Quality of Maternity Care in Rural Tanzania: Understanding Local Realities and Identification of Opportunities for Improvement

Maternal health remains a challenge in sub-Saharan Africa, and Tanzania is no exception. Despite increases in access and use of health care services maternal deaths have not decreased at a sufficient rate. Attention for the quality of care that women receive reveals that the content of care is not always in accordance with evidence-based standards. This thesis describes and assesses the quality of care provided by facility based health workers during pregnancy and birth in a rural setting in. Data was collected over several periods between 2012 and 2016 and took place in the Mwanza region, Tanzania. Participant observation formed an important part of the research approach. Mixed-methods were used to assess the quality of antenatal care at 13 dispensaries, one health centre and one district hospital. Data collection included a facility survey, direct observations of antenatal care consultations, and exit interviews with women attending care. In order to gain understanding of the quality of care during birth I observed and participated for more than 1300 hours on maternity wards in four rural and semi-urban health facilities. Additionally, I followed 14 women during pregnancy, birth and in the post-partum period. Findings revealed that quality of care, provided during antenatal care and birth, was severely compromised due to health system challenges. Health workers prioritized or neglected elements of essential care, influenced by complex working conditions, rather than adhering to evidence-based guidelines. All 14 women that were followed throughout their pregnancy were exposed to non-supportive care, including incidences of disrespect and abuse, during antenatal care and birth. Women’s normalization and justification of these experiences revealed how structural and ingrained substandard care has become throughout women’s reproductive lives. In conclusion, the quality of care that women received during pregnancy and birth was sub-standard, both from a technical and interpersonal perspective. Strengthening the health system to ensure availability of ‘good enough’ quality and respectful care, to ensure women have a positive pregnancy and birth experience, will likely encourage more women to seek care in a timely manner during birth. Substandard care and mistreatment of women across the continuum of care, must be holistically tackled, and needs to consider the realities of people’s lives and the context of structural social, economic and political forces driving the health system