Journey of vulnerability: a mixed-methods study to understand intrapartum transfers in Tanzania and Zambia

Abstract

Background: Timely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred. Methods: We used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss's constant comparative approach. Results: Intrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability. Conclusion: Although intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women's (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women's resilience and influence positive decision-making, for the index and future pregnancy.

Examining vulnerability and resilience in maternal, newborn and child health through a gender lens in low-income and middle-income countries: a scoping review

“…Access to resources emerged as the dominant gender-focused theme (8 of 17 studies) 30–37. In most studies, pregnant women or mothers lived in households characterised by low socioeconomic status and had lower levels of education, all of which are potentially related to poor access to maternal and child healthcare services.…”

“…Some women failed to attend clinics because of a lack of support from their husbands. Most husbands did not provide their wives with adequate funds for their needs during delivery 32. The lack of rapid access to money was another important contributing factor to a child’s deteriorating condition; it influenced the initiation of a treatment-seeking action, including where and by whom (all households) the action was performed.…”

Understanding the complexities of unexplained stillbirth in sub‐Saharan Africa: a mixed‐methods study

“…The higher risk of stillbirth amongst women with a previous stillbirth, as found in this study, reflects this and indicates a failure to understand and tackle individual health issues affecting pregnancy. Moreover, the role of health system issues that may impact on stillbirth, such as delays and transfer of care, 20 remain an issue to be addressed. This lack of understanding compromises the aim of reducing global stillbirth rates, which is hampered by the failure to understand reasons for the deaths 3 …”

The tipping point of antenatal engagement: A qualitative grounded theory in Tanzania and Zambia

“…Half of all stillbirths are estimated to occur in the antepartum period, thus early detection of problems is imperative. Furthermore, the way women experience antenatal care, can have an impact on facility attendance, leading to delays in treatment and subsequent intrapartum stillbirths [6]. Thus, good quality, effective, antenatal care has the potential to reduce both antepartum and intrapartum stillbirths.…”

“…However, effective antenatal care is challenging to deliver in many low-income settings. Long distances to the health facilities, poor road conditions [6,10], lower education and income levels [10][11], sociocultural beliefs, perceptions of health provider attitudes [6,10,12], and fear of HIV testing [10] are reported as key barriers to ANC utilisation.…”