effect of home based life saving skills education on...
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ACTAUNIVERSITATIS
UPSALIENSISUPPSALA
2016
Digital Comprehensive Summaries of Uppsala Dissertationsfrom the Faculty of Medicine 1174
Effect of Home Based Life SavingSkills education on knowledgeof obstetric danger signs, birthpreparedness, utilization of skilledcare and male involvement
A Community-based intervention study in ruralTanzania
FURAHA AUGUST
ISSN 1651-6206ISBN 978-91-554-9457-5urn:nbn:se:uu:diva-272245
Dissertation presented at Uppsala University to be publicly examined in Rosensalen,Akademiska sjukhuset, Entrance 95/96, Uppsala, Thursday, 3 March 2016 at 09:15 for thedegree of Doctor of Philosophy (Faculty of Medicine). The examination will be conductedin English. Faculty examiner: Professor Albrecht Jahn (Institute of Public Health, Universityof Heidelberg).
AbstractAugust, F. 2016. Effect of Home Based Life Saving Skills education on knowledge ofobstetric danger signs, birth preparedness, utilization of skilled care and male involvement. ACommunity-based intervention study in rural Tanzania. Digital Comprehensive Summaries ofUppsala Dissertations from the Faculty of Medicine 1174. 76 pp. Uppsala: Acta UniversitatisUpsaliensis. ISBN 978-91-554-9457-5.
Use of skilled care during antenatal visits and delivery is recommended to address the burdenof maternal mortality. However there are few facility deliveries and insufficient knowledge ofdanger signs, especially in rural Tanzania.
The aim of this thesis was to explore the perceptions and challenges that the communityfaces while preparing for childbirth and to evaluate an intervention of the Home Based LifeSaving Skills education programme on knowledge of danger signs, facility delivery and maleinvolvement when delivered by rural community health workers in Tanzania.
In Paper I, Focus Group Discussions explored the perceptions and challenges that thecommunity encounters while preparing for childbirth. Structured questionnaires assessed men’sknowledge of danger signs and birth preparedness and complication readiness in Paper II.The effect of the Home Based Life Saving Skills education programme in the communitywas assessed with a before-and-after evaluation in two districts; one intervention and onecomparison. Paper III assessed the effect of the programme on knowledge of danger signs andbirth preparedness and facility delivery among women, while Paper IV evaluated its effect onmale involvement.
The community perceived that all births must be prepared for and that obstetric complicationdemands hospital care; hence skilled care was favoured. Men’s knowledge of danger signs waslimited; only 12% were prepared for childbirth and complications. Preparedness was associatedwith knowledge of obstetric complications (AOR=1.4 95% CI 1.8 – 2.6). The interventionshowed women utilizing antenatal care (four visits) significantly more (43.4 vs 67.8%) with anet effect of 25.3% (95% CI: 16.9 – 33.2; p < .0001). The use of facility delivery improved in theintervention area (75.6 vs 90.2%; p = 0.0002), but with no significant net effect 11.5% (95% CI:-5.1 – 39.6; p = 0.123) when comparing the two districts. Male involvement improved (39.2% vs80.9%) with a net intervention effect of 41.1% (CI: 28.5 – 53.8; p < .0001). Improvements weredemonstrated in men’s knowledge level, in escorting partners for antenatal care and delivery,making birth preparations, and shared decision-making.
The intervention, in educating this rural community, is effective in improving knowledge,birth preparedness, male involvement and use of skilled care.
Keywords: Birth Preparedness and Complication Readiness, Obstetric danger signs, MaleInvolvement, Community Health Workers, Maternal Health, Rural, Tanzania
Furaha August, Department of Women's and Children's Health, International Maternaland Child Health (IMCH), Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala,Sweden.
© Furaha August 2016
ISSN 1651-6206ISBN 978-91-554-9457-5urn:nbn:se:uu:diva-272245 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-272245)
To my parents, my wife Abella and my daughters Siriel and Shannen
List of Papers
This thesis is based on the following papers, which are referred to in the text by their Roman numerals.
I. August F, Pembe AB, Kayombo E, Mbekenga C, Axemo P, Darj E:
Birth preparedness and complication readiness – a qualitative study among community members in rural Tanzania. Glob Health Action 2015, 8:26922.
II. August F, Pembe AB, Mpembeni R, Axemo P, Darj E: Men’s Knowledge of Obstetric Danger Signs, Birth Preparedness and Complication Readiness in Rural Tanzania. PLoS ONE 2015, 10(5):e0125978.
III. August F, Pembe AB, Mpembeni R, Axemo P, Darj E: Effective-
ness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania. Submitted
IV. August F, Pembe AB, Mpembeni R, Axemo P, Darj E: Community
Health Workers can improve male involvement in maternal health: Evidence from rural Tanzania. Glob Health Action 2016, 9:30064.
Reprints were made with permission from the respective publishers.
Contents
Preface ........................................................................................................... 11
Introduction ................................................................................................... 13 The global burden of maternal mortality .................................................. 13 Birth preparedness and complication readiness ........................................ 15 Male involvement in maternal health ....................................................... 16 Community-based interventions for maternal and child health care ........ 17 Home Based Life Saving Skills ................................................................ 17 United Republic of Tanzania .................................................................... 18 Health system in Tanzania ........................................................................ 20
Health system structure ........................................................................ 20 Health delivery services ....................................................................... 21 Human Resources for Health ............................................................... 21 Health care financing ........................................................................... 22
Maternal health care in Tanzania .............................................................. 22
Theoretical Framework ................................................................................. 24 The Three-Delays Model .......................................................................... 24 Health Belief Model ................................................................................. 24 Social construction of gender and masculinities ...................................... 25
Rationale of the study .................................................................................... 26
Aim and objectives ........................................................................................ 27 Aim ........................................................................................................... 27 Specific Objectives ................................................................................... 27
Material and Methods .................................................................................... 28 Study Design ............................................................................................. 28 Study Setting ............................................................................................. 29 Study Participants and Data collection ..................................................... 29
Paper I .................................................................................................. 29 Papers II, III and IV ............................................................................. 30
Intervention ............................................................................................... 32 Training of health workers and Community Health Workers ............. 33 Training of the community .................................................................. 33
Outcome measures .................................................................................... 36
Data Quality .............................................................................................. 36 Data Analysis ............................................................................................ 37 Ethical considerations ............................................................................... 38
Results ........................................................................................................... 39 Community perceptions on childbirth, birth preparedness and complication readiness (Paper I) .............................................................. 39 Men’s knowledge of danger signs and BP/CR (Paper II) ........................ 40 Effect of the intervention (Papers III and IV) ........................................... 41 Paper IV .................................................................................................... 43
Discussion ..................................................................................................... 45 Discussion of findings .............................................................................. 45
Perceived benefits of utilisation of skilled care ................................... 45 Perceived barriers ................................................................................. 46 Perceived severity/susceptibility .......................................................... 46 The role of CHWs in educating the community .................................. 47 Male Involvement in preparation for childbirth ................................... 49
Methodological considerations ................................................................. 51 Qualitative study .................................................................................. 51 Quantitative studies .............................................................................. 52
Conclusion ..................................................................................................... 55
Implications and Recommendations ............................................................. 56
Summary in English ...................................................................................... 58
Summary in Swahili ...................................................................................... 61
Acknowledgements ....................................................................................... 63
References ..................................................................................................... 65
Abbreviations
ACNM American College of Nurse Midwives ANC Antenatal Care AMO Assistant Medical Officer BEmOC Basic Emergency Obstetric Care BP/CR Birth Preparedness and Complication Readiness CBO Community-Based Organisations CEmOC Comprehensive Emergency Obstetric Care CHWs Community Health Workers DID Difference in Differences FANC Focused Antenatal Care FBO Faith-Based Organisation FGD Focus Group Discussions HBLSS Home Based Life Saving Skills ICPD International Conference on Population and Development MDGs Millennium Development Goals MOHSW Ministry of Health and Social Welfare MMR Maternal Mortality Ratio NBS National Bureau of Statistics NIE Net Intervention Effect SDGs Sustainable Development Goals TDHS Tanzania Demographic Health Survey WHO World Health Organization
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Preface
Growing up as a young boy, I always wanted to become a doctor, but I never imagined I would ever become an obstetrician/gynaecologist. I think my parents inspired me, as both are doctors, my father being a paediatri-cian/neonatologist, and my mother an obstetrician/gynaecologist. I actually took a long route to arrive at medical school. In my secondary school, phys-ics was not taught routinely as a subject. This subject is a prerequisite to enter medical school. I had to put in extra hours to study physics so that I could get enough credits to be accepted into the medical school. In 2000, I was able to conclude my medical degree and graduated. One is always undecided about in which subject to specialise after medical school. After medical school I was employed to work as a paediatric surgeon. It was an exciting time but I still felt I was interested in doing obstetrics and gynae-cology. Finally, I joined a master’s programme in obstetrics and gynaecolo-gy and graduated in 2007. I was then lucky enough to join the academic staff at Muhimbili University. I liked teaching and I enjoy interacting with my students. During my residency and afterwards, I have sadly witnessed how women who came to hospital, arriving late with complications, and later succumbed to death. It often bothered me and I was always thinking that there must be a way to prevent this problem. Something needed to be done to help these women before they experienced serious complications. I was given an opportunity by the White Ribbon Alliance Tanzania Chapter to be trained as master trainer of Home Based Life Saving Skills. Consult-ants from the American College of Nurse Midwives conducted this training. I really liked this kind of training and I thought to myself that this might be one of the ways to educate the community on how to recognise danger signs, prepare for childbirth and, ultimately, travel to hospital for any life-threatening event on time. When an opportunity came to pursue a PhD degree, I welcomed it and I de-cided that I would use my skills to design and conduct an intervention in a research setting in the rural area. This was to be done by educating the com-munity on Home Based Life Saving Skills by deploying community health workers. It has been a rewarding experience and, of course, at times a chal-lenging undertaking.
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It is my hope this work will contribute towards improving the lives of our pregnant mothers and in empowering the community to take actions in case of emergencies, and, ultimately, to help in the prevention of maternal deaths in rural Tanzania.
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Introduction
The global burden of maternal mortality Maternal mortality is unsatisfactorily high and is a public health concern that is recognised worldwide. Several initiatives have been advocated in address-ing this problem. These include; the 1987 Safe Motherhood Conference, the 1994 International Conference on Population and Development in Cairo, and the 1997 Safe Motherhood Technical Consultation in Sri Lanka (1). In addi-tion, to reduce this staggering burden of death, the Millennium Development Goal (MDG) 5, target 5A was launched with the aim of reducing maternal mortality numbers by 75% between 1990 and 2015. Since 1990, the maternal mortality ratio has declined by 43% worldwide, with most of the decline occurring after 2000 (2). Although the maternal mortality ratio is decreasing globally, its reduction in sub-Saharan countries is proceeding at a much slower rate (1, 3). The average decline worldwide is 2.6% instead of the 5.5% that would have been necessary to contribute to achieving the MDG 5 worldwide (4).
It is estimated that in 2015, more than 303,000 women died from preventa-ble complications related to pregnancy and childbirth, with most of these deaths occurring in low-income countries (1, 5). It was estimated that only 16 countries would achieve the MDG 5 by the year 2015 (6). Current data demonstrate that only 9 countries have reached MDG 5A; namely, Bhutan, Cape Verde, Cambodia, Iran, Laos, Maldives, Mongolia, Timor-Leste and Rwanda. Another 39 countries, including Tanzania, have made significant progress. However, these countries have not reached the goal of reducing maternal mortality by 75% (5). In September 2015, the new initiative of Sustainable Development Goals (SDG), specifically Goal number 3, was launched to reduce the maternal mortality ratio worldwide from 216 per 100,000 live births in 2015 to less than 70 per 100,000 live births by 2030. In addition to this target, there should be no individual country going beyond 140 maternal deaths per 100,000 live births (5, 7). It is the responsibility of each country to have clear political will and commitment to work towards improving health systems and access to quality of care, before, during and after childbirth in order to achieve the SDGs.
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The direct causes of maternal mortality include haemorrhage, pregnancy-related hypertensive disorders, puerperal infections, obstructed labour, and abortion complications. These account for more than 70% of maternal deaths worldwide, while indirect causes, such as pre-existing conditions including HIV/AIDS, malaria, anaemia, cardiovascular diseases and diabetes, contrib-ute to more than 28% of maternal deaths (4, 8). Evidence-based interven-tions, such as increasing access to skilled attendance during pregnancy and childbirth, timely access to emergency obstetric care, and access to family planning, are important in reducing maternal mortality (9-13). Most obstetric complications occur during childbirth and are unpredictable. Skilled attend-ance at birth is therefore the most critical strategy in order to significantly prevent maternal mortality (14).
One important indicator for MDG 5 was the proportion of births attended by skilled health workers. A skilled attendant is defined as someone who is “trained to proficiency in the skills needed to manage normal (uncomplicat-ed) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” (15). Mbizvo and Say reviewed factors that contributed to the decline in maternal mortality in Bangladesh, Bolivia, Cambodia, Morocco and Rwanda, and demonstrated that increased uptake of skilled attendance of between 20% and 50% was likely to have contributed to the decline in ma-ternal mortality (16). However, rates of skilled attendance have changed little in sub-Saharan countries since the launch of the MDGs (2). Analysis of 54 countries completed by Barros and colleagues shows that wealth inequali-ty remains high when it comes to utilisation of skilled attendance at birth (17). Several other factors are known to contribute to the non-use and low utilisation of skilled care, including physical distance, economic reasons, sociocultural factors and perceived need for the services, as well as quality of care (18-21).
In order to increase the use of skilled attendance, there is a need for interven-tions that increase supply and demand of the utilisation of these services. The supply side involves improvements in the provision of maternal health services; both in terms of staff number, training, accountability and equip-ment, and the demand side involves the perceived need of individuals or the community to utilise the services (22-24). An increase in utilisation of skilled maternity care can be achieved by providing birth preparedness in-formation that empowers the community with knowledge about danger signs and ways to prepare for childbirth and emergency situations. An increased knowledge level is envisaged to reduce delays in seeking care, accessing care and even receiving appropriate care (25). Community-based interven-tions that provide education to women, men and the community have also
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been shown to have potential to increase demand for utilisation of skilled care (26-28).
Birth preparedness and complication readiness In order to make the family ready for childbirth and any obstetric emergen-cy, the concept of birth preparedness and complication readiness (BP/CR) is currently advocated to be introduced to the communities (29). BP/CR in-volves acquiring knowledge about the danger signs, identifying a skilled attendant for childbirth, identifying which health facility to approach in an emergency situation, identifying transport to use in advance, having money set aside, and identifying a blood donor (29). When these steps are followed they are expected to reduce the three delays (delays in seeking care, reaching care and accessing care), and promote and increase utilisation of skilled care and obstetric emergency care. BP/CR messages aimed at individuals, fami-lies and communities would help with reducing the first two delays. Ensur-ing that health facilities and referral systems are prepared to manage normal labour and emergencies is crucial in reducing the third delay. Ultimately, this strategy will lead to a reduction in maternal mortality (25). BP/CR is includ-ed in the new World Health Organization (WHO) model for antenatal care education in a clinical setting (30, 31). Initiatives that promote BP/CR are described as compelling and as logical means to ensure the receiving of timely skilled care for delivery and in emergency obstetric care (32). The WHO recommends the use of community-based interventions to provide communities with BP/CR messages through home visits (33).
Counselling on danger signs and birth preparedness should be given during antenatal care (ANC) visits, as recommended by the WHO. However, wom-en having little knowledge of danger signs have been reported in several studies conducted in Tanzania and other developing countries (34-36). In addition, studies from Ethiopia, Nigeria and Kenya have also shown women to have insufficient knowledge on birth preparedness and emergency readi-ness (37-40). This raises questions about whether facility-based dissemina-tion of messages to increase awareness of danger signs can continue to be the only reliable means of conveying this knowledge, or whether there is a need to introduce other methods so as to involve the whole community. This could be done in new ways that go beyond the health facility by making members of the family and the community aware of the complications, as they participate in one way or another in the decision-making process when a complication occurs. Because decision-making for accessing or reaching care has been shown to be dominated by men (41-43), it is important to in-volve men in these strategies and regard them as partners.
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Male involvement in maternal health Men’s involvement in maternal and reproductive health has been encouraged for the last two decades (44). The programme of action of the 1994 Interna-tional Conference on Population and Development (ICPD) emphasised the importance of men’s active inclusion and shared responsibilities in reproduc-tive health (45). It has been demonstrated that there is elevated use of skilled attendance, use of contraceptives and antiretroviral treatment when men are involved (26, 46, 47). Women’s reproductive choices or outcomes depend on the financial power and support of their husbands. Participation in birth pre-paredness and partner involvement in the decision-making process have been reported to be factors affecting the choice of place of delivery in Uganda and Nigeria (39, 46). Studies completed in Malawi and Kenya point towards a growing number of men who take an interest and are keen to participate in maternal health if an environment conducive to their participation is provid-ed at ANC (42, 48, 49). However, barriers that have been shown to impede male involvement include factors related to social, cultural and health ser-vices. Men may see pregnancy as ‘women’s business’, or they might feel shy, embarrassed or ‘out of place’ in the ANC clinic and this is due to gen-der norms that maintain the idea that it is unnecessary for men to be involved in pregnancy and post-partum periods (50-53). In addition, men may not have the necessary knowledge to understand the importance of engaging in active involvement with their spouse’s health during pregnancy and child-birth has also been identified as a barrier (53-55). An insufficient number of staff, inadequate training of health workers, and the policies in place at the health facilities regarding men’s participation are some of the known health system barriers (52, 53, 56, 57). One of the strategies to increase male involvement is to improve men’s knowledge of obstetric danger signs and birth preparedness which eventually will make them better positioned to assist their spouses in making decisions regarding accessing ANC and delivery care. ANC have focused mainly on women who are traditionally not decision-makers and have no financial power (42, 58). It is therefore important to design interventions that involve men in maternal health and that accommodate both genders (59). Men should be regarded as partners in the programmes that involve maternal health by actively encouraging them to participate in ANC counselling, rais-ing their awareness of danger signs, making shared decisions, and providing social support (60, 61). A community-based approach such as the Home Based Life Saving Skills (HBLSS) training programme can be one way to achieve this goal.
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Community-based interventions for maternal and child health care Community-based interventions have been shown to reduce neonatal and childhood mortality (62). Community-based packages that promote BP/CR messages in the community by using support groups and women’s groups have been found to be the most effective in reducing neonatal deaths (63). A Cochrane review of 2010 has shown that the interventions contributed to an increased rate in the initiation of breastfeeding (63, 64). A recent review of 26 randomised controlled trials and quasi-experimental studies completed in low-income countries on the effectiveness of community-based interventions in reducing maternal and neonatal morbidity and mortality has shown that there is a reduction in maternal mortality and morbidity, and an increase in institutional deliveries (65). The WHO now recommends the use of Com-munity Health Workers in maternal and child health care following promis-ing results in achieving reductions in neonatal mortality in low-income coun-tries where such services have been implemented (66, 67). The WHO defines Community Health Workers (CHWs) as “members of the communities where they work, selected by the communities, answerable to the communities for their activities, supported by the health system but not necessarily a part of its organization, and have shorter training than profes-sional workers” (68). In 2012, a campaign was introduced to train one million community health workers by the year 2015 in sub-Saharan countries (69). It aimed to com-plement the health system where CHWs would be compensated for their work and be supervised by the relevant authorities such as the Ministry of Health. Their work would be linked with primary health care and mostly geared towards achieving reduced maternal and perinatal mortality (MDGs 4 and 5). In addition, their work was meant to be facilitated by mobile phone technology in order to reach poor communities in rural areas (70).
Home Based Life Saving Skills HBLSS is a programme developed and introduced by the American College of Nurse Midwives (ACNM) which involves the joint training of the preg-nant woman, her partner and other family members (71, 72). The aim is to equip the immediate family members with knowledge in recognising life-threatening danger signs, make birth preparedness arrangements, promote health-seeking behaviour, and promote the acquisition of skills to help the woman if any problem occurs at home. The training is conducted through encouraging dialogue so that joint informed decisions can be made when the
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need for action arises. HBLSS is a community competency-based pro-gramme that aims to reduce maternal and newborn mortality by increasing access to basic lifesaving measures within the home and community and decreasing delays in seeking and accessing care (71). The HBLSS was con-ceived as a component of the Community Partnership for Safe Motherhood Model. Previous studies, which were done in Bangladesh, Indonesia and Liberia, have shown that, by using HBLSS, community members acquired knowledge of danger signs and skills for helping a woman who has an ob-stetric complication to access care and receive a timely referral (27, 73-75). HBLSS is implemented through a cascade training strategy and was intro-duced in Tanzania in 2007 where 24 health workers from various parts of the country were trained by ACNM consultants. The 24 health workers became master trainers. The training was provided in collaboration with the White Ribbon Alliance as advocacy in addressing the challenges of maternal mor-tality in Tanzania. The Ministry of Health and Social Welfare (MOHSW) supported the training. The master trainers then went on to train HBLSS trainers and they eventually trained HBLSS guides. The HBLSS guides were mainly health attendants who were working at health facilities. The HBLSS guides trained pregnant mothers together with other family members on HBLSS modules. While the HBLSS programme is designed to be delivered in the community by health professionals, such as midwives, nurses or other health attendants, in this study project we trained community health workers as HBLSS guides instead.
United Republic of Tanzania Tanzania is an eastern African country with a population of about 45 million inhabitants (76) with a population density of 51 per square kilometer. The annual population growth rate is 2.7%. With a total area of 945,000 square kilometers, Tanzania is the largest country compared to its neighbours in the west (Rwanda and Burundi), north (Kenya and Uganda), and south (Zambia, Mozambique and Malawi). To the east is the Indian Ocean where island of Zanzibar is located 30 kilometers from the mainland. One of the world’s most recognised landmarks in Tanzania is Mount Kilimanjaro, which, at 5,985 meters above sea level, is the tallest mountain in Africa (Figure 1). Mainland Tanzania has 27 administrative regions, 133 districts and 1,632 councils. Each council is divided into divisions, which in turn are composed of three to four wards. The wards are composed of 5 – 7 villages. The local
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government councils are the most important local administrative body and are responsible for the implementation units for public health services (77).
Figure 1. Map of Tanzania regions and boundaries and Pwani region showing Mkuranga and Rufiji districts
Life expectancy at birth for men is 60 years, while for women, it is 63 years. The literacy rate is, on average, 71.5% in the country, while literacy among adult women is 76% compared to 87% for men with education. The Total Fertility Rate is 5.2 and women of childbearing age (15–49) make up 47.1% of the total population (76). The majority of the population (71%), which is mainly involved in agriculture, resides in the rural areas, and is mainly in-volved in agriculture. The annual growth domestic product for Tanzania is 7% and the per capita GDP for 2014 was 939 US dollars. Agriculture (em-ploying 80% of the workforce), tourism and gold mining are the main sources of revenue for the national income (78, 79). The proportion of the population living below the national poverty line spending less than 0.60 USD per day is 28.2%, the majority of whom reside in rural areas (80). The infant mortality rate (IMR) has been declining in Tanzania: currently, it is estimated to be 45 per 1,000 live births, compared to 115 per 1,000 live births in 1988 (76) and, in this case, MDG 4 has been achieved.
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Health system in Tanzania
Health system structure The health system in Tanzania is a pyramidal structure of health care ser-vices. According to the current Health Sector Strategic Plan, July 2015 – June 2020 (81), at the bottom of the pyramid is the Household/Community level, whereby community-based health activities provide health promotions and prevention services to families in villages and neighbourhoods (Figure 2). At the village level, there are public and private dispensaries that provide preventive and curative services. ANC and delivery services are provided in the dispensaries. At ward level there are rural health centres, which can ad-mit patients and, in some, caesarean sections can be performed. District and council hospitals provide care to patients referred from dispensaries and health as well as providing basic surgical services (81). Regional Referral Hospitals are level 2 facilities that receive referral patients from lower levels (district and council hospitals and health centres) and also provide specialist medical care such as general surgery, cardiology, nephrology and gynaeco-logical services. Zonal and national hospitals provide advanced medical care and serve as teaching hospitals for biomedical, medical and nursing training (81).
Figure 2. Health care pyramid in Tanzania. Source: MOSHW; Health Sector Strate-gic Plan 2015–2020 (81).
Key to Figure 2: APHFTA: Association of Private Health Facilities in Tanzania, CBO: Community Based Organisations, FBO: Faith Based Organisations, NGO: Non-Government Organisation.
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Health delivery services In Tanzania, at least 90% of the population lives within five kilometers of a primary health care facility. Currently there are 5,819 public dispensaries and 1,123 private dispensaries. There are 614 public health centres and 78 private health centres. There are 15 private and 12 faith-based regional hos-pitals, that receive referrals from 63 government-owned district hospitals and 37 designated hospitals. Designated hospitals are faith-based hospitals that have been contracted by the government to provide health services in dis-tricts where there are no public hospitals (81). Council health management teams are responsible in organising and implementing health services and health promotion at community, health center and district level. Information on maternal and child health is available in the national health management information system (HMIS) known as MTUHA.
Human Resources for Health Human Resources for Health (HRH) is a major constraint to service delivery in Tanzania. Data from the Health Sector Strategic Plan IV (HSSP IV) of 2014 show that there are 929 medical specialists, 1,157 medical doctors, 1,710 Assistant Medical Officers (AMOs), and 13,848 enrolled nurses and nurse midwives in Tanzania (81). This translates to only 8 skilled health personnel (doctors, nurses and midwives) per 10,000 persons (82), which is well below the minimum of 23 per 10,000 recommended by the WHO (83). Rural and remote areas face a major shortage of health staff and many pri-mary health care facilities in these areas do not have qualified staff. In Tan-zania, medical doctors include physicians and AMOs. Training of physicians consists of 6 years of study at any public or private medical universities. AMOs, also known as non-physician clinicians, are those who have worked as clinical officers (and are trained for three years in general medicine) be-fore undergoing two years of additional non-university training that also includes training in obstetric operative care (84). Midwifery services are provided by registered and enrolled nurses who have had training in nursing for two years and midwifery for three years. These professionals provide ANC and delivery services as well as life-saving procedures that may be needed before referring the patients (85). Another cadre of health care staff, Mother and Child Health Aides (MCHAs), receive two years’ training in mother and child health care. MCHAs were the major providers of reproduc-tive health care in the 1990s but their roles are currently being phased out and replaced by registered and enrolled nurses. In Tanzania, community health workers (CHWs) are volunteers selected from the villages and each village has two community health workers both men and women. They provide health promotion messages and assist during
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the implementation of interventions such as vaccinations. Recently there have been efforts made by the government to enhance the role of CHWs in the strategies to attain MDGs 4 and 5. The Primary Health Care Services Development Programme (2007–2017) (77) and the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths (One Plan), have articulated and emphasised the importance of the role of CHWs. In order to achieve this strategy, national guidelines and training materials for Integrated Maternal and Child Health CHWs were approved in 2012 (86). A pilot study was conducted in Morogoro region to evaluate a way forward in integrating CHWs in 2012. Furthermore, the Health Sector Strategic Planning of 2015 – 2020 seeks to formalise the role of CHW from being a volunteer to one that is part of the professional health cadres and is integrated into the health care system (81).
Health care financing The Government of Tanzania allocated about 10% of its total expenditure to health in 2012/2013. This figure is short of the target according to the Abuja declaration which advised an expenditure of 15% of the total budget on health (81). Of the total expenditure for health, 33% was made available for reproductive, maternal and child health (87). Tanzania has also introduced health insurance schemes that could help in the reduction of primary health care cost. These include the National Health Insurance fund that covers civil servants, the National Social Security Fund and Community Health Funds. In total, these schemes accounted for 5% of the overall government expendi-ture in 2012 (82).
Maternal health care in Tanzania According to the Census of 2012, the Maternal Mortality Ratio (MMR) in Tanzania was 432 per 100,000 live births, which is slightly lower compared with the Demographic Health survey data of 2010 which reported a rate of 454 per 100,000 live births (76, 78). The target in Tanzania for MDG 5, of reaching 193 per 100,000 live births, down from 910 per 100,000 in 1990, has not been reached, but progress has been made (5). Fifty percent of births in Tanzania occur in health facilities and 48% are delivered at home. There are variations depending on the region of the coun-try, for example, in a southwest region called Rukwa, the facility delivery rate is 30%, while in Dar es Salaam, it is 98%. Although the proportion of mothers who deliver in health facilities is low, more than 96% of women attend antenatal care (ANC) in health facilities at least once and 43% attend-ed four times, as recommended (78).
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The Tanzanian Government has embarked on ambitious plans and policies to address the challenge of high maternal mortality, including the introduction of Focused Antenatal Care (FANC) in 2002. This entailed the provision of ANC services free of charge and women are supposed to attend the ANC at least four times and receive counseling on birth preparedness messages (88). In 2008, a strategic road map to reduce maternal and neonatal mortality was launched with the aim of increasing antenatal attendance to at least 4 visits from 64% in 2005 (89) to 90% in 2015 (90). In addition, the policy aimed to increase the coverage of births attended by skilled attendants from 46 to 80%. Furthermore, the goal was to have increased coverage of Comprehen-sive Emergency Obstetric Care (CEmOC) from 64% of hospitals to 100%, and of Basic Emergency Obstetric Care (BEmOC) from 5% of health centres and dispensaries to 70% (90). A recent review of the achievement of these goals demonstrates that, in 2012, 20% of dispensaries and 39% of health centres could provide BEmOC, while 73% of hospitals could provide CEmOC (87). All of these improvements will obviously increase the supply side of care; therefore, increasing the demand side of obstetric care is of utmost necessity and can be achieved by employing community-based strat-egies.
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Theoretical Framework
The Three-Delays Model In order to understand the causes of maternal mortality, a three-delays model was developed by Thaddeus and Maine (25). In their model, they described three delays; delay in seeking care, delay in reaching care, and lastly, delay in receiving appropriate care. Delays in seeking care can be due to failure to recognise danger signs, or not perceiving the severity of the obstetric com-plication, socio-cultural factors, lack of money, or previous experiences in contact with the health system. Delays in reaching care can be caused by facilities being a long distance from the pregnant woman’s home, poor roads and the absence of affordable transportation to the health facility. Delays in receiving care may be due to the negative attitude of health providers, poor skills of health personnel, lack of health providers as well as shortages and stock-outs of basic equipment and supplies.
Health Belief Model Access and utilisation of safe and skilled care for delivery also depends on the behaviour of the individuals and/or the community. The Health Belief Model (HBM) has been used to describe behavioural changes and has six main constructs that will influence people to take action. The HBM posits that a person’s or a community’s health-related behaviour depends on their perceived risk of outcome where there is susceptibility to a maternal compli-cation (perceived susceptibility) or with severe consequences (perceived severity). Taking actions such as utilising skilled care in ANC and delivery will minimise risk of unwanted outcome (perceived benefits) and the bene-fits outweigh the obstacles (perceived barriers) in taking actions. When in-dividuals are exposed to factors that help them to strategise to take action such as through training (cues for action), then they will be confident in their ability to take action (self-efficacy) (91, 92).
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Social construction of gender and masculinities
Connell (93) has described a dominant form of masculinity; hegemonic masculinity. This is defined as the “configuration of gender practice which embodies the currently accepted answer to the problem of legitimacy of pa-triarchy, which guarantees (or is taken to guarantee) the dominant position of men and subordination of women” (93, 94). This is seen as an idealised phe-nomenon of “a real man” who is obliged to be strong and who can be enti-tled to violence, risk-taking, expressing no emotions, being the provider and decision-maker in the family and having material success. This social con-struction of masculinities is also relevant in issues related to male involve-ment in maternal health. Despite an increased interest in studying male in-volvement in maternal health care, there is no consensus on which theoreti-cal framework is most appropriate in studying male involvement. Two ap-proaches have been considered while designing programmes to involve men. First, male involvement is seen as a marker of gender equity as part of social determinants of health (95). This social determinants approach posits the adoption of more equitable gender roles such as joint decision-making among couples, shared household chores and parenting that will eventually lead to healthier behaviours, such as immunisation for children, improved contraceptive use and improved health care seeking in case of emergency. This has a potential to position man as an agent of positive change (60). The second approach relates to the consideration that male involvement is merely instrumental, for example, providing direct assistance, such as money, leads to the improvement of the health of their spouse and children. The latter approach is seen as ‘gender neutral’ (61, 96) or ‘gender blind’ (52), because it considers men’s action independent of their gendered roles and there is a risk of reinforcing gender norms that disempower women (56).
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Rationale of the study
Despite the implementation of several initiatives, such as the Safe Mother-hood Initiative and the introduction of FANC, maternal mortality is still unacceptably high in Tanzania. The utilisation of skilled care during preg-nancy and delivery is crucial in reducing mortality as life-threatening com-plications can occur without warning. The community must be empowered by having adequate knowledge and understanding the importance of access-ing skilled care. Previous studies in Rufiji district showed that the community has a low compliance to facility delivery and referral to hospitals when advised (41). As in other parts of Tanzania, women in Rufiji district have limited knowledge of the danger signs of complications that may arise during preg-nancy, delivery and after delivery, despite having a high attendance rate at antenatal care (34, 97). In a study done in the rural district of Rufiji on the use of essential obstetric care facilities, Urassa and colleagues found that a quarter of women with complications were referred to the hospital level but less than half arrived at their referral points. Out of 60 referred cases, 52% did not arrive in any of the two hospitals of the district (98). The introduction of Focused Antenatal Care (FANC) in 2002 was expected to increase client-provider contact time, allowing every woman to receive adequate individual counseling on the danger signs and other education mes-sages, including preparation of a birth plan and emergency readiness. De-spite this effort, the Tanzania Demographic Health Survey (TDHS) of 2010 reports that the majority of women receive antenatal care, but less than half of them are informed of the danger signs of pregnancy complications (78). In addition, studies have shown that at ANC, the duration of contact between the health worker and the pregnant woman is low (99, 100). Therefore, there is a need to apply innovative community-based interven-tions involving the pregnant woman, her partner and closest family mem-bers, to help reinforce the importance of BP/CR messages to eventually im-prove the utilisation of skilled care and thereby lead to a reduction of mater-nal mortality.
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Aim and objectives
Aim The aim of this thesis was to explore the perceptions and challenges that the community faces regarding preparations for childbirth and to evaluate an intervention of Home-Based Life Saving Skills training on the knowledge of danger signs, facility delivery and male involvement in a rural community in Tanzania.
Specific Objectives 1. To explore the perceptions, experiences, and challenges that the
community faces on birth preparedness and complication readiness (Paper I).
2. To assess men’s knowledge of danger signs, birth preparedness and complication readiness (Paper II).
3. To determine the effect of the HBLSS educational programme on
birth preparedness and complication readiness, utilisation of maternal health care services and facility delivery (Paper III).
4. To assess the impact of the HBLSS educational programme on male
involvement in maternal health (Paper IV).
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Material and Methods
Study Design This study used mixed research methods and consisted of three phases. The first phase involved conducting baseline studies using a qualitative research method (Paper I) along with a quantitative component (Paper II). The second phase was a community-based intervention. In the third phase, household surveys were used to evaluate the HBLSS education performed by CHWs. A quasi-experimental study was designed using pre/post, non-equivalent groups in an intervention district and a comparison district (Papers III and IV). An overview of the study design and participants is shown in Table 1.
Table 1. Overview of study design, participants and methods used
Paper Paper I Paper II Paper III Paper IV Study Design Qualitative
study Cross-sectional survey
Comparison Intervention/ Control districts
Comparison Intervention/ Control districts
Participants
67 women and 65 men
725 men
1,542 women (intervention) and 1,528 women (comparison)
1,378 men (intervention) and 1,358 men (comparison)
Data collection Data analysis
12 Focus Group Discussions (FGDs) Qualitative Content Analysis
Structured questionnaire Descriptive Statistics, Bivariate and multivariate analysis
Structured questionnaire Descriptive statistics, SPSS Difference in Differences (DID) SAS
Structured questionnaire Descriptive statistics, SPSS Difference in Differences (DID) SAS
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Study Setting The study was conducted in two districts, Rufiji and Mkuranga, in the Pwani region, which consists of a total of six districts. Rufiji district was used as the intervention district and is located about 200km south of Dar es Salaam and covers an area of 13,339 km2. The district has 6 divisions, 19 wards, and 128 villages. It has an estimated population of 212,000 according to the re-cent census conducted in 2012 (76). The Rufiji River traverses the district and divides it into flood plains, plateau and a coastal area. Mkuranga was chosen to be a comparison district because of its similar demographic and socio-economic characteristics. It has an area of 2,827 km2. The district has 4 divisions, 15 wards, and 109 villages. The population of Mkuranga as per the 2012 national census is estimated to be near 223,000 (76). The literacy rate in Pwani region is 83.1% among men and 66.9% among women. The percentage of women of reproductive age (15 – 49 years) is 47.5%. The an-nual population growth rate in this region is 2.2% (76). A major highway links Dar es Salaam to the southern regions of the country. However, a limited transport system makes people depend more on the health services that are available within their locality. The main mode of transport is bicycles, motorcycles and vehicles along the main road. Current-ly there are many motorcycles available in the area. These are sometimes used as paid transportation to take pregnant women to a hospital. The eco-nomic activities in both districts are similar, and include small-scale agricul-ture of cassava, rice and maize, and fishing. Cashewnut is the main cash crop in both districts with Mkuranga producing the largest in terms of tonnage. In Rufiji district there are two hospitals; one public and one private (not-for-profit), five health centres and 56 dispensaries. Mkuranga has one public hospital, two health centres and 47 dispensaries.
Study Participants and Data collection Paper I The aim of Paper I was to explore the community perceptions of preparing for childbirth. Purposeful sampling, including both men and women of different ages, living in rural or semi-urban areas and having recent or previous experi-ences of childbirth, were invited to participate in the study, in order to ensure as broad a perspective on BP/CR as possible (101). Included in the study were men and women who were 40 years of age or younger and who had a baby delivered in the last 2 years, and older men and women above 50 years of age. Homoge-nous groups of young men and women, and older men and women, were sepa-
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rated in the discussions, so as to mitigate the effect of feelings of insubordina-tion. Village leaders assisted with recruiting the participants. The villages that provided the participants were selected purposefully from semi-urban and rural areas with health facilities that serve as referral points in these areas.
Data collection In order to capture perceptions in the community, Focus Group Discussions (FGDs) were chosen as the most relevant tool to collect the data. Utilising FGDs facilitates group interactions and can provide rich information about perceptions and experiences in a way that a questionnaire would not to be able to (101). A village was selected and four FGDs with young men, young women, older men and older women were performed. Another village was approached and, in a similar way, four FGDs were held. In order to be sure of saturation of the mate-rial, a third village was added, however, no essential new information was re-vealed. In total, 12 FGDs with 10 – 12 participants in each were conducted in the Swahili language that was known to all participants. Five FGDs were con-ducted by a male social scientist and the rest were moderated by an obstetri-cian/gynaecologist, the author of this thesis. Another gynaecologist took notes during the discussions. A topic guide that had been pre-tested in another district was used to collect the information. Topics for discussion included cultural and social issues surrounding pregnancy and childbirth, use of traditional medicine during pregnancy and childbirth, and steps taken to prepare for safe pregnancy and potential complications. The discussions were introduced by asking the participants to discuss what happens when a woman in the family conceives and what are the preparations made for childbirth and for any possible emergency or unforeseen incident. The FGDs were tape-recorded upon consent being given by the participants and were transcribed verbatim.
Papers II, III and IV Community-based surveys were conducted in Rufiji and Mkuranga districts. Data for Papers II, III, and IV were collected using a structured question-naire developed by JHPIEGO, an affiliate of John Hopkins University, and adapted to the Tanzanian context (102). Experienced research assistants, both men and women piloted the questionnaire in nearby Kisarawe district before collecting the data. Information collected included socio-demographic characteristics, such as age, marital status, education level, knowledge of danger signs during pregnancy, childbirth and postpartum, knowledge of BP/CR and actions taken on BP/CR. Related to knowledge of danger signs, participants were asked to mention spontaneously any danger signs during pregnancy, childbirth and the postpartum phases. During pregnancy, correct possible options were signs such as excessive vaginal bleeding, swollen hands and feet, fits, fever, severe abdominal pain, premature rupture of membranes, and blurred vision. Obstetric danger signs during childbirth
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were for example excessive vaginal bleeding, severe headache, fits, severe abdominal pain, labour lasting more than 12 hours and retained placenta. In the postpartum phase, possible danger signs were excessive vaginal bleed-ing, severe headache, and fits after delivery, foul-smelling discharge, fever and severe abdominal pain (Table 2). For BP/CR, knowledge and actions taken included: saving money; identify-ing transport, a skilled attendant, where to go in case of emergency and a blood donor; and preparing a birth kit. In our study identifying a birth kit meant buying materials such as surgical blades, clean clothes, syringes and surgical gloves as part of the preparation (Table 2).
Table 2. Summary of items used to identify knowledge of danger signs, knowledge on BP/CR and actions taken
During Pregnancy
During Childbirth
During Postpartum
Knowledge of BP/CR
Actions taken on BP/CR
Excessive vaginal bleeding Convulsions Fever Blurred visions Difficulty in breath-ing Swelling of hands and feet Severe abdominal pain Dizziness Reduced or in-creased fetal movements Premature rupture of membranes
Excessive vaginal bleeding Convulsions Delay in placenta delivery Fever Preterm rupture of membranes Prolonged labour
Excessive vaginal bleeding Convulsions Foul smelling discharge Difficulty breathing Abdominal pain Pain in the perine-um Body weakness Swollen or tender breasts
Saving money Identifying transport Identify where to go in case of emer-gency Identifying skilled birth attendant Identifying blood donor Identifying birth kit
Saved money Identified transport Identified where to go in case of emer-gency Identified skilled birth attendant Identified blood donor Prepared birth kit
The household wealth was estimated using ownership of assets. The wealth quintiles index was calculated using principal component analysis. The asset items included were; owning a radio, bicycle, and mobile phone, type of flooring material, source of drinking water and source of cooking energy. The sample was divided into 5 population quintiles with A1 being poorest (20%) and A5 being least poor (20%).
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In Paper II, the aim was to determine the actions taken on BP/CR and knowledge of danger signs among men. Baseline data were collected from men who had partners who had given birth in the last two years in Rufiji. A total of 756 men were invited and 725 men (95.9%) agreed to participate. They were randomly selected from the community using a two-stage cluster sampling technique. First, all health facilities were listed in each district, then 14 health facilities were randomly selected by ballot method. Secondly, two villages from the catchment area of each facility were randomly selected and all men in these villages whose partner had delivered within the last two years were invited to participate. Paper III aimed at determining the effect of the intervention on facility de-livery, ANC attendance, knowledge of danger signs, and knowledge and actions on BP/CR among women. The same two-stage cluster sampling technique was used, and all women from the villages who had delivered a child in the last two years were invited to participate in the study. The calcu-lated sample size was estimated to be 1,400 (700 per district) based on a facility delivery of 47% (89) in Tanzania with the assumption of detecting a 15% effect on increased facility delivery as the primary outcome, the power of 90% with a 5% significant level, design effect of 1.5 and assuming a 3% non-response rate. The same villages in both districts were visited before and after the intervention. In Paper IV we assessed the effect of the intervention on male involvement in maternal health in this rural community. Information on socio-demographic characteristics, accompanying wife to ANC, shared decision-making, knowledge of danger signs, and knowledge and action on BP/CR were collected. Using the same procedure for sampling as in Paper III, men whose wives had delivered in the last two years were selected. The estimated sample size was 1,300 (650 per district), based on the proportion of male involvement in accompanying their spouse to ANC of 65% in Uganda with similar context to rural Tanzania (47), and detecting a 10% effect on increas-ing male involvement, the power of 80% with a 5% significant level, design effect of 1.5 and assuming a 20% non-response rate. Participants were not necessarily the same during the two surveys.
Intervention The intervention package had two components. The first one involved the training of health workers and community health workers and the second was the training of the community on HBLSS by community health workers (Figure 3).
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Figure 3. Phases of the intervention
Training of health workers and Community Health Workers HBLSS training is provided through cascade training. The American College of Nurse Midwives (ACNM) provided training to 24 master trainers in Tan-zania. The author of this thesis is one of the master trainers and trained 24 health workers who were selected from 14 health facilities in Rufiji district. The training of the health workers on HBLSS topics, how to conduct HBLSS training to CHWs and how to supervise them were conducted over a period of one week. The training employed different pedagogical methods such as lectures and role-playing. In addition, adult learning techniques, such as use of stories, discussions and demonstrations, were used to train the partici-pants. The master trainer supervised the health workers and they in turn trained 66 CHWs both men and women from the villages forming the catchment population for two weeks.
Training of the communityIn the HBLSS programme, CHWs are also known as community guides. They are trusted men and women selected from the community, who can all read and write. They usually volunteer to take part in health promotion campaigns such as the immunisation of children and pregnant women. The CHWs were required to make four home visits with pregnant women and their families, including hus-bands, throughout the pregnancy. It was the responsibility of the CHWs to iden-tify all pregnant women in their catchment villages. Once identified, the preg-nant women and their families would make arrangements for a feasible and appropriate time for the training to be conducted at their homes. During the visits the CHWs conducted training about recognising obstetric and neonatal
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34
danger signs, the importance of attending ANC and delivering in a health facili-ty, shared decision-making, BP/CR, hygiene, and the importance of rest during pregnancy. Details of the content of the visits are shown in Table 3. To maxim-ise effective learning and communication among the community members, the CHWs used different methods including the use of stories and case histories, discussions and demonstration, and the identification of danger signs using pic-torial cards and Take Action Cards (TAC). These cards contained images de-picting potential problems on one side and on the reverse side, information on what action to take for each (Figure 4). At the end of the training visits, the cards were left with the family to keep for their own use.
CHWs were given register books to record the home visits they had made. The health workers, who were supervisors to CHWs, checked these books regularly. The health workers made occasional visits with the CHWs and participated in the training of the families. Health workers also documented their supervision visits. The master trainer supervised the health workers by reviewing their rec-ords and participated in the education of families occasionally. There was a one-day refresher course for the health workers and CHWs once every two months to update their training skills. During these meetings, challenges regarding the implementation of the educational home visits were discussed.
The CHWs were provided with bicycles in order to assist in moving around in the rural areas. They also received training materials, T-shirts with the HBLSS logo, and a small bag in which to keep the materials. They were provided with a monthly allowance of 30,000 Tanzanian shillings (USD $13.60). Table 3. Training of pregnant women, husbands and family members on HBLSS
Visit 1 Visit 2 Visit 3 Visit 4 Importance of at-tending antenatal early
Recognition of maternal danger signs and actions to take
Recognition of maternal danger signs and actions to take
Birth preparedness and complication readiness
Importance of rest during pregnancy and nutrition
Importance of help-ing the woman with household chores
Recognition of danger signs and actions to take for early referral
Birth preparedness and complication readiness
Importance of skilled care for delivery and joint decision-making in seeking delivery care
Recognition of maternal newborn danger signs and actions to take
Birth preparedness and complication readiness
Importance of skilled care for delivery and joint decision-making in seeking delivery care
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Kadi ya kuchukua hatua: Matatizo ya mama
Figure 4. Pictorial card demonstrating danger signs; Line 1; Antepartum and Post-partum bleeding (left), Abdominal pain, fever, painful micturition (right). Line 2; Headache, fits during pregnancy (left), Prolonged labour (right). Line 3; Foul smell-ing vaginal discharge and weakness due to malaria (left), Family size discussion (right).
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Outcome measures Community perceptions, experiences and challenges regarding BP/CR were the outcome measures in Paper I. In the cross-sectional survey, Paper II, the main outcome measure was the level of BP/CR in terms of actions among men. If a man had made three of the six actions he was considered to be prepared (Table 2). This technique was considered appropriate as a study in rural Uganda used a similar proce-dure (35). Associations between being prepared and socio-demographic characteristics and selected reproductive characteristics were determined. The main outcome measure in Paper III was place of delivery for the women within the last two years. Other measures included: attendance to antenatal care; knowledge of three or more danger signs during pregnancy, childbirth and postpartum; knowledge of three or more BP/CR; and three or more ac-tions taken on BP/CR (Table 2). The main outcome for Paper IV was male involvement. There are no com-mon criteria in the literature defining male involvement. Criteria such as escorting their partner to ANC or childbirth as a measure of male involve-ment has been used in some studies, while others have used a combination of indicators (47, 103, 104). A composite score was used to describe male in-volvement in our study. The male involvement score was based on a dichot-omous answer (yes/no) to the following five components: 1) men escorting their wives to ANC; 2) escorting women to place of delivery; 3) joint deci-sion-making on the place of childbirth; 4) knowledge of at least three or more danger signs in each of the phases (pregnancy, childbirth and the post-partum period), however, the items to identify knowledge were not ranked according to importance); and 5) at least three BP/CR actions taken. A com-posite index for male involvement was based on having made three out of the five above actions. The knowledge of danger signs and BP/CR was ob-tained by letting the participants mention danger signs without giving any options (Table 2). The location of the last delivery for the wife was also doc-umented.
Data Quality Data were collected using a pre-tested questionnaire. Seven research assis-tants both men and women were trained for five days and supervised by the author of this thesis during the data collection. The research assistants were medical students who had experience in conducting household surveys relat-ed to reproductive health. At the end of each day of data collection, all ques-
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tionnaires were reviewed for any missing information. If any information was lacking, the research assistant contacted the participant the following day to fill in the missing information. If an eligible participant was not around, he or she was visited three times before being regarded a non-responder.
Data Analysis For the qualitative study (Paper I), data analysis was guided by using the Qualitative Content Analysis approach, described by Graneheim and Lundman (105). The transcripts were translated into English in order for the international research team members to participate in the analysis. They were uploaded into the NVivo 10 software package (QSR International) to aid in the sorting of the data. The focus of the analysis was to obtain the manifest meaning of the text, to get an understanding of what the text says, and not an in-depth interpretation of the underlying meanings of the text material. The transcripts were read several times to allow the research team to become acquainted with the data. Paragraphs and text referring to the perceptions and experiences regarding BP/CR were identified and were used to form the meaning units. The meaning units were further condensed to form condensed meaning unit and codes. The codes were combined into subcategories and categories in relation to their differences and similarities. All authors read the material and reflected on each of the meaning units, condensed units, codes, subcategories, and categories, and discussed each of these until agreement was reached. For the quantitative studies, data were cleaned and entered in a database. For Paper II, binary logistic regression and multiple logistic regression analysis were performed to determine the association between being prepared and socio demographic characteristics and predictors of being prepared using SPSS version 18. Adjusted odds ratio (AOR) and 95% Confidence Interval (CI) were used to express the results. In Papers III and IV, descriptive statistics were used to describe the socio- demographic characteristics and the chi-square test was used to compare the intervention and comparison districts using SPSS version 18. Changes in proportions of knowledge of danger signs, knowledge and actions on BP/CR, antenatal care attendance and facility delivery were calculated in the intervention and comparison district before and after the intervention (Paper III). In Paper IV, the male involvement, defined as; escorting wife to ANC and childbirth, making joint decisions, knowledge of danger signs and ac-tions taken for BP/CR, were assessed before and after the intervention in both districts.
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The net intervention effect (NIE) was estimated as the difference in propor-tions between baseline and endline in the intervention district minus the dif-ference between the baseline and endline in the comparison district. Post-intervention differences within and in between the districts were also calcu-lated. For each variable, an estimated proportion and its variance was calcu-lated according to cluster sampling design (106). The net effect is the linear combination of four independent samples. P-values from a Z-test and 95% confidence intervals for the intervention effect were calculated based on a normal distribution. A p-value of < 0.05 was considered statistically signifi-cant. The analysis was performed with SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Ethical considerations Ethical approval was obtained from Muhimbili University of Health and Allied Sciences, Senate Research and Publication Committee. Permission to conduct the study was granted by the local government authorities of the districts and villages in Rufiji and Mkuranga districts. The participants were given information regarding the study and were explained their rights to continue or withdraw from the study at any time without giving a reason. They were assured that the information provided would be kept safely to ensure confidentiality. Upon accepting to participate in the study, informed consent was obtained by each participant signing the information sheet. Those who could not read or write declared their consent by inserting a thumbprint.
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Results
Community perceptions on childbirth, birth preparedness and complication readiness (Paper I) In Paper I there were 132 participants. The young participants’ age range was 19 – 36 years, while for the older men and women the range was 51 – 76 years. Two categories emerged from the analysis as shown in Table 4. The community expressed the importance of birth preparations geared to-wards delivering in health facilities. Moreover, they recognised that compli-cations during pregnancy are better handled at hospitals. Attending ANC was perceived as part of preparation for childbirth where pregnant women would be examined, tested and receive information about the progress of the pregnancy.
“When I was told that my daughter or granddaughter was pregnant, the first thing was to take her to hospital to check whether she really was pregnant. She would un-dergo a general health check-up. She would continue to attend clinic as her preg-nancy grows. Her doctor would advise her on what to do, whether to go and deliver at a normal clinic or not”. (Older woman FGD 4)
They reported the importance of delivering in hospital where qualified staffs are present to deal with any complications that may arise. However, obsta-cles related to poverty, lack of advance preparation, stigma directed towards unmarried women and those who attend ANC without partners as well as informal user fees affect their BP/CR and hinder the intention to use skilled care for ANC and delivery (Table 4).
“You went there so that she would help you, instead she sends you to go and buy gloves so she would make some tests on you. The situation you left at home was not good financially, yet she wants you to go home first and ask your husband to go and buy gloves for you then go back to the health centre. At the same time, your time to give birth is almost up and you’re in a critical condition. So, sometimes you think it would be better for you to remain seated where you are so that you would give birth right there alone … unless a neighbour passes by and is kind enough to help you …” (Young woman FGD 1)
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Table 4. Categories and subcategories on perception of birth preparedness and com-plication readiness
1. All births need to be prepared • Antenatal care prioritised but has challenges • Family responsible for supporting the pregnant mother • Stigmatising of unmarried women affects preparation • Practical preparations are financially demanding • Facility delivery preferred
2. Danger signs demand hospital care • Recognising danger signs • Health care services, ‘free but not free’ • Men decide but in consultation • Traditional beliefs are fading out • Herbal remedies still used for treatment
Men’s knowledge of danger signs and BP/CR (Paper II) The proportion of men who could mention at least one danger sign during pregnancy was 53.5%. Of these, 21.6%, mentioned high fever as a danger sign while only ten percent mentioned excessive vaginal bleeding as one of the danger signs during pregnancy. Forty-four percent of men mentioned at least one danger sign during childbirth and excessive vaginal bleeding was mentioned by 22.7%. In the postpartum period, 34.6% of men mentioned at least one danger sign, with excessive bleeding (17.8%) being mentioned by most, and only one percent mentioned severe headache. With regards to actions taken for BP/CR, only eighty-seven men (12%) made three actions out of six. The most common preparation made was purchasing a birth kit (54.3%) and the least made was the identification of a blood donor (0.1%). In the binary logistic regression calculations, knowledge of danger signs during pregnancy, place of residence (semi-urban/rural) and escorting wife to ANC were associated with being prepared. After adjusting for age, marital status, and level of education in multivariable logistic regression, knowledge of danger signs during pregnancy was strongly associated with being pre-pared (AOR = 1.4, 95% CI; 1.8 – 2.6) and it was less likely to be prepared if living in rural area (AOR = 0.6, 95% CI; 0.5 –0.8).
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Effect of the intervention (Papers III and IV) A total of 1,584 and 1,486 women were interviewed at baseline and endline, respectively. There were no differences in terms of socio-demographic char-acteristics such as age, marital status, education level and wealth quintiles between the intervention and comparison districts. We observed significant improvement of knowledge of three or more danger signs during pregnancy (15.2% vs. 48.1%) with a net intervention effect of 29.0% in the intervention area (95% CI: 12.8 - 36.2; p < .0001) (Table 5) compared with the compari-son district. There was a significant effect on the knowledge of three or more danger signs during childbirth (15.3% vs. 43.1%) with a net intervention effect (NIE) of 18.3% (95% CI: 11.4 – 25.2; p < .0001) and postpartum for those mentioning three or more of the signs (8.8% vs. 19.8%) with an NIE of 10.7% (95% CI: 6.4 – 15.7; p < .0001). Birth preparedness practice im-proved for those who made more than three actions (20.8 vs. 35.3%) with an NIE of 12.8 % (CI: 10.3 – 20.3; p < .0001) between the intervention and control district at baseline and endline. In the intervention area, utilisation of antenatal care with four visits improved significantly (42.4 vs 67.8%) with an NIE of 25.2% (95% CI: 16.9 – 33.2; p < .0001), and the use of facility delivery improved (75.6 vs. 90.2%; p = 0.0002) (Figure 5), but the NIE was not significant, at only 11.5% (95% CI: -5.1 – 39.6; p = 0.123), when com-pared to comparison district (Table 5).
Figure 5: Facility delivery rate at baseline and endline in the intervention and comparison districts
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Table 5. Effect of intervention on utilisation of skilled care, knowledge of danger signs and birth preparedness among women in Intervention and Comparison districts
Variable Intervention % Estimate
change
Comparison % Estimate
change
NIE 95% CI p-value
Facility delivery
14.6 3.1 11.5 -5.1–39.6 0.123
ANC visits
At least 1 4.3 0.5 3.7 -1.1–5.6 0.119 4 or more 25.4 0.2 25.2 16.9–33.2 < .0001
Knowledge danger signs
Pregnancy Knowledge of at least 3
32.9 3.9 29.0 12.8–36.2 < .0001
Childbirth Knowledge of at least 3
27.8 9.6 18.3 11.4–25.2 < .0001
Postpartum Knowledge of at least 3 BP/CR actions
11.0 0.3 10.7 6.4–15.7 < .0001
Money 22.2 15.8 6.4 -3.5–16.4 0.195 Transport 15.9 1.8 13.9 3.8–27.4 < .0001 Skilled attendant
4.4 0.1 4.3 2.5–8.1 < .0001
Where to go 9.6 -0.1 9.7 3.3–17.9 0.035 Blood donor 4.4 0.2 4.2 2.0–6.5 < .0001 Birth Kit 23.4 22.2 1.2 0.2–5.1 0.582 BP/CR actions ≥ 3 Knowledge of 3 BP/CR
14.5 11.3
1.7 2.1
12.8 9.2
10.3–20.3 2.8–13.2
< .0001 < .0001
NIE: Net intervention effect; CI: Confidence interval; % Estimate change = differ-ence in proportion between baseline and endline after the intervention
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Paper IV There were no differences in terms of socio-demographic characteristics such as age, marital status, education level and wealth quintiles between the intervention and comparison districts. The results show that there was im-provement in male involvement (39.2 % vs 80.9%) with a net intervention effect of 41.1% (CI: 28.5 – 53.8; p < .0001). There was improvement in the knowledge of danger signs during pregnancy, childbirth and postpartum periods. The proportion of men accompanying their wives to antenatal and delivery also improved. Shared decision-making for place of delivery im-proved markedly (46.8% vs. 86.7%), showing a net intervention effect of 38.5% (CI: 28.0 – 49.1; p <. 0001). Whilst facility delivery for spouses of the participants improved in the intervention district, this did not show statis-tical significance when compared to the comparison district with a net inter-vention effect of 12.2% (95% CI: -2.8 – 27.1: p = 0.103) (Table 6).
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Table 6. Effect of intervention on male involvement in intervention and comparison district Variable Intervention
% Estimate change
Comparison % Estimate
change
NIE 95% CI p-value
Wife’s Facility delivery
11.6 -0.6 12.2 -2.8–27.1 0.103
Escorted wife to ANC
20.3 3.9 16.4 5.6–27.2 0.002
Escorted wife to de-livery
33.8 0.7 33.1 24.1–42.1 < .0001
Shared deci-sion-making
39.9
1.4 38.5 28.0–49.1 < .0001
Male in-volvement score Knowledge Pregnancy
41.7 0.5 41.1 28.5–53.8 < .0001
Knowledge of ≥ 3
22.4 1.1 21.3 13.7–28.9 < .0001
Childbirth Knowledge of ≥ 3
14.1 0.1 13.9 10.5–17.4 < .0001
Postpartum Knowledge of ≥ 3
15.1 0 15.1 9.2–21.0 < .0001
BP/CR actions Three or more
22.9
-3.8
26.8
15.3–38.2
< .0001
NIE: Net intervention effect; CI: Confidence interval; % Estimate change= differ-ence in proportion between baseline and endline after the intervention
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Discussion
The community perceived that all births need to be prepared for and that all pregnant women presenting with danger signs should be treated at health facilities hence the use of skilled care was favoured. However, barriers relat-ed to the inability to prepare in advance hindered the realisation of the inten-tion to use skilled care. Men’s knowledge of danger signs was found to be limited and few men were prepared for childbirth and any related complica-tions. The novelty of using CHWs to educate the community on HBLSS in Tanza-nia showed significant improvement in several aspects of making prepara-tions for childbirth and is a major result of this thesis. Knowledge of danger signs related to pregnancy, childbirth and the postpartum period increased significantly among women and men. Likewise, birth preparedness practices increased significantly as did utilisation of antenatal care with the recom-mended four visits. After the intervention, the use of facility delivery im-proved in the intervention area. Another major result of the thesis is that men’s involvement increased signif-icantly after they took part in the education programme at home. The propor-tion of men accompanying their spouse for ANC and delivery increased and shared decision-making for place of delivery improved markedly.
Discussion of findings Perceived benefits of utilisation of skilled care The first delay in the ‘Three Delay Model’ focuses on delay in seeking care. This aspect is illustrated in this thesis by the limited knowledge of possible obstetric complications and joint preparations before childbirth in the fami-lies at large. However, participants recognised the need to be prepared for childbirth. They identified some danger signs such as severe obstetric hem-orrhage and convulsions as being dangerous enough to cause death (Paper I). According to the Health Belief Model, the community perceived benefits of attending ANC, delivering at a health facility and seeking skilled care in case of an emergency. Attending ANC was seen as a good way to start childbirth
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preparation and ensure that a normal pregnancy progresses well by getting tested and receiving prenatal medication such as iron tablets. They also re-spected the competence of health workers and considered them to be well-trained and “experts”, as reported in other studies completed in developing countries (107-110). Furthermore, ANC attendance is believed to be a pre-ventive measure to minimise the likelihood of birth complications (111, 112). This could also explain why, in some areas, such as in Kenya, Tanza-nia, China and Indonesia, there is high ANC attendance but a low number of facility deliveries (97, 113-115).
Perceived barriers The participants described their perceived barriers for birth preparation and delivery at a health facility. Perceived barriers included, meeting the cost of purchasing materials such as clean clothes, surgical blades and transporta-tion, Others included lack of advanced preparation, decisions being made by family members, and the distance to a health facility, which illustrates Thad-deus and Maine’s second delay, the delay to reach care (20, 41, 97, 116-123). User fees for ANC and delivery services have been eliminated in Tan-zania; however, the need to buy certain supplies in these poor communities contributes to the low uptake of facility-based deliveries (124-126). A third delay was identified, adding to the failure to bring the partner to ANC, health workers’ attitudes towards pregnant women and accompanying men, and the lack of motivation among health workers were perceived as being additional barriers in the utilisation of skilled care for ANC and delivery. These find-ings are similar to those of other studies that have been conducted in low-income countries, including Tanzania (127-130). It is important that these barriers are mitigated so that families can prepare for childbirth and so that delays in seeking and accessing skilled care are minimised, ultimately pre-venting maternal morbidity and mortality (25).
Perceived severity/susceptibility Awareness of obstetric danger signs is essential in helping a pregnant wom-an, her husband or her family to make a quick decision to seek care if the need arises. Obstetric complications such as excessive haemorrhage, fits during pregnancy, and malaria were perceived as being serious enough to require immediate care (Paper I). Prompt arrival for women with complica-tions to hospitals providing emergency obstetric care is fundamental in re-ducing maternal morbidity and mortality (131). Men in Rufiji demonstrated a low susceptibility to recognise danger signs during pregnancy, childbirth and the postpartum period (Paper II). This lack of awareness may lead to making delayed decisions to seek and access care for routine health care seeking, in case of an emergency or in complying with a referral (132, 133).
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Knowledge of danger signs in men and the community at large is critical in making informed decisions regarding birth preparations and being ready for taking action if complications arise (134-136). Few studies have been done on men’s awareness of risks of obstetric severities. In a study completed in Kenya, knowledge of danger signs among men was found to be higher than in our study (137). This contrast can be explained by a difference in method-ology used in eliciting the data; in our study, the men’s level of knowledge was obtained by asking unprompted answers, while in the Kenyan study, men were asked to respond with yes or no answers to danger signs that were read out to them. When answers are read to participants they may tend to respond “yes” and this may overestimate the knowledge of danger signs. Slightly more than ten percent of men were prepared for birth and complica-tion readiness based on our definition (Paper II). This result indicates a low susceptibility to recognise possible complications and understanding of the need for increased BP/CR in the community (102, 138). Men play a key role in determining women’s access to antenatal and delivery care through mak-ing sure transport is available, and by deciding whether to successfully com-ply with emergency referral (41, 139-142). This is an additional reason why men also need to be equipped with knowledge on why ANC and skilled birth is essential and on how to prepare for childbirth and identify signs of com-plications. The likelihood of families of pregnant women to follow recommended ad-vice in a perceived threatening situation during pregnancy and childbirth depends on them deciding whether the perceived benefits exceed the barri-ers. Modifying factors, such as socio-demographic factors, poverty, living in a rural area, knowledge and previous experiences, influence the judgment (91, 92). If positive actions are seen as important, they may be supported by raised awareness and knowledge provided in different ways, according to the HBM and this is what we expected to do in this project. The knowledge that was provided regarding danger signs and how to prepare for childbirth and complication could provide cues for action and encourage readiness in case of any life-threatening complications arising during pregnancy and child-birth.
The role of CHWs in educating the community One intervention to reduce maternal morbidity and mortality is increasing skilled attendance for ANC and facility-based deliveries (10, 143-145). In this thesis, the community-based intervention, deploying CHWs to train the community on HBLSS and BP/CR, had the effect of increasing the propor-tion of women who made more than four ANC visits as recommended by the
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WHO (Paper III). In addition, the proportion of women who delivered at a health facility increased in the intervention area. The lack of net effect on facility deliveries could be due to the already higher numbers of facility-based deliveries in Pwani region than anticipated accord-ing to the national figures, hence no significant effect could be demonstrated. Findings from similar studies employing community-based interventions, completed by using women’s groups and CHWs in low-income countries to increase demand of maternal health services, although occurring in different socio-cultural settings, have shown similar results in improving the number of ANC visits and facility-based deliveries (26, 146-153). A randomised controlled trial conducted in Northern Tanzania to improve birth prepara-tions showed that counselling on BP/CR messages at facility level had the effect of increasing BP/CR among the women (154). When pregnant women book early for antenatal visits and make at least four visits, there is increased likelihood that they will also use skilled care for delivery (155, 156). The use of CHWs to identify pregnant women early in the community, as done in this study, may have contributed to the increased number of ANC visits and facility-based deliveries. Since CHWs live in the community and are trusted members of the community, the information they provided to the pregnant women and other members of the family might have been accepted and in-ternalised. It is also important to ensure that, with the increased demand gen-erated by BP/CR messages to prepare and hence utilise facility delivery, health service providers and health systems are well prepared for the in-creased caseload. Negative experiences of sub-standard or quality of care in the facility may refrain or delay families in seeking care (25). Knowledge of danger signs during pregnancy, childbirth and the postpartum period improved among men and women in this community-based interven-tion (Papers III and IV). Community-based interventions carried out in Ken-ya, Eritrea and Bangladesh to improve maternal health knowledge and utili-sation employing CHWs as promoters of safe motherhood have demonstrat-ed similar improvements in knowledge of obstetric danger signs (157-159). It is also crucial that men’s knowledge of danger signs is improved, and this was achieved in this intervention (Paper IV). Making informed decisions regarding the wellbeing of their spouses for childbirth and in case of an emergency would help in reducing delays to seek care and reaching care (160). Studies completed in India and Uganda have demonstrated that when men are knowledgeable about danger signs they encourage their wives to have facility-based deliveries (47, 161). This signifies the importance of involving men in counselling for danger signs during ANC visits with their spouses as this enhances the utilisation of skilled care for delivery.
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Having knowledge of at least three BP/CR components and making three or more actions of BP/CR significantly improved among men and women in the intervention district compared with the comparison district (Papers III and IV). Identifying a skilled attendant, where to go in case of emergency, a blood donor and transport arrangements were components for which the intervention had a significant effect. Studies designed to measure improve-ments in maternal health service utilisation in Burkina Faso, Nepal, India, Eritrea and Bangladesh reported a similar effect in improving BP/CR by receiving information on BP/CR (134, 153, 159, 162-166). A similar inter-vention in Tanzania designed to improve skilled care utilisation, which had several components including community mobilisation, health facility infra-structure improvement, and health worker training, had a positive impact on improving BP/CR in the community (167, 168). This study used CHWs in educating the community and did not implement any other intervention at facility level, apart from training health workers to train and supervise CHWs. It is imperative that men and women in the community have knowledge and are prepared for childbirth as it has been demonstrated elsewhere that having knowledge of BP/CR and being prepared is highly associated with the use of skilled care for delivery (169-171).
Male Involvement in preparation for childbirth Traditionally, interventions to improve gender inequity have been designed to empower women (172). There have been some documented gains in women’s autonomy using this strategy. However, exclusive focus on women to address gender inequity is recognised as being limited (54). Gender ineq-uity cannot be fully addressed when the focus is placed only on women ra-ther than focusing on gender as a social construct that affects both men and women (61). This is also reinforced by the social construction of masculinity whereby the man is always the decision-maker and has access to financial resources (93, 94). Interventions to improve health outcomes that work with men and women together have been shown to successfully transform gender roles and norms (172, 173). Our study shows that male involvement in ma-ternal health in this rural community improved. The counselling of men to-gether with their wives on BP/CR messages during the ANC visits has pre-viously shown to improve male involvement in maternal care, even so in countries with varying degrees of patriarchal male structures such as Paki-stan, El Salvador and South Africa (139, 163, 174-176). The studies showed that men’s involvement could be achieved through escorting their wives to ANC, participating in the preparations for childbirth, and helping with household chores.
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This study demonstrated that male accompaniment increased by 20% with significant intervention effect. The practice of men progressively attending ANC could promote equal participation of men and women in maternal care and could have a subtle effect on hegemonic masculinity, as explained by Connell (93). In addition, it could underline the understanding that pregnan-cy is not only a women’s issue; rather, it is a couple’s issue. When men and women are counselled together there is a potential for women to make more preparations for childbirth as was shown in previous randomised controlled trials to improve male involvement in maternal health at facility level in South Africa, India and Nepal (163, 176, 177). A recent systematic review on the impact of male accompaniment to ANC on perinatal health outcomes in developing countries resulted in improving knowledge of danger signs in women, increased numbers of facility deliveries and skilled care attendance (178). Similarly, a systematic review and meta-analysis of male involvement and maternal outcome demonstrated significant effects on facility deliveries, BP/CR and reduced maternal depression (179). These beneficial effects could be explained by the acquired knowledge about the importance of ma-ternal health. This makes the couple aware of the potential dangers of preg-nancy and childbirth and the importance of seeking care as well as being prepared for childbirth and complications. As others have argued, those in-terventions that improve knowledge of maternal health in the whole commu-nity especially among expectant fathers lead to improved male involvement (104, 180). The intervention conducted in this study contributed to improved knowledge and hence larger involvement, which, hopefully, will lead to a reduction in maternal morbidity and mortality. Another explanation for improved male involvement could be shared deci-sion-making in the family on matters related to seeking care for childbirth. The intervention has shown there was greater shared decision-making for the place of delivery. Shared decision-making is often taken as a proxy for spousal communication (103, 104, 163, 181). In a patriarchal society such as this community, men are regarded as providers and decision-makers in all matters related to pregnancy and childbirth, reinforcing hegemonic mascu-linity constructs (93, 94). However, there are positive changes in this regard where men consult with their wives before making a decision on what action to take (110). When women are involved in decision-making they feel em-powered to decide and they involve their spouses in achieving their own health-care-seeking during the prenatal period. This also contributes to more men accompanying their spouses to ANC and eventually increases utilisation of skilled care (182). In addition, increased couple communication contrib-utes to a more equitable relationship and hence challenges the pervasive gender norms. In a study completed in Malawi, the Malawi Male Motivator project demonstrated an increased use of contraceptives among couples when spousal communication was encouraged (183).
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Whilst it is important to encourage male involvement, it is essential for health workers not to unintentionally reinforce gender roles by demanding that pregnant women who are single be accompanied by a man to ANC or else they will sometimes be refused access to the services they provide (Pa-per I). These actions could lead to a reduction in attendance or non-attendance at ANC due to such stigmas, especially those in relation to the testing of HIV (184). This effect has also been demonstrated elsewhere, for example, in Malawi and Tanzania (48, 185). A qualitative research study conducted in Malawi on male involvement in ANC described that the policy of ‘first and fast’ services to women who came with spouses could cause stigmatisation and unfair treatment of unaccompanied pregnant women (48). This has a further potential to reinforce gender norms and constructs of heg-emonic masculinity that promote the idea that men are more important in the community. This highlights the need for health workers to encourage women to attend ANC, even if they are unable or disinclined to bring their male partner along to the appointments. Equally, the infrastructure at the facilities that provide couples with privacy and the attitude of health workers towards men should be improved so that the health system can accommodate the increasing interest of male involvement in maternal health.
Methodological considerations Qualitative study This thesis has used mixed methods. In Paper I, a qualitative method was used to explore a deeper understanding of the community perspectives in relation to birth preparedness and complication readiness (BP/CR). Focus Group Discussions (FGDs) allowed the community members to discuss openly their experiences, perception and challenges using their own words, which is difficult to achieve with quantitative studies (186). Furthermore, participants were selected according to age; hence they were given a sense of freedom to speak without fearing insubordination from the elders. Partici-pants’ views and the phrases that they used in relation to their BP/CR were used to make minor changes in the JHPIEGO questionnaire for Papers II, III and IV. One such change included adding the purchase of a birth kit as an extra component in BP/CR. The community mentioned that, as part of prepa-ration for childbirth, they had to buy materials such as syringes, sterile gloves, cord ties, mackintoshes and surgical blades. Making these additions to the questionnaire contributed highly to the quality of the study. In qualitative research, trustworthiness has been established as a means of assessing the quality and validity of qualitative research. The four aspects of
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trustworthiness in qualitative research are credibility, transferability, de-pendability and conformability (101, 105). Credibility refers to whether data and its analysis address the intended focus. In this study we aimed to ensure credibility by describing thoroughly the method (FGD) that was employed, using a topic guide during the discus-sions, systematically analysing the data, staying close to the transcripts and describing the findings illustrated by quotes. Repeated reflection over the emerging subcategories and categories was seen as crucial during the analy-sis; this, and the collaboration with the international team of co-authors, added to the credibility of the findings. The degree to which the findings can be applicable to other settings is re-ferred as transferability. The detailed descriptions of the study context, se-lection criteria, description of the participants, data collection and analysis, together with use of quotes, will assist the reader to assess the possibility to apply the findings to other settings. The use of theoretical frameworks dur-ing analysis supports the improvement of the transferability (187). Dependability refers to the possibility of changes in data collection and anal-ysis over time and the ability of the research to account for any changes. Threat to the dependability was reduced by using a topic guide that allowed for consistency throughout the entire data collection process. The same group of researchers held the FGDs during a relatively short period of time; two months. Providing this information will enable future researchers to understand the study and repeat similar works. Using Swahili for data collection ensured that participants spoke freely in the FGDs and that they could interact with researchers and feel able to express their experiences and perceptions. This contributed to the confirmability of the study. Furthermore, the researchers involved in the data collection and analysis had extensive knowledge and pre-understanding of maternal health, which is described. The study was strengthened by having a combination of researchers from Tanzania and Sweden and by having frequent constructive discussions. Methodological descriptions, including strength and limitations, have been discussed in the separate publications in order to allow the reader to be aware of possible bias.
Quantitative studies Cross-sectional studies This was a before-and-after study with a comparison group that utilised cross-sectional surveys (Papers II – IV). In Paper II, the study aimed at
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demonstrating the association between being prepared and socio-demographic characteristics and knowledge of danger signs. Inherent to cross-sectional studies is the issue that we cannot establish causation. One limitation is recall bias however some participants might have remembered vividly if a complication occurred in the two years before the study was con-ducted. Additionally, we believe that the short duration might not have pro-foundly affected the recall bias. Further, social desirability is another limita-tion. By working with experienced senior medical students using a standard-ised instrument, and also by guaranteeing confidentiality and anonymity of the information obtained, we aimed to minimise this bias. Non-response bias was dealt with by following up eligible participants at least three times, as well as following up with those who had incomplete data for completion and correction. Another important limitation is that answers to knowledge questions were all given the same weight during data analysis. One could argue, for example, that knowledge of severe bleeding during childbirth is more important than high-grade fever. However, it was decided to use the composite scoring sys-tem to capture male involvement. In the literature there is no standardised way to evaluate male involvement; therefore it is important that the research community devises a standardised methodology so that results can be com-pared across different contexts. This could be in the form of describing dif-ferent distinct domains of male involvement such as inter-spousal communi-cations or practical preparations and measure each individually. It is also difficult to make causal pathways between before and after in an intervention study design due to its lack of randomisation.
Internal validity Internal validity refers to whether the study outcome is caused by the inde-pendent variable rather than other factors. There are several potential threats to internal validity. Several measures were taken to make sure these threats were addressed. The participants were selected randomly in the intervention and comparison districts and this could have reduced the risk of selection bias. History concerns with whether unanticipated events, such as intensive media campaigns, occurred during the intervention and whether these affect-ed the outcome. However, there were no such campaigns promoted during the study period in the area. The use of a comparison group minimised the risk of maturation that is related to the processes that affect the study partic-ipants in relation to time rather than the intervention itself. In our study, we used the same validated pre-tested questionnaire at baseline and endline sur-veys and this helped to minimise the threat of instrumentation that is the risk associated with changing the measures that were used between two data collections.
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External validity, generalisability External validity indicates whether the finding would hold true for other persons in other places and at other times. One way to ensure this is the in-clusion of a representative sample and setting. Participants were selected using a multi-stage random sampling technique to ensure that they were representative of the population being studied. This study was conducted in a rural setting and the communities were well matched in socio-demographic characteristics. This strategy could have improved the reliability of the re-sults in terms of the knowledge on maternal health. However, it cannot be stated that this rural population sample is applicable to the urban setting, for example. Therefore, caution must be exercised when generalising the results of this study to the total population.
Difference in Differences (DID) To assess the impact of the intervention, this thesis employed the Difference in Differences method. This method, also known as ‘double difference’, compares the changes of outcome over time between the intervention and comparison groups. It gives a stronger impact estimate than a single differ-ence, which only compares the difference in outcome between intervention and comparison groups following the intervention. Applying the DID meth-od removes the difference in outcome between intervention and comparison groups at the baseline. This is a good approach for calculating quantitative impact estimate; however, one of the limitations of this method is that it is does not completely avoid selection bias.
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Conclusion
Challenges that a rural Tanzanian community face to prepare for childbirth were explored. Prioritised needs were identified, together with barriers to fulfill the intentions to act. In order to reduce the barriers and improve knowledge, facility deliveries and male involvement in maternal health, an intervention of Home Based Life Saving Skills training, provided by CHWs, was performed and evaluated. This thesis has shown that this rural community favours the utilisation of skilled care attendance for ANC and delivery. There are some barriers that may contribute to non-realisation of this intention. These barriers included high costs of transport, long distance to health facility, lack of advanced preparations for childbirth and complications, costs related to purchase of birth kits and inappropriate attitude of health workers for example towards unmarried mothers. Men were shown to have limited knowledge of dangers signs and only a small proportion was prepared for childbirth and obstetric complication. Living in a rural area was associated with less likelihood of being prepared for childbirth. Knowledge of danger signs during pregnancy was associated with being prepared among men. The community-based intervention of educating pregnant women, husbands and families on HBLSS by CHWs has demonstrated that it is effective. This kind of intervention is effective in improving knowledge of danger signs, knowledge and actions on BP/CR among men and women. Utilisation of ANC by making the recommended four visits improved following the inter-vention. The intervention demonstrated effect in increasing facility delivery in the rural community. Male involvement was demonstrated to improve in terms of men escorting their spouses to ANC and delivery and shared decision-making for place of delivery. Further, it might possibly be feasible to conduct a similar interven-tion by deploying CHWs in other rural communities in Tanzania.
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Implications and Recommendations
Based on the research findings, there are several policy implications that can be derived from this thesis. The linkage between health workers and CHWs in this type of intervention has the potential to improve the utilisation of skilled care for antenatal care and delivery. Addressing the issues that relate to the barriers affecting that utilisation is important so as to improve mater-nal health, especially in rural areas. The following is recommended in order to improve service provision in the health system; Policy/National level
• The formalisation of integrating CHWs into the health system must be implemented as they make an important contribution to health promotion during ANC and delivery.
• As there is a clear benefit of involving men in maternal health, it is advisable to include a strategy on the promotion of male involve-ment in the National Maternal Neonatal and Child Health policy documents related to ANC and delivery care.
• There is a need to improve rural infrastructure so that roads are pass-able and health facilities are accessible by providing reliable and supportive mechanisms, for example, ambulance services, through-out the year.
Health Facility level
• Health facilities should be well equipped and health workers should, through their continued training, and health workers are able to pro-vide equal, accountable care of good quality to accommodate the in-creasing demand for services.
• The training of health workers on how to encourage male involve-ment in a positive way is advocated.
• As the health workers will preferably be linking with CHWs in the provision of services, they will also need training in effective super-vision methods.
• Health workers can facilitate participatory community sessions on pregnancy and childbirth with CHWs, community members and vil-lage leaders to foster an understanding of the importance of men and
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women getting involved together towards improving maternal health.
• To accommodate an increased interest in men for attending ANC and delivery, the health facilities must present an environment that is conducive to promoting and supporting their involvement.
At community/individual level
• Communities should be encouraged to start discussions in relation to the solutions to transportation problems through the creation of common transportation schemes, or the use of common health insur-ance funds, for women to reach skilled care for birth.
• This intervention has demonstrated that men can be positive agents for change in matters related to maternal health. Communities should be encouraged to continue the dialogue between men and women to reduce gender inequalities.
• The continued use of services provided by CHWs by both men and women is strongly encouraged as this is shown to make a potential contribution in increasing male involvement.
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Summary in English
Maternal mortality is a major health problem, particularly in low-income countries and especially in the Sub-Saharan regions. The WHO estimated in 2015 that 303,000 women died from complications related to pregnancy, childbearing or unsafe abortion, mostly in developing countries. The unfin-ished agenda from the Millennium Development Goals continues in the new Sustainable Developing Goals focusing on every nation’s responsibility to improve health systems to meet their specific challenges. Tanzania still has unacceptably high maternal mortality; 432 per 100,000 live births and an infant mortality rate of 45 per 1,000 live births. The country has a population of 45 million people and a rapid population growth; 71% reside in rural areas and almost a third of the population is living below the national poverty line of less than 0.60 USD a day. Fifty percent of deliveries occur at home in Tanzania, without skilled birth attendants. Previous studies from Tanzania have shown weaknesses in the quality of care and referrals, low knowledge and preparation of childbirth, and low compliance to referral advice in rural areas. These findings lead to the need of an intervention in rural Tanzania to improve the outcome of pregnancies.
The aim of the project was to explore social-cultural, community and tradi-tional practices that impact on women’s birth preparedness and access and utilisation of emergency obstetric care services in a rural district. A further aim was to assess the impact of the Home Based Life Saving Skills (HBLSS) programme on facility delivery, knowledge of obstetric danger signs, birth preparedness and complication readiness among both women and men in the community. This project started with a qualitative study to obtain an understanding of the perceptions, experiences and challenges that the community faces on birth preparedness and complication readiness. Twelve focus group discussions (FGD) with a total of 132 participants were held in rural villages. The find-ings showed that community members considered the family to be responsi-ble for supporting the pregnant women. Despite the fact that maternal health care should be provided for free, it was not perceived as such, due to addi-tionally demanded costs. Among the community members, there was an understanding of the necessi-ty to prepare for childbirth and facility delivery is preferred. However, there
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were barriers to adhere to this intention that were associated with poverty and the stigmatisation of unmarried women, which affected the preparation for childbirth. Traditional beliefs were seen as fading out, which illustrated that men, traditionally the sole decision-makers, are nowadays more in-volved and consulted the women in their family more often in matters relat-ed to childbirth (Paper I). In order to determine the knowledge of danger signs of obstetric complica-tions and birth preparedness among men in the community, a cross-sectional survey in a rural region was performed. Seven hundred and fifty-six men were invited to participate, 96% of which agreed to answer a questionnaire. They were all fathers and their partners had delivered within the last two years. Only half of the interviewed men could mention at least one complica-tion during pregnancy, and less during delivery and in the postpartum period. Only twelve percent of the men were considered to be prepared for the com-ing childbirth, according to a scoring system that was developed. Birth pre-paredness was associated with men’s knowledge of danger signs; however, it was less likely for men living in the rural area to be well prepared. These findings suggest a need to execute an educational intervention that includes men (Paper II). With the aim of increasing knowledge, preparedness for childbirth and insti-tutional deliveries, an intervention was performed following the concept of the HBLSS programme. This is a community-based training programme developed by the American College of Nurse Midwives. The author of this thesis is, by profession, an obstetrician/gynaecologist and has been trained in HBLSS approach and is a master trainer. The training is provided to preg-nant women together with their immediate family members in their homes, with the aim of recognising life-threatening conditions, promoting health-seeking behavior, birth preparedness and complication readiness, and to use life-saving skills if a problem occurs. The novelty in this project is to use community health workers to provide this home-based training, instead of professional health workers. Community health workers (CHWs) are trusted volunteers within the community, and are usually employed for assisting in immunisation programmes and in public health information. The master trainer conducted HBLSS training with 24 health workers. This training is conducted through story-telling, role-playing and skill acquisition. The health workers trained and supervised 66 commu-nity health workers, who reached 1,542 pregnant women and their families in 28 randomly selected villages. The CHWs made four visits in each home and gave the families education using dialogue and pictorial ‘Take Action Cards’. Another district in the same region, with the same socio-demographic, economic and occupational determinants, was used as a com-
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parison district, where pregnant women received routine antenatal care. Evaluation of the intervention, with a survey two years later, included 1,528 women in the two districts. The effect showed that utilisation of antenatal care, facility deliveries, knowledge of danger signs, knowledge and practice of birth preparedness and complication readiness increased significantly among women in the intervention district compared to the other district (Pa-per III). Reproductive health programmes often evaluate the situation for women only. However, men, having the financial power in the families and tradi-tionally being the main decision-makers, which, to a large extent, influences the possibility for women to access health care, are less often involved and studied. At baseline, 1,378 men were interviewed, and 1,358 after two years of HBLSS intervention. The effect, focusing on male involvement, was compared before and after the intervention in the intervention and the com-parison districts. With this home-based education programme, provided by CHWs, we found an increase in male involvement, regarding the escorting of the wife to antenatal visits, and escorting her to facility deliveries, making joint discussions with the partner on where to deliver, having knowledge of obstetric danger signs, birth preparedness, complication readiness, and facili-ty deliveries. These are all promising results and demonstrate that when the health system has a limited number of skilled health workers to provide this training to increase knowledge to prepare for childbirth, CHWs can be de-ployed to improve male involvement and reproductive health outcomes (Pa-per IV).
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Summary in Swahili
Vifo vya akina mama nchini Tanzania ni vingi sana. Kwa utafiti uliofanyika mwaka 2011 inaonyesha akina mama 454 kati ya vizazi hai laki moja wana-kufa kutokana na matatizo ya mimba, wakati wa kujifungua au baada ya kujifungua. Sababu kubwa za vifo hivi ni kutokwa damu nyingi wakati wa ujauzito au kujifungua, kupata kifafa cha mimba, kutoa mimba kusiko sa-lama, kutumika muda mrefu wakati wa kujifungua na uambukizo wa vi-jidudu baada ya kujifnugua. Vifo hivi havipaswi kutokea kwa sababu vi-naweza kuzuilika kabisa. Njia tatu kuu za kuzuia vifo hivi ni pamoja na akina mama wajawazito kuhudhuria kliniki ya mama mjazito na kujifungua salama kwnye kitu cha afya, kuwahi kwenye kituo cha afya kupata matibabu haraka endapo tatizo kubwa limetokea, na kutumia uzazi wa mpango. Vifo vya akina mama vinaweza kuathiri uchumi wa nchi kwa kupoteza nguvu kazi hii muhimu. Kwa iyo ni muhimu kwa jamii nan chi kwa ujumla kufanya kila linalowezekana ili kupunguza vifo hivi. Utafiti unaonyesha kwamba akina mama wachache wanajifungulia hospitali. Takribani nchini Tanzania asilimia hamsini ya akina mama wanajifungulia hospitali, wengine wanaobaki wanajifungulia majumbani. Vile vile akina mama wapatao asilimia 96 wanakwenda kliniki ya ujauzito mara moja wa-kati wa ujazito. Inashauriwa akina mama waende kliniki walau mara nne wakati wa ujauzito lakini ni asilimia 43 tu wanahudhuri mara nne. Ni muhimu akina mama waende kliniki mana huko wanapatiwa huduma za kupimwa ili kujua afya yao, wanapatiwa ushauri nasihi kuhusu jinsi ya ku-andaa mpango binafsi wa kujifungua. Ili kuongeza idadi ya akina mama kujifungua katika hospitali ni muhimu wafahamu umuhimu wake kwa kujua dalili za hatari za ujauzito, wakati wa kujifungua na baada ya kujifungua. Utafiti uliofanywa awali katika wilaya ya Rufiji unaonyesha kwamba ni akina mama wachache wenye ufahamu wa dalili hizi. Vilevile ni muhimu akina mama wajiandae mapema na mpango binafsi wa kujifungua ili wawe tayari wakati wowote. Ni muhimu vile vile akina baba wajihusishe kwa karibu katika kumsaidia mama ajiandae na kasha aweze kujifungua salama. Kwa mantiki iyo basi tulifanya utafiti katika wilaya ya Rufiji mkoani Pwani ili kuongeza ufahamu wa jamii kuhusu dalili za hatari wakati wa ujauzito,
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kujifungua, na baada ya kufijungua, jinsi ya kujiandaa kwa mpango binafsi wa kujifungua, kuongeza idadi ya akina kujifungulia hospitali na mwisho kuongeza ushiriki wa akina baba katika afya ya mama wakati wa ujauzito. Katika utafiti huu mbinu iliyotumika ni kutumia wahudumu wa afya vijijini (WAVI) kuelimisha jamii kuhusu Stadi za kuchukua hatua majumbani. Elimu hii walipatiwa akina mama wajawazito pamoja na mume au mwenza akiwa na wanafamilia wengine kama baba mkwe au mama mkwe au shan-gazi. WAVI walitembelea familia hizi mara nne wakati wa mama ni mjamzito. Matokeo ya utafiti huu yanaonyesha kwamba jamii ilielimika na ufahamu wa dalili za hatari zinazoweza kumsabibishia mama kifo uliongezeka. Akina baba na akina mama waliweza kuongeza ufahamu ukilinganisha na kabla ya elimu haijatolewa na WAVI. Vilevile idadi ya akina baba na akina mama iliongezekea katika kufanya maandalizi ya mpango binafsi wa kujifungua ukilinganisha na kabla ya elimu kutolewa. Idadi ya akina mama ambao waliweza kwenda kliniki mara nne kama inavoshauriwa iliongezeka kutoka asilimia 42 mpaka 68. Akina mama zaidi waliweza kujifungua katika hospi-tali ukilinganisha na kabla ya utafiti haujaanza kutoaka asilimia 75.6 hadi 90%. Matokeo haya yanatia moyo kwa sababu inaeleweka kwamba njia mojawapo ya kupunguza vifo vya akina mama ni kwa akina mama kuji-fungulia katika vituo vya afya. Utafiti huu pia umeonyesha ushiriki wa akina baba uliongezeka. Akina baba wengi zaidi waliwasindikiza wenza wao kwenda kliniki pamoja na kuwasin-dikiza kwenda kujifungua. Hii inaonyesha utayari wa akina baba katika kumsaidia na kumtunza mama aliye mjazito. Vilevile akina baba wa-lionyesha kushirikiana vizuri na akina mama katika kufanya maamuzi ni wapi mama mjamzito akajifungulie. Hii inasaidia kupunguza mfumo dume ambapo uamuzi hutolewa na mwanaume pekee katika masuala ya afya ya mama. Kwa kuongeza ushiriki wa wanaume pia kuna faida ya kwamba mama ana nafasi ya kujifungua salama na hivo kuepuka vifo vinavyotokana na ujauzito au wakati wa kujifungua. Hivyo basi njia hii ya kutumia WAVI kutoa elimu kwa jamii inaonekana ina manufaa sana katika jamii. Ni njia ambayo inashauriwa itumike katika se-hemu zingine za vijijini ili kuimarisha afya ya mama wakati akiwa mjamzito na wakati wa kujifungua. Kwa kushirikiana na watoa huduma wa afya ka-tika hospitali WAVI ni kiungo muhimu katika mapambano ya kupunguza vifo vya akina mama.
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Acknowledgements
At the outset, let me say that without the help, support and contributions of individuals and institutions I would not have been able to accomplish this important milestone in my academic life. I acknowledge the financial support provided by Swedish International De-velopment Cooperation Agency (SIDA), Uppsala University Department of Women’s and Children’s health. I also express my sincere appreciation to Swedish church through the Anna Thorfins Foundation for supporting my stay while I am in Uppsala. To my main supervisor, Elisabeth Darj, I say thank you so much for guiding me through this process. You have provided me with support both scientifi-cally and personally when things seemed tough. Your constructive criticisms and attention to detail have left an indelible mark on my journey. There are not enough words to express my appreciation. I would also like to express my special thanks to my co-supervisor, Pia Axemo, for your constant support and scientific guidance, especially ac-commodating me when I constantly knocked on your door at IMCH to help me with manuscripts. I am also grateful to my co-supervisor, Andrea Pembe, for your valuable input since the beginning of the project and for providing me with scientific knowledge throughout the process of pursuing the doctorate studies. I am also grateful to my co-authors; Rose Mpembeni for your valuable in-puts and thoughtful suggestions with statistical analysis, Columba Mbekenga for your insights in the analysis and discussion of the qualitative part of this thesis, and Edmund Kayombo for introducing me to the qualitative research method on how to conduct Focus Group Discussions. I would like to express my sincere appreciation to all the study participants, both men and women, who agreed to participate in these studies. And to all the health care workers and community health workers I say thank you for your diligent work that made the project run efficiently.
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To all my research assistants I express my heartfelt gratitude for your dedi-cation in collecting the community survey data by enduring long hot days in the remote rural areas. I wish you good luck in pursuit of your medical ca-reers. To Edward Aron our project driver, thanks for the professional drive every time we went for field work. I also extend my sincere gratitude all the academic and administrative staff at IMCH for all your support in both administrative and academic issues. Particularly I thank Karin Törnblom for making sure the financial side of my stay was settled, to Cristiana Niska Bachelet for making travel and accom-modation arrangements, and now Hanna Taylor, thank you for continuing with administrative support seamlessly. Many thanks to Kristine Eklund for always being ready to help with technical support on my computer. And to Jenny Thor, thank you for your kindness and willingness to teach me a few words of Swedish. I also convey my deep appreciation to Pia Olson for in-troducing me and being available to answer my questions about qualitative research. I also acknowledge the generosity of Jill Trenholm for inviting me to her home for delicious dinners and social gathering. To my fellow PhD students, past and present, I express many thanks for your friendship, stimulating scientific discussion and support. Particularly I ex-press my gratitude to Aimable, Amare, Duc, Andrew (my room-mates), Muzdalifat, Eunice, Soorej, Petrida, Anna A, Anna W, Pernilla, Elin, Maja, Elazar, Annika, Shirin, Mandira, Jessica, Dorcus, Helena, Mariella, William, Wilton, Amal, Nga, Freddy, Leif, Malin, Emily, Paridhi, Emma, Wanjiku, and Pauline. I am deeply grateful to Aileen Ireland for her excellent English language editing and proficiency. You have always been professional, supportive and responsive even at short notice. My very special thanks to my parents Siriel Massawe and Augustine Mas-sawe for their love and giving me the opportunity to have a good foundation of education and supporting me all the time in the pursuit of this academic journey. You are the pillar in my life and I am really indebted to you and be blessed always. Special thanks for your support and encouragement to my brother Bumija and sister-in-law Judith, my sister Clara and brother-in-law Joseph, and my sister Cecilia. Above all, I would like to express my heartfelt thanks and appreciation to my wife Abella and our daughters, Siriel and Shannen, for their support and for believing in me throughout this journey. I thank you Abella for your enduring love and taking care of the family while I was away, particularly in the last twelve months.
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References
1. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2015. 13 November 2015. E-publication head of print.
2. United Nations. The Millenium Development Goals Report 2015. New York: United Nations; 2015. Available from: http://www.undp.org/ content/dam/undp/library/MDG/english/ UNDP_MDG_Report_2015.pdf [Accessed: 15 December 2015].
3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375(9726):1609-23.
4. WHO UNICEF, UNFPA, World Bank. Trends in Maternal Mortality 1990 to 2013. Geneva: World Health Organization; 2014.
5. WHO UNICEF, UNFPA, World Bank. Trends in Maternal Mortality 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015.
6. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):980-1004.
7. United Nations. Time for Global Acton. Sustainable Development Goals. New York: United Nations; 2015. Available from: http://www.un.org/sustainabledevelopment/health/ [Accessed: 15 December 2015].
8. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014;2(6):e323-33.
9. Berer M. Maternal mortality and morbidity: is pregnancy getting safer for women? Reprod Health Matters. 2007;15(30):6-16.
10. Campbell OMR, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284-99.
11. Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha M, Anwar I, et al. Going to scale with professional skilled care. Lancet. 2006;368(9544):1377-86.
12. Hussein J, Kanguru L, Astin M, Munjanja S. The Effectiveness of Emergency Obstetric Referral Interventions in Developing Country Settings: A Systematic Review. PLoS Med. 2012;9(7):e1001264.
13. Buor D, Bream K. An Analysis of the Determinants of Maternal Mortality in Sub-Saharan Africa. J Womens Health. 2004;13(8):926-38.
66
14. WHO. Reduction of maternal mortality: A joint WHO/UNFPA/UNICEF/World Bank statement. 1999. Available from:
http://www.who.int/reproductivehealth/publications/monitoring/9789241561952/en/ [Accessed: 17 November 2014].
15. WHO. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva: World Health Organization; 2004.
16. Mbizvo MT, Say L. Global progress and potentially effective policy responses to reduce maternal mortality. Int J Gynecol Obstet. 2012;119, Supplement 1:S9-S12.
17. Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, Franca GV, et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet. 2012;379(9822):1225-33.
18. Gabrysch S, Campbell O. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34.
19. Kruk ME, Paczkowski M, Mbaruku G, de Pinho H, Galea S. Women’s Preferences for Place of Delivery in Rural Tanzania: A Population-Based Discrete Choice Experiment. Am J Public Health. 2009;99(9):1666-72.
20. Gabrysch S, Cousens S, Cox J, Campbell O. The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system. PLoS Med. 2011;8(1):e1000394.
21. Bohren M, Hunter E, Munthe-Kaas H, Souza J, Vogel J, Gulmezoglu A. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11(1):71.
22. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004;19(2):69-79.
23. De Brouwere V, Richard F, Witter S. Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Trop Med Int Health. 2010;15(8):901-9.
24. Ng'anjo Phiri S, Fylkesnes K, Ruano A, Moland K. ‘Born before arrival’: user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia. BMC Pregnancy Childbirth. 2014;14(1):323.
25. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091-110.
26. Mushi D, Mpembeni R, Jahn A. Effectiveness of community based Safe Motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy Childbirth. 2010;10:14.
27. Fullerton JT, Killian R, Gass PM. Outcomes of a Community–and Home-Based Intervention for Safe Motherhood and Newborn Care. Health Care Women Int. 2005;26(7):561-76.
28. Darmstadt GL, Choi Y, Arifeen SE, Bari S, Rahman SM, Mannan I, et al. Evaluation of a cluster-randomized controlled trial of a package of community-based maternal and newborn interventions in Mirzapur, Bangladesh. PLoS One. 2010;5(3):e9696.
29. JHPIEGO. Monitoring birth preparedness and complication readiness: tools and indicators in maternal and newborn health. Baltimore, MD: JHPIEGO; 2004. Available from: http://www.jhpiego.org/files/BPCRtoolkit.pdf [Ac-cessed: 19 November 2014].
67
30. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357(9268):1551-64.
31. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357(9268):1565-70.
32. Stanton CK. Methodological Issues in the Measurement of Birth Preparedness in Support of Safe Motherhood. Eval Rev. 2004;28(3):179-200.
33. WHO. Working with Individuals, Families and Communities to Improve Maternal and Newborn Health. Geneva: World Health Organization; 2010.
34. Pembe A, Urassa D, Carlstedt A, Lindmark G, Nystrom L, Darj E. Rural Tanzanian women's awareness of danger signs of obstetric complications. BMC Pregnancy Childbirth. 2009;9:12.
35. Kabakyenga JK, Ostergren PO, Turyakira E, Pettersson KO. Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda. Reprod Health. 2011;8(1):33.
36. Hailu M, Gebremariam A, Alemseged F, Deribe K. Birth Preparedness and Complication Readiness among Pregnant Women in Southern Ethiopia. PLoS One. 2011;6(6):e21432.
37. Kaso M, Addisse M. Birth preparedness and complication readiness in Robe Woreda, Arsi Zone, Oromia Region, Central Ethiopia: a cross-sectional study. Reprod Health. 2014;11(1):55.
38. Markos D, Bogale D. Birth preparedness and complication readiness among women of child bearing age group in Goba woreda, Oromia region, Ethiopia. BMC Pregnancy Childbirth. 2014;14(1):282.
39. Iliyasu Z, Abubakar IS, Galadanci HS, Aliyu MH. Birth preparedness, complication readiness and fathers’ participation in maternity care in a northern Nigerian community. Afr J Reprod Health. 2010;14(1):21-32.
40. Mutiso S, Qureshi Z, Kinuthia J. Birth preparedness among antenatal clients. East Afr Med J. 2008;85:275-83.
41. Pembe AB, Urassa DP, Darj E, Carlsted A, Olsson P. Qualitative study on maternal referrals in rural Tanzania: decision making and acceptance of referral advice. African Journal of Reproductive Health. 2008;12(2):120-31.
42. Kwambai TK, Dellicour S, Desai M, Ameh CA, Person B, Achieng F, et al. Perspectives of men on antenatal and delivery care service utilisation in rural western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2013;13(1):134.
43. Ganle J, Obeng B, Segbefia A, Mwinyuri V, Yeboah J, Baatiema L. How intra-familial decision-making affects women's access to, and use of maternal healthcare services in Ghana: a qualitative study. BMC Pregnancy Childbirth. 2015;15(1):173.
44. Mbizvo MT, Bassett MT. Reproductive health and AIDS prevention in sub-Saharan Africa: the case for increased male participation. Health Policy Plan. 1996;11(1):84-92.
45. UNFPA. International Conference on Population and Development Program of Action 1994. Available from: http://www.un.org/popin/icpd/conference/ offeng/poa.html [Accessed: 13 September 2015].
46. Amooti-Kaguna B, Nuwaha F. Factors influencing choice of delivery sites in Rakai district of Uganda. Soc Sci Med. 2000;50(2):203-13.
47. Tweheyo R, Konde-Lule J, Tumwesigye NM, Sekandi JN. Male partner attendance of skilled antenatal care in peri-urban Gulu district, Northern Uganda. BMC Pregnancy Childbirth. 2010;10(1):53.
68
48. Kululanga LI, Sundby J, Malata A, Chirwa E. Male involvement in maternity health care in Malawi. Afr J Reprod Health. 2012;16(1):145-57.
49. Kululanga L, Sundby J, Malata A, Chirwa E. Striving to promote male involvement in maternal health care in rural and urban settings in Malawi - a qualitative study. Reprod Health. 2011;8(1):36.
50. Story WT, Burgard SA, Lori JR, Taleb F, Ali NA, Hoque DE. Husbands’ involvement in delivery care utilization in rural Bangladesh: A qualitative study. BMC Pregnancy Childbirth. 2012;12.
51. Falnes E, Moland K, Tylleskar T, de Paoli M, Msuya S, Engebretsen I. “It is her responsibility”: partner involvement in prevention of mother to child transmission of HIV programmes, northern Tanzania. J Int AIDS Soc. 2011;14(1):21.
52. Mullany BC. Barriers to and attitudes towards promoting husbands’ involvement in maternal health in Katmandu, Nepal. Soc Sci Med. 2006;62(11):2798-809.
53. Theuring S, Mbezi P, Luvanda H, Jordan-Harder B, Kunz A, Harms G. Male Involvement in PMTCT Services in Mbeya Region, Tanzania. AIDS Behav. 2009;13(1):92-102.
54. Sternberg P, Hubley J. Evaluating men’s involvement as a strategy in sexual and reproductive health promotion. Health Promot Int. 2004;19(3):389-96.
55. August F, Pembe AB, Mpembeni R, Axemo P, Darj E. Men’s Knowledge of Obstetric Danger Signs, Birth Preparedness and Complication Readiness in Rural Tanzania. PLoS One. 2015;10(5):e0125978.
56. Carter M. Husbands and maternal health matters in rural Guatemala: wives’ reports on their spouses’ involvement in pregnancy and birth. Soc Sci Med. 2002;55:437-50.
57. Reece M, Hollub A, Nangami M, Lane K. Assessing male spousal engagement with prevention of mother-to-child transmission (pMTCT) programs in western Kenya. AIDS Care. 2010;22(6):743-50.
58. Aarnio P, Chipeta E, Kulmala T. Men’s Perceptions of Delivery Care in Rural Malawi: Exploring Community Level Barriers to Improving Maternal Health. Health Care Women Int. 2013;34(6):419-39.
59. Kraft JM, Wilkins KG, Morales GJ, Widyono M, Middlestadt SE. An evidence review of gender-integrated interventions in reproductive and maternal-child health. J Health Commun. 2014;19 Suppl 1(sup1):122-41.
60. Greene ME, Mehta M, Pulerwitz J, Wulf D, Bankole A, Singh S. Involving Men in Reproductive Health: Contributions to Development. Washington, DC: Millennium Project; 2006.
61. Barker G, Ricardo C, Nascimento M, Olukoya A, Santos C. Questioning gender norms with men to improve health outcomes: evidence of impact. Glob Public Health. 2010;5:539-53.
62. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet. 2008;371(9628):1936-44.
63. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010;11:CD007754.
64. Lassi Z, Das J, Salam R, Bhutta Z. Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings. Reprod Health. 2014;11(Suppl 2):S2.
69
65. Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2015;3:CD007754.
66. Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Global Health Workforce Alliance. 2010. Available from:
http://www.who.int/entity/workforcealliance/knowledge/publications/CHW_FullReport_2010.pdf?ua=1 [Accessed: 12 November 2014].
67. Lehmann U, Sanders D. Community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization; 2007. Available from:
http://www.who.int/hrh/documents/community_health_workers.pdf [Accessed: 12 November 2014].
68. WHO. World Health Organization. Community healthworkers: What do we know about them? Geneva: WHO Department of Human Resources for Health; 2007.
69. The Earth Institute, Columbia University. One Million Community Health Workers: Technical Task Force Report 2012. Available from: http://1millionhealthworkers.org/files/2013/01/1mCHW_TechnicalTaskForceReport.pdf [Accessed: 12 November 2014].
70. Singh P, Sachs JD. 1 million community health workers in sub-Saharan Africa by 2015. Lancet. 2013;382(9889):363-5.
71. Sibley L, Buffington ST, Beck D, Armbruster D. Home based life saving skills: Promoting safe motherhood through innovative community-based interventions. J Midwifery Womens Health. 2001;46(4):258-66.
72. Sibley L, Buffington ST, Haileyesus D. The American College of Nurse-Midwives’ home-based lifesaving skills program: a review of the Ethiopia field test. J Midwifery Womens Health. 2004;49(4):320-8.
73. Ronsmans C, Endang A, Gunawan S, Zazri A, McDermott J, Koblinsky M, et al. Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia. Trop Med Int Health. 2001;6(10):799-810.
74. Lori JR, Majszak CM, Martyn KK. Home-Based Life-Saving Skills in Liberia: Acquisition and Retention of Skills and Knowledge. J Midwifery Womens Health. 2010;55(4):370-7.
75. Lori JR, Amable EE, Mertz SG, Moriarty K. Behavior Change Following Implementation of Home-Based Life-Saving Skills in Liberia, West Africa. J Midwifery Womens Health. 2012;57(5):495-501.
76. National Bureau of Statistics (NBS). Population and Housing Census. Dar es Salaam, Tanzania: NBS; 2013.
77. MOHSW. Primary Health Services Development Programme-MMAM 20072017. Dar es Salaam, Tanzania: MOHSW; 2007.
78. National Bureau of Statistics (NBS) [Tanzania], Macro I. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS; 2011.
79. CIA. The Word Factbook. CIA; 2014. Available from: https://www.cia.gov/library/publications/resources/the-world-
factbook/geos/tz.html [Accessed: 23 November 2015]. 80. National Bureau of Statistitcs (NBS) [Tanzania]. 2011/12 Household Budget
Survey: Key Findings. Dar es Salaam, Tanzania: NBS; 2013.
70
81. MOHSW. Health Sector Strategic Plan July 2015 – June 2020 (HSSP IV). Dar es Salaam, Tanzania: MOHSW; 2015.
82. WHO. World Health Statistics 2015. Geneva: World Health Organization; 2015. Available from:
http://www.who.int/gho/publications/world_health_statistics/ EN_WHS2015_Part2.pdf?ua=1 [Accessed: 18 November 2015].
83. WHO. Working together for health. The World Health Report. Geneva: World Health Organization; 2006.
84. Pereira C, Mbaruku G, Nzabuhakwa C, Bergström S, McCord C. Emergency obstetric surgery by non-physician clinicians in Tanzania. Int J Gynecol Obstet. 2011;114(2):180-3.
85. UNFPA. The State of the World’s Midwifery 2014. A Universal Pathway. A Woman’s Right to Health. 2014. Available from:
http://www.unfpa.org/sites/default/files/pub-pdf/EN_SoWMy2014_complete.pdf [Accessed: 25 November 2015].
86. MOHSW. National Integrated Community Maternal, Newborn and Child Health Guidelines. Dar es Salaam, Tanzania: MOHSW; 2012.
87. MOHSW. Mid Term Review of the Health Sector Strategic Plan III 2009 – 2015, MainReport. Dar es Salaam, Tanzania: MOHSW; 2013.
88. MOHSW. Focused antenatal care, malaria and syphylis in pregnancy: Orientation package for service providers. Dar es Salaam, Tanzania: MOHSW; 2002.
89. National Bureau of Statistics (NBS) [Tanzania], Macro I. Tanzania Demographic and Health Survey 2004/5. Dar es Salaam, Tanzania: NBS; 2005.
90. MOHSW. The national road map strategic plan to accelerate reduction of maternal, newborn and child deaths in Tanzania 2008-2015. Dar es Salaam: MOHSW; 2008.
91. Glanz K, Rimer B, Viswanath K. Health behavior and health education, theory research and practice. 4th ed. San Fransisco, CA: Jossey-Bass A Wiley Imprint; 2008.
92. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Educ Behav. 1984;11(1):1-47.
93. Connell RW. Masculinities. Cambridge, UK: Polity Press; 1995. 94. Connell R. Gender, health and theory: conceptualizing the issue, in local and
world perspective. Soc Sci Med. 2012;74(11):1675-83. 95. WHO. Commission on Social Determinants of Health. Closing the Gap in
aGeneration: Health Equity through Action on the Social Determinants of Health, Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008.
96. Barker G, Ricardo C, Nascimento M. Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization; 2007.
97. Magoma M, Requejo J, Campbell OM, Cousens S, Filippi V. High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention. BMC Pregnancy Childbirth. 2010;10(1):13.
98. Urassa DP, Carlstedt A, Nyström L, Massawe SN, Lindmark G. Are Process Indicators Adequate to Assess Essential Obstetric Care at District Level?: A Case Study from Rufiji District, Tanzania. African Journal of Reproductive Health/La Revue Africaine de la Santé Reproductive. 2005;9(3):100-11.
71
99. Magoma M, Requejo J, Merialdi M, Campbell OM, Cousens S, Filippi V. How much time is available for antenatal care consultations? Assessment of the quality of care in rural Tanzania. BMC Pregnancy Childbirth. 2011;11:64.
100. Pembe A, Carlstedt A, Urassa D, Lindmark G, Nystrom L, Darj E. Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs. BMC Pregnancy Childbirth. 2010;10(1):35.
101. Dahlgren L, Emmelin M, Winkvist A. Qualitative Methodology for International Public Health. Umeå: Umeå University Publications; 2007.
102. JHPIEGO. A Matrix For Monitoring Birth Preparedness and Complication Readiness: Tools and Indicators for Maternal and Newborn Health. Baltimore, MD: JHPIEGO; 2004. Available from:
http://www.jhpiego.org/files/BPCRtoolkit.pdf [Accessed: 19 November 2014].
103. Byamugisha R, Astrom AN, Ndeezi G, Karamagi CA, Tylleskar T, Tumwine JK. Male partner antenatal attendance and HIV testing in eastern Uganda: a randomized facility-based intervention trial. J Int AIDS Soc. 2011;14:43.
104. Ampt F, Mon MM, Than KK, Khin MM, Agius PA, Morgan C, et al. Correlates of male involvement in maternal and newborn health: a cross-sectional study of men in a peri-urban region of Myanmar. BMC Pregnancy Childbirth. 2015;15:122.
105. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105-12.
106. Cochran WG. Sampling Techniques. Third Edition. New York: John Wiley & Sons; 1977.
107. Sorensen BL, Nielsen BB, Rasch V, Elsass P. User and provider perspectives on emergency obstetric care in a Tanzanian rural setting: a qualitative analysis of the three delays model in a field study. Afr J Reprod Health. 2011;15(2):117-30.
108. Larson E, Hermosilla S, Kimweri A, Mbaruku G, Kruk M. Determinants of perceived quality of obstetric care in rural Tanzania: a cross-sectional study. BMC Health Serv Res. 2014;14(1):483.
109. Oyerinde K, Harding Y, Philip A, Garbrah-Aidoo N, Kanu R, Oulare M, et al. Barriers to Uptake of Emergency Obstetric and Newborn Care Services in Sierra Leone: A Qualitative Study. J Commun Med Health Educ. 2012;2(5):1-8.
110. August F, Pembe AB, Kayombo E, Mbekenga C, Axemo P, Darj E. Birth preparedness and complication readiness – a qualitative study among community members in rural Tanzania. Glob Health Action. 2015;8:26922.
111. Kumbani L, Bjune G, Chirwa E, Malata A, Odland JO. Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi. Reprod Health. 2013;10(1):9.
112. Tsegay Y, Gebrehiwot T, Goicolea I, Edin K, Lemma H, Sebastian M. Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study. Int J Equity Health. 2013;12(1):30.
113. Mwangome FK, Holding PA, Songola KM, Bomu GK. Barriers to hospital delivery in a rural setting in Coast Province, Kenya: community attitude and behaviours. Rural Remote Health. 2012;12:1852.
72
114. Gao Y, Barclay L, Kildea S, Hao M, Belton S. Barriers to increasing hospital birth rates in rural Shanxi Province, China. Reprod Health Matters. 2010;18(36):35-45.
115. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia. BMC Pregnancy Childbirth. 2010;10:43.
116. Singh PK, Kumar C, Rai RK, Singh L. Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts. Health Policy Plan. 2013.
117. Wilunda C, Quaglio G, Putoto G, Lochoro P, Dall'Oglio G, Manenti F, et al. A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming. BMC Pregnancy Childbirth. 2014;14(1):259.
118. Jahn A, Kowalewski M, Kimatta SS. Obstetric care in southern Tanzania: does it reach those in need? Trop Med Int Health. 1998;3(11):926-32.
119. Kowalewski M, Mujinja P, Jahn A. Can mothers afford maternal health care costs? User costs of maternity services in rural Tanzania. Afr J Reprod Health. 2002;6(1):65-73.
120. Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tanner M, et al. Factors affecting home delivery in rural Tanzania. Trop Med Int Health. 2007;12(7):862-72.
121. Titaley CR, Dibley MJ, Roberts CL. Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 2002/2003 and 2007. BMC Public Health. 2010;10:485.
122. Cofie LE, Barrington C, Singh K, Sodzi-Tettey S, Akaligaung A. Birth location preferences of mothers and fathers in rural Ghana: Implications for pregnancy, labor and birth outcomes. BMC Pregnancy Childbirth. 2015;15(1):1-8.
123. Anastasi E, Borchert M, Campbell O, Sondorp E, Kaducu F, Hill O, et al. Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda. BMC Pregnancy Childbirth. 2015;15(1):287.
124. De Allegri M, Tiendrebeogo J, Muller O, Ye M, Jahn A, Ridde V. Understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural Burkina Faso. BMC Pregnancy Childbirth. 2015;15(1):330.
125. Pfeiffer C, Mwaipopo R. Delivering at Home or in a Health Facility? Health-Seeking Behaviour of Women and the Role of Traditional Birth Attendants in Tanzania. BMC Pregnancy Childbirth. 2013;13:55.
126. Mills S, Williams J, Adjuik M, Hodgson A. Use of Health Professionals for Delivery Following the Availability of Free Obstetric Care in Northern Ghana. Matern Child Health J. 2008;12(4):509-18.
127. Tann CJ, Kizza M, Morison L, Mabey D, Muwanga M, Grosskurth H, et al. Use of antenatal services and delivery care in Entebbe, Uganda: a community survey. BMC Pregnancy Childbirth. 2007;7:23.
128. Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs. 2008;61(3):244-60.
73
129. Mselle L, Kohi T, Mvungi A, Evjen-Olsen B, Moland K. Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour. BMC Pregnancy Childbirth. 2011;11(1):75.
130. Pell C, Meñaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. Factors Affecting Antenatal Care Attendance: Results from Qualitative Studies in Ghana, Kenya and Malawi. PLoS One. 2013;8(1):e53747.
131. WHO. WHO Recommended Interventions for Improving Maternal and Newborn Health Geneva: World Health Organization; 2009. Available from: http://apps.who.int/iris/bitstream/10665/69509/1/WHO_MPS_07.05_eng.pdf?ua=1 [Accessed: 12 November 2015].
132. Graham W, Themmen E, Bassane B, Meda N, De Brouwere V. Evaluating skilled care at delivery in Burkina Faso: principles and practice. Trop Med Int Health. 2008;13(Suppl 1):6-13.
133. Pembe A, Carlstedt A, Urassa D, Lindmark G, Nystrom L, Darj E. Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania. BMC Health Serv Res. 2010;10(1):326.
134. McPherson R, Khadka N, Moore J, Sharma M. Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal. J Health Popul Nutr. 2006;24(4):479-88.
135. Mpembeni R, Killewo J, Leshabari M, Massawe S, Jahn A, Mushi D, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth. 2007;7(1):29.
136. Aboud FE, Singla DR. Challenges to changing health behaviours in developing countries: a critical overview. Soc Sci Med. 2012;75(4):589-94.
137. Dunn A, Haque S, Innes M. Rural Kenyan men’s awareness of danger signs of obstetric complications. Pan Afr Med J. 2011;10:39.
138. Solnes Miltenburg A, Roggeveen Y, Shields L, van Elteren M, van Roosmalen J, Stekelenburg J, et al. Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review. PLoS One. 2015;10(11):e0143382.
139. Olayemi O, Bello F, Aimakhu C, Obajimi G, Adekunle A. Male participation in pregnancy and delivery in Nigeria: a survey of antenatal attendees. J Biosoc Sci. 2009;41:493-503.
140. Waiswa P, Kemigisa M, Kiguli J, Naikoba S, Pariyo G, Peterson S. Acceptability of evidence-based neonatal care practices in rural Uganda - implications for programming. BMC Pregnancy Childbirth. 2008;8(1):21.
141. Gross K, Alba S, Glass TR, Schellenberg JA, Obrist B. Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. BMC Pregnancy Childbirth. 2012;12:16.
142. Danforth EJ, Kruk M, Rockers PC, Mbaruku G, Galea S. Household Decision-making about Delivery in Health Facilities: Evidence from Tanzania. J Health Popul Nutr. 2009;27(5)(5):693-703.
143. Stanton C, Blanc A, Croft T, Choi Y. Skilled care at birth in the developing world: progress to date and strategies for expanding coverage. J Biosoc Sci. 2007;39(1):109-20.
144. WHO. Making pregnancy safer: The critical role of the skilled attendant: A joint statement by WHO, ICM and FIGO. Geneva: World Health Organization; 2004.
74
145. Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth. 2011;11:30.
146. Hounton S, Byass P, Brahima B. Towards reduction of maternal and perinatal mortality in rural Burkina Faso: communities are not empty vessels. Glob Health Action. 2009;2.
147. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004;364(9438):970-9.
148. Lewycka S, Mwansambo C, Rosato M, Kazembe P, Phiri T, Mganga A, et al. Effect of women’s groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial. Lancet. 2013;381(9879):1721-35.
149. Persson LA, Nga NT, Malqvist M, Thi Phuong Hoa D, Eriksson L, Wallin L, et al. Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial. PLoS Med. 2013;10(5):e1001445.
150. Fottrell E, Azad K, Kuddus A, Younes L, Shaha S, Nahar T, et al. The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial. JAMA Pediatr. 2013;167(9):816-25.
151. Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J. Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ. 2008;86.
152. Shrestha JR, Manandhar DS, Manandhar SR, Adhikari D, Rai C, Rana H, et al. Maternal and Neonatal Health Knowledge, Service Quality and Utilization: Findings from a Community Based Quasi-experimental Trial in Arghakhanchi District of Nepal. J Nepal Health Res Counc. 2015;13(29):78-83.
153. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. Int J Gynecol Obstet. 2006;92(3):320-8.
154. Magoma M, Requejo J, Campbell O, Cousens S, Merialdi M, Filippi V. The effectiveness of birth plans in increasing use of skilled care at delivery and postnatal care in rural Tanzania: a cluster randomised trial. Trop Med Int Health. 2013;18(4):435-43.
155. Ensor T, Quigley P, Green C, Razak Badru A, Kaluba D, Siziya S. Knowledgeable antenatal care as a pathway to skilled delivery: modelling the interactions between use of services and knowledge in Zambia. Health Policy Plan. 2014;29(5):580-8.
156. Mishra V, Retherford R. The Effect of Antenatal Care on Professional Assistance at Delivery in Rural India. Popul Res Policy Rev. 2008;27(3):307-20.
157. Adam MB, Dillmann M, Chen MK, Mbugua S, Ndung'u J, Mumbi P, et al. Improving maternal and newborn health: effectiveness of a community health worker program in rural Kenya. PLoS One. 2014;9(8):e104027.
158. Dynes M, Rahman A, Beck D, Moran A, Rahman A, Pervin J, et al. Home-based life saving skills in Matlab, Bangladesh: a process evaluation of a community-based maternal child health programme. Midwifery. 2011;27(1):15-22.
75
159. Turan JM, Tesfagiorghis M, Polan ML. Evaluation of a Community Intervention for Promotion of Safe Motherhood in Eritrea. J Midwifery Womens Health. 2011;56(1):8-17.
160. Roth DM, Mbizvo MT. Promoting safe motherhood in the community: the case for strategies that include men. African Journal of Reproductive Health. 2001; 5(2): 10-21.
161. Aparajita C. Men in Maternal Health Care: Evidence form India. J Biosoc Sci. 2012;44(02):129-53.
162. Moran A, Sangli G, Dineen R, Rawlins B, Yaméogo M, Baya B. Birth-preparedness for maternal health: findings from Koupéla District, Burkina Faso. J Health Popul Nutr. 2006;24(4):489-97.
163. Mullany BC, Becker S, Hindin M. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Educ Res. 2007;22(2):166-76.
164. Hodgins S, McPherson R, Suvedi BK, Shrestha RB, Silwal RC, Ban B, et al. Testing a scalable community-based approach to improve maternal and neonatal health in rural Nepal. J Perinatol. 2010;30(6):388-95.
165. Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh. New Delhi, India: Population Council; 2008.
166. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet. 2008;372(9644):1151-62.
167. Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. Int J Gynecol Obstet. 2003;82(2):231-40.
168. Family Care International. Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Igunga District, Tanzania. Dar es Salaam,Tanzania: FCI, 2007.
169. Brazier E, Fiorentino R, Barry S, Kasse Y, Millimono S. Rethinking How to Promote Maternity Care-Seeking: Factors Associated With Institutional Delivery in Guinea. Health Care Women Int. 2014;35(7-9):878-95.
170. Soubeiga D, Sia D, Gauvin L. Increasing institutional deliveries among antenatal clients: effect of birth preparedness counselling. Health Policy Plan. 2013.
171. Kabakyenga JK, Östergren PO, Turyakira E, Pettersson KO. Influence of birth preparedness, decision-making on location of birth and assistance by skilled birth attendants among women in south-western Uganda. PLoS One. 2012;7.
172. Comrie-Thomson L, Tokhi M, Ampt F, Portela A, Chersich M, Khanna R, et al. Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Cult Health Sex. 2015:1-13.
173. Barker G. A Radical Agenda for Men's Caregiving. IDS Bulletin. 2014;45(1):85-90.
174. Carter M, Speizer I. Salvadoran fathers’ attendance at prenatal care, delivery, and postpartum care. Rev Panam Salud Publ. 2005;18:149-56.
175. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reprod Health. 2010;7(1):30.
76
176. Kunene B, Beksinska M, Zondi S, Mthembu M, Mullick S, Ottolenghi E. Involving men in maternity care: South Africa. Washington, DC: Population Council; 2004.
177. Varkey L, Mishra A, Das A, Ottolenghi E, Huntington D, Adamchak S. Involving men in maternity care in India. New Delhi: Population Council, 2004.
178. Aguiar C, Jennings L. Impact of Male Partner Antenatal Accompaniment on Perinatal Health Outcomes in Developing Countries: A Systematic Literature Review. Matern Child Health J. 2015;19(9):2012-9.
179. Yargawa J, Leonardi-Bee J. Male involvement and maternal health outcomes: systematic review and meta-analysis. J Epidemiol Community Health. 2015;69(6):604-12.
180. Davis J, Luchters SH, W. Men and maternal and newborn health: benefits, harms, challenges and potential strategies for engaging men, Compass: Women’s and Children’s Health Knowledge Hub. Melbourne, Australia: Burnet Institute, 2012.
181. Valente TW, Saba WP. Campaign exposure and interpersonal communication as factors in contraceptive use in Bolivia. J Health Commun. 2001;6(4):303-22.
182. Jennings L, Na M, Cherewick M, Hindin M, Mullany B, Ahmed S. Women’s empowerment and male involvement in antenatal care: analyses of Demographic and Health Surveys (DHS) in selected African countries. BMC Pregnancy Childbirth. 2014;14:297.
183. Shattuck D, Kerner B, Gilles K, Hartmann M, Ng'ombe T, Guest G. Encouraging contraceptive uptake by motivating men to communicate about family planning: the Malawi Male Motivator project. Am J Public Health. 2011;101:1089-95.
184. Ditekemena J, Koole O, Engmann C, Matendo R, Tshefu A, Ryder R, et al. Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review. Reprod Health. 2012;9(1):32.
185. Becker S, Mlay R, Schwandt H, Lyamuya E. Comparing Couples’ and Individual Voluntary Counseling and Testing for HIV at Antenatal Clinics in Tanzania: A Randomized Trial. AIDS Behav. 2010;14(3):558-66.
186. Kitizinger J, Barbour R. Introduction: The cllenge and promise of focus groups. In: Barbour RS & Kitzinger J (Eds) Developing Focus Group Research: Politics , Theory and Practice. London: SAGE Publications; 1999.
187. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483-8.
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