Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis

Abstract

Background: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania. Methods: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders' meetings held at ward level in which 450 people participated. Data were analysed using thematic approach. Results: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers. Conclusions: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women's rights to access ANC services.

Vaccines safety and maternal knowledge for enhanced maternal immunization acceptability in rural Uganda: A qualitative study approach

“…Behavior of a few of the health workers and how they treat pregnant women was termed as harsh, rude and abusive, which is a massive inconvenience while attending ANC. This is similar to findings in Ethiopia and Tanzania [ 46 , 47 ]. Evidence has shown that a recommendation from a health care professional for vaccination is the most important factor in decision-making for uptake of a maternal vaccine [ 16 ].…”

Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya

“…As much as the healthcare workers would like to maintain a high vaccine coverage, issues such as delays in vaccine delivery to the health facilities meant that even when mothers showed up and demanded to be vaccinated the vaccines were out of stock, causing a missed opportunity. Similar to what has been found in Ethiopia (Gebremichael et al 2018), Tanzania (Maluka et al 2020) and Uganda (Kajungu et al 2020), we observed that if a health care worker was harsh, abusive or rude, it could discourage women from attending ANC clinics, which has a ripple effect on uptake of vaccines by the mothers.…”

A network analysis of patient referrals in two district health systems in Tanzania

“…Our analysis points to the importance of adequate investments in infrastructure for intermediate secondary-level referral facilities ( Mwangome et al , 2017 ). For instance, there is compelling evidence the rural and mountainous Kilolo district saw few funds allocated to construction and maintenance of secondary and tertiary facilities, to means of transportation ( Kigume and Maluka, 2018b ) and staffing ( Maluka et al , 2020 ). Consequently, an FBO-managed hospital is designated as district referral hospital, which may discourage attendance of poor households imposing user fees, contrary to public facilities ( Saksena et al , 2010 ).…”

“…These well-known disruptions in the intended referral flows may further discourage access to care due to high travel expenses ( Saksena et al , 2010 ) and specific cultural policies, e.g. spouse accompany ( Maluka et al , 2020 ). Lastly, health facilities located close to district borders—or in districts that do not have a tertiary-level facility—naturally refer patients to other facilities located in neighbouring district not included in our analysis.…”

“…Additionally, the high financial burden associated to private transportation remains a major barrier for successful referral among low-income households ( Pembe et al , 2008 ; Porter et al , 2013 ; Boex et al , 2015 ). The referral system in Tanzania faces several challenges including the lack of adequate resources and means to transfer patients ( Simba et al , 2008 ), lack of solid referral criteria and compliance at higher level ( Jahn et al , 1998 ; Jahn and De Brouwere, 2001 ), poor households’ decision-making process especially for maternal health ( Maluka et al , 2020 ), frequent delays ( Schmitz et al , 2019 ), frequent self-referrals to hospitals related to the perceived poor quality of care at primary-level facilities ( Manzi et al , 2012 ; Yahya and Mohamed, 2018 ). Yet, to the best of our knowledge, little is known about referral flows, whether dispensaries and health centres effectively act as gatekeepers of the system and which health facility characteristics are associated with the occurrence of referrals between facilities.…”