Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania

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Abstract

Background

In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, " Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania.

Method

This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues.

Results

Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues.

Conclusion

The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.

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Most cited references 16

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Too far to walk: maternal mortality in context.

S Thaddeus, D Maine (1994)

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

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Theories and intervention approaches to health-behavior change in primary care.

John P Elder, Guadalupe Ayala, Stewart Harris (1999)

Providers typically rely on health information and their professional status to convince patients to change. Health-behavior theories and models suggest more effective methods for accomplishing patient compliance and other behavior change related to treatment regimens. Behavior modification stresses the remediation of skill deficits or using positive and negative reinforcement to modify performance. Like behavior modification, the Health Belief Model stresses a reduction of environmental barriers to behavior. Social Learning Theory suggests that perceptions of skills and reinforcement may more directly determine behavior. Self-management models put the above theories into self-change actions. Social support theories prioritize reinforcement delivered through social networks, whereas the Theory of Reasoned Action emphasizes perceptions of social processes. Finally, the Transtheoretical Model speaks of the necessity to match interventions to cognitive-behavioral stages. Strategies derived from each of these theories are suggested herein.

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Why do at-risk mothers fail to reach referral level? Barriers beyond distance and cost.

S Kimatta, Jacob Kowalewski, Linda Jahn (2000)

In southern Tanzania, few high-risk pregnancies are channeled through antenatal care to the referral level. We studied the influences that make pregnant women heed or reject referral advice. Semi-structured interviews with sixty mothers-to-be, twenty-six health workers and six key-informants to identify barriers to use of referral level were conducted. Expert-defined risk-status was found to have little influence on a woman's decision to seek hospital care. Besides well known geographical and financial barriers, we found that pregnant women have different perceptions and interpretations of danger signs. Furthermore, rural women avoid the hospital because they fear discrimination. We conclude that a more individualised antenatal consultation could be provided by taking into account women's perception of risk and their explanatory models. Hospital services should be reorganised to address rural women's feelings of fear and insecurity.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Pregnancy Childbirth

Title: BMC Pregnancy and Childbirth

Publisher: BioMed Central

ISSN (Electronic): 1471-2393

Publication date Collection: 2010

Publication date (Electronic): 1 April 2010

Volume: 10

Page: 14

Affiliations

[1 ]Department of Community Health, Tumaini University-Kilimanjaro Christian Medical Centre, P.O. Box, 2240, Moshi, Kilimanjaro, Tanzania

[2 ]School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O Box 65015, Dar es Salaam, Tanzania

[3 ]Institute of Public Health, Ruprecht-Karls-University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany

Article

Publisher ID: 1471-2393-10-14

DOI: 10.1186/1471-2393-10-14

PMC ID: 2858713

PubMed ID: 20359341

SO-VID: 01f14db8-09df-4fba-a6a5-4565dd965a0b

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania

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Abstract

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Method

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Conclusion

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Most cited references 16

Too far to walk: maternal mortality in context.

Theories and intervention approaches to health-behavior change in primary care.

Why do at-risk mothers fail to reach referral level? Barriers beyond distance and cost.

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