Low utilization of skilled birth attendants in Ngorongoro Conservation Area, Tanzania: A complex reality requiring action

Abstract

Limited integration of contextual factors in maternal care contributes to slow progress towards achieving MDG5 in sub-Sahara Africa. In Ngorongoro, rural Tanzania, the maternal mortality ratio is high with 642 maternal deaths/100,000 live births. Skilled birth attendants (SBAs) assist only 7% of deliveries. This study, undertaken from 2009 to 2011, used Participatory Action Research involving local stakeholders (Maasai women and men, traditional birth attendants (TBAs), hospital staff) to examine reasons for low utilization of SBAs and moreover to develop proposals how to integrate contextual factors and local needs in the health care system. Interviews, observations and literature study were also conducted. Thaddeus and Maine's Three Delays model is used to structure the analysis. Delaying factors in decision making at home: negative perceptions by the community on availability and quality of care in the hospital; discontinuity of care by TBAs; food and financial insecurity; desired nearness to cattle and family; limited recognition of maternal deaths; limited male health education and suboptimal birth preparedness. Delaying factors in reaching the hospital: vehicle and road limitations. Delaying factors in receiving hospital care: limited (human) resources and limited knowledge sharing at the hospital. Community members and health workers proposed: increasing food/financial security; tailoring male health education; combining TBA/SBA care to provide continuous, culturally appropriate labour support; creating separate maternity wards; increasing the number and training of staff; ensuring continuous availability of Emergency Obstetric Care. Applying solutions to increase hospital utilization seems complex as collaborative actions by multiple actors and institutions are needed to create both a needs based and clinically sound continuum of maternal care. To follow-up this process of integrating local solutions into the maternal care system, we suggest to adapt the WHO Strategic Approach-a top-down framework for the implementation of innovations-to fit this bottom-up approach.

Factors influencing adoption of facility-assisted delivery - a qualitative study of women and other stakeholders in a Maasai community in Ngorongoro District, Tanzania

“…Consistent with findings of several studies in Ngorongoro district [8,9,20], where Nainokanoka ward is located, project baseline data indicated a much higher rate of women attending 4+ ANC visits (51%) than facility deliveries (2%) at baseline. In the following 15 months since project implementation, both indicators increased (Figure 1) but the gap between them remains proportionally constant.…”

“…[7] In northern Tanzania, particularly in rural districts of Arusha region with a high proportion of Maasai pastoralists, operationalizing these objectives has been difficult, most notably the objective of increasing the adoption of facility delivery-a practice which challenges traditional norms around childbirth in these communities. Several studies in Ngorongoro district of Northern Tanzania document the robust preference for home delivery even among women who attend 4+ ANC visits [8,9]. The seeming paradox of high ANC and low facility birth is not unique to pastoralist groups in Tanzania, and is confirmed by studies of similar populations in Zambia [10], Kenya [11], Uganda [12] and Malawi [13].…”

Exploring Beliefs and Knowledge about Maternal Health: The Case of Women in Korogocho Slums, Nairobi

“…This argument concurs with the findings of Byrneet al,(2016), who observed that MHS provided by TBAs adheres to the traditional practices of their clients, which makes their services more appealing. Other studies concur that the holistic approach of TBAs takes into account the cultural conceptualization of maternal health (Akunga et al, 2014;Kaingu et al, 2011;Roggeveen et al, 2013). Table 1 also reveals that approximately two thirds of the respondents associate post-partum complications with supernatural factors.…”

Understanding Barriers to Adoption of Facility Assisted Delivery in a Maasai Community in Ngorongoro District, Tanzania: A qualitative study to document psychosocial preferences, agency for decision-making, access barriers, and other factors that influence where a woman in Nainokanoka Ward will deliver

“…[7] In northern Tanzania, particularly in rural districts of Arusha region with a high proportion of Maasai pastoralists, operationalizing these objectives has been difficult, most notably increasing the adoption of facility delivery--a practice which challenges traditional norms around childbirth in these communities. Several studies in Ngorongoro district of Northern Tanzania document the robust preference for home delivery even among women who attend 4+ ANC visits [8,9]. This seeming paradox is not unique to Tanzania, as confirmed by studies in Zambia [10], Kenya [11], Uganda [12] and Malawi [13].…”

“…Barriers to accessing skilled delivery services in rural Sub-Saharan Africa are well documented and commonly cited factors include: fear of mistreatment or abuse in facilities [14,15], long distance and difficulty in access [9], poverty and education [9], lack of decision-making power and support [16,17], other culture issues such as birth position and preference for traditional birth attendants [13,18], lack of knowledge of risk and promotion of health seeking behavior [19].…”