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

Abstract

Background Tanzania’s One Plan II health sector program aims to increase facility deliveries from 50 to 80% from 2015 to 2020. Success is uneven among certain Maasai pastoralist women in Northern Tanzania who robustly prefer home births to facility births even after completing 4+ ANC visits. Ebiotishu Oondomonok Ongera (EbOO) is a program in Nainokanoka ward to promote facility births through a care-group model using trained traditional birth attendants (TBAs) as facilitators. Results to date are promising but show a consistent gap between women completing ANC and those going to a facility for delivery. A qualitative study was conducted to understand psychosocial preferences, agency for decision-making, and access barriers that influence where a woman in the ward will deliver. Methods In-depth interviews, focus group discussions and key-informant interviews were conducted with 24 pregnant and/or parous women, 24 TBAs, 3 nurse midwives at 3 health facilities, and 24 married men, living in Nainokanoka ward. Interviews and discussions were transcribed, translated, and analyzed thematically using a grounded theory approach. Results Most women interviewed expressed preference for a home birth with a TBA and even those who expressed agency and preference for a facility birth usually had their last delivery at home attributed to unexpected labor. TBAs are engaged by husbands and play a significant influential role in deciding place of delivery. TBAs report support for facility deliveries but in practice use them as a last resort, and a significant trust gap was documented based on a bad experience at a facility where women in labor were turned away. Conclusions EbOO project data and study results show a slow but steady change in norms around delivery preference in Nainokanoka ward. Gaps between expressed intention and practice, especially around ‘unexpected labor’ present opportunities to accelerate this process by promoting birth plans and perhaps constructing a maternity waiting house in the ward. Rebuilding trust between facility midwives, TBAs, and the community on the availability of health facility services, and increased sensitivity to women’s cultural preferences, could also close the gap between the number of women who are currently using facilities for ANC and those returning for delivery.

Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis

“…Thirty-one secondary sources and six interviews informed CMOC5 which relates to families’ ability to overcome barriers impeding their access to MWH-facility birth services. Women and/or families were more likely to have an MWH-birth facility experience if they were able to afford associated costs, such as travel including over long distances or by private vehicle, MWH-facility birth user fees (where applicable) or food and other required supplies 14 91 95 102 104 113 119 125 133. There were instances were women and families reduced their barriers to utilisation by selling assets, borrowing money or incurring debt from the health facility 92 96 114 119.…”

“…Included studies involved qualitative, quantitative or mixed-methods design (see online supplemental appendix C). Sixty-six sources involved one or more countries in Africa (62.3%),9–15 23 25 28–32 34 36 37 39 42–47 49 77–119 25 involved 1 or more countries in South America (23.6%)8 18 19 21 22 24 26 33 35 40 41 48 50 51 81 120–129 and 7 involved one or more countries from Asia (6.6%) 38 130–135. Eight sources involved multiple continents (7.5%) 16 17 20 136–140…”

Perceived differences on the role of traditional birth attendants in rural Tanzania: a qualitative study

“…Hence, the authors concluded that, although a leadership empowerment model is desirable, it may be unfeasible to implement in highly hierarchical cultures. Conversely, a recent study among Maasai tribes in Tanzania described the need to rebuild trust among SBAs, TBAs, and the community [32]. That study emphasized that increased sensitivity to women's cultural preferences could close the gap in the trust between these stakeholders.…”

Peran Ayah dalam Meningkatkan Kesehatan pada Ibu Hamil

“…Penghambat peran ayah yang kami temukan adalah stigma sosial. Stigma sosial yang ada mempengaruhi laki-laki untuk tidak ikut dalam proses fertilitas, yang jelas dapat berdampak buruk pada kesehatan ibu (Mosley et al, 2020). Studi ini Rosmadewi & Aliyanto (2022) menemukan faktor kinerja kesehatan yang tidak memuaskan, mecipt pelayanan yang buruk dan perilaku petugas kesehatan yang tidak sopan membuat laki-laki sulit mendampingi istrinya.…”