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"It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania. Midwifery.
(Midwifery, 2024-03) Mbekenga, Columba K.
Objective To explore healthcare workers’ and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania. Design A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis. Setting This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care. Participants Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility. Findings Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility. Key conclusions The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities. Implications for practice Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision. Keywords Maternal healthChildbirth careUrban healthDelaysObstetric emergencyTanzania
Assessment of knowledge on the danger signs of pregnancy among pregnant women at Sinza Palestina Hospital in Ubungo Municipality, Tanzania
(Tanzania Journal of Health Research, 2023-09-28) Sungwa, Edson.; Mwakanyamale, Adela A.
Background: The rate of maternal mortality has dropped globally however in some developing countries the rate of decline has been slow. Several efforts have been made to improve maternal health and reduce maternal mortality. Lack of information on danger signs during pregnancy is one of the factors that contribute to maternal mortality. The study aimed to assess knowledge of pregnancy danger signs among pregnant women at Sinza Palestina Hospital in Ubungo Municipality, Tanzania. Methods: This was a cross-sectional study involving all pregnant women who attended RHC services at Sinza Palestina Hospital in Ubungo Municipality. Socio-demographic characteristics and obstetrics experiences in the last pregnancy, knowledge on danger signs of pregnancy were collected. Data were analysed using the SPSS statistical package. Categorical and continuous variables were summarized and presented in tables and bar charts. Any p-value of < 0.05, at a 95% confidence interval was regarded as statistically significant. Results: A total of 410 pregnant women aged 18 – 46 years, mean age of 27 years were enrolled in this study. Amongst, 66 (16.1%) had low knowledge on obstetric danger signs and associated with age less than 20 years (aOR = 15.3, 95% CI: 4.8 – 48.3, p–value, < 0.001), education level (aOR = 27.7, 95% CI: 5.0 – 152, p–value, < 0.001), being single (aOR = 3.5, 95% CI: 1.1 – 12.9, p–value, < 0.04), parity (aOR = 1.9, 95% CI: 1.1 – 3.4, p–value, < 0.02 and less ANC visits (aOR = 2.6, 95% CI: 1.2 – 7.0, p–value, < 0.04). Moreover, occupation which was thought to have an association with knowledge of obstetrics danger signs, the association did not reach a statistically significant with p = 0.44. Conclusions and recommendations: In general, the findings of this study, show that the vast majority (83.9%) of pregnant mothers have sufficient knowledge of obstetric danger signs. Vaginal bleeding was the most commonly mentioned obstetric danger while Convulsion and fever were mentioned less. Age and education level of pregnant women, parity and ANC visits were identified as the significant factors for knowledge of obstetric danger signs among pregnant women. We recommend that health education and behavioural change programs to continue be implemented in all health facilities to continue imparting knowledge to all pregnant mothers. Efforts should be directed towards empowering nurse midwives.
Perceived Gender Inequality and Psychological Well-being in Women Aged 18 to 25 Years: An Integrative Review Design
(Journal of Community Medicine and Public Health Reports, 2023-07-06) Mwandali, Bupe K.
Purpose: To determine how perceived gender inequality in women between 18 to 25 years affects their psychological well-being. Methods: An integrative review design was conducted, guided by Whittemore and Kanfl's (2005) five steps. Published peer-review articles were searched from CINAHL, PubMed, Google Scholar, and other sources. Four papers were included in the review, organized and summarized in the table. The documents' quality was evaluated using Johns Hopkins, and all pieces were at level III (B). Results: Higher prevalence of gender inequality was perceived among Black women more than White women from different settings, with a higher percentage in service provision (91.3 %). All articles showed direct connections between psychological effects and gendered racism. One study reported that 73 % of participants suffered from stress. Approximately all participants used disengagement as a coping mechanism, which in turn increased the psychological effects due to poor social support. Conclusions: The magnitude of gender inequality was higher among African American women with poor coping and support systems, which increased the psychological distress among participants. The government and stakeholders should develop strategies that focus on integrating social systems and policies to support the reduction of gendered racism. The intersectionality framework was highly suggested in research and practice. Keywords: Gendered inequality, women aged 18-25 years, emerging adults, African American Women, psychological well-being.
A cohort study to compare banana leaves dressing with convention dressing for children with burn wounds at Bugando Medical Centre, Mwanza, Tanzania 2021
(Tanzania journal of health research, 2023-03-26) Sungwa, Edson.; Mwakanyamale, Adela A.; Stephen, Ambroce M.
Background: Globally burns among children is a public health concern. Banana leaf dressings or Conventional dressing materials may be used to dress burn wounds to children. The study aimed to explore outcomes of burn wounds dressed using banana leaves and conventional dressing materials respectful. Methods: Hospital based cohort study design conducted at Bugando Medical Center Burn Unit. Non-probability convenient sampling method with a sample size of 35 pediatric patients with burn wounds for each group of convectional dressing methods and banana leaf dressings were reached. Stata program Version 13 was used to analyze data. Results: A total of 70 children; 1 to 18 years, median age of 4 and interquartile range [IQR: 1-17] years were enrolled in the study. Thirty-five were dressed with Banana leaf other 35 were dressed with convention materials. Results showed that Banana leaf dressing was associated with; less pain (aOR = 0.2, 95% CI: 0.1 – 0.5, p – value <0.001), less medication use (aOR = 3.0,95% CI: 1.1 – 8.7, p – value 0.02) and good satisfaction (aOR = 85.6, 95% CI: 3.3 – 219, p – value <0.001) respectful during dressing change compared to conventional dressing method. However, no different observed between length of hospital stay and dressing method chosen. Conclusions: Although there is no evidence of a dressing method that is best for burn wounds. This study shows that Banana leaf dressing is convenient in terms of having less pain experiences and that it can be locally obtained in areas where banana plant is easily available. We recommend the use of banana leaf dressings for burns moreover, enlightenment of the public on the intervention and prevention of burns among children. Keywords: Banana leaf dressing, Conventional dressing, Burns, wound
The future of higher education and its place in society through the prism of health and allied sciences
(International Association of Universities (IAU), 2022-10) Mbekenga, Columba K.; Mashalla, Yohana J.
States regard universities as national think tanks providing strategic leadership in new knowledge generation and developing innovative solutions to societal problems. Institutional objectives of any university include teaching, research and service to society. Universities are thus central for the advancement of knowledge, generation and development of human capital, and innovations aimed at solving societal challenges and sustainable development. In a fast-changing world due to population growth, technological transformations, emerging and re-emerging diseases and increased mobility, the key challenge to universities is how to remain relevant in meeting societal expectations. The article highlights key challenges experienced by higher education institutions (HEIs), especially in health education, and proposes strategies that would help transform HE institutions in LICs for the future.
Fear of Childbirth: Validation of the Kiswahili Version of Wijma Delivery Expectancy/Experience Questionnaire Version A&B in Tanzania
(BMC Pregnancy and Childbirth, 2022) Mbekenga, Columba K.
Abstract Background: Fear of childbirth is common both before and after childbirth, often leading to complications in mother and new-born. The Wijma Delivery Expectancy/Experience Questionnaires (W-DEQ) are commonly used to measure fear of childbirth among women before (version A) and after childbirth (version B). The tools are not yet validated in the Tanzanian context. This study aimed to validate the reliability, validity, and factorial structure of their Kiswahili translations. Methods: A longitudinal study was conducted in six public health facilities in the Pwani region, Tanzania. In all, 694 pregnant and 625 postnatal women were concurrently selected and responded to W-DEQ-A and W-DEQ-B. Validation involved: translating the English questionnaires into Kiswahili; expert rating of the relevancy of the Kiswahili versions’ items; computing content validity ratio; piloting the tools; data collection; statistical analysis with reliability evaluated using Cronbach’s alpha and the intraclass correlation coefficient. Tool validity was assessed using factor analysis, con- vergent and discriminant validity. Exploratory factor analysis and confirmatory factor analysis were conducted on data collected using W-DEQ-A and W-DEQ-B, respectively. Results: Exploratory factor analysis revealed seven factors contributing to 50% of the total variation. Four items did not load to any factor and were deleted. The factors identified were: fear; lack of self-efficacy; lack of positive anticipa- tion; isolation; concerns for the baby; negative emotions; lack of positive behaviour. The factors correlated differently with each other and with the total scores. Both Kiswahili versions with 33 items had good internal consistency, with Cronbach’s alphas of .83 and .85, respectively. The concerns for the baby factor showed both convergent and discrimi- nant validity. The other six factors showed some problems with convergent validity. The final model from the con- firmatory factor analysis yielded 29 items with good psychometric properties (χ2 /df = 2.26, p = < .001, RMSEA = .045, CFI = .90 and TLI = .81) Conclusions: The Kiswahili W-DEQ-A-Revised and W-DEQ-B-Revised are reliable tools and measure fear of childbirth with a multifactorial structure, encompassing seven factors with 29 items. They are recommended for measuring fear of childbirth among pregnant and postnatal Tanzanian women. Further studies are needed to address the inconsist- ent convergent validity in the revised versions and assess the psychometric properties of W-DEQ-A among pregnant women across gestational ages. Keywords: Fear of childbirth, Pregnancy, Postnatal, W-DEQ, Validity, Reliability, Tanzania
Patterns and predictors of fear of childbirth and depressive symptoms over time in a cohort of women in the Pwani region, Tanzania
(PLoS one, 2022-11-03) Mbekenga, Columba K.
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 sociodemo- graphic and obstetric characteristics. Methods We conducted a longitudinal study at six health facilities in Tanzania in 2018–2019. Preg- nant women were consecutively assessed for FoB and DS before and after childbirth using the Wijma Delivery Expectancy/Experience Questionnaire versions A & B and the Edin- burgh 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 time- points. 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). Post- partum DS was more common in women with an ill child/stillbirth/early neonatal death (aOR4.78, 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 caesar- ean sections could underestimate FoB and DS prevalence rates.
Factors shaping good and poor nurse-client relationships in maternal and child care in rural Tanzania
(Research squire, 2022-09-05) Mbekenga, Columba K.
Background Evidence indicates that poor nurse-client relationships within maternal and child health ( Methods Qualitative descriptive design was employed. About 9 Focus Group Discussions ( Results Factors shaping nurse-client relationships were heuristically categorized into nurse, client and health system factors. Nurse contributors of poor relationship ranged from poor reception and hospitality, not expressing care and concern, poor communication and negative attitudes, poor quality of services, job dissatisfaction and unstable mental health. Client contributors of poor relationship include being ‘much know’, late attendance, non-adherence to procedures and instructions, negative attitudes, poor communication, inadequate education and awareness, poverty, dissatisfaction with care, faith in traditional healers and unstable mental health. Health system contributors were inadequate resources, poor management practices, inadequate policy implementation and absence of an independent department or agency for gathering and management of complaints. Suggestions for improving nurse-client relationship included awards and recognition of good nurses, improving complaints mechanisms, continued professional development, peer to peer learning and mentorship, education and sensitization to clients, improving service quality and working conditions, improving renumeration and incentives, strengthening nursing school’s student screening and nursing curriculum and improving mental health for both nurses and clients. Conclusions The factors shaping poor nurse- client relationships appear to extend beyond nurses to both clients and healthcare facilities and system. Implementation of effective interventions for addressing identified factors considering feasibility and acceptance to both nurses and clients using novel strategies such as HCD could pave the way for employing good nurse-client relationships as a tool for improving performance indicators and health outcomes within MCH care.
Using a human centered design (HCD) approach to strengthen interpersonal relationships in maternal and child health care in rural Tanzania: Study Design
(JMIR Research Protocols, 2022-03-12) Mbekenga, Columba K.
Background: Evidence indicates that clients’ dissatisfaction with providers’ competences within maternal and child health (MCH) continues to impact trust in formal health care systems, service uptake, continuity with care and MCH outcomes. A major problem with existing interventions is the failure to address all the complexities of provider-client relationships necessitating targeted contextualised innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation. In attempt to improve provider-client relationship, the Aga Khan University is piloting a human centered -design (HCD) intervention where MCH nurses and clients are invited to partner in the intervention design and evaluation process to better understand and address the identified challenges. Objective: The objective of this intervention is to co-design a prototype for improving nurse-client relationship in Shinyanga region of rural Tanzania by piloting HCD; a problem-solving approach that utilizes a series of iterative steps to tailor-make solutions for complex problems Methods: A five step HCD approach will be implemented, including: (i) Community-driven discovery through qualitative research methods using Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs); ii) Co-design of an intervention package through ideation meetings and creation workshops with nurses, clients and other stakeholders; iii) Prototype validation through qualitative insight gathering using FGDs; iv) Refinement/Adaptation meetings and; (v) Documentation and sharing of lessons learnt before the final prototype is tested and validated in a broader community (phase 2). Results: The results of the intervention are expected to include a co-designed prototype characterized by a package of interventions for improving nurse-client relationships in maternal and child health care in rural contexts. Conclusions: Human centered -design approach provides a novel entry point for strengthening provider-client relationships where clients are invited to partner with providers in the design of highly acceptable and feasible interventions. Clinical Trial: None
Healthcare providers' experiences with a clinical mentorship intervention to improve reproductive, maternal and newborn care in Mwanza, Tanzania
(Frontiers in Health Services, 2022-05-06) Mbekenga, Columba K.
Introduction: There is increasing evidence suggesting that clinical mentorship (CM) involving on-the-job training is one of the critical resources—friendly entry points for strengthening the knowledge and skills of healthcare providers (HCPs), which in turn facilitate the delivery of effective reproductive, maternal, and newborn health (RMNH) care. The article explores the experiences of HCPs following participation in the CM program for RMNH in eight districts of Mwanza Region in Tanzania. Materials and Methods: A qualitative descriptive design employing data from midterm project review meetings and Key Informant Interviews (KIIs) with purposefully selected HCPs (mentors and mentees) and District Medical Officers (DMOs) during endline evaluation were employed. Interview data were managed using Nvivo Software and analyzed thematically. Results: A total of 42 clinical mentors and master mentors responded to a questionnaire during the midterm review meeting. Then, a total of 17 KIIs were conducted with Mentees (8), Mentors (5), and DMOs (4) during endline evaluation. Five key themes emerged from participants’ accounts: (i) the topics covered during CM visits; (ii) the benefits of CM; (iii) the challenges of CM; (iv) the drivers of CM sustainability; and (iv) suggestions for CM improvement. The topics of CM covered during visits included antenatal care, neonatal resuscitation, pregnancy monitoring, management of delivery complications, and infection control and prevention. The benefits of CM included increased knowledge, skills, confidence, and change in HCP’s attitude and increased client service uptake, quality, and efficiency. The challenges of CM included inadequate equipment for learning and practice, the limited financial incentive to mentees, shortage of staff and time constraints, and weaker support from management. The drivers of CM sustainability included the willingness of mentees to continue with clinical practice, ongoing peer-to-peer mentorship, and integration of the mentorship program into district health plans. Finally, the suggestions for CM improvement included refresher training for mentors, engagement of more senior mentors, and extending mentorship beyond IMPACT catchment facilities. Conclusion: CM program appears to be a promising entry point to improving competence among HCPs and the quality and efficiency of RMNH services potentially contributing to the reduction of maternal and neonatal deaths. Addressing the challenges cited by participants, particularly the equipment for peer learning and practice, may increase the success of the CM program. Keywords: clinical mentorship, on-the-job training, reproductive maternal and newborn health, Mwanza, Tanzania, rural, low-income countries
The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey
(Reproductive health, 2022-06-20) Mbekenga, Columba K. Mathias,Victor A.
Background Delivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania. Methods The study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann–Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05. Results The study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050), Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002). Conclusions This study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes.
Effectiveness of maternal referral system in Tanzania: a mixed method study
(Research Gate, 2022-07-15) Mbekenga, Columba K.; Bugomola,Monica A.
Background: Poor accessibility of emergency obstetric care services contributes to severe morbidity and high maternal mortality. Variations in the capacity of providing Emergency obstetric care by different levels of public health facilities highlights the fundamental role of maternal referral system. There has being no significant changes in the maternal mortality for the past 15 years despite the feasibility of interventions within the limited resources hospital settings. There is still a paucity of evidence on the effectiveness of the obstetric referral process in reducing maternal mortality. This study was conducted to determine referral reasons, referral delays and communication barriers influencing referrals of women with obstetric complications in order to evaluate the effectiveness of the maternal referral system. Methods: A descriptive cross-sectional design employing mixed methods approach was used to evaluate effectiveness of the maternal referral system. A 7 weeks prospective study was conducted at Muhimbili National Hospital. Quantitative data were collected through reviewing referral slips of 426 women referred from various health facilities due to obstetric complications in the peripartum period and admitted in the labour ward, postnatal ward, ICU and high dependant ward. Analysis was done using SPSS. Qualitative data was collected using 9 semi-structured in-depth interviews with nurse-midwives and obstetricians who were selected purposively, and data was analysed with qualitative content analysis. Results: A total of 426 records of referred women with obstetric complications were reviewed. Most documented reasons for referral were hospital based (62%), which included theatre being busy (25.1%), unavailability of blood (11.3%) and lack of equipment and inadequate supplies (10.3%). 60.3% accounted for delayed referrals. The study identified referral-receiver communication barriers which include inconsistent use of phones before referral, unsatisfactory referral form documentation and inadequate feedback mechanism. Conclusion: The study demonstrates lack of both human and non-human resources required for provision of health care services in the referring facilities. It identifies high proportion of late referrals and deficiencies in the referral process which illustrate ineffective referral system.
Strengthening interpersonal relationships in maternal and child health care in rural Tanzania: protocol for a human-centered design intervention
(Jmir Research Protocols, 2022-07-07) Mbekenga, Columba K.
Background: Evidence indicates that clients’ dissatisfaction with providers’ competencies within maternal and child health (MCH) continues to impact trust in formal health care systems, service uptake, continuity with care, and MCH outcomes. A major problem with existing interventions is the failure to address all the complexities of provider-client relationships necessitating targeted, contextualized, innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation. To improve the provider-client relationship, the Aga Khan University is piloting a human-centered design (HCD) intervention where MCH nurses and clients are invited to partner with researchers in the intervention design and evaluation process. Objective: The objective of this research is to co-design an intervention package (prototype) for improving nurse-client relationships in the rural Shinyanga region of Tanzania using a series of iterative HCD steps, involving key stakeholders to tailor solutions for complex problems impacting provider-client interactions in MCH care. Methods: The following 5-step HCD approach will be implemented: (1) community-driven discovery through qualitative descriptive research methods using focus group discussions and key informant interviews; (2) co-design of an intervention package through consultative ideation and cocreation meetings with nurses, clients, and other stakeholders; (3) prototype validation through qualitative insight gathering using focus group discussions; (4) refinement and adaptation meeting; and (5) documentation and sharing of lessons learned before the final prototype is tested and validated in a broader community. Results: A prototype characterized by a package of interventions for improving nurse-client relationships in MCH care in rural contexts is expected to be developed from the co-design process. Conclusions: An HCD approach provides a novel entry point for strengthening provider-client relationships, where clients are invited to partner with providers in the design of acceptable and feasible interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/37947 (JMIR Res Protoc 2022;11(7):e37947) doi: 10.2196/37947 KEYWORDS human-centered design; user-centred design; human-centred design; provider-patient relationship; nurse-client relationship; nurse;nursing; maternal and child health; maternal; maternity; mother; child; primary health care; primary care; rural; Tanzania; Africa;community-based; focus group; co-design; prototype; validation; nurse-patient; provider-client
Scaling up locally adapted clinical practice guidelines for improving childbirth care in Tanzania: a protocol for programme theory and qualitative methods of the partoma scale-up study
(Global health action, 2022-03-21) Mbekenga, Columba K.
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. Keywords: Practice theory; co-creation; intervention; obstetrics; respectful maternity care.
Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study)
(Global health action, 2022-04-12) Mbekenga, Columba K.
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. Keywords: Africa; Obstetrics; co-creation; cost-effectiveness; de-colonizing; intervention; low dose high frequency training; perinatal death; programme theory; respectful maternity care; stillbirth; urbanization
Fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Tanzania
(Research Square, 2021) Mbekenga, Columba K.
Background: Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors. Methods: A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale. We performed multivariable logistic regression to investigate the predictors of FoB and DS. Results: The prevalence rates of FoB and DS among pregnant women were 15.1% and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years (AOR 6.29, 95% CI 1.43–27.84) and in single mothers (AOR 2.57, 95% CI 1.14–5.78). Women with secondary education and above and those who had given birth previously were less likely to have FoB (AOR 0.22, 95%CI 0.05–0.99) and DS (AOR 0.27, 95% CI 0.01–0.87). Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95% CI 21.20–5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95% CI 1.38–3.99) or had previously experienced a perineal tear (AOR 2.32, 95% CI 1.31–4.08). Conclusions: Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth
Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members
(Global health action, 2017) Mbekenga, Columba K.
Background: In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice. Objective: To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community. Methods: Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process. Results: In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives’ advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral. Conclusions: Declining maternal referral advice centred around the pregnant women’s position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals.
Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania
(BMC pregnancy and childbirth, 2021) Mbekenga, Columba K.
Background: Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors. Methods: A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored ≥66 and ≥ 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS. Results: The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43–27.84] and in single mothers (AOR 2.57, 95%CI 1.14–5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05–0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09–0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12–5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38–3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31–4.08). Conclusions: Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.
Knowledge, Attitudes, and Practice on Malaria Prevention and Treatment among Pregnant Women in Karatu District, Arusha Region, Tanzania
(Nursing and primary care, 2021-12-16) Sungwa, Edson.
The spread of Malaria has been increasing rapidly in many Sub-Saharan countries including Tanzania. The increase in mortality rate caused by Malaria among people including pregnant women is contributed mainly by the absence of sufficient knowledge, attitudes, and practices of how to prevent and treat Malaria. This study explored knowledge, attitudes, and practice among pregnant women in Malaria prevention and treatment in Endabash Ward, Karatu District, Tanzania. Pregnant women are vulnerable to Malaria due to invasion of the placenta by Plasmodium. This study involved a Descriptive Cross-Sectional Design. The study used Mixed Approach. Data were collected through In-Depth Interview (IDI), Focused Group Discussion (FGD), and Questionnaire. It was found that the majority of pregnant women had an understanding of the meaning, transmission, signs and symptoms and ways of preventing and treating Malaria. However, there were some pregnant women who still lacked knowledge on this condition. It is recommended that policy-makers should improve knowledge and control strategies on Malaria in this population.
Perceptions about the cultural practices of male partners during postpartum care in rural Tanzania: a qualitative study
(Global health action, 2017) Mbekenga, Columba K.
Background: Men play an important role in maternal health. The postpartum period is a critical stage, yet there is a scarcity of research that explores men’s involvement during this stage. Objective: The aim of the study was to explore male partners’ perceptions of the cultural practices during postpartum care in rural Tanzania. Methods: Fourteen focus group discussions were conducted with 93 men, with an age range of 19–65 years, in August 2013. The study was conducted in the Kongwa District, located in the Dodoma region in central Tanzania. Qualitative data were digitally recorded, transcribed verbatim and analyzed using content analysis. Results: Four categories emerged, namely: ‘Men as providers and, occasionally, care takers’, ‘Men as decision makers’, ‘Diverse perceptions of sexual abstinence’ and ‘Barriers for men in using/accompanying partners to use reproductive and child healthcare services’. The cross-category theme ‘Men during postpartum: remaining powerful but excluded’ refers to how men are in a powerful position above women in different aspects of life. Elderly women played an important role in caring for postpartum mothers and their newborns, but men were the ones making the final decision about where to seek care. Traditional practices isolated men from their partners for a certain period, and enforced sexual abstinence for the women during the postpartum period. However, cultural norms permitted men to engage in extramarital relations. Reproductive and child healthcare services were perceived by men as not welcoming the male partners, and local gender norms discouraged men from accompanying their partners to seek services. Conclusions: In this study, we found that men perceived their role during the postpartum period as financial providers, decision makers and, occasionally, care givers. Men also held diverse perceptions with regard to sexual abstinence and felt excluded from participating in maternal healthcare services.

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