Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations.

INTRODUCTION: Midwifery associations are organisations that represent midwives and the profession of midwifery. They support midwives to reduce maternal and newborn mortality and morbidity by promoting the overall integration of midwifery in health systems. Our objective was to generate a framework for evidence-informed midwifery association strengthening. METHODS: A critical interpretive synthesis complemented by key informant interviews, focus groups, observations, and document review was used to inform the development of concepts and theory. Three electronic bibliographical databases (CINAHL, EMBASE and MEDLINE) were searched through to 2 September 2020. A coding structure was created to guide the synthesis across the five sources of evidence. RESULTS: A total of 1634 records were retrieved through electronic searches and 57 documents were included in the critical interpretive synthesis. Thirty-one (31) key informant interviews and five focus groups were completed including observations (255 pages) and audio recordings. Twenty-four (24) programme documents were reviewed. The resulting theoretical framework outlines the key factors by context, describes the system drivers that impact the sustainability of midwifery associations and identifies the key-enabling elements involved in designing programmes that strengthen midwifery associations. CONCLUSION: Midwifery associations act as the web that holds the profession together and are key to the integration of the profession in health systems, supporting enabling environments and improving gender inequities. Our findings highlight that in order to strengthen midwifery (education, regulation and services), we have to lead with association strengthening. Building strong associations is the foundation necessary to create formal quality midwifery education systems and to support midwifery regulation and accreditation mechanisms.

Nurses' and midwives' awareness of intimate partner violence-related mental healthcare and associated factors in Tanzania.

Although intimate partner violence (IPV) is a significant public health problem in Tanzania, the country's system to provide IPV-related mental healthcare is not sufficiently prepared to respond to IPV care needs. This study aimed to assess nurses' and midwives' awareness of IPV-related mental healthcare and associated factors to encourage care provision. A cross-sectional, anonymous, self-administered survey was conducted among nurses and midwives in health facilities in the Mbeya region, from December 2018 to January 2019. The questions gauged awareness of IPV-related mental disorders, availability of screening tools, confidence in providing IPV-related mental healthcare and the presence of a mental health focal/resource person, in addition to socio-demographic and institutional characteristics. Of 1,321 nurses and midwives in the region, 662 (50.1%) participated in the study, and the analysis included 568 (85.8%) responses without missing values. The median awareness score was 5 (range: 0-6), and 34.0% of the participants were aware of all six examined IPV-related mental health disorders. Separate logistic regression analyses were conducted for those working in hospitals and those working in health centres (HCs), assessing potential factors associated with nurses' and midwives' awareness of IPV-related mental disorders. Among nurses and midwives in hospitals, high professional education (adjusted odds ratio [AOR]: 1.207; 95% confidence interval [CI]: 0.787, 1.852; p = .045) and long work experience (AOR: 1.479; 95% CI: 1.009, 2.169; p = .007) were associated with high awareness of IPV-related mental disorders. For those in HCs, government ownership (AOR: 3.526; 95% CI: 1.082, 11.489; p = .037) and having a mental health focal/resource person (AOR: 3.251; 95% CI: 1.184, 8.932; p = .036) were associated with high awareness of IPV-related mental disorders. Appropriate distribution of mental health focal/resource persons is required for improving awareness of IPV-related mental healthcare provision among nurses and midwives in remote areas of Tanzania.

Factors associated with the awareness of contraceptive methods, understanding the prevention of HIV/AIDS and the perception of HIV/AIDS risk among secondary school students in Dar es Salaam, Tanzania.

Objective: To assess the awareness of contraceptive methods, understanding of HIV/AIDS prevention and the perception of HIV/AIDS risks among secondary school students in Tanzania. Methods: An anonymous self-administered questionnaire survey was conducted among secondary school students in Tanzania. The questionnaire included sociodemographic characteristics, awareness of contraceptive methods, an understanding of HIV/AIDS prevention, and the perception of HIV/AIDS risks. Three secondary schools were selected by considering the gender balance and location, which included the urban and surrounding areas. The research objectives, methods, and ethical considerations were explained, and the students voluntarily completed the questionnaire. Results: A total of 233 responses were collected, and 204 responses were considered valid for the analysis. The mean and standard deviation of age were 18.5 ± 1.0. Regardless of the gender, age, religion, and major course of study, the maternal educational status (adjusted odds ratio [AOR]: 3.129; 95% confidence interval [CI]: 1.324, 7.398; P=0.009) and the number of information sources (AOR: 7.023, 95% CI: 3.166, 15.579, P<0.001) demonstrated associations with the awareness of contraceptive methods. Respondents who lived outside a dormitory (AOR: 3.782; 95% CI: 1.650, 8.671; P=0.002) and who currently had a partner (AOR: 3.616; 95% CI: 1.486, 8.800; P=0.005) were associated with a high level of understanding of HIV/AIDS prevention regardless of gender, age, religion, and major course of study. Respondents with few information sources were associated with a high level of perception of HIV/AIDS risks (AOR: 0.293; 95% CI: 0.115, 0.747; P=0.010), regardless of gender, age, religion, and major course of study. Conclusion: Factors associated with the awareness of contraceptive methods, the understanding of HIV/AIDS prevention, and perception of HIV/AIDS risks were not consistent. To ensure the improvement of these factors among secondary school students, sexual health education should be integrated into educational programs and provided holistically.

Self-reported disrespect and abuse by nurses and midwives during childbirth in Tanzania: a cross-sectional study.

BACKGROUND: Facility-based childbirth has increased globally. Unfortunately, there have also been reports of women experiencing disrespect and abuse by healthcare providers during childbirth. This study aimed to measure the prevalence of self-reported disrespect and abuse (D&A) by healthcare providers of women during childbirth in health facilities in Tanzania, and to clarify the factors related to D&A. METHODS: A cross-sectional survey was conducted in public health facilities of three regions in Tanzania from September 2016 to October 2016. Nurses and midwives who had ever conducted deliveries completed a 22-item section about D&A and three sections about working conditions and environment. A model for predicting D&A based on several factors such as their characteristics, working conditions, and working environment was developed by conducting multiple regression analysis. RESULTS: Thirty public health facilities in three regions within Tanzania were selected to reflect different levels of hospitals. Among 456 participants (nurses, midwives, and nursing assistants), 439 were included in the analysis. Average number of self-reported D&A out of 22 items was five, and nearly all participants (96.1%) reported enacting one form of D&A at the least and two forms of D&A at the most. About 25-44% of D&A items were in the forms related to women's experiences with childbirth psychologically. Moreover, at least 10-30% of the participants enacted some form of D&A which could directly affect the well-being of mothers and babies. D&A scores increased with an increase in 'working hours per week' and 'taking a break during evening shifts'. D&A scores decreased with an increase in the scores of the 'two components of the Index of Working Satisfaction (professional status and interaction between nurses)', and 'any type of supervision for new nurse-midwives'. CONCLUSION: Most studies about D&A of healthcare providers previously focused on the reports of women. To our knowledge, this is the first report that focused on D&A reported by healthcare providers. Working conditions and systems including personal relationships with colleagues were both positively and negatively related to D&A of healthcare providers rather than the provider's individual and facility structural characteristics.

Stronger together: midwifery twinning between Tanzania and Canada.

This article describes a twinning relationship between the Canadian Association of Midwives (CAM) and the Tanzania Midwives Association (TAMA). It argues that the twinning relationship strengthened both associations. The article briefly reviews the existing literature on professional associations and association strengthening to demonstrate that professional associations are a vital tool for improving the performance of healthcare workers and increasing their capacity to contribute to national and international policy-making. It then suggests that midwifery associations are particularly significant given the frequent professional marginalization of midwives. The article then describes in depth the relationship between CAM and TAMA, highlighting the accomplishments of the twinned partners, and analyzing the factors that contributed to the success of the relationship. The findings demonstrate that twinning can successfully strengthen associations, increasing their ability to support their membership, care for the public, and shape national policy-making. The article therefore proposes twinning as a successful and cost-effective model for encouraging the growth of the midwifery profession.

Evaluation of a family-oriented antenatal group educational program in rural Tanzania: a pre-test/post-test study.

BACKGROUND: To increase births attended by skilled birth attendants in Tanzania, studies have identified the need for involvement of the whole family in pregnancy and childbirth education. This study aimed to develop, implement, and evaluate a family-oriented antenatal group educational program to promote healthy pregnancy and family involvement in rural Tanzania. METHODS: This was a quasi-experimental 1 group pre-test/post-test study with antenatal education provided to pregnant women and their families in rural Tanzania. Before and after the educational program, the pre-test/post-test study was conducted using a 34-item Birth Preparedness Questionnaire. Acceptability of the educational program was qualitatively assessed. RESULTS: One-hundred and thirty-eight participants (42 pregnant women, 96 family members) attended the educational program, answered the questionnaire, and participated in the feasibility inquiry. The mean knowledge scores significantly increased between the pre-test and the post-test, 7.92 and 8.33, respectively (p = 0.001). For both pregnant women and family members, the educational program improved Family Support (p = 0.001 and p = 0.000) and Preparation of Money and Food (p = 0.000 and p = 0.000). For family members, the scores for Birth Preparedness (p = 0.006) and Avoidance of Medical Intervention (reversed item) (p = 0.002) significantly increased. Despite the educational program, the score for Home-based Value (reversed item) (p = 0.022) and References of SBA (p = 0.049) decreased in pregnant women. Through group discussions, favorable comments about the program and materials were received. The comments of the husbands reflected their better understanding and appreciation of their role in supporting their wives during the antenatal period. CONCLUSIONS: The family-oriented antenatal group educational program has potential to increase knowledge, birth preparedness, and awareness of the need for family support among pregnant women and their families in rural Tanzania. As the contents of the program can be taught easily by reading the picture drama, lay personnel, such as community health workers or traditional birth attendants, can use it in villages. Further development of the Birth Preparedness Questionnaire is necessary to strengthen the involved factors. A larger scale study with a more robust Birth Preparedness Questionnaire and documentation of skilled care use is needed for the next step. TRIAL REGISTRATION: No.2013-273-NA-2013-101 . Registered 12 August 2013.

Midwives' respect and disrespect of women during facility-based childbirth in urban Tanzania: a qualitative study.

BACKGROUND: Over the last two decades, facility-based childbirths in Tanzania have only minimally increased by 10% partly because of healthcare providers' disrespect and abuse (D&A) of women during childbirth. Although numerous studies have substantiated women's experience of D&A during childbirth by healthcare providers, few have focused on how D&A occurred during the midwives' actual care. This study aimed to describe from actual observations the respectful and disrespectful care received by women from midwives during their labor period in two hospitals in urban Tanzania. METHODS: This descriptive qualitative study involved naturalistic observation of two health facilities in urban Tanzania. Fourteen midwives were purposively recruited for the one-on-one shadowing of their care of 24 women in labor from admission to the fourth stage of labor. Observations of their midwifery care were analyzed using content analysis. RESULTS: All the 14 midwives showed both respectful and disrespectful care and some practices that have not been explicated in previous reports of women's experiences. For respectful care, five categories were identified: 1) positive interactions between midwives and women, 2) respect for women's privacy, 3) provision of safe and timely midwifery care for delivery, 4) active engagement in women's labor process, and 5) encouragement of the mother-baby relationship. For disrespectful care, five categories were recognized: 1) physical abuse, 2) psychological abuse, 3) non-confidential care, 4) non-consented care, and 5) abandonment of care. Two additional categories emerged from the unprioritized and disorganized nursing and midwifery management: 1) lack of accountability and 2) unethical clinical practices. CONCLUSIONS: Both respectful care and disrespectful care of midwives were observed in the two health facilities in urban Tanzania. Several types of physical and psychological abuse that have not been reported were observed. Weak nursing and midwifery management was found to be a contributor to the D&A of women. To promote respectful care of women, pre-service and in-service trainings, improvement of working conditions and environment, empowering pregnant women, and strengthening health policies are crucial.

Evaluating the effect of the Helping Mothers Survive Bleeding after Birth (HMS BAB) training in Tanzania and Uganda: study protocol for a randomised controlled trial.

BACKGROUND: Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie® birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health provider's knowledge, skills and confidence, evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. METHODS/DESIGN: In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively, with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome, which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase, which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used, taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health provider's skills, care and interventions and health system readiness. DISCUSSION: This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial, the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201604001582128 . Registered on 12 April 2016.

Perceptional gaps among women, husbands and family members about intentions for birthplace: a cross-sectional study.

OBJECTIVE:: women are more likely to give birth at a health facility when their families agree with the birthplace. However, in rural areas of Tanzania, women are often marginalized from decision-making. This study predicted birthplace intention and identified factors to reduce perceptional gaps among pregnant women, husbands and family members. METHOD:: explanatory cross-sectional survey was conducted in three villages in North Eastern Tanzania. Participants were 138 pregnant women and their families who answered the Birth Intention Questionnaire (BIQ), measuring knowledge, attitude, perceived behavioral control, subjective norms and intention for birthplace. Descriptive analysis, ANOVA, Chi-square, and multiple linear regression was used to analyze the data. RESULTS:: the regression model showed that knowledge, perceived behavioral control, and subjective norms predicted intention for birthplace (R2 = .28). While 81% of pregnant women thought their husbands were decision-makers for their birth, only 38% of husbands and 37% of family members agreed. Pregnant women had significantly lower scores on the item "I will prepare for childbirth with my family" compared with husbands (p < .01) and other family members (p < .001). CONCLUSION:: providing evidence-based birth preparation and reducing the identified perceptual gaps may enhance women's intention to deliver at health facilities. OBJETIVO:: as mulheres são mais propensas a dar à luz em um centro de saúde quando suas famílias estão de acordo com o local de nascimento. No entanto, nas áreas rurais da Tanzânia, as mulheres são muitas vezes marginalizadas do processo de decisão. Este estudo fez previsoes de intenção para o local do parto e fatores para reduzir as lacunas de percepção entre as mulheres grávidas, seus maridos e familiares identificados. MÉTODO:: estudo transversal explicativo realizado em três aldeias no nordeste da Tanzânia. Os participantes foram 138 mulheres grávidas e suas famílias que responderam ao Questionário de Intenção sobre Parto (BIQ), medindo o conhecimento, atitude, percepcão de controle comportamental, normas subjetivas e intenção para lugar de parto. Análise descritivas, ANOVA, Qui-quadrado e regressão linear múltipla foram utilizados para analisar os dados. RESULTADOS:: o modelo de regressão mostrou que o conhecimento, percepcão de controle comportamental e normas subjetivas previram intenção de lugar de parto (R2 = 0,28). Enquanto 81% das mulheres grávidas pensavam que seus maridos eram os decisores para seu parto, apenas 38% dos maridos e 37% dos membros da família concordaram. As mulheres grávidas tiveram escores significativamente mais baixos sobre o item "Vou me preparar para o parto com a minha família", em comparação com os maridos (p < 0,01) e outros membros da família (p < 0,001). CONCLUSÃO:: Proporcionar preparação para o parto baseada em evidencias e a redução das lacunas de percepção identificadas podem melhorar a intenção das mulheres para dar à luz em unidades de saúde. OBJETIVO:: las mujeres son más propensas a dar a luz en un centro de salud cuando sus familias están de acuerdo con el lugar de parto. Sin embargo, en las zonas rurales de Tanzania, las mujeres son a menudo marginadas de la toma de decisiones. Este estudio predijo la intención del lugar de parto y los factores identificados para reducir la brecha de percepción entre las mujeres embarazadas, esposos y miembros de la familia. MÉTODO:: encuesta transversal explicativa llevada a cabo en tres aldeas en el noreste de Tanzania. Los participantes fueron 138 mujeres embarazadas y sus familias, que respondieron al Cuestionario sobre Intención del Parto (BIQ), que mide el conocimiento, la actitud, percepción de control del comportamiento, las normas subjetivas y la intención de lugar de parto. Se utilizaron análisis descriptivo, ANOVA, Chi-cuadrado y regresión lineal múltiple para analizar los datos. RESULTADOS:: el modelo de regresión mostró que el conocimiento, la percepción de control del comportamiento, y las normas subjetivas predijeron la intencion del lugar de parto (R2 = 0,28). Mientras que el 81% de las mujeres embarazadas pensaba que sus maridos estaban encargados de tomar decisiones para el nacimiento, sólo el 38% de los esposos y el 37% de los miembros de la familia estuvieron de acuerdo. Las mujeres embarazadas tenían puntuaciones significativamente más bajas en el tema "Me prepararé para el parto con mi familia", en comparación con los maridos (p < 0,01) y otros miembros de la familia (p < 0,001). CONCLUSIÓN:: proporcionar la preparación al parto basada en la evidencia y reducir las brechas de percepción identificadas pueden mejorar intención de las mujeres a dar a luz en centros de salud.

Perceptional gaps among women, husbands and family members about intentions for birthplace: a cross-sectional study / Lacunas de percepção entre as mulheres, maridos e membros da família sobre intenções para local de parto: um estudo transversal / Brechas de percepción entre mujeres, maridos y familiares acerca de las intenciones de lugar del parto: un estudio transversal

ABSTRACT Objective: women are more likely to give birth at a health facility when their families agree with the birthplace. However, in rural areas of Tanzania, women are often marginalized from decision-making. This study predicted birthplace intention and identified factors to reduce perceptional gaps among pregnant women, husbands and family members. Method: explanatory cross-sectional survey was conducted in three villages in North Eastern Tanzania. Participants were 138 pregnant women and their families who answered the Birth Intention Questionnaire (BIQ), measuring knowledge, attitude, perceived behavioral control, subjective norms and intention for birthplace. Descriptive analysis, ANOVA, Chi-square, and multiple linear regression was used to analyze the data. Results: the regression model showed that knowledge, perceived behavioral control, and subjective norms predicted intention for birthplace (R2 = .28). While 81% of pregnant women thought their husbands were decision-makers for their birth, only 38% of husbands and 37% of family members agreed. Pregnant women had significantly lower scores on the item “I will prepare for childbirth with my family” compared with husbands (p < .01) and other family members (p < .001). Conclusion: providing evidence-based birth preparation and reducing the identified perceptual gaps may enhance women’s intention to deliver at health facilities.

RESUME Objetivo: as mulheres são mais propensas a dar à luz em um centro de saúde quando suas famílias estão de acordo com o local de nascimento. No entanto, nas áreas rurais da Tanzânia, as mulheres são muitas vezes marginalizadas do processo de decisão. Este estudo fez previsoes de intenção para o local do parto e fatores para reduzir as lacunas de percepção entre as mulheres grávidas, seus maridos e familiares identificados. Método: estudo transversal explicativo realizado em três aldeias no nordeste da Tanzânia. Os participantes foram 138 mulheres grávidas e suas famílias que responderam ao Questionário de Intenção sobre Parto (BIQ), medindo o conhecimento, atitude, percepcão de controle comportamental, normas subjetivas e intenção para lugar de parto. Análise descritivas, ANOVA, Qui-quadrado e regressão linear múltipla foram utilizados para analisar os dados. Resultados: o modelo de regressão mostrou que o conhecimento, percepcão de controle comportamental e normas subjetivas previram intenção de lugar de parto (R2 = 0,28). Enquanto 81% das mulheres grávidas pensavam que seus maridos eram os decisores para seu parto, apenas 38% dos maridos e 37% dos membros da família concordaram. As mulheres grávidas tiveram escores significativamente mais baixos sobre o item “Vou me preparar para o parto com a minha família”, em comparação com os maridos (p < 0,01) e outros membros da família (p < 0,001). Conclusão: Proporcionar preparação para o parto baseada em evidencias e a redução das lacunas de percepção identificadas podem melhorar a intenção das mulheres para dar à luz em unidades de saúde.

RESUMEN Objetivo: las mujeres son más propensas a dar a luz en un centro de salud cuando sus familias están de acuerdo con el lugar de parto. Sin embargo, en las zonas rurales de Tanzania, las mujeres son a menudo marginadas de la toma de decisiones. Este estudio predijo la intención del lugar de parto y los factores identificados para reducir la brecha de percepción entre las mujeres embarazadas, esposos y miembros de la familia. Método: encuesta transversal explicativa llevada a cabo en tres aldeas en el noreste de Tanzania. Los participantes fueron 138 mujeres embarazadas y sus familias, que respondieron al Cuestionario sobre Intención del Parto (BIQ), que mide el conocimiento, la actitud, percepción de control del comportamiento, las normas subjetivas y la intención de lugar de parto. Se utilizaron análisis descriptivo, ANOVA, Chi-cuadrado y regresión lineal múltiple para analizar los datos. Resultados: el modelo de regresión mostró que el conocimiento, la percepción de control del comportamiento, y las normas subjetivas predijeron la intencion del lugar de parto (R2 = 0,28). Mientras que el 81% de las mujeres embarazadas pensaba que sus maridos estaban encargados de tomar decisiones para el nacimiento, sólo el 38% de los esposos y el 37% de los miembros de la familia estuvieron de acuerdo. Las mujeres embarazadas tenían puntuaciones significativamente más bajas en el tema “Me prepararé para el parto con mi familia”, en comparación con los maridos (p < 0,01) y otros miembros de la familia (p < 0,001). Conclusión: proporcionar la preparación al parto basada en la evidencia y reducir las brechas de percepción identificadas pueden mejorar intención de las mujeres a dar a luz en centros de salud.

Healthcare providers' knowledge and practices associated with postpartum hemorrhage during facility delivery in Dar es Salaam, Tanzania.

OBJECTIVE: To investigate healthcare providers' knowledge and practices associated with prevention and management of postpartum hemorrhage (PPH) to improve care in urban settings and reduce maternal morbidity and mortality. METHODS: As part of a cross-sectional, survey-based study, providers from 14 government health facilities providing maternal delivery services in the Ilala Municipality, Dar es Salaam, Tanzania, were surveyed about PPH-related practices and knowledge in April 2015. The data were analyzed descriptively, and χ2 tests of independence were used to examine relationships between experience, facility type, and knowledge. RESULTS: Among 115 respondents, 7 (6.1%) answered all PPH knowledge questions correctly. The mean knowledge score was 63.9%±21.1%. Non-calibrated methods for estimating postpartum blood loss were common; only 62 (53.9%) respondents reported direct collection. Referral of patients for PPH-related transfer was reported by 49 (42.6%) respondents; transportation and finances were barriers to transfer. Respondents requested continued training and additional supplies to address emergencies. CONCLUSION: Healthcare providers had suboptimal knowledge of PPH risk factors, diagnosis, and causes. Strategies that provide ongoing education and equip lower-level facilities with adequate supplies might minimize PPH-related transfers. Providing prenatal women with basic delivery items (e.g. a blood collection device) and misoprostol is a viable option to ensure that essential PPH-prevention tools are available at delivery.

Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study.

BACKGROUND: In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians. METHODS: The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania's largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis. RESULTS: Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case. CONCLUSIONS: For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.

The crisis in human resources for health care and the potential of a 'retired' workforce: case study of the independent midwifery sector in Tanzania.

The human resource crisis in health care is an important obstacle to attainment of the health-related targets for the Millennium Development Goals. One suggested strategy to alleviate the strain upon government services is to encourage new forms of non-government provision. Detail on implementation and consequences is often lacking, however. This article examines one new element of non-government provision in Tanzania: small-scale independent midwifery practices. A multiple case study analysis over nine districts explored their characteristics, and the drivers and inhibitors acting upon their development since permitted by legislative change. Private midwifery practices were found concentrated in a 'new' workforce of 'later life entrepreneurs': retired, or approaching retirement, government-employed nursing officers. Provision was entirely facility-based due to regulatory requirements, with approximately 60 'maternity homes' located mainly in rural or peri-urban areas. Motivational drivers included fear of poverty, desire to maintain professional status, and an ethos of community service. However, inhibitors to success were multiple. Start-up loans were scarce, business training lacking and registration processes bureaucratic. Cost of set-up and maintenance were prohibitively high, registration required levels of construction and equipping similar to government sector dispensaries. Communities were reluctant to pay for services that they expected from government. Thus, despite offering a quality of basic maternity care comparable to that in government facilities, often in poorly-served areas, most private maternity homes were under-utilized and struggling for sustainability. Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially increase rates of skilled attendance at delivery at peripheral level. The model also extends the working life of members of a professional group at a time of shortage. However, the potential remains unrealized. Successful multiplication of this model in resource-poor communities requires more than just deregulation of private ownership. Prohibitive start-up expenses need to be reduced by less emphasis on facility-based provision. On-going financing arrangements such as micro-credit, contracting, vouchers and franchising models require consideration.