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Quality Assessment and Monitoring of Maternal Referrals in Rural Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (International maternal and reproductive health)
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

An efficient referral system is essential in providing access to emergency obstetric care at higher levels of care by supporting antenatal and delivery services in the primary level of care facilities (PLCF). The aim of this thesis was to assess community and health service factors affecting the quality of maternal referrals in rural Tanzania.

Ten focus group discussions (FGDs) with health workers and community members were conducted to describe their perceptions on maternal referrals. Women (n=1118) were interviewed to determine awareness of obstetric danger signs and associated factors. Compliance with referral advice was analysed for 1538 women referred from PLCF. Counselling on danger signs and adherence to referral criteria was observed in 438 antenatal consultations.

FGDs indicated that women had limited influence, especially on emergency referrals. The process of deciding to seek referral care considered the perception of seriousness and past experience of referral, access to transport, and the cost involved. Women had low awareness of danger signs of obstetric complications: higher years of schooling increased the likelihood of being aware of danger signs. Demographic risks accounted for 70% of referred women but less than half complied with the advice. Compliance was higher for historical obstetric risks, prenatal, natal, and postnatal complications groups. Few women were counselled on pregnancy danger signs and a significant number with ≥5 pregnancies and primigravidae <20 years were not informed of the risk factors.

This thesis demonstrated a need for reviewing referral guidelines and an increase in supportive supervision for health workers counselling on obstetric danger signs to enhance acceptance of referrals advices. Women’s education should be given priority for increasing participation in decisions and becoming more aware of danger signs. Costs involved in maternal referrals can be relieved by improving family income, infrastructure, and alleviating the cost of referral through mobilising community transport and financial schemes.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2010. , p. 62
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 552
Keywords [en]
Quality, maternal referral, counselling, monitoring, rural, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
International Health
Identifiers
URN: urn:nbn:se:uu:diva-122166ISBN: 978-91-554-7784-4 (print)OAI: oai:DiVA.org:uu-122166DiVA, id: diva2:309614
Public defence
2010-05-20, Rosénsalen, University Hospital, entrance 95/96 nb, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2010-04-29 Created: 2010-04-06 Last updated: 2010-04-29Bibliographically approved
List of papers
1. Qualitative study on maternal referrals in rural Tanzania: Decision making and acceptance of referral advice
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2008 (English)In: African Journal of Reproductive Health, ISSN 1118-4841, Vol. 12, no 2, p. 120-131Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe perceptions of maternal referrals in a rural district in Tanzania. Focus groupdiscussions (FGDs) with health workers and community members, stratified by age and gender, were conducted.The FGDs revealed that husbands and relatives are the decision makers in maternal referrals, whereas the womenhad limited influence, especially on emergency referrals. The process in deciding to seek referral care is envisagedwithin community perception of seriousness of the condition, difficulty to access and cost involved in transport,living expenses at the hospital, and perceived quality of care at facility level. The hospitals were seen as providingacceptable quality of care, whereas, the health centres had lower quality than expected.

To improve maternal referral compliance and reduce perinatal and maternal morbidity and mortality,communityviews of existing referral guidelines, poverty reduction, women’s empowerment and male involvement inmaternal care are necessary.

Keywords
maternal referrals, decision making, rural, Tanzania, FGD
Research subject
Identifiers
urn:nbn:se:uu:diva-87188 (URN)
Available from: 2008-11-27 Created: 2008-09-22 Last updated: 2017-12-13Bibliographically approved
2. Rural Tanzanian women's awareness of danger signs of obstetric complications
Open this publication in new window or tab >>Rural Tanzanian women's awareness of danger signs of obstetric complications
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2009 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 9, no 12Article in journal (Refereed) Published
Abstract [en]

ABSTRACT: BACKGROUND: Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania. METHODS: A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs. RESULTS: More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR=5.8; 95% CI: 1.8-19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care. CONCLUSION: Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-100708 (URN)10.1186/1471-2393-9-12 (DOI)000208106900012 ()19323836 (PubMedID)
Available from: 2009-04-06 Created: 2009-04-06 Last updated: 2017-12-13Bibliographically approved
3. Maternal referral system in Rufiji rural district in Tanzania
Open this publication in new window or tab >>Maternal referral system in Rufiji rural district in Tanzania
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(English)Manuscript (preprint) (Other (popular science, discussion, etc.))
Abstract [en]

Objective: To evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.

Design: A prospective cohort study.

Setting: Rufiji rural district, Tanzania.

Study participants: One thousand five hundred and thirty eight women referred from 18 primary level of care facilities during the 13 months.

Data collection: Referred women were identified at hospitals. Those not reaching the hospitals were traced and interviewed.

Main outcome measures: Compliance to referral advice, reasons for non-compliance, appropriateness of referral indication, and perinatal outcome.

Results: Out of 1538 women referred 70% were referred for demographic risks, 12% for historical obstetric risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age <20 years were the most common referral indications. The compliance rate was 37% for women referred due to demographic risks and more than 50% among women referred in the other groups. Among women who did not comply with referral advice, almost half of them mentioned financial constraints as the major factor. Lack of compliance with the referral did not significantly increase the risk for a perinatal death.

Conclusion: Majority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review referral indications and strengthen counselling on birth preparedness and complication readiness.

Keywords
Maternal referral, obstetric complication, high risk pregnancies, rural, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-122148 (URN)
Available from: 2010-04-07 Created: 2010-04-06 Last updated: 2010-04-07
4. Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs
Open this publication in new window or tab >>Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs
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2010 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 10, article id 35Article in journal (Refereed) Published
Abstract [en]

Background: The high rate of antenatal care attendance in sub-Saharan Africa, should facilitate information on signs of potential pregnancy complications and advice the women on referral where indicated. The aim of this study was to assess quality of antenatal care with respect to providers’ counselling of pregnancy danger signs and adherence to referral criteria in Rufiji district, Tanzania.

Methods: A cross-sectional study was conducted in 18 primary health facilities. Thirty two providers were observed providing antenatal care to 438 pregnant women. Information on counselling on pregnancy danger signs and women’s use of health facility for delivery was collected by an observer. Exit interviews were conducted to 435 women.

Results: One hundred and eighty five (42%) clients were not informed of any pregnancy danger signs. The most common pregnancy danger sign informed on was vaginal bleeding 50% followed by severe headache/blurred vision 45%. Maternal Child Health Aides (MCHAs) were three times more likely to inform a client of a danger sign than nurse auxiliaries (OR=3.7; 95% CI: 2.1-6.5) while public health nurses and registered/enrolled nurses were both two times more likely to inform on danger signs (OR=2.3: 95% CI: 1.3-4.3 and OR=2.4; CI: 1.4-4.2 respectively). Among grand multiparous and primigravida below 20 years identified on exit interview, 63% and 71% had been informed of the risk factors during the during interaction with providers.

Conclusion: Two out of five clients were not counselled on danger signs of obstetric complication and not advised to use referral services, despite of having a risk factor. Nurse auxiliaries were less capable of counselling clients. Supportive supervision should be made to enhance counselling of danger signs and adherence to referral indications. Nurse auxiliaries should be encouraged and given chance for further training and upgrading to improve their performance and increase human resource for health.

Keywords
Referral, quality, antenatal care, high risk pregnancy, obstetric danger signs, rural, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-122164 (URN)10.1186/1471-2393-10-35 (DOI)000296439300002 ()
Available from: 2010-04-07 Created: 2010-04-06 Last updated: 2017-12-12Bibliographically approved

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