Innovative partnerships for Safe Motherhood::participation and transdisciplinary collaboration as tools towards increasing skilled birth attendance

Abstract

Motherhood is far from safe in various contexts and settings. Maternal mortality is still unacceptably high, as World Health Organization (WHO) reports indicate. In 2017, around 295 000 women died during pregnancy, childbirth and puerperium. Many initiatives contribute to decreasing the number of maternal deaths, among which those stemming from the Millennium Development Goals and more recently, the Sustainable Development Goals. The new goal is that in 2030, less than 70 women die per 100.000 live births. However, especially in vulnerable populations, the decrease in maternal mortality is too slow to reach this target. Although clear international strategies exist, these are not effective in some contexts. One of the strategies to decrease maternal mortality, is giving birth in the presence of a skilled birth attendant (SBA). Unfortunately, diverse barriers to SBA utilization exist. The underlying causes are often complex and insufficiently researched. In this thesis, underutilization of SBAs is analyzed in two ways. In the first part, is described if interventions can increase skilled birth attendance through using the Birth Preparedness and Complication Readiness model (BPCR). In part two a local context in northern Tanzania is studied, where most women of the mainly Maasai population, give birth in the presence of a traditional birth attendant (TBA) instead of a SBA. This thesis endorses, through analysis of the BPCR model and a local context in northern Tanzania, the importance of: participatory evaluation of contexts in which skilled birth attendance is low, collaboration between all parties involved through co-creating context specific solutions and maternity care. Possibly this facilitates skilled birth attendance, but more certain this increases experiences quality of care and collaboration between maternity care providers, like TBAs and SBAs. The adaptive research approach made the research directly locally relevant. In the discussion I describe that context specific care is often a social innovation and inherently a challenging process. Challenges include: making context specific care measurable, sustainable within health systems, taking power dynamics within communities and health systems into account. It is essential, that those who hold power in (the organization of) maternity care, give way to wishes and needs of women, their families and of those who care for them, both TBAs and SBAs. The research in this thesis fits new definitions of implementation research, in which knowledge is represented in a trans disciplinary way. Insights from this thesis add, modestly, to how we can bridge the “know-do” gap between knowledge and practice. More specifically: how we can understand and counter underutilization of SBA: through participation and collaboration while respecting local expertise. I recommend continuing the co-creation in maternity care and as such contribute to maternity health, wellbeing and the decrease of maternal mortality globally