Improve Maternal and Perinatal Health Outcomes in Sub-Sahara Africa by focus on Quality of Care

Quality of care during pregnancy and childbirth in low-resource settings, such as Tanzania, is reported to be of low quality. There are also reports that highlight substandard care provided by healthcare workers. It is increasingly acknowledged that women's perceptions of the quality of care are likely to influence their choice to seek care and might explain remaining low figures of women who give birth at a health facility. This project, a personal PhD granted project, is aimed to gain additional knowledge on how quality of care influenced care seeking and how this potentially could be improved. This was a collaborative project between University in Oslo, Local policy makers and the School of Public in Mwanza, Tanzania. Based on data collected through assessments of available supplies and services in 15 health facilities, observations of antenatal care consultations (N=664) and exit interviews with pregnant women (N=286) we found sub-optimal performance of key-routine antenatal care services which were partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client's wellbeing, basic physical examination and adequate counseling and education, while such services are important for quality of care during pregnancy. Few women were asked if they had any current complaints or problems (20%), were asked about the presence of danger signs (6%) or asked about the presence of fetal movements (3%). Despite poor performance, 96% of women interviewed said they were happy with the care received. Observations of the quality of care during birth reveal poor performance of routine care for uncomplicated pregnancies. Based on 1300 hours of participant observation we found women are rarely cared for during the first stage of labour. Partly as a result of women being placed in a waiting room, located out of sight of the nursing station. Assumptions and hope for good outcomes appeared to reduce health worker motivation for routine monitoring. This was rooted in a belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. In contrast, fear for poor outcomes and being held responsible triggered active management in second and third stage of labour, even if there was no indication to intervene. Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. Both underuse and overuse of interventions contribute to poor quality of care during childbirth. We followed 14 women throughout their pregnancy until after birth. Observation of 25 ANC visits, three births and 94 interviews were used to develop in-depth narratives for each woman. Of the 14 women 7 gave birth at home and 7 at a health facility. One woman had a stillbirth and two lost their babies in the first year. All women were exposed to both supportive and non-supportive care, the latter including instances of disrespect and abuse, throughout their pregnancy and birth. Women and health workers often interacted in complete silence. Women were rarely informed of findings of examination and their concerns, opinions and knowledge were frequently ignored. Women were sometimes scolded at if they did not behave according to health worker expectations. During antenatal care women could be refused services for not bringing their husbands. At birth, women could be left unattended or experience forced vaginal examination or other harmful practices. Such behaviour was considered normal and often justified by women themselves. Even if women disapproved of how they were treated at a facility, they often referred to services being 'normal' or 'good'. Disrespect and abuse occurs in an impoverished social and political context, in which women's broader needs during pregnancy and birth have been systematically ignored or devalued. Detailed narratives of women's reproductive lives and the linking of women's live events, in relation to their social context were linked to women's decision making and individual choices made for care seeking during birth. The various factors interplaying and influencing women's thought processes throughout their pregnancy, in anticipation for birth, was closely related to women's different prior birth experiences and socio-economic contexts. Isolated factors such as distance to the health facility, socio-economic status, years of schooling and previous birth location were not sufficient to predict women's choice of birth location. Women's agency, including women's perception of self, the self in relation to the environment and reflection on risks associated with the range of options, determined the final decision made for birth. Women´s stories suggest that quality of care can function as a primary pull factor for facility birth.

Outcomes: - Increased understanding of women's experiences with care provision during pregnancy and birth and how this influences decision making for health care seeking. - Increased understanding of health providers decision making in care provision acknowledging the complex working condition and societal challenges that influence care. Impacts: - Increased value of interdisciplinary approach to quality of care assessments, with specific success with regards to the indispensable importance of long term involvement, fieldwork and repetition while making use of qualitative research methods. - Acknowledgement of local stakeholders' difficulties with implementing internationally designed interventions, without adaptation to local settings. - Critical reflection on global recommendations and provision of context to local settings which can steer changes in how such recommendations need to be implemented in resource constrained setting.

This project is inspired by a determination to improve quality of maternity care for the most vulnerable and hard to reach populations, that are most at risk for adverse pregnancy outcomes (MDG 4 & 5). It is a multidiciplinary effort to promote and facilitate better quality care for pregnant women at basic, peripheral maternities in Sub-Saharan Africa. The project addresses cornerstones of quality care delivery: specific clinical skills, communication in health systems, and socioeconomic and cultural context. The conceptual approach is that of a broadened operations research framework, including a situational analysis, multifaceted local interventions at facility and community level, and impact evaluation. We also want to frame the project in an expanded "quality of care" format, where formal technical/ medical/interpersonal quality is assessed toghether with a broader in depth understanding of barriers at all levels. Collaborating partners in this project are the African Woman Foundation (Amsterdam, the Netherlands) and the Catholic University of Health and Allied Sciences School of Public Health (Mwanza, Tanzania)