“You should go so that others can come”; The Role of Facilities in Determining an Early Departure After Childbirth in Morogoro Region, Tanzania

Background

Tanzania is among ten countries that account for a majority of the world’s newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women’s experiences in the time preceding discharge from a facility after childbirth are limited.

Methods

Household survey of 1267 women who delivered in the preceding 2–14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.

Results

Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001).

Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.

Conclusion

Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women’s perceptions that it is safe and beneficial to leave hospitals soon after birth.

Full article at:  http://goo.gl/hCgolx

By:  Shannon A. McMahon^15*, Diwakar Mohan¹, Amnesty E. LeFevre¹, Idda Mosha², Rose Mpembeni³, Rachel P. Chase¹, Abdullah H. Baqui¹⁴ and Peter J. Winch¹

¹Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore 21205-2179, MD, USA

²School of Public Health and Social Sciences, Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam, Tanzania

³School of Public Health and Social Sciences, Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam, Tanzania

⁴International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore 21205-2179, MD, USA

⁵Institute of Public Health, Ruprecht-Karls-Universität, Heidelberg, Germany

More at:  https://twitter.com/hiv_insight

And:        http://twitter.com/Prison_Health

“Every Method Seems to Have Its Problems”- Perspectives on Side Effects of Hormonal Contraceptives in Morogoro Region, Tanzania

Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning's multiple benefits, women's experiences of - or concerns related to - side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use.

Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis.

Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn’s health in the first months of life.

To meet Tanzania’s national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed.

Full article at: http://goo.gl/Oj1Ke1

By: Joy J. Chebet^1*, Shannon A. McMahon¹², Jesse A. Greenspan¹, Idda H. Mosha³, Jennifer A. Callaghan-Koru¹, Japhet Killewo⁴, Abdullah H. Baqui¹ and Peter J. Winch¹

¹Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA

²Institute of Public Health, Ruprecht-Karls-Universität, Im Neuenheimer Feld 324, Heidelberg, 69120, Germany

³Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

⁴Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

  

More at:  https://twitter.com/hiv_insight

Supply-Side Dimensions & Dynamics of Integrating HIV Testing & Counselling into Routine Antenatal Care: A Facility Assessment from Morogoro Region, Tanzania

Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania.

This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti.

Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. 

• While assessment of infrastructure, including waiting areas, appeared adequate, 
• long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. 
• Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women’s care seeking at health centers. 
• In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. 
• Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. 
• In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability.

Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes.

Below:  Availability of Infrastructure. The health infrastructure composite scores include a) HIV diagnostic and treatment services (laboratory, presence of CTC); b) waiting and registration area (waiting area, covered or roofed waiting area, well-ventilated registration/waiting area); c) counselling area (dividing curtain or screen, well-ventilated group counselling area, and sufficient space for pregnant women to walk); d) furniture (at least one desk and at least one chair for provider, at least one chair for patient; sufficient chairs and space for one companion of each patient)

Below:  Availability of functional essential supplies and equipment for delivery of integrated HIV/ANC services

Below: ANC provider knowledge and percent of observed counselling sessions with delivery of HIV- and ANC-related messages

Full article at: http://goo.gl/P3krmH

By: Selena J. An^1*, Asha S. George¹, Amnesty E. LeFevre¹, Rose Mpembeni², Idda Mosha³,Diwakar Mohan¹, Ann Yang¹, Joy Chebet¹, Chrisostom Lipingu⁵, Abdullah H. Baqui¹,Japhet Killewo², Peter J. Winch¹ and Charles Kilewo⁴

More at:  https://twitter.com/hiv_insight

Estimation of Mortality among HIV-Infected People on Antiretroviral Therapy Treatment in East Africa

Below:  Mortality among a sample of patients lost to follow-up. Incidence and the hazard of mortality among a random sample of patients lost to follow-up and successfully sought in the community, stratified by program.

We evaluated in HIV-infected adults on ART in 14 clinics in five settings in Kenya, Uganda and Tanzania using a sampling-based approach in which we intensively traced a random sample of lost patients (> 90 days late for last scheduled visit) and incorporated their vital status outcomes into analyses of the entire clinic population through probability-weighted survival analyses.

We followed 34,277 adults on ART from Mbarara and Kampala, Uganda; Eldoret and Kisumu, Kenya; and Morogoro, Tanzania. The median age was 35 years, 34% were men, and median pre-therapy CD4 count was 154 cells/μl. Overall 5,780 (17%) were LTFU, 991 (17%) were randomly selected for tracing and vital status was ascertained in 860 of 991 (87%). Incorporating outcomes among the lost increased estimated 3-year mortality from 3.9% (95% CI: 3.6%-4.2%) to 12.5% (95% CI: 11.8%-13.3%). The sample-corrected, unadjusted 3-year mortality across settings ranged from 7.2% in Mbarara to 23.6% in Morogoro. After adjustment for age, sex, pre-therapy CD4 value, and WHO stage, the sample-corrected hazard ratio comparing the setting with highest vs. lowest mortality was 2.2 (95% CI: 1.5-3.4) and the risk difference for death at 3 years was 11% (95% CI: 5.0%-17.7%).

A sampling based approach is widely feasible and important for understanding mortality after starting ART. After adjustment for measured biological drivers, mortality differs substantially across settings despite delivery of a similar clinical package of treatment. Implementation research to understand the systems, community, and patient behaviors driving these differences is urgently needed.

Via:   http://ht.ly/QnW0w HT @UCSF