requires careful consideration of the context: previous experience with participation, who will be involved, gender norms, and the timeframe for implementation. Relevant stakeholders must be actively involved, particularly those often excluded from decision making. Current limited evidence suggests that the vision of community participation as a process and the presence of a focus to strengthen community capacity to participate and to improve health may be a key factor for long term success

Assessing emergency obstetric and newborn care:Can performance indicators capture health system weaknesses?

Background: Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement. Methods: Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives. Results: Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance. Conclusions: Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement

Labor curves based on cervical dilatation over time and their accuracy and effectiveness: A systematic scoping review

Objectives: This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation. Methods: A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies. Results and implications for research: Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle–income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness

Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client’s wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria

Quality of Maternity Care in Rural Tanzania: Understanding Local Realities and Identification of Opportunities for Improvement

Maternal health remains a challenge in sub-Saharan Africa, and Tanzania is no exception. Despite increases in access and use of health care services maternal deaths have not decreased at a sufficient rate. Attention for the quality of care that women receive reveals that the content of care is not always in accordance with evidence-based standards. This thesis describes and assesses the quality of care provided by facility based health workers during pregnancy and birth in a rural setting in. Data was collected over several periods between 2012 and 2016 and took place in the Mwanza region, Tanzania. Participant observation formed an important part of the research approach. Mixed-methods were used to assess the quality of antenatal care at 13 dispensaries, one health centre and one district hospital. Data collection included a facility survey, direct observations of antenatal care consultations, and exit interviews with women attending care. In order to gain understanding of the quality of care during birth I observed and participated for more than 1300 hours on maternity wards in four rural and semi-urban health facilities. Additionally, I followed 14 women during pregnancy, birth and in the post-partum period. Findings revealed that quality of care, provided during antenatal care and birth, was severely compromised due to health system challenges. Health workers prioritized or neglected elements of essential care, influenced by complex working conditions, rather than adhering to evidence-based guidelines. All 14 women that were followed throughout their pregnancy were exposed to non-supportive care, including incidences of disrespect and abuse, during antenatal care and birth. Women’s normalization and justification of these experiences revealed how structural and ingrained substandard care has become throughout women’s reproductive lives. In conclusion, the quality of care that women received during pregnancy and birth was sub-standard, both from a technical and interpersonal perspective. Strengthening the health system to ensure availability of ‘good enough’ quality and respectful care, to ensure women have a positive pregnancy and birth experience, will likely encourage more women to seek care in a timely manner during birth. Substandard care and mistreatment of women across the continuum of care, must be holistically tackled, and needs to consider the realities of people’s lives and the context of structural social, economic and political forces driving the health system

Quality of care during childbirth in Tanzania: identification of areas that need improvement

Background Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania. Methods The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the ‘stages of labour’. Themes were identified through identification of recurrent patterns. Results Three themes were identified: 1) Women’s movement between rooms during birth, 2) health providers’ assumptions and hope for a ‘normal’ birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers ’assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers’ experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene. Conclusions Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women

Mobilizing community action to improve maternal health in a rural district in Tanzania:lessons learned from two years of community group activities

Background: Community participation can provide increased understanding and more effective implementation of strategies that seek to improve outcomes for women and newborns. There is limited knowledge on how participatory processes take place and how this affects the results of an intervention. Objective: This paper presents the results of two years of implementing (2013–2015) community groups for maternal health care in Magu District, Tanzania. Method: A total of 102 community groups were established, and 77 completed the four phases of the participatory learning and action cycle. The four phases included identification of problems during pregnancy and childbirth (phase 1), deciding on solutions and planning strategies (phase 2), implementation of strategies (phase 3) and evaluation of impact (phase 4). Community group meetings were facilitated by 15 trained facilitators and groups met monthly in their respective villages. Data was collected as an ongoing process from facilitator and meeting reports, through interviews with facilitators and local leaders and from focus group discussions with community group participants. Results: The majority of groups prioritized problems related to the availability of and accessibility to health services. The most commonly actioned solution was the provision of health education to the community. Almost all groups (95%) experienced a positive impact on the community as results of their actions, including increased maternal health knowledge and positive behaviour changes among health care workers. Facilitators were positive about the community groups, stating that they were grateful for the gained knowledge on maternal health, and positively regarded the involvement of men in community groups, which are traditionally women-only. Conclusion: The process of establishing and undertaking community groups in itself appeared to have a positive perceived impact on the community. However, sustained behaviour change, power dynamics and financial incentives need to be carefully considered during implementation and sustaining the community groups

Symphysis-fundal height, gestational age and its value for identification of foetuses at risk in rural Tanzania: A qualitative follow-up study

Preterm birth and abnormal foetal growth increase the risk of perinatal morbidity and mortality. Timely identification of foetuses at risk is critical to improving maternal and neonatal outcomes. The objective of this study was to increase understanding of the quality of foetal growth monitoring during antenatal care in Tanzania. Between 2015 and 2017, 13 women were followed throughout their pregnancy, childbirth and postpartum period. Participants were recruited using a staggered approach at selected health facilities. Data collection included direct observations of 25 of 48 antenatal care consultations, review of the women’s antenatal cards, 88 in-depth interviews and participant observation at the health facilities. Six women had facility births and seven had home births. There was one stillbirth, one preterm birth and two term infants died between the age of 3-6 months. Of the 9 newborns with a known birthweight, 3 were possibly growth-restricted. During 12 ANC visits (25%) Symphysis-Fundal Height (SFH) was not recorded and during 22 visits (46%) the recorded Gestational Age (GA) was incorrect. Despite regular assessment of SFH, three possible growth-restricted infants remained undetected. There is a need to improve nurse-midwives ability to determine a reliable GA and improve critical reflection on SFH measurement. (Afr J Reprod Health 2021; 25[5]: 140-149)

Symphysis-fundal height, gestational age and its value for identification of foetuses at risk in rural Tanzania: A qualitative follow-up study

Preterm birth and abnormal foetal growth increase the risk of perinatal morbidity and mortality. Timely identification of foetuses at risk is critical to improving maternal and neonatal outcomes. The objective of this study was to increase understanding of the quality of foetal growth monitoring during antenatal care in Tanzania. Between 2015 and 2017, 13 women were followed throughout their pregnancy, childbirth and postpartum period. Participants were recruited using a staggered approach at selected health facilities. Data collection included direct observations of 25 of 48 antenatal care consultations, review of the women's antenatal cards, 88 in-depth interviews and participant observation at the health facilities. Six women had facility births and seven had home births. There was one stillbirth, one preterm birth and two term infants died between the age of 3-6 months. Of the 9 newborns with a known birthweight, 3 were possibly growth-restricted. During 12 ANC visits (25%) Symphysis-Fundal Height (SFH) was not recorded and during 22 visits (46%) the recorded Gestational Age (GA) was incorrect. Despite regular assessment of SFH, three possible growth-restricted infants remained undetected. There is a need to improve nurse-midwives ability to determine a reliable GA and improve critical reflection on SFH measurement. (Afr J Reprod Health 2021; 25[5]: 140-149)