Understanding the complexities of unexplained stillbirth in sub-Saharan Africa: a mixed-methods study.

OBJECTIVE: To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia. DESIGN: Mixed-methods study. SETTING: Tertiary, secondary and primary care facilities in Mansa, Zambia, and Mwanza, Tanzania. SAMPLE: Quantitative: 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative: 48 women and 19 partners from tertiary, secondary and primary care facilities. METHODS: Case review using data from a target of 2000 consecutive case records. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach. RESULTS: A total of 261 stillbirths were recorded, with a rate of 16% in Tanzania and 10% in Zambia, which is higher than the previous estimates of 2.24 and 2.09%, respectively, for those countries. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR 1.86, 95% CI 1.23-2.81). The cause of death was unexplained in 28% of cases. Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by the poor communication skills of health professionals, who displayed little empathy and skill when counselling bereaved families. CONCLUSIONS: The stillbirth risk in both facilities was far higher than the risk recorded from national data, with women reporting a previous stillbirth being at higher risk. Women want to know the cause of stillbirth and an exploration of appropriate investigations in this setting is required. Providing health professionals with support and continuing training is key to improving the experiences of women and future care. TWEETABLE ABSTRACT: Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.

An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool.

This paper presents the findings of a multi-centre study assessing the impact of Health Workers for Change (HWFC) workshops in seven different primary care sites, based on the common core protocol described in this paper. The paper discusses a common methodology used by the studies, consisting of a triangulation of qualitative and quantitative methods. Such methodologies are inherently complex as they require comparisons across systems, sites and procedures. The studies were conducted in six sites in Africa and one site in Argentina. Generally, the intervention resulted either in positive change or in no change, except in the area of staff relationships where conflicts were more frequent after the intervention than before. This may reflect a willingness to confront problems or contentious issues. Implementing the HWFC workshops improved provider-client relations, facility level functioning and aspects of staff interrelationships, and had some impact at the system level. All studies indicated that overall health system development is essential for improved service provision including quality of care. The findings also indicated that this intervention complemented and could assist health sector reform efforts and can play a role in sensitizing health workers to gender issues. The paper concludes with a discussion of the robustness of the methodology used in the studies.