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Background/Aims: Extensive research focuses on the advantages and disadvantages of various positions throughout active second stage labour, but there is limited focus on midwives' practice. This study aimed to explore midwives' practice of maternal positions throughout the active phase of second stage labour. Methods: An integrative review of three databases was carried out for research papers published between 2015 and 2022. Thematic analysis was used for data analysis and synthesis. Results: Five eligible research papers were included. There were four key findings: maternal positions practised by midwives, midwives as the prime decision maker, midwives' personal convenience and comfort, and barriers to practising maternal positions. Conclusions: Midwives were seen as prime decision makers, who hindered informed decision making on maternal positions during active second stage labour. Inadequate knowledge, skills and confidence were barriers to practice and attributed to midwives adopting positions that were convenient and comfortable for themselves. Strategies are needed to enhance practice through review and evaluation of current clinical settings, regular updates to evidence-based practice and refreshing essential midwifery skills. [ABSTRACT FROM AUTHOR]

This paper is an attempt to address the question of gender and the manner that it is constructed in the songs of Wahehe in Iringa, Tanzania. Kiduo dance songs are used as a case in point. The reason for picking Kiduo songs is grounded on familiarity. I participated in singing Kiduo songs as a child and later as a fully-fledged adult. Singing the aforesaid songs for such a long time and being exposed to gender issues I became conscious of the fact that some songs (not all) typecast women in different ways as reproductive devices, poor, weak, sexual outlets of men and individuals who cannot make proper decisions. As a member of the community and current a scholar, I strived to find answers to three questions: how women are constructed in songs of Wahehe; how the social construction is regarded as reality of women; and how this impacts lives of women. Findings for this research were collected through observations and focus group interviews. The paper uses the tenet of constructionism to argue that women in Kiduo songs are projected as dependents of men in decision-making. They are featured as poor and timid in a way that weakens their bargaining power. In some songs women are portrayed as sexual outlets of men and reproductive devices whose sense of purpose in life is void except for getting married and giving birth to children. Examining how women are constructed in Kiduo songs of Wahehe is a profound contribution this paper makes to the scholarship of gender and performance in Tanzania. [ABSTRACT FROM AUTHOR]

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation. [ABSTRACT FROM AUTHOR]

Background: Fear of childbirth (FoB) and depressive symptoms (DS) are experienced by many women and can negatively affect women during and after pregnancy. This study assessed patterns of FoB and DS over time and associations of postpartum FoB and DS with sociodemographic and obstetric characteristics. Methods: We conducted a longitudinal study at six health facilities in Tanzania in 2018–2019. Pregnant women were consecutively assessed for FoB and DS before and after childbirth using the Wijma Delivery Expectancy/Experience Questionnaire versions A & B and the Edinburgh antenatal and postnatal depressive scale. This paper is based on 625 women who completed participation. Results: The prevalence rates of FoB and DS during pregnancy were 16% and 18.2%, respectively, and after childbirth, 13.9% and 8.5%. Some had FoB (6.4%) and DS (4.3%) at both timepoints. FoB was strongly associated with DS at both timepoints (p < 0.001). Both FoB (p = 0.246) and DS (p < 0.001) decreased after childbirth. Never having experienced obstetric complications decreased the odds of postpartum and persisting FoB (adjusted odds ratio (aOR) 0.44, 95% confidence interval (CI) 0.23–0.83). Giving birth by caesarean section (aOR 2.01, 95% CI 1.11–3.65) and having more than 12 hours pass between admission and childbirth increased the odds of postpartum FoB (aOR 2.07, 95% CI 1.03–4.16). Postpartum DS was more common in women with an ill child/stillbirth/early neonatal death (aOR 4.78, 95% CI 2.29–9.95). Persisting DS was more common in single (aOR 2.59, 95% CI 1.02–6.59) and women without social support from parents (aOR 0.28, 95% 0.11–0.69). Conclusions: FoB and DS coexist and decrease over time. Identifying predictors of both conditions will aid in recognising women at risk and planning for prevention and treatment. Screening for FoB and DS before and after childbirth and offering psychological support should be considered part of routine antenatal and postnatal care. Furthermore, supporting women with previous obstetric complications is crucial. Using interviews instead of a self-administered approach might have contributed to social desirability. Also, excluding women with previous caesarean sections could underestimate FoB and DS prevalence rates. [ABSTRACT FROM AUTHOR]

Background: Labour pain usually brings with it many concerns for a parturient and her family. The majority of the women in labour pain may require some sort of pain relief method during this period, be it pharmacological or non-pharmacological. In Tanzania, the use of non-pharmacological methods to relief labour pain remains low among nurse-midwives. We analysed the experiences of nurse-midwives in the use of non-pharmacological methods to manage labour pain, in two selected districts of Pwani and Dar es Salaam regions in eastern Tanzania. This paper describes Non-pharmacological Methods (NPMs) currently used by nurse-midwives, the facilitators, myths and fears related to the use of NPMs.Materials and Methods: An exploratory qualitative study using in-depth interviews was conducted with 18 purposively recruited nurse-midwives working in labour wards in two selected district hospitals in Pwani and Dar es Salaam regions in eastern Tanzania. Qualitative conventional content analysis was used to generate categories describing the experience of using non-pharmacological methods in managing labour pain.Results: This study revealed that nurse-midwives encouraged women to tolerate labour pain and instructed them to change positions and to do deep breathing exercises as a means to relief labour pain. Nurse-midwives' inner motives facilitated the use of non-pharmacological strategies for labour pain relief despite the fear of using them and myths that labour pain is necessary for childbirth.Conclusion: This study generates information about the use of non-pharmacological strategies to relief labour pain. Although nurse-midwives are motivated to apply various non-pharmacological strategies to relief labour pain, fear and misconceptions about the necessity of labour pain during childbirth prohibit the effective use of these strategies. Therefore, together with capacity building the nurse-midwives in the use of non-pharmacological strategies to relief labour pain, efforts should be made to address the misconceptions that may partly be of socio-cultural origin. [ABSTRACT FROM AUTHOR]

Background: Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period.Methods: This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial's primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention.Discussion: There is evidence that each of the ALERT intervention components improves health providers' practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions.Trial Registration: Pan African Clinical Trial Registry ( www.pactr.org ): PACTR202006793783148. Registered on 17th June 2020. [ABSTRACT FROM AUTHOR]

Background: Tanzania is one of the Sub-Saharan African country with nearly 12 out of 60 million people being adolescent. The prevalence of child marriage is higher with one out of every three girls being married before reaching their 18th birthday, 5 % being married by the age of 15, and 31% by the age of 18 years. Literature shows early pregnancy is associated with Low Birth Weight (LBW) and stunting among children under 5 years. This paper explores variation and factors associated with low birth weight and stunting among children born by adolescent and non-adolescent mothers. Methods: Data from 13,266 women with children under 5 years collected as part of the 2015/2016 TDHS was re-analyzed using STATA version 14 software while accounting for survey design. A total of 6385 women (of which 7.2% were adolescent) and 8852 women (of which 6.7% were adolescent) were involved in the analysis of child birth weight and stunting respectively. Descriptive statistics stratified by maternal age was conducted with LBW and stunting as outcome variables followed by logistic regressions models controlling for confounding variables. Results: The proportion of obese or overweight adolescent and non-adolescent mothers was 11.8 and 36.5% respectively. Antenatal care (ANC) attendance, areas of residence and social economic status were very similar in the two maternal age groups. Non- adolescent mothers had reduced odds of giving birth to LBW babies compared to adolescent mothers (Adjusted Odds Ratio (AOR) = 0.34; 95% CI: 0.22–0.50). Maternal undernutrition (AOR = 2.29; 95% CI: 1.43–3.67), being divorced, separated or widowed (AOR = 1.76; 95% CI: 1.24–2.50) and having at least four ANC visits (AOR = 0.64; 95% CI: 0.49–0.83) were significantly associated with reduced odds of having a LBW. Child stunting was not associated with maternal age. Maternal high socioeconomic status (AOR = 0.69; 95% CI: 0.57–0.84) and maternal obesity or overweight (AOR = 0.77; 95% CI: 0.64–0.92) were negatively associated with stunting. Child birth weight, sex, and age were significantly associated with stunting. Conclusion: Maternal age was a predictor of LBW but not stunting. ANC attendance and not living with a spouse increase the risk of LBW babies. Stunting was associated with low maternal body mass index (BMI), low socioeconomic status, child birth weight, gender, and age. A multi-sectoral approach is needed to address child nutrition problems with teenagers 'specific intervention that offer emotional support, and health education during pregnancies for improving immediate and later life child birth outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial Registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009. [ABSTRACT FROM AUTHOR]

Background: Increasing births with skilled attendants and increasing health facilities with Emergency Obstetric Care (EmOC) can reduce maternal mortality and are considered critical interventions for ensuring safe motherhood. Despite Tanzania's policy to support women to give birth with the assistance of skilled personnel, some women do not access this care. This article uses women's stories to illustrate the challenges that caused them to fail to access adequate obstetric care in a timely manner, hence causing the development of fistulas. Methods: This paper presents the narratives of 16 women who were conveniently selected based on their experiences of not being able to access adequate obstetric care in timely manner. The analysis was guided by recommendations for the identification and interpretation of narratives, and identified important components of women's experiences, paying attention to commonalities, differences and areas of emphasis. Semi-structured interviews were carried out at CCBRT hospital in Dar es Salaam. Results: Four (4) general story lines were identified from women description of their inability to access quality obstetric care in a timely manner. These were; failing to decide on a health care facility for delivery, lacking money to get to a health care facility, lacking transportation to a health care facility and lacking quality birth care at the health care facility. Conclusion: Women were unable to reach to the health care facilities providing comprehensive emergency obstetric care (CEmOC) in time because of their lack of decision-making power, money and transportation, and those who did reach the facilities received low quality birth care. Empowering women socially and financially, upgrading primary health care facilities to provide CEmOC and increased numbers of skilled personnel would promote health care facility deliveries. [ABSTRACT FROM AUTHOR]

Background: Improving access to facility-based delivery care has the potential to reduce maternal and newborn deaths across settings. Yet, the access to a health facility for childbirth remains low especially in low-income settings. To inform evidence-based interventions, more evidence is needed especially accounting for demand- and supply-side factors influencing access to facility-based delivery care. We aimed to fill this knowledge gap using data from Tanzania. Methods: We used data from a cross-sectional survey (conducted in January 2012) of 150 health facilities, 1494 patients and 2846 households with women who had given births in the last 12 months before the survey across 11 districts in three regions in Tanzania. The main outcome was the place of delivery (giving birth in a health facility or otherwise), while explanatory variables were measured at the individual woman and facility level. Given the hierarchical structure of the data and variance in demand across facilities, we used a multilevel mixed-effect logistic regression to explore the determinants of facility-based delivery care. Results: Eighty-six percent of 2846 women gave birth in a health facility. Demand for facility-based delivery care was influenced more by demand-side factors (76%) than supply-side factors (24%). On demand-side factors, facility births were more common among women who were educated, Muslim, wealthier, with their first childbirth, and those who had at least four antenatal care visits. On supply-side factors, facility births were more common in facilities offering outreach services, longer consultation times and higher interpersonal quality. In contrast, facilities with longer average waiting times, longer travel times and higher chances of charging delivery fees had few facility births. Conclusions: Policy responses should aim for strategies to improve demand like health education to raise awareness towards care seeking among less educated groups and those with higher parity, reduce financial barriers to access (including time costs to reach and access care), and policy interventions to enhance interpersonal quality in service provision. [ABSTRACT FROM AUTHOR]

Background: Inadequate water and sanitation during childbirth are likely to lead to poor maternal and newborn outcomes. This paper uses existing data sources to assess the water and sanitation (WATSAN) environment surrounding births in Tanzania in order to interrogate whether such estimates could be useful for guiding research, policy and monitoring initiatives. Methods: We used the most recent Tanzania Demographic and Health Survey (DHS) to characterise the delivery location of births occurring between 2005 and 2010. Births occurring in domestic environments were characterised as WATSAN-safe if the home fulfilled international definitions of improved water and improved sanitation access. We used the 2006 Service Provision Assessment survey to characterise the WATSAN environment of facilities that conduct deliveries. We combined estimates from both surveys to describe the proportion of all births occurring in WATSAN-safe environments and conducted an equity analysis based on DHS wealth quintiles and eight geographic zones. Results: 42.9% (95% confidence interval: 41.6%–44.2%) of all births occurred in the woman's home. Among these, only 1.5% (95% confidence interval: 1.2%–2.0%) were estimated to have taken place in WATSAN-safe conditions. 74% of all health facilities conducted deliveries. Among these, only 44% of facilities overall and 24% of facility delivery rooms were WATSAN-safe. Combining the estimates, we showed that 30.5% of all births in Tanzania took place in a WATSAN-safe environment (range of uncertainty 25%–42%). Large wealth-based inequalities existed in the proportion of births occurring in domestic environments based on wealth quintile and geographical zone. Conclusion: Existing data sources can be useful in national monitoring and prioritisation of interventions to improve poor WATSAN environments during childbirth. However, a better conceptual understanding of potentially harmful exposures and better data are needed in order to devise and apply more empirical definitions of WATSAN-safe environments, both at home and in facilities. [ABSTRACT FROM AUTHOR]

Background: Violence during childbirth indirectly contributes to maternal and neonatal morbidity and mortality. It also causes intrapartum health consequences such as prolonged labor, postpartum hemorrhage, and postpartum psychological problems, including postpartum depression, post-traumatic stress disorder, and other negative feelings that lead to a decreased desire for facility delivery and increase the events of home deliveries which reduce the quality of life. In Tanzania, several efforts have been made to promote respectful maternity care. However, violence during childbirth continues to create a critical barrier for facility-based delivery and is in need of considerable attention throughout the health system. Objectives: This study aimed to assess types of intrapartum violence and its determinants among postnatal women in the Dodoma Region, Tanzania. Design: A cross-sectional study using a questionnaire to interview postnatal women at the exit point after being discharged from the health facility to assess intrapartum violence and its determinants. Methods: This study was conducted in Dodoma Region involving 307 postnatal women from April to June 2022. A simple random method was used to select respondents. The Chi-square and Fisher's exact tests were used to assess the association between the categorical variables. The predictors of intrapartum violence were determined using binary logistic regression analysis. Statistical analysis was performed using Statistical Package for Social Science version 25.0. P < 0.05 was considered to be significant. Results: Overall, 307 postnatal women participated in the study. Among them, 158 (51.5%) postnatal women experienced at least one form of intrapartum violence. The most common forms of intrapartum violence included breach of confidentiality 205 (66.8%), undignified care/verbal abuse 178 (58%), physical abuse 139 (45.3%), and denial or neglected care by midwives 113 (36.8%). Husband employment, urban residence, and being referred from primary hospitals were significant determinants associated with intrapartum violence (adjusted odds ratio = 0.233, 95% confidence interval = 0.057–0.952, p = 0.043, adjusted odds ratio = 2.67, 95% confidence interval = 1.13–10.93, p = 0.026 and adjusted odds ratio = 3.673, 95% confidence interval = 1.131–11.934, p = 0.030, respectively). Conclusion: Violence during childbirth was highly prevalent in this study. Understanding the prevalence and types of intrapartum violence is important in order to promote changes in all levels of the health system. This study reveals the need for key interventions to effect change at many levels; including an interventional study to educate women and birth partners on client rights, and strengthening the health system to meet the needs of women during labor and childbirth. Policies and systems that support respectful maternity care are urgently needed in this setting, including universal training of health professionals in respectful maternity care [ABSTRACT FROM AUTHOR]

Safer Births Bundle of Care (SBBC) consists of innovative clinical and training tools for improved labour care and newborn resuscitation, integrated with new strategies for continuous quality improvement. After implementation, we hypothesised a reduction in 24-h newborn deaths, fresh stillbirths, and maternal deaths by 50%, 20%, and 10%, respectively. This is a 3-year stepped-wedged cluster randomised implementation study, including 30 facilities within five regions in Tanzania. Data collectors at each facility enter labour and newborn care indicators, patient characteristics and outcomes. This halfway evaluation reports data from March 2021 through July 2022. In total, 138,357 deliveries were recorded; 67,690 pre- and 70,667 post-implementations of SBBC. There were steady trends of increased 24-h newborn and maternal survival in four regions after SBBC initiation. In the first region, with 13 months of implementation (n = 15,658 deliveries), an estimated additional 100 newborns and 20 women were saved. Reported fresh stillbirths seemed to fluctuate across time, and increased in three regions after the start of SBBC. Uptake of the bundle varied between regions. This SBBC halfway evaluation indicates steady reductions in 24-h newborn and maternal mortality, in line with our hypotheses, in four of five regions. Enhanced focus on uptake of the bundle and the quality improvement component is necessary to fully reach the SBBC impact potential as we move forward. [ABSTRACT FROM AUTHOR]

Background: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned.Methods: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries.Results: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1.Conclusions: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries. [ABSTRACT FROM AUTHOR]

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem. [ABSTRACT FROM AUTHOR]

Determinants for women's care seeking for birth in low-income setting are multifactorial and remain poorly understood. A life course approach can assist to structure the interplay of the different factors that lead to women seeking care or not. In this study we aimed to explore individual women's reproductive pathways, and increase understanding of how important life events including previous pregnancy and birth experiences can help us to understand individual choices made for care seeking during childbirth. The study took place in Tanzania between 2015 and 2017. 14 women were followed throughout their pregnancy, birth and postpartum period through participant observation and in-depth interviews. In total 94 in-depth interviews were held (between 5–7 interviews per woman). Analysis occurred continuous throughout the data collection period resulting in detailed narratives of crucial events across women's life course, with specific attention to their current pregnancy. Of the 14 women, seven had a facility birth, six a home birth and one woman gave birth at the home of a local birth attendant. Four different story plots were identified: expected home birth, expected facility birth, unexpected facility birth and unexpected home birth. Birth narratives of four women representative of the different story plots are presented. Narratives illustrate women's individual reproductive pathways including the various factors influencing women's expectations and justifications for their actions during their pregnancy and birth. Women's agency, including women's perception of self, the self in relation to the social environment and reflection on risks associated with the range of options, influences the final decision made for birth. Women's narratives suggest that quality of care can function as a primary pull factor for facility birth. As long as home birth is by some perceived to be a better alternative, achieving skilled care for all will be difficult to achieve. [ABSTRACT FROM AUTHOR]

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained. Trial registration number: NCT04685668 [ABSTRACT FROM AUTHOR]

Introduction: Despite skilled attendance during childbirth has been linked with the reduction of maternal deaths, equality in accessing this safe childbirth care is highly needed to achieving universal maternal health coverage. However, little information is available regarding the extent of inequalities in accessing safe childbirth care in Tanzania. This study was performed to assess the current extent, trend, and potential contributors of poor-rich inequalities in accessing safe childbirth care among women in Tanzania. Methods: This study used data from 2004, 2010, and 2016 Tanzania Demographic Health Surveys. The two maternal health services 1) institutional delivery and 2) skilled birth attendance was used to measures access to safe childbirth care. The inequalities were assessed by using concentration curves and concentration indices. The decomposition analysis was computed to identify the potential contributors to the inequalities in accessing safe childbirth care. Results: A total of 8725, 8176, and 10052 women between 15 and 49 years old from 2004, 2010, and 2016 surveys respectively were included in the study. There is an average gap (>50%) between the poorest and richest in accessing safe childbirth care during the study period. The concentration curves were below the line of inequality which means women from rich households have higher access to the institutional delivery and skilled birth attendance inequalities in accessing institutional delivery and skilled birth attendance. These were also, confirmed with their respective positive concentration indices. The decomposition analysis was able to unveil that household's wealth status, place of residence, and maternal education as the major contributors to the persistent inequalities in accessing safe childbirth care. Conclusion: The calls for an integrated policy approach which includes fiscal policies, social protection, labor market, and employment policies need to improve education and wealth status for women from poor households. This might be the first step toward achieving universal maternal health coverage. [ABSTRACT FROM AUTHOR]

Background: In many low to middle income countries, traditional birth attendants (TBAs) play various roles (e.g., provision of health education, referral to hospitals, and delivery support) that can potentially improve women's access to healthcare. In Tanzania, however, the formal healthcare systems have not acknowleded the role of the TBAs. TBAs' contributions are limited and are not well described in policy documents. This study aimed to examine the perspectives of both TBAs and skilled birth attendants (SBAs) to clarify the role of TBAs and issues impacting their inclusion in rural Tanzania.Methods: We used a qualitative descriptive design with triangulation of investigators, methods, and data sources. We conducted semi-structured interviews with 15 TBAs and focus group discussions with 21 SBAs in Kiswahili language to ask about TBAs' activities and needs. The data obtained were recorded, transcribed, and translated into English. Two researchers conducted the content analysis.Results: Content analysis of data from both groups revealed TBAs' three primary roles: emergency delivery assistance, health education for the community, and referrals. Both TBAs and SBAs mentioned that one strength that the TBAs had was that they supported women based on the development of a close relationship with them. TBAs mentioned that, while they do not receive substantial remuneration, they experience joy/happiness in their role. SBAs indicated that TBAs sometimes did not refer women to the hospital for their own benefit. TBAs explained that the work issues they faced were mainly due to insufficient resources and unfavorable relationships with hospitals. SBAs were concerned that TBAs' lacked formal medical training and their actions could interfere with SBAs' professional work. Although there were no between-group interactions at the time of this study, both groups expressed willingness to collaborate/communicate to ensure the health and lives of mothers and babies.Conclusions: TBAs and SBAs have different perceptions of TBAs' knowledge and skills, but agreed that TBAs need further training/inclusion. Such collaboration could help build trust, improve positive birth experiences of mothers in rural Tanzania, and promote nationwide universal access to maternal healthcare. [ABSTRACT FROM AUTHOR]

• Our paper reports on adverse pregnancy outcomes of women living in artisanal gold mining communities in Tanzania. • We highlight the prospective longitudinal study design which obtained pregnancy outcomes on 961 women and the use of direct measurement of mercury and arsenic levels during the pregnancy. • Just over 50% of women living in these gold mining communities had an adverse pregnancy outcome. Exposure to arsenic and mercury in artisanal and small-scale gold mining (ASGM) communities is an issue that predominantly affects low and middle-income countries. Large epidemiology studies in these communities are rare, and the impact of such exposures on reproductive outcomes are not well understood. To examine associations between prenatal maternal arsenic and mercury exposure and birth outcomes in both ASGM and non-ASGM communities in Northern Tanzania. This longitudinal prospective study included 961 women (ASGM = 788, non-ASGM = 173) of the original cohort of 1056 who were followed until a pregnancy outcome was registered. Maternal spot urine samples and dried blood spots were used to measure total arsenic (T-As) and total mercury (T-Hg) in the second trimester of pregnancy. Data on adverse birth outcomes were collected in 5 categories: spontaneous abortion, stillbirth, preterm birth, low birth weight, and visible congenital anomalies. Mann-Whitney U -tests were used to test for differences between median T-As and T-Hg by area of residence. Logistic regression models were used to estimate the odds of stillbirth and visible congenital anomalies given maternal T-As and T-Hg levels. Modified Poisson regressions were used to estimate relative risk ratios between maternal T-As and T-Hg levels and composite adverse birth outcome, spontaneous abortion, low birth weight, and preterm birth. Statistically significant differences were found in median T-As (9.6 vs. 6.3 µg/L, Mann-Whitney U -tests , Z = −3.50, p < 0.001) and median T-Hg blood concentrations (1.2 vs. 0.70 µg/L, Z = −9.88, p-value < 0.001) between women living in ASGM and non-ASGM areas respectively. In ASGM areas, the adjusted relative risk (aRR) of a composite adverse birth outcome increased with increasing T-As (aRR 1.23, 95%CI: 1.14–1.33, p < 0.0001) and T-Hg (aRR 1.17, 95%CI: 1.1–1.25, p < 0.0001) exposure. Spontaneous abortion (aRR 1.53, 95%CI: 1.28–1.83), stillbirth (adjusted odds ratio (aOR) 1.97, 95%CI: 1.45–2.66) and preterm birth (1.17, 95%CI: 1.01–1.36) were significantly associated with elevated T-As, whereas elevated T-Hg was significantly associated with stillbirth (aOR 2.49, 95%CI: 1.88–3.29) and visible congenital anomalies (aOR 2.24, 95%CI: 1.3–3.87). Over half (54.7%) of women in ASGM areas of Northern Tanzania had adverse birth outcomes and the risk of adverse birth outcomes was significantly associated with increased prenatal exposure to arsenic and mercury. [ABSTRACT FROM AUTHOR]

Background: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania.Methods: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders' meetings held at ward level in which 450 people participated. Data were analysed using thematic approach.Results: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers.Conclusions: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women's rights to access ANC services. [ABSTRACT FROM AUTHOR]

Background: In order improve the quality of birth care and women satisfaction with birthing process it is recommended that every woman should be offered the option to experience labour and childbirth with a companion of her choice. Involving husbands who are decision makers in the household may a play role in reducing maternal mortality which is unacceptably high despite the targeted goal to reduce this mortality up to three quarters as targeted in the MDGs by 2015. This is still addressed in the Sustainable Development Goals (SDGs) of 2015/30. This study aimed to explore the experiences and perceptions of husbands' support of their wives during pregnancy, labour and deliveries in Tanzania.Methods: Qualitative descriptive study design was employed; involving men aged between 24 and 63 years. Participants were selected purposefully at the clinic and in labour ward of SekouToure Regional Referral Hospital (SRRH). The in-depth interview, guided by semi structured interview guide was used to collect the audio recorded and hand written information. Data were analysed using qualitative content analysis.Results: Nine semi-structured interviews were conducted with husbands of women attended for antenatal care and those came for deliveries. Four themes emerged; Demonstrating care, love and affection, adopting modern life style, observing women's right and meeting social economic difficulties. Husbands' support to their partners is a good behaviour practiced during matrimonial lives. Husbands who support their partners during pregnancy and delivery consider themselves as being modern men as they at home take duties beside their usual tasks to let their wives have adequate time to rest during pregnancy. Poor road infrastructure makes difficult to get transport to the healthcare facility especially when labour is imminent. Also ward infrastructure is not supportive to accommodate husbands when they accompany their wives to the healthcare facility.Conclusions: The healthcare settings in low income countries need to accommodate men during the routine antenatal and intranatal care for the positive outcome of labour and delivery. Educating men on importance of active involvement in reproductive and child health services is important. Exploratory research should be conducted to understand how education and urbanisation affects men involvement in maternal and child health specifically in the low income countries. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to examine whether exposure to Intimate Partner Violence (IPV) is associated with premature termination of Exclusive Breastfeeding (EB). Per WHO recommendations, this was defined as ceasing breastfeeding or supplementing with other foods or liquids before the child was 6 months old. Method: It is a prospective cohort study set in Moshi, Tanzania consisting of 1128 pregnant women with live singleton births. Women were enrolled during pregnancy and followed up with interviews during pregnancy, after birth and 2–3 years postpartum, using structured questionnaires. Emotional, physical and sexual IPV exerted by the current partner was assessed at 34 weeks gestational age with WHO questionnaires. Months of EB was assessed 2–3 years postpartum. Premature termination of EB was defined as less than 6 months of EB. Analyses were made using a logistic regression model adjusted for maternal age, education, HIV-status, alcohol use during pregnancy and parity. Confounding variables were determined using a theoretical framework approach, i.e. a Directed Acyclic Graph model to minimize bias. Results: Women who were exposed to IPV had more than 50% higher odds of terminating EB before the child was 6 months old compared to women who were not exposed (aOR = 1.62, 95%CI: 1.27–2.06). Women exposed to all three types of IPV had twice the odds of early termination of EB (aOR = 1.95, 1.12; 3.37). Furthermore, the odds were tripled if exposure happened specifically during the index pregnancy (aOR = 2.93 95%CI: 1.3; 6.6). Stratified analyses showed the most severely affected groups were the mothers older than 30 and those who gave birth to girls. Conclusions: The results indicated that exposure to IPV is associated with increased risk of premature termination of EB. The odds increase with multiple types of the IPV, especially when exposed during the index pregnancy. [ABSTRACT FROM AUTHOR]

Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR:.53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time. [ABSTRACT FROM AUTHOR]

Background: Over the last two decades, facility-based childbirths in Tanzania have only minimally increased by 10% partly because of healthcare providers' disrespect and abuse (D&A) of women during childbirth. Although numerous studies have substantiated women's experience of D&A during childbirth by healthcare providers, few have focused on how D&A occurred during the midwives' actual care. This study aimed to describe from actual observations the respectful and disrespectful care received by women from midwives during their labor period in two hospitals in urban Tanzania. Methods: This descriptive qualitative study involved naturalistic observation of two health facilities in urban Tanzania. Fourteen midwives were purposively recruited for the one-on-one shadowing of their care of 24 women in labor from admission to the fourth stage of labor. Observations of their midwifery care were analyzed using content analysis. Results: All the 14 midwives showed both respectful and disrespectful care and some practices that have not been explicated in previous reports of women's experiences. For respectful care, five categories were identified: 1) positive interactions between midwives and women, 2) respect for women's privacy, 3) provision of safe and timely midwifery care for delivery, 4) active engagement in women's labor process, and 5) encouragement of the motherbaby relationship. For disrespectful care, five categories were recognized: 1) physical abuse, 2) psychological abuse, 3) non-confidential care, 4) non-consented care, and 5) abandonment of care. Two additional categories emerged from the unprioritized and disorganized nursing and midwifery management: 1) lack of accountability and 2) unethical clinical practices. Conclusions: Both respectful care and disrespectful care of midwives were observed in the two health facilities in urban Tanzania. Several types of physical and psychological abuse that have not been reported were observed. Weak nursing and midwifery management was found to be a contributor to the D&A of women. To promote respectful care of women, pre-service and in-service trainings, improvement of working conditions and environment, empowering pregnant women, and strengthening health policies are crucial. [ABSTRACT FROM AUTHOR]

Background: Rubella primary infection during early stages of pregnancy is associated with high risk of congenital Rubella syndrome (CRS). Prevention of CRS in the resource-limited countries requires multiple strategies. Here, we document the data on the magnitude of Rubella natural immunity among adolescent girls which is a crucial group in devising effective control strategies to prevent CRS.Methods: A cross sectional study involving 397 adolescent girls was conducted in the city of Mwanza involving five secondary schools. Socio-demographic and other relevant information were collected using pre-tested data collection tool. Rubella IgG antibodies were determined using enzyme immunoassay. The presence of Rubella IgG titers of >10 IU/ml indicated natural immunity.Results: The mean age of the study participants was 15.18 ± 1.48 years. Of 397 girls, 340 (85.6%) and 57 (14.4%) were from secondary schools representing peri-urban and rural areas, respectively. Out of 397 girls, 90.4% (95% CI: 87-93) were found to be naturally immune with median Rubella IgG antibodies titers of 56.7 IU/ml interquartile range (IQR): 40.8-137. The median Rubella IgG antibodies titers were significantly high in adolescent girls from families with high socio-economic status (63.96 vs. 47.13 IU/ml, P < 0.001) and in adolescent girls from peri-urban areas of the city (63.33 vs. 39.9 IU/ml, P < 0.001).Conclusion: The majority of adolescent girls in the city of Mwanza are naturally immune to Rubella virus. There is a need to compare the effectiveness of screening and vaccinating susceptible adolescent girls with the effectiveness of vaccinating all women of childbearing in controlling CRS in low-income countries. [ABSTRACT FROM AUTHOR]

Background: Low knowledge of danger signs has been shown to delay seeking obstetric care which leads to high maternal mortality and morbidity worldwide. In Tanzania about half of pregnant women are informed about obstetric danger signs during antenatal care, but the proportion of those who have full knowledge of these obstetric danger signs is not known. This study assessed the knowledge of obstetric danger signs and its associated factors among recently-delivered women in Chamwino District, Tanzania.Methods: A community-based cross-sectional study was conducted in January 2014 in Chamwino District, Tanzania. A woman was considered knowledgeable if she spontaneously mentioned at least five danger signs in any of the three phases of childbirth (pregnancy, childbirth and postpartum) with at least one in each phase. Multistage cluster sampling was used to recruit study participants. Descriptive and bivariate analyses were conducted. Multivariable logistic regression analyses were performed to control for confounding and other important covariates.Results: A total of 428 women were interviewed. The median age (IQR) was 26.5 (22-33) years. Only 25.2% of respondents were knowledgeable about obstetric danger signs during pregnancy, childbirth/labour and postpartum. Significant explanatory variables of being knowledgeable about obstetric danger signs were found to be maternal education (AOR = 1.96; 95% CI: 1.01, 3.82), maternal occupation (AOR = 2.23; 95% CI; 1.10, 4.52), spouse occupation (AOR = 2.10; 95% CI: 1.02, 4.32) and counseling on danger signs (AOR = 3.42; 95% CI: 1.36, 8.62) after controlling for the clustering effect, confounding and important covariates.Conclusion: A low proportion of women was found to be knowledgeable about obstetric danger signs in Chamwino district. Therefore, we recommend the Ministry of Health to design and distribute the maternal health booklets that highlight the obstetric danger signs, and encourage antenatal care providers and community health workers to provide frequent health education about these danger signs for every pregnant woman in order to increase their level of knowledge about obstetric danger signs. [ABSTRACT FROM AUTHOR]

Background: Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women's poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania.Methods and Findings: We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21-0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05-0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19-0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings.Conclusions: After implementation of the combined intervention, the likelihood of women's reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project's facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486.Trial Registration: ISRCTN Registry, ISRCTN 48258486. [ABSTRACT FROM AUTHOR]

Background: Tanzania achieved the Millennium Development Goal for child survival, yet made insufficient progress for maternal and neonatal survival and stillbirths, due to low coverage and quality of services for care at birth, with rural women left behind. Our study aimed to evaluate Tanzania's subnational (regional-level) variations for rural care at birth outcomes, i.e., rural women giving birth in a facility and by Caesarean section (C-section), and associations with health systems inputs (financing, health workforce, facilities, and commodities), outputs (readiness and quality of care) and context (education and GDP).Methods: We undertook correlation analyses of subnational-level associations between health system inputs, outputs, context, and rural care at birth outcomes; and constructed implementation readiness barometers using benchmarks for each health system input indicator. We used geographical information system (GIS) mapping to visualise subnational variations in care at birth for rural women, with a focus on service availability and readiness, and collected qualitative data to investigate financial flows from national to council level to understand variation in financing inputs.Results: We found wide subnational variation for rural care at birth outcomes, health systems inputs, and contextual indicators. There was a positive association between rural women giving birth in a facility and by C-section; maternal education; workforce and facility density; and quality of care. There was a negative association between these outcomes and proportion of all births to rural women, total fertility rate, and availability of essential commodities at facilities. Per capita recurrent expenditure was positively associated with facility births (correlation coefficient = 0.43; p = 0.05) but not with C-section. Qualitative results showed that the health financing system is complex and insufficient for providing care at birth services. Bottlenecks for care at birth included low density of health workers, poor availability of essential commodities, and low health financing in Lake and Western Zones.Conclusions: No region meets the benchmarks for the four health systems building blocks including health finance, health workforce, health facilities, and commodities. Strategies for addressing health system inequities, including overall increases in health expenditure, are needed in rural populations and areas of highest unmet need for family planning to improve coverage of care at birth for rural women in Tanzania. [ABSTRACT FROM AUTHOR]

Disrespect and abuse (D&A) during facility-based childbirth is a topic of growing concern and attention globally. Several recent studies have sought to quantify the prevalence of D&A, however little evidence exists about effective interventions to mitigate disrespect and abuse, and promote respectful maternity care. In an accompanying article, we describe the process of selecting, implementing, and evaluating a package of interventions designed to prevent and reduce disrespect and abuse in a large urban hospital in Tanzania. Though that study was not powered to detect a definitive impact on reducing D&A, the results showed important changes in intermediate outcomes associated with this goal. In this commentary, we describe the factors that enabled this effect, especially the participatory approach we adopted to engage key stakeholders throughout the planning and implementation of the program. Based on our experience and findings, we conclude that a visible, sustained, and participatory intervention process; committed facility leadership; management support; and staff engagement throughout the project contributed to a marked change in the culture of the hospital to one that values and promotes respectful maternity care. For these changes to translate into dignified care during childbirth for all women in a sustainable fashion, institutional commitment to providing the necessary resources and staff will be needed. [ABSTRACT FROM AUTHOR]

Background: Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited.Methods: Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.Results: Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.Conclusion: Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth. [ABSTRACT FROM AUTHOR]

Objectives: In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. Methods: Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. Results: 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19-0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35-0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32-0.82). Conclusions: Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women's confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health. [ABSTRACT FROM AUTHOR]

Introduction: Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access. Methods: Data on health facilities’ location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites. Results: About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours’ walking time. Conclusions: Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings. [ABSTRACT FROM AUTHOR]

Background: Unacceptably high maternal mortality rates remain a challenge in developing countries such as Tanzania. Birth Preparedness and Complication Readiness is among the key interventions that can reduce maternal mortality. Despite this, its status in Tanzania is not well documented. We assessed the practice and determinants of Birth preparedness and complication readiness among recently delivered women in Chamwino district, Central Tanzania. Methods: A community based cross-sectional study was conducted to women who delivered two years prior to survey in January 2014 at Chamwino district, Tanzania. Woman was considered as prepared for birth and its complication if she reported at least three of these; know expected date of delivery, saved money, identified a skilled birth attendant/health facility, mode of transport and Identified two compatible blood donors. Descriptive, bivariate and multivariable logistic regression analyses were performed at P value < 0.05 level of significance. Results: We interviewed 428 women whose median age (IQR) was 26.5 (22-33) years. About 249 (58.2 %) of the respondents were considered as prepared for birth and its complications. After controlling for confounding and clustering effect, significant determinants of birth preparedness and complication readiness were found to be maternal education (AOR = 2.26, 95 % CI; 1.39, 3.67), spouse employment (AOR = 2.18, 95 % CI; 1.46, 3.25), booking at ANC (AOR = 2.03, 95 % CI; 1.11, 3.72), Four or more antenatal visits, (AOR = 1.94, 95 % CI; 1.17, 3.21) and knowledge of key danger signs (AOR = 4.16, 95 % CI; 2.32, 7.45). Prepared for birth was found to be associated with institutional delivery (AOR = 2.45, 95 % CI; 1.12, 5.34). Conclusion: The proportion of women who prepared for birth and its complications were found to be low. District reproductive and child health coordinator should emphasis on early and frequent antenatal care visits, since they were among predictors of birth preparedness and complication readiness. [ABSTRACT FROM AUTHOR]

Introduction Globally, health facility delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. However, access to facility-based delivery care remains low in many less developed countries. This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Methods Data come from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Results Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Conclusion Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area. [ABSTRACT FROM AUTHOR]

Background Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning. Methods This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described. Results The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency. Conclusions Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives. [ABSTRACT FROM AUTHOR]

Background Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. Results Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2-3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of firstline facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. Conclusion Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage. [ABSTRACT FROM AUTHOR]

Background: In Tanzania, half of all pregnant women access a health facility for delivery. The proportion receiving skilled care at birth is even lower. In order to reduce maternal mortality and morbidity, the government has set out to increase health facility deliveries by skilled care. The aim of this study was to describe the weaknesses in the provision of acceptable and adequate quality care through the accounts of women who have suffered obstetric fistula, nurse-midwives at both BEmOC and CEmOC health facilities and local community members. Methods: Semi-structured interviews involving 16 women affected by obstetric fistula and five nurse-midwives at maternity wards at both BEmOC and CEmOC health facilities, and Focus Group Discussions with husbands and community members were conducted between October 2008 and February 2010 at Comprehensive Community Based Rehabilitation in Tanzania and Temeke hospitals in Dar es Salaam, and Mpwapwa district in Dodoma region. Results: Health care users and health providers experienced poor quality caring and working environments in the health facilities. Women in labour lacked support, experienced neglect, as well as physical and verbal abuse. Nurse-midwives lacked supportive supervision, supplies and also seemed to lack motivation. Conclusions: There was a consensus among women who have suffered serious birth injuries and nurse midwives staffing both BEmOC and CEmOC maternity wards that the quality of care offered to women in birth was inadequate. While the birth accounts of women pointed to failure of care, the nurses described a situation of disempowerment. The bad birth care experiences of women undermine the reputation of the health care system, lower community expectations of facility birth, and sustain high rates of home deliveries. The only way to increase the rate of skilled attendance at birth in the current Tanzanian context is to make facility birth a safer alternative than home birth. The findings from this study indicate that there is a long way to go. [ABSTRACT FROM AUTHOR]

Various theories exist for the ways in which social and material disparities are incorporated within human bodies and then expressed as health outcomes with uneven distributions. From a political economy perspective, one pathway involves processes of social exclusion that take place on articulating local and global fields of power. This study explores such situated processes as they produce and perpetuate embodied inequality at childbirth in the Kilombero Valley of South-Central Tanzania. Ethnographic narratives illustrate how these processes differentially affect the kind of care women seek and receive. Also described are women's complex yet pragmatic responses to potential exclusion in the attempt to secure a safe and otherwise positive outcome. In a culturally constructed world of childbirth, face-to-face claims on entitlement to biomedical services collide with enactments of discrimination at multiple levels, creating a space of contestation for social and material positioning as well as for physical well-being. [embodied inequality; childbirth; Tanzania; social exclusion; maternal health] [ABSTRACT FROM AUTHOR]

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Background: Emerging research evidence suggests a potential benefit in being upright in the first stage of labour and a systematic review of trials suggests both benefits and harmful effects associated with being upright in the second stage of labour. Implementing evidence-based obstetric care in African countries with scarce resources is particularly challenging, and requires an understanding of the cumulative nature of science and commitment to applying the most up to date evidence to clinical decisions. In this study, we documented current practice rates, explored the barriers and opportunities to implementing these procedures from the provider perspective, and documented women's preferences and satisfaction with care. Methods: This was an exploratory study using quantitative and qualitative methods. Practice rates were determined by exit interviews with a consecutive sample of postnatal women. Provider views were explored using semi-structured interviews (with doctors and traditional birth attendants) and focus group discussions (with midwives). The study was conducted at four government hospitals, two in Dar es Salaam and two in the neighbouring Coast region, Tanzania. Main outcome measures: Practice rates for mobility during labour and delivery position; women's experiences, preferences and views about the care provided; and provider views of current practice and barriers and opportunities to evidence-based obstetric practice. Results: Across all study sites more women were mobile at home (15.0%) than in the labour ward (2.9%), but movement was quite restricted at home before women were admitted to labour ward (51.6% chose to rest with little movement). Supine position for delivery was used routinely at all four hospitals; this was consistent with women's preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest obstetricians and midwives favoured confining to bed during the first stage of labour, and supine position for delivery. Conclusions: The barriers to change appear to be complicated and require providers to want to change, and women to be informed of alternative positions during the first stage of labour and delivery. We believe that highlighting the gap between actual practice and current evidence provides a platform for dialogue with providers to evaluate the threats and opportunities for changing practice. [ABSTRACT FROM AUTHOR]

Objectives. As part of a community-based reproductive health project in rural Tanzania, a maternal and perinatal health care surveillance system was established to monitor pregnancy outcomes. This report presents preliminary results. Methods. Village health workers were trained to collect data during health education visits to pregnant and postpartum women. Maternal and fetal or infant survival or deaths were tracked on a community monitoring board. Results. Among 904 pregnancies, the fetoneonatal mortality rate was 69.4 deaths per 1000 live births and fetal deaths; 4 maternal deaths occurred. Intrapartum and early neonatal deaths of infants with birthweights of 1500 g or greater represented a large proportion of deaths. Conclusions. These preliminary results will be used to prioritize project interventions, including increasing access to skilled delivery care. (Am J Public Health. 2001;91:1636-1640) [ABSTRACT FROM AUTHOR]

Background: Facility-based childbirth has increased globally. Unfortunately, there have also been reports of women experiencing disrespect and abuse by healthcare providers during childbirth. This study aimed to measure the prevalence of self-reported disrespect and abuse (D&A) by healthcare providers of women during childbirth in health facilities in Tanzania, and to clarify the factors related to D&A.Methods: A cross-sectional survey was conducted in public health facilities of three regions in Tanzania from September 2016 to October 2016. Nurses and midwives who had ever conducted deliveries completed a 22-item section about D&A and three sections about working conditions and environment. A model for predicting D&A based on several factors such as their characteristics, working conditions, and working environment was developed by conducting multiple regression analysis.Results: Thirty public health facilities in three regions within Tanzania were selected to reflect different levels of hospitals. Among 456 participants (nurses, midwives, and nursing assistants), 439 were included in the analysis. Average number of self-reported D&A out of 22 items was five, and nearly all participants (96.1%) reported enacting one form of D&A at the least and two forms of D&A at the most. About 25-44% of D&A items were in the forms related to women's experiences with childbirth psychologically. Moreover, at least 10-30% of the participants enacted some form of D&A which could directly affect the well-being of mothers and babies. D&A scores increased with an increase in 'working hours per week' and 'taking a break during evening shifts'. D&A scores decreased with an increase in the scores of the 'two components of the Index of Working Satisfaction (professional status and interaction between nurses)', and 'any type of supervision for new nurse-midwives'.Conclusion: Most studies about D&A of healthcare providers previously focused on the reports of women. To our knowledge, this is the first report that focused on D&A reported by healthcare providers. Working conditions and systems including personal relationships with colleagues were both positively and negatively related to D&A of healthcare providers rather than the provider's individual and facility structural characteristics. [ABSTRACT FROM AUTHOR]

Background: In Tanzania, the provision of humanized care is increasingly being emphasized in midwifery practice, yet studies regarding perceptions and practices of skilled health personnel towards the humanization of birth care are scare. Previous reviews have identified that abuse and disrespect is not limited to individuals but reflects systematic failures and deeply embedded provider attitudes and beliefs. Therefore, the current study aims to explore the perceptions and practices of skilled health personnel on humanizing birth care in Tanzania by identifying current barriers and facilitators. Methods: Semi-structured interviews were held with skilled health personnel including midwives (n = 6) and obstetricians (n = 2) working in the two district hospitals of Tanzania. Data were analyzed using thematic coding. Results: Skilled health personnel identified systematic barriers to providing humanizing birth care. Systematic barriers included lack of space and limited facilities. Institutional norms and practices prohibited family involvement during the birth process,including beliefs that limited choice of birth position as well as disrespected beliefs, traditions, and culture. Participants also acknowledged four facilitators that improve the likelihood of humanized care during childbirth in Tanzania: ongoing education of skilled health personnel on respectful maternal care, institutional norms designed for continuous clinic support during childbirth, belief in the benefit of having family become active participants, and respecting maternal wishes when appropriate. Conclusion: To move forward with humanizing the birth process in Tanzania, it will be essential that systematic barriers are addressed as well as changing the mindset of personnel towards respectful maternal care. It will be essential for the government and private hospitals to revalue their labour wards to increase the space and staff allocated to each mother to enhance family-integrated care. Additionally, in-service training as well as incorporation of respectful maternal care during pre-service training is key to changing the culture in the labour ward. [ABSTRACT FROM AUTHOR]

Background: Despite the efforts to promote male involvement in maternal and child health, studies in low and middle income countries have reported that male participation is still low. While factors that hinder male partners from participating in maternal and child healthcare are well documented, there is dearth of studies on local perceptions about male involvement in pregnancy and delivery care. The main objective of this study was to explore local perceptions about male involvement in pregnancy and childbirth in Tanzania. Methods: Semi-structured individual interviews were conducted with key respondents and a thematic approach was used to analyse data. Results: The findings revealed that women preferred to be accompanied by their partners to the clinics, especially on the first antenatal care visit. Men did not wish to be more actively involved in antenatal care and delivery. Respondents perceived men as being breadwinners and their main role in pregnancy and child birth was to support their partners financially. The key factors which hindered male participation were traditional gender roles at home, fear of HIV testing and unfavourable environment in health facilities. Conclusion: This study concludes that traditional gender roles and health facility environment presented barriers to male involvement. District health managers should strengthen efforts to improve gender relations, promote men's understanding of the familial and social roles in reproductive health issues as well as provide male friendly services. However, these efforts need to be supported by women and the society as a whole. [ABSTRACT FROM AUTHOR]

Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. 'Three categories emerged that reflected women's perceptions of maternal health care services: "mothers perceive that maternal health services are beneficial," "barriers to accessing maternal health services" such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and "ambivalence regarding the quality of maternal health services" reflecting that women had both positive and negative perceptions in relation to quality of health care services offered'. Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women. [ABSTRACT FROM AUTHOR]

In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who had a delivery within 5 years about the place of their most recent delivery. Information on all functioning health facilities in the area were obtained from the district health office. Women who delivered in a health facility that was not the nearest available facility were considered bypassers. Forty-four per cent (186/423) of women who delivered in a health facility bypassed their nearest facility. In adjusted analysis, women who bypassed were more likely than women who did not bypass to be 35 or older (OR 2.5, P ≤ 0.01), to have one or no living children (OR 2.2, P = 0.03), to have stayed in a maternity waiting home prior to delivery (OR 4.3, P ≤ 0.01), to choose a facility on the basis of quality or experience (OR 2.1, P ≤ 0.01), to have a high level of trust in health workers at the delivery facility (OR 2.7, P ≤ 0.01), and to perceive the nearest facility to be of low quality (OR 3.1, P ≤ 0.01). Bypassing for facility delivery is frequent among women in rural Tanzania. In addition to obstetric risk factors, a major reason for this appears to be a concern about the quality of care at government dispensaries and health centres. Investing in improved quality of care in primary care facilities may reduce bypassing and improve the efficiency and effectiveness of the health system in providing coverage for facility delivery in rural Africa. [ABSTRACT FROM AUTHOR]