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Health system support for childbirth care in Southern Tanzania: results from a health facility census.

ABSTRACT: 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 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.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 first-line 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.Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains 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.

SUBMITTER: Hanson C

PROVIDER: S-EPMC4228478 | biostudies-literature | 2013 Oct

REPOSITORIES: biostudies-literature

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Health system support for childbirth care in Southern Tanzania: results from a health facility census.

Hanson Claudia C Ronsmans Carine C Penfold Suzanne S Maokola Werner W Manzi Fatuma F Jaribu Jenny J Mbaruku Godfrey G Mshinda Hassan H Tanner Marcel M Schellenberg Joanna J

BMC research notes 20131030

<h4>Background</h4>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 sy ...[more]

PMID: 24171904

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Project description:BackgroundClient satisfaction is an essential component of quality of care. Health system factors, processes of care as well as mothers' characteristics influence the extent to which care meets the expectations of mothers and families. In our study, we specifically aimed to address the mothers' experiences of, and satisfaction with, care during childbirth.MethodsA population-based cross-sectional study, using structured interviews with published sequences of questions assessing satisfaction, including 4358 mothers who gave birth during the 12 months before June 2016 to estimate satisfaction with childbirth care. Regression analysis was used to determine the predictors of client satisfaction.ResultsMost mothers (92.5%) reported being satisfied with care during childbirth and would recommend that a family member to deliver at the same facility. Specifically, 94.7% were satisfied with the cleanliness of the facility, 92.0% reported being satisfied with the interaction with the healthcare providers, but only 49.8% felt satisfied with the assistance to feed their baby. Mothers who had negative experiences during the process of care, such as being abandoned when needing help, disrespect, humiliation, or physical abuse, reported low levels of satisfaction when compared to those who had not had such experiences (68.5% vs 93.5%). Additionally, they reported higher levels of dissatisfaction (20.1% vs 2.1%). Regression analysis revealed that mothers who gave birth in primary level facilities tended to be more satisfied than those who gave birth in hospitals, and having a companion increased, on average, the overall satisfaction score, with 0.06 in type II health centres (CI 0.03-0.10) and with 0.05 in type I health centres (CI - 0.02 - 0.13), compared to - 0.01(CI -0.08 - 0.07) in the hospitals, irrespective of age, education and socio-economic background.ConclusionChildbirth at the primary level facilities contributes to the level of satisfaction. The provision of childbirth care should consider women's preferences and needs, including having a companion of choice. We highlight the challenge in balancing safety of care versus satisfaction with care and in developing policies on the optimum configuration of childbirth care. Interventions to improve the interaction with providers and the provision of respectful care are recommended.

Project description: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.

Project description:BackgroundActionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards.MethodsWe used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume.ResultsIndices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices.ConclusionSARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.

Project description:Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.

Project description:BACKGROUND:Health system performance is one of the important components of the health care delivery; its achievement depends on the quality of services rendered and the health system responsiveness of its beneficiaries. Health system responsiveness is a multi-dimensional concept and is usually measured through several domains. Health system responsiveness (HSR) remains to be a key indicator for evaluation of health system performance in any settings. This study aimed at assessing the situation of health system responsiveness in primary health facilities in Tanzania prior to introduction of the Direct Health Facility Financing (DHFF) program. METHODS:This was a cross sectional study conducted between January and February in 2018. We collected data from 42 primary health facilities (14 health centers and 28 dispensaries) where a questionnaire was administered to a total of 422 participants. The questionnaire collected information on attention, respect to dignity, clear communication, autonomy, access to care, respect to confidentiality and basic amenities. Descriptive analysis was done to determine the distribution of the variables whereas ANOVA and linear regression analysis was employed to discern the association between variables. RESULTS:More than 67% of participants had visited the same health facility more than 5 times. Sixty seven percent of the patients were residing within 5kms from the public primary health care facilities. The geographical access to health care scored the lowest (43.5% for Dispensaries and 36% for Health center) mean as compared to other domains of health system responsiveness. The highest score was in respect to confidentiality (86.7%) followed by respect to dignity (81.4%). Linear regression analysis revealed no statistical association between any of the social demographic features with the overall HSR performances. However, in post hoc analysis, Pwani and Shinyanga regions didn't differ significantly in terms of their performances whereas those two regions differ from all other regions. CONCLUSION:Based on the study findings health system responsiveness domains has performed relatively poor in many regions except for respect of dignity and confidentiality scored high of all the domains. Shinyanga and Pwani regions scored relatively well in all domains this could have been due to the effect of Results Based financing (RBF) in the respective regions. All in all the Government and other stakeholders in the health sector they should deliberately invest on the access to care domain as seem to be a challenge as compared to others.

Project description:BACKGROUND:Evidence suggests that many women experience mistreatment during childbirth in health facilities across the world, but the magnitude of the problem is unknown. The occurrence of disrespect and abuse (D&A) in maternity care services affects the overall quality of care and may undermine women's trust in the health system. Studies about the occurrence of disrespect and abuse in Mozambican health facilities are scarce. The aim of this study was to explore the experience of women giving birth in hospital in different settings in Maputo City and Province, Mozambique. METHODS:A cross sectional descriptive survey was conducted between April and June 2018 in the Central Hospital of Maputo (HCM) and district hospitals of Manhiça and Marracuene, Maputo Province, Mozambique. Five hundred seventy-two exit interviews were conducted with women leaving the hospital after delivery. The questionnaire consisted of the following components: socio-demographic characteristics, the occurrence of disrespect and abuse, male involvement during labor and childbirth and intrapartum family planning counselling and provision. RESULTS:Prevalence of disrespect and abuse ranged from 24% in the central hospital to 80% in the district hospitals. The main types of D&A reported were lack of confidentiality/privacy, being left alone, being shouted at/scolded, and being given a treatment without permission. While very few women's partners attended the births, the majority of women (73-80%) were in favor of involving their partner as a birth companion. Intrapartum counseling of family planning was very low (9-17%). CONCLUSION:The occurrence of disrespect and abuse was much higher in the district hospitals compared to the central hospital, emphasizing the high need for interventions outside Maputo City. Allowing male partners as birth companions should be explored further, as women seem in favor of involving their partners. Investing in intrapartum counselling for family planning is currently a missed opportunity for improving the uptake of contraception in the country.

Project description:BackgroundIn The Gambia, a woman faces 1 in 24-lifetime risk of maternal death due to pregnancy and childbirth, yet, only 57% of deliveries are conducted by skilled birth attendants. However, poor provider attitude has been identified as one of the contributing factors hampering the efforts of the government in improving access to skilled care during childbirth. This study, therefore, explored women's perception of support and control during childbirth in The Gambia.MethodsA descriptive cross-sectional study was employed. A convenience sampling method was used to select participants in two regions in The Gambia. A sample size of 200 women who met the eligibility criteria was recruited after informed consent. The demographic-obstetric information sheet and the Support and Control in Birth scale (SCIB) were used to collect data. Data analysis was done using SPSS software version 23.0.ResultsWomen's perceptions of support and control were low. External control 1.85 (SD?±?0.43) recorded the least perception compared to internal control 2.41 (SD?±?0.65) and perception of support 2.52 (SD?±?0.61). Participants reported the lowest perceptions in pain control, involvement in decision making, information sharing and the utilization of different position during birth. Women's age (p?<?.001) and mode of delivery (p?=?.01), significantly predicted women's perception of internal control. Educational status (p?=?.02), mode of delivery (p?=?.04), place of delivery (p?<?.001) and perception of support (p?<?.001) significantly predicted women's perception of external control, whilst birth plan (p?=?.001), mode of delivery (p?=?.04), and perception of external control (p?<?.001) significantly predicted women's perception of support.ConclusionThis study concluded that an environment that promotes women feeling a sense of control and support during childbirth should be created in order to ensure a dignified intrapartum care in The Gambia. This can be achieved through effective training of skilled birth attendants on non-pharmacological pain management, effective communication with clients and promoting women's participation in decision-making regarding their care throughout the process of childbirth.

Project description:Despite the importance of health facility capacity to provide comprehensive care, the most widely used indicators for global monitoring of maternal and child health remain contact measures which assess women's use of services only and not the capacity of health facilities to provide those services; there is a gap in monitoring health facilities' capacity to provide newborn care services in low and middle income countries.In this study we demonstrate a measurable framework for assessing health facility capacity to provide newborn care using open access, nationally-representative Service Provision Assessment (SPA) data from the Demographic Health Surveys Program. In particular, we examine whether key newborn-related services are available at the facility (ie, service availability, measured by the availability of basic emergency obstetric care (BEmOC) signal functions, newborn signal functions, and routine perinatal services), and whether the facility has the equipment, medications, training and knowledge necessary to provide those services (ie, service readiness, measured by general facility requirements, equipment, medicines and commodities, and guidelines and staffing) in five countries with high levels of neonatal mortality and recent SPA data: Bangladesh, Haiti, Malawi, Senegal, and Tanzania.In each country, we find that key services and commodities needed for comprehensive delivery and newborn care are missing from a large percentage of facilities with delivery services. Of three domains of service availability examined, scores for routine care availability are highest, while scores for newborn signal function availability are lowest. Of four domains of service readiness examined, scores for general requirements and equipment are highest, while scores for guidelines and staffing are lowest.Both service availability and readiness tend to be highest in hospitals and facilities in urban areas, pointing to substantial equity gaps in the availability of essential newborn care services for rural areas and for people accessing lower-level facilities. Together, the low levels of both service availability and readiness across the five countries reinforce the vital importance of monitoring health facility capacity to provide care. In order to save newborn lives and improve equity in child survival, not only does women's use of services need to increase, but facility capacity to provide those services must also be enhanced.

Dataset Information

Health system support for childbirth care in Southern Tanzania: results from a health facility census.

Publications

Health system support for childbirth care in Southern Tanzania: results from a health facility census.

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