Clean Home-Delivery in Rural Southern Tanzania: Barriers, Influencers, and Facilitators

The study explored the childbirth-related hygiene and newborn care practices in home-deliveries in Southern\ud Tanzania and barriers to and facilitators of behaviour change. Eleven home-birth narratives and six focus group discussions were conducted with recently-delivering women; two focus group discussions were conducted with birth attendants. The use of clean cloth for delivery was reported as common in the birth narratives; however, respondents did not link its use to newborn’s health. Handwashing and wearing of gloves by birth attendants varied and were not discussed in terms of being important for newborn’s health, with few women giving reasons for this behaviour. The lack of handwashing and wearing of gloves was most commonly linked to the lack of water, gloves, and awareness. A common practice was the insertion\ud of any family member’s hands into the vagina of delivering woman to check labour progress before calling the birth attendant. The use of a new razor blade to cut the cord was near-universal; however, the cord was usually tied with a used thread due to the lack of knowledge and the low availability of clean thread. Applying something to the cord was near-universal and was considered essential for newborn’s health. Three hygiene practices were identified as needing improvement: family members inserting a hand into\ud the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting\ud substances on the cord. Little is known about families conducting internal checks of women in labour, and more research is needed before this behaviour is targeted in interventions. The use of clean thread as cord-tie appears acceptable and can be addressed, using the same channels and methods that were used for successfully encouraging the use of new razor blade

How long-distance truck drivers and villagers in rural southeastern Tanzania think about heterosexual anal sex: a qualitative study

Objective: To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks. Methods: Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques. Results: Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to ‘fatten the female buttocks’. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only ‘reside in wet places’ (vagina) and that the anus is not ‘conducive’ for condom use; condoms reduce ‘dryness’ and ‘friction’ (pleasure) and may ‘get stuck inside’. Conclusions: The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes

Overcoming the risk of inaction from emissions uncertainty in smallholder agriculture

The potential for improving productivity and increasing the resilience of smallholder agriculture, while also contributing to climate change mitigation, has recently received considerable political attention (Beddington et al 2012). Financial support for improving smallholder agriculture could come from performance-based funding including sale of carbon credits or certified commodities, payments for ecosystem services, and nationally appropriate mitigation action (NAMA) budgets, as well as more traditional sources of development and environment finance. Monitoring the greenhouse gas fluxes associated with changes to agricultural practice is needed for performance-based mitigation funding, and efforts are underway to develop tools to quantify mitigation achieved and assess trade-offs and synergies between mitigation and other livelihood and environmental priorities (Olander 2012)

Roles and Responsibilities in Newborn Care in four African Sites.

To explore roles and responsibilities in newborn care in the intra- and postpartum period in Nigeria, Tanzania and Ethiopia. Qualitative data were collected using in-depth interviews with mothers, grandmothers, fathers, health workers and birth attendants and were analysed through content and framework analyses. We found that birth attendants were the main decision-makers and care takers in the intrapartum period. Birth attendants varied across sites and included female relatives (Ethiopia and Nigeria), traditional birth attendants (Tanzania and Nigeria), spiritual birth attendants (Nigeria) and health workers (Tanzania and Nigeria). In the early newborn period, when the mother is deemed to be resting, female family members assumed this role. The mothers themselves only took full responsibility for newborn care after a few days or weeks. The early newborn period was protracted for first-time mothers, who were perceived as needing training on caring for the baby. Clear gender roles were described, with newborn care being considered a woman's domain. Fathers had little physical contact with the newborn, but played an important role in financing newborn care, and were considered the ultimate decision-maker in the family. Interventions should move beyond a focus on the mother-child dyad, to include other carers who perform and decide on newborn care practices. Given this power dynamic, interventions that involve men have the potential to result in behaviour change

Birthweight measurement processes and perceived value: qualitative research in one EN-BIRTH study hospital in Tanzania.

BACKGROUND: Globally an estimated 20.5 million liveborn babies are low birthweight (LBW) each year, weighing less than 2500 g. LBW babies have increased risk of mortality even beyond the neonatal period, with an ongoing risk of stunting and non-communicable diseases. LBW is a priority global health indicator. Now almost 80% of births are in facilities, yet birthweight data are lacking in most high-mortality burden countries and are of poor quality, notably with heaping especially on values ending in 00. We aimed to undertake qualitative research in a regional hospital in Dar es Salaam, Tanzania, observing birthweight weighing scales, exploring barriers and enablers to weighing at birth as well as perceived value of birthweight data to health workers, women and stakeholders. METHODS: Observations were undertaken on type of birthweight scale availability in hospital wards. In-depth semi-structured interviews (n = 21) were conducted with three groups: women in postnatal and kangaroo mother care wards, health workers involved in birthweight measurement and recording, and stakeholders involved in data aggregation in Temeke Hospital, Tanzania, a site in the EN-BIRTH study. An inductive thematic analysis was undertaken of translated interview transcripts. RESULTS: Of five wards that were expected to have scales, three had functional scales, and only one of the functional scales was digital. The labour ward weighed the most newborns using an analogue scale that was not consistently zeroed. Hospital birthweight data were aggregated monthly for reporting into the health management information system. Birthweight measurement was highly valued by all respondents, notably families and healthcare workers, and local use of data was considered an enabler. Perceived barriers to high quality birthweight data included: gaps in availability of precise weighing devices, adequate health workers and imprecise measurement practices. CONCLUSION: Birthweight measurement is valued by families and health workers. There are opportunities to close the gap between the percentage of babies born in facilities and the percentage accurately weighed at birth by providing accurate scales, improving skills training and increasing local use of data. More accurate birthweight data are vitally important for all babies and specifically to track progress in preventing and improving immediate and long-term care for low birthweight children

Counting on birth registration: mixed-methods research in two EN-BIRTH study hospitals in Tanzania.

BACKGROUND: Birth registration marks a child's right to identity and is the first step to establishing citizenship and access to services. At the population level, birth registration data can inform effective programming and planning. In Tanzania, almost two-thirds of births are in health facilities, yet only 26% of children under 5 years have their births registered. Our mixed-methods research explores the gap between hospital birth and birth registration in Dar es Salaam, Tanzania. METHODS: The study was conducted in the two Tanzanian hospital sites of the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) multi-country study (July 2017-2018). We described the business processes for birth notification and registration and collected quantitative data from women's exit surveys after giving birth (n = 8038). We conducted in-depth interviews (n = 21) to identify barriers and enablers to birth registration among four groups of participants: women who recently gave birth, women waiting for a birth certificate at Temeke Hospital, hospital employees, and stakeholders involved in the national birth registration process. We synthesized findings to identify opportunities to improve birth registration. RESULTS: Standard national birth registration procedures were followed at Muhimbili Hospital; families received birth notification and were advised to obtain a birth certificate from the Registration, Insolvency, and Trusteeship Agency (RITA) after 2 months, for a fee. A pilot programme to improve birth registration coverage included Temeke Hospital; hand-written birth certificates were issued free of charge on a return hospital visit after 42 days. Among 2500 women exit-surveyed at Muhimbili Hospital, 96.3% reported receiving a birth notification form and nearly half misunderstood this to be a birth certificate. Of the 5538 women interviewed at Temeke Hospital, 33.0% reported receiving any documentation confirming the birth of their child. In-depth interview respondents perceived birth registration to be important but considered both the standard and pilot processes in Tanzania complex, burdensome and costly to both families and health workers. CONCLUSION: Birth registration coverage in Tanzania could be improved by further streamlining between health facilities, where most babies are born, and the civil registry. Families and health workers need support to navigate processes to register every child

Study protocol : improving newborn survival in rural southern Tanzania : a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening

Child mortality has declined substantially in many countries including Tanzania, but newborn mortality remains high and around 3 million babies die every year in the first 28 days of life. Community-based approaches with home visits in the first week of life have shown great potential to reduce newborn mortality. INSIST aimed1 to develop, implement and evaluate an integrated, two-part strategy that combines interventions at community level with health system strengthening in rural Southern Tanzania to reduce newborn mortality. The community intervention focused around interpersonal communication through home visits in pregnancy and the early neonatal period by a village-based "agent of change". Key messages focused on hygiene during delivery, immediate and exclusive breastfeeding, and identification and extra care for babies born small because of low birth weight or prematurity. Extra care for babies born small included skin-to-skin care for small babies and referral to hospital for very small babies. The community intervention was implemented in six poor rural districts in Southern Tanzania, with 65 of the 132 wards within these districts randomized to receive the community intervention. In addition, a health system quality-improvement package was implemented in all health facilities of one district. Data collection for the evaluation included i) a baseline household survey in 2007 of all 243,000 households in 5 of the 6 study districts to estimate baseline mortality and prevalence of newborn care behaviours, ii) an adequacy survey in 2011 in a representative sample of 5,000 households to estimate coverage of home visits and prevalence of newborn care behaviours, and iii) an endline household survey in 2013 in a representative sample of 200,000 households to estimate newborn and maternal mortality and prevalence of newborn care behaviours. The final analysis was based on "intention to treat", comparing newbor

Effect of home-based counselling on newborn care practices in southern Tanzania one year after implementation: a cluster-randomised controlled trial.

BACKGROUND: In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation. METHODS: All 132 wards in the 6-district study area were randomised to intervention or comparison groups. Starting in 2010, in intervention areas trained volunteers made home visits during pregnancy and after childbirth to promote recommended newborn care practices including hygiene, breastfeeding and identification and extra care for low birth weight babies. In 2011, in a representative sample of 5,240 households, we asked women who had given birth in the previous year both about counselling visits and their childbirth and newborn care practices. RESULTS: Four of 14 newborn care practices were more commonly reported in intervention than comparison areas: delaying the baby's first bath by at least six hours (81% versus 68%, OR 2.0 (95% CI 1.2-3.4)), exclusive breastfeeding in the three days after birth (83% versus 71%, OR 1.9 (95% CI 1.3-2.9)), putting nothing on the cord (87% versus 70%, OR 2.8 (95% CI 1.7-4.6)), and, for home births, tying the cord with a clean thread (69% versus 39%, OR 3.4 (95% CI 1.5-7.5)). For other behaviours there was little evidence of differences in reported practices between intervention and comparison areas including childbirth in a health facility or with a skilled attendant, thermal care practices, breastfeeding within an hour of birth and, for home births, the birth attendant having clean hands, cutting the cord with a clean blade and birth preparedness activities. CONCLUSIONS: A home-based counselling strategy using volunteers and designed for scale-up can improve newborn care behaviours in rural communities of southern Tanzania. Further research is needed to evaluate if, and at what cost, these gains will lead to improved newborn survival. TRIAL REGISTRATION: Trial Registration Number NCT01022788 (http://www.clinicaltrials.gov, 2009)

A typology of modifications to peer support work for adults with mental health problems:systematic review

© The Authors 2020. Background Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects. Aims To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems. Method We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications. Results A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues. Conclusions Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings. Declaration of interest None

Thermal care for newborn babies in rural southern Tanzania: a mixed-method study of barriers, facilitators and potential for behaviour change

Background: Hypothermia contributes to neonatal morbidity and mortality in low-income countries, yet little is known about thermal care practices in rural African settings. We assessed adoption and community acceptability of recommended thermal care practices in rural Tanzania. / Methods: A multi-method qualitative study, enhanced with survey data. For the qualitative component we triangulated birth narrative interviews with focus group discussions with mothers and traditional birth attendants. Results were then contrasted to related quantitative data. Qualitative analyses sought to identify themes linked to a) immediately drying and wrapping of the baby; b) bathing practices, including delaying for at least 6 hours and using warm water; c) day to day care such as covering the baby’s head, covering the baby; and d) keeping the baby skin-to-skin. Quantitative data (n = 22,243 women) on the thermal care practices relayed by mothers who had delivered in the last year are reported accordingly. / Results: 42% of babies were dried and 27% wrapped within five minutes of birth mainly due to an awareness that this reduced cold. The main reason for delayed wrapping and drying was not attending to the baby until the placenta was delivered. 45% of babies born at a health facility and 19% born at home were bathed six or more hours after birth. The main reason for delayed bathing was health worker advice. The main reason for early bathing believed that the baby is dirty, particularly if the baby had an obvious vernix as this was believed to be sperm. On the other hand, keeping the baby warm and covered day-to-day was considered normal practice. Skin-to-skin care was not a normalised practice, and some respondents wondered if it might be harmful to fragile newborns. / Conclusion: Most thermal care behaviours needed improving. Many sub-optimal practices had cultural and symbolic origins. Drying the baby on birth was least symbolically imbued, although resisted by prioritizing of the mothers. Both practical interventions, for instance, having more than one attendant to help both mother and baby, and culturally anchored sensitization are recommended