Manzi, Fatuma

Mwaipopo, Rose

Mwifadhi, Mrisho

Pfeiffer, Constanze

Ramsey, Kate

English

Digital Library of the Tanzania Health Community

 
Spotlight 
August 2012 
Issue 12 
 
  
1 
 
 
Introduction 
Despite decades of global health initiatives focused on 
maternal  health,  maternal  mortality  has  remained  an 
intractable  problem.  One  of  the  Millennium 
Development  Goals  (MDG)  indicators  for  maternal 
health—the  maternal  mortality  ratio—showed 
promising  signs  of  a  decline  in  some  developing 
countries.  However,  800  women  still  die  during 
pregnancy and childbirth every day and many countries 
especially in Sub-Saharan Africa will not reach the MDG 
5  target  of  reducing  maternal  deaths  by  75  per  cent 
from 1990 to 2015 (WHO, 2012).  
 
Skilled attendance in childbirth, another MDG indicator, 
is a key component of primary care strategies in most 
developing countries  and a core part of the essential 
package  of  health  services.  Regular  antenatal  care  is 
important for identifying women who are at increased 
risk  of  adverse  pregnancy  outcomes,  ensuring  birth 
planning  and  for  establishing  good  relations  between 
the  women  and  their  health  care  providers.  Most 
maternal  deaths  occur  during  labour,  delivery  or  the 
first 24 hours after delivery.  
 
Generally, most complications occurring during delivery 
cannot be reliably predicted or prevented, though most 
can be successfully treated with prompt diagnosis and 
care.  Consequently  the  role  of  timely,  efficient  and 
appropriate health services cannot be underestimated. 
Nevertheless,  facility  delivery  rates  in  Sub-Saharan 
Africa are still some of the lowest in the world. 
 
Tanzania has made impressive progress in the reduction 
of  child  mortality  (Masanja  et  al.,  2008),  however 
maternal mortality changed insufficiently between 2000 
and  2010  and  the  attainment  of  the  MDG  5  –is  in 
jeopardy. Health facility delivery rates in Tanzania are 
still low. According to the Tanzania Demographic and 
Health Survey (TDHS) 2010, 50 per cent of births are 
delivered  at  a  health  facility,  and  48  per  cent  are 
delivered at home. Compared to 2004-2005, this is only 
a  slight  increase  from  47  per  cent  to  50  percent  in 
health facility deliveries (NBS and ICF Macro, 2011). 
 
Urban-rural differences 
In  Dar  es  Salaam,  achievements  have  been  made  in 
terms  of  promoting  pregnancy  and  delivery  related 
services  by  skilled  health  workers.  Many  pregnant 
women  have  a  high  level  of  awareness  and  clearly 
prefer  to  deliver  at  a  health  facility.  Only  in  rare 
occasions  do  women  turn  to  a  Traditional  Birth 
Attendant  (TBA)  for  delivery.  Access  to  health  care 
services  is  easier  in  urban  than  rural  areas  due  to 
availability  and  reliability  of  transport  and  higher 
coverage of health facilities. Costs in the city are low 
and  mainly  involve  delivery  kits  and  transport  fees. 
Women  in  Dar  es  Salaam  seem  to  be  well  informed 
about the importance of antenatal as well as postnatal 
Bridging the gap between 
health system and 
community to increase 
health facility delivery 
  
 
  
2 
 
care  services  and  danger  signs  during  pregnancy 
(Pfeiffer & Mwaipopo, 2011).  
 
While  women  in  southern  Tanzania  are  generally 
positive about both antenatal and postnatal care, the 
use of antenatal care services does often not translate 
into a health facility delivery.  Although many women 
often  prefer  delivering  in  a  health  facility,  various 
factors prevent them from doing so. Attitudes of health 
workers, shortage of well trained health workers, lack of 
well  equipped  health  facilities,  shortage  of  essential 
drugs, inability to pay for transport and supplies, poor 
referral systems as well as lack of confidentiality at a 
health  facility  negatively  impact  the  credibility  of  the 
health services offered by the health system (Mrisho et 
al.,  2008;  Mbaruku  et  al.,  2009;  Gross  et  al.,  2011; 
Pfeiffer & Mwaipopo, 2011).  
 
Role of Traditional Birth Attendants  
The  utilization  of  TBAs  and  traditional  medicines 
remains  widespread  in  Tanzania,  particularly  in  rural 
areas.  The  government  of  Tanzania  has  officially 
recognized  the  potential  contribution  of  traditional 
knowledge, including the role of TBAs in communities. 
However,  while  provision  of  maternal  and  neonatal 
health counselling and initiating timely referral by TBAs 
is  promoted,  the  Tanzanian  government  does  not 
support them to attend deliveries (MoHSW, 2008).  
 
 
Uniformed TBAs who support health facilities in 
Mtwara 
TBAs lack biomedical skills and resources, and yet still 
handle  complicated  deliveries  (Pfeiffer  &  Mwaipopo, 
2011). Standards of safety and hygiene procedures are 
often  not  maintained.  But  being  community-based, 
TBAs  command  a  culturally-assigned  level  of  respect 
and confidence. In addition, they are geographically and 
financially accessible (Mrisho et al., 2008).   
 
Following training provided in the past decade, many 
TBAs  today  possess  basic  understanding  of  maternal 
and neonatal health issues. Although TBAs are often not 
as  skilled  as  health  workers,  community  members 
appreciate  them  due  to  their  accessibility,  availability 
and caring behaviour.  
 
 
Items used by TBAs for delivery in Dar es Salaam  
Besides their positive reputation in terms of providing 
psychosocial support, no positive traditional knowledge 
related to medicine, practices and resources could be 
identified in Dar es Salaam or Mtwara. In contrast, some 
of  the  practices  such  as  manipulating  the  uterus  by 
hand and use of herbs (applying “mlenda” leaves on the 
uterus) were encountered. Such practices are harmful 
and  might  risk  the  life  of  the  mother  and  the  child. 
There  was  no  evidence  that  the  traditional  sector 
complements  the  formal  health  system  (Pfeiffer  & 
Mwaipopo, 2011).  
 
While TBAs, who are mainly elderly, are slowly phasing 
out, home deliveries for instance with the assistance of 
relatives are likely to remain for the immediate future 
and beyond. The role of community based actors, TBAs 
or  relatives  cannot  be  underestimated.  Instead  of 
focusing on the traditional sector, it is argued that more 
attention should be paid towards a systematic approach 
to overcome health-system constraints and to extend 
the health system beyond the facility to the community 
level.  
 
  
3 
 
Improving access to and strengthening 
of the health system 
The following recommendations can be drawn: 
 
  There is a need to promote health facility delivery 
as well as antenatal and postnatal care services by 
skilled health facility personnel.  
  Investment in the capacities of health facility staff 
(clinical and interpersonal skills) especially of female 
nurses and midwives is crucial.  
  Overcoming access barriers by exploring a variety 
of  options  is  necessary,  including  setting  up 
maternity waiting homes and improving means of 
transport  such  as  different  types  of  ambulance 
services and community-based transport schemes.    
  Guarantee  private  and  confidential  environment 
and adequacy of staff. In this case, female staff are 
preferred during delivery.  
  Providing  sufficient  equipment  and  commodities 
including medical supplies and essential drugs.  
  Incorporating existing TBAs into the health system 
by training them as community health workers, who 
are  advocates  for  referral  and  skilled  childbirth 
attendants. 
  Exploring  the  potential  of  free  distribution  of 
delivery kits in health facilities. The kits should be 
handed out to women in their last trimester during 
ANC services for use in case of unexpected delivery 
at home.  
 
Bridging the gaps between 
communities and the health sector  
While  there  is  no  evidence  on  the  contribution  of 
trained  TBAs  to  reducing  maternal  and  neonatal 
mortality  rates,  services  offered  by  Village  Health 
Workers  globally  have  contributed  to  the  decline  of 
maternal and child mortality rates (Bhutta et al., 2010).  
In  order  to  contribute  to  bridging  the  gaps  between 
communities and the health sector, the Ifakara Health 
Institute (IHI) with the support of international partners 
is  implementing  intervention-based  research  projects, 
including  ‘The Connect Project: Introducing Community 
Health Agents (CHAs) to facilitate accelerated progress 
towards achievement of MDGs 4 and 5 in Tanzania’ and 
‘Improving  Newborn  Survival  in  Southern  Tanzania’ 
(INSIST) that aims at evaluating the effectiveness and 
cost  of  scalable  strategies  to  improve  neonatal  and 
maternal  health  in  rural  southern  Tanzania.  In  this 
regard, the following aspects are stressed:   
 
Provide  community-based  counselling  and  health 
education  through  well-trained  and  supported 
community health workers (CHWs), who are members 
of and chosen by the community and can therefore be 
more acceptable due to cultural awareness.  
 
Utilise CHWs that are formally trained, supervised and 
employed  by  the  health  system  in  order  to  provide 
promotional and preventive health services in general. 
The  training  will  include  a  package  of  maternal  and 
neonatal health related services in the community and 
the way in which CHWs can engage in risk identification 
and management. 
 
Integrate CHWs into  the formal  health  systems. The 
development  of  strong  referral  links,  health  planning 
and budgeting as well as supplies for community health 
workers needs to be considered.  
 
 
References 
Bhutta,  AZ  et  al.:  Global  Experience  of  Community  Health 
Workers for Delivery of Health Related Millennium 
Development  Goals:  A  Systematic  Review,  Country 
Case Studies, and Recommendations for Integration 
into National Health Systems. Geneva, Switzerland: 
World Health Organization, Global Health Workforce 
Alliance; 2010. 
Gross K et al.: Antenatal care in practice: An exploratory study 
in  antenatal  care  clinics  in  the  Kilombero  Valley, 
south-eastern  Tanzania,  BMC  Pregnancy  and 
Childbirth, 2011, 11:36.  
 
  
4 
 
Masanja, H et al.: Child survival gains in Tanzania: analysis of 
data from demographic and health surveys, Lancet 
2008; 371: 1276–83 
Mbaruku  G  et  al.:  Dissatisfaction  with  traditional  birth 
attendants in rural Tanzania, International Journal of 
Gynaecology and Obstetrics 2009, 107, 8 – 11.  
Ministry  of  Health  and  Social  Welfare:  The  National  Road 
Map  Strategic  Plan  2008-2015.  Dar  es  Salaam, 
Tanzania:  Ministry  of  Health  and  Social  Welfare; 
2008. 
Mrisho  M  et  al.:  Factors  affecting  home  delivery  in  rural 
Tanzania,  Tropical  Medicine  and  International 
Health, 2008, 12:862-872. 
Mrisho M et al.: Understanding home based neonatal care 
practices in rural Southern Tanzania. Transactions of 
the Royal Society of Tropical Medicine and Hygiene, 
2008, 102: 669-678. 
National Bureau of Statistics (NBS) and ICF Macro: Tanzania 
Demographic  and  Health  Survey  2010.  Dar  es 
Salaam, Tanzania: NBS and ICF Macro; 2011. 
Pfeiffer  C  &  Mwaipopo  R.:  Findings  of  a  Study  into  the 
Traditional  Knowledge  of  Traditional  Birth 
Attendants  related  to  Maternal  Health  in  Dar  es 
Salaam  and  Mtwara  Regions  of  Tanzania: 
SDC/Tanzania; 2011. 
World  Health  Organization:  Trends  in  Maternal  Mortality: 
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Acknowledgements 
We thank all involved community members and health staff 
in Dar es Salaam and Mtwara Region for their participation in 
the mentioned studies. The study by Pfeiffer and Mwaipopo 
was  funded  by  the  Swiss  Agency  for  Development  and 
Cooperation SDC Tanzania. Mrisho received funding through 
the IPTi project funded by Bill and Melinda Gates Foundation. 
Constanze Pfeiffer acknowledges the Swiss National Centre of 
Competence in Research (NCCR) North-South for funding the 
project “Reproductive Resilience”. Special thanks to Marcel 
Tanner, Jacques Mader, Elizeus Kahigwa, Brigit Obrist, Claudia 
Kessler  and  Kate  Molesworth  for  their  comments  and 
support. Thanks to the staff of IHI Resource Centre for editing 
and laying out the final manuscript.  
 
 
 
 
The *pdf version can be downloaded from our website: 
www.ihi.or.tz 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Authors 
This  paper  was  written  by  Constanze  Pfeiffer,  Rose 
Mwaipopo,  Kate  Ramsey,  Mrisho  Mwifadhi,  Joanna 
Schellenberg  and  Fatuma  Manzi.  Constanze  Pfeiffer  is  a 
researcher at the Swiss Tropical and Public Health Institute, 
Switzerland. Rose Mwaipopo is the director of the Gender 
Centre at the University of Dar es Salaam, Tanzania. Joanna 
Schellenberg is Reader at the London School of Hygiene and 
Tropical  Medicine,  UK.  Kate  Ramsey  is  a  researcher  at 
Columbia University Mailman School of Public Health, USA 
based at IHI. All other authors are IHI researchers.  
Ifakara Health Institute. Plot 463, Kiko Avenue, Mikocheni. PO Box 78373, Dar es Salaam, Tanzania. 
Phone: +255 (0)22 2774756 Fax: +255 (0)22 2771714   Web: www.ihi.or.tz ; E-mail address: info@ihi.or.tz 
  

Antenatal care in practice: An exploratory study in antenatal care clinics in the Kilombero Valley, south-eastern Tanzania, BMC Pregnancy and Childbirth,

Child survival gains in Tanzania: analysis of data from demographic and health surveys, Lancet 2008; 371: 1276–83 Mbaruku G et al.: Dissatisfaction with traditional birth attendants in rural Tanzania,

Factors affecting home delivery in rural Tanzania, Tropical Medicine and International Health,

Findings of a Study into the Traditional Knowledge of Traditional Birth Attendants related to Maternal Health in Dar es Salaam and Mtwara Regions of Tanzania: SDC/Tanzania;

Ministry of Health and Social Welfare: The National Road Map Strategic Plan 2008-2015. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare;

Organization: Trends in Maternal Mortality:

Understanding home based neonatal care practices in rural Southern Tanzania.

Bridging the Gap Between Health System and Community to Increase Health Facility Delivery

http://ihi.eprints.org/1797/1/Health_Facility_Delivery_Spotlight.pdf

Bridging the Gap Between Health System and Community to Increase Health Facility Delivery

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