When the women of Iringa speak about maternal healthcare, the community listens. Their messages to boost women’s access to and use of antenatal care services are particularly effective because the women themselves identified the pressing challenges they face. With community support, they also designed strategies to overcome them.
This success is the result of an innovative implementation research project carried out in Kilolo and Mufindi districts by the University of Dar es Salaam, Tanzania, and HealthBridge Foundation of Canada, in collaboration with Iringa Municipal Council’s Health Department. Funding was provided by the Innovating for Maternal and Child Health in Africa (IMCHA) initiative.
Why women don’t seek early care
Improving maternal and child health in Tanzania is an urgent need. The country reported 8,200 annual maternal deaths due to complications of pregnancy or childbirth in 2015 and 45,691 annual deaths of infants within 28 days of birth in 2017. According to World Health Organization and UNICEF statistics, these figures place Tanzania among the 10 countries with the highest numbers.
Tanzania is working to reduce these sobering indicators of maternal and child health through national policies, health sector reforms, and targeted plans and programs. But as the research team identified, the improvements don’t always respond to local realities. In Iringa, one of the most pressing needs is to find ways of increasing the use of antenatal services. Tanzanian Ministry of Health guidelines recommend at least four visits to a healthcare facility for uncomplicated pregnancies, starting with a consultation during the first 12 weeks of gestation. However, according to the Regional Commissioner’s Office of Iringa, only 27% of women in Kilolo and 17% in Mufindi attend a health centre before their fourth month of pregnancy.
Why do women wait so long? To find an answer, researchers held focus group discussions and interviewed women, men, local healthcare providers, and officials in 20 villages in each district. They found that, beyond the lack of transportation to reach distant health facilities, poor understanding of the importance of antenatal care looms large.
Traditional gender roles also limit women’s ability to decide if and when to seek healthcare. Similarly, these traditional gender roles discourage men from accompanying their partner, despite government policy that requires that pregnant women bring their spouses to their first consultation. Poor reception by health workers can discourage the men who do attend from returning.
Fear of being stigmatized because of short spacing between births also keeps women at home: “You will always feel very shy to go for antenatal care service while you know — and nurses know for sure — you have left a 6-month-old child at home,” said one woman.
This unfavourable environment, combined with long wait times at the health facility, deters pregnant women from seeking early care.
Home-grown strategies to improve maternal and child health
The project is studying how locally appropriate solutions could help surmount these hurdles. As an entry point, the research team set up Women’s Participatory Learning and Action Groups in the 20 villages to identify and prioritize problems related to their poor maternal and child health outcomes, then strategize about how to solve them.
The groups identified four main areas of concern: home deliveries; low participation of men in antenatal care; late use or no use of antennal care services; and poor birth spacing. The groups suggested many strategies to address these issues, such as:
- using women’s groups and champions to educate other women on how best to share information with their partners during pregnancy and childbirth;
- partnering with community health workers to educate the community on the importance of early antenatal care and to visit pregnant women to encourage them to give birth at the health facility;
- identifying male champions in each village to deliver key health messages to men wherever they gather (bars, football matches, and other social gatherings);
- improving the capacity of existing health facility governing committees to educate health providers about their roles and ways to better engage with the communities and village health workers.
Improving the care provided
Health system issues — disrespectful language and behaviour on the part of the health providers; delays in providing appropriate care; lack of facilities and equipment; and shortage of drugs and supplies — require a different kind of intervention.
The research showed that health facility governing committees had difficulty planning and implementing services, leading to the neglect of the poorest and most vulnerable. In May 2018, the research team trained committee members from the 12 dispensaries in the project area. All were shocked at the poor maternal and child health indicators and low participation in antenatal care. They committed to collaborating with women’s groups and promised to work closely with the community and health facilities to overcome gender norms that constitute barriers to maternal and child health, including setting an example byaccompanying their own wives to the clinics. “As district health managers, we are going to take action on a number of issues suggested by the women’s groups,” a committee member said.
The power of action research
With key messages at the ready, women, male champions, and community leaders have started implementing the selected strategies in their respective villages. The project team is documenting how this is unfolding. It has already presented some of its work to local and national stakeholders, including the Ministry of Health, and published results in peer-reviewed journals on topics such as male involvement to break barriers to maternal and child health. “This type of research is very important as it is already bringing a change,” said a ward councillor.
The research team points out that this project is one of only a few in Tanzania to use an action-research approach to involve communities in the changes they want to see in the health sector. As one participant noted, “This approach has empowered us to diagnose our problems and design strategies to address them. This is a very innovative way of engaging communities.”
The community members and decision-makers involved were able to design culturally acceptable strategies that stand a good chance of remaining in place beyond the end of the project in 2020.
Learn more about the Innovating for Maternal and Child health in Africa initiative