TITLE:
Low utilization of skilled birth attendants in Ngorongoro Conservation Area, Tanzania: A complex reality requiring action
AUTHORS:
Yadira Roggeveen, Lauren Birks, Jetty van Kats, Mange Manyama, Jennifer Hatfield, Joske Bunders, Fedde Scheele, Jos van Roosmalen
KEYWORDS:
Collaboration; Maternal Health; Quality of Care; Maasai; Complexity
JOURNAL NAME:
Health,
Vol.5 No.7D,
July
18,
2013
ABSTRACT: Limited integration of contextual factors in maternal care contributes
to slow progress towards achieving MDG5 in sub-Sahara Africa. In Ngorongoro,
rural Tanzania, the maternal mortality ratio is high with 642 maternal deaths/100,000
live births. Skilled birth attendants (SBAs) assist only 7% of deliveries. This
study, undertaken from 2009 to 2011, used Participatory Action Research involving local stakeholders (Maasai women
and men, traditional birth attendants (TBAs), hospital staff) to examine
reasons for low utilization of SBAs and moreover to develop proposals how to
integrate contextual factors and local needs in the health care system. Interviews,
observations and literature study were also conducted. Thaddeus and Maine’s
Three Delays model is used to structure the analysis. Delaying factors in decision
making at home: negative perceptions by the community on availability and
quality of care in the hospital; discontinuity of care by TBAs; food and financial insecurity; desired nearness to cattle and family; limited recognition of
maternal deaths; limited male health education and suboptimal birth
preparedness. Delaying factors in reaching the hospital: vehicle and road
limitations. Delaying factors in receiving hospital care: limited (human)
resources and limited knowledge sharing at the hospital. Community members
and health workers proposed: increasing food/financial security; tailoring
male health education; combining TBA/SBA care to provide continuous, culturally
appropriate labour support; creating separate maternity wards; increasing the
number and training of staff; ensuring continuous availability of Emergency
Obstetric Care. Applying solutions to increase hospital utilization seems
complex as collaborative actions by multiple actors and institutions are
needed to create both a needs based and clinically sound continuum of
maternal care. To follow-up this process of integrating local solutions into
the maternal care system, we suggest to adapt the WHO Strategic Approach—a top-down framework for the implementation of
innovations—to fit this bottom-up
approach.