Stillbirth mortality by Robson ten-group classification system: A cross-sectional registry of 80 663 births from 16 hospital in sub-Saharan Africa.

OBJECTIVE: To assess stillbirth mortality by Robson ten-group classification and the usefulness of this approach for understanding trends. DESIGN: Cross-sectional study. SETTING: Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda. POPULATION: All women aged 13-49 years who gave birth to a live or stillborn baby weighting >1000 g between July 2021 and December 2022. METHODS: We compared stillbirth risk by Robson ten-group classification, and across countries, and calculated proportional contributions to mortality. MAIN OUTCOME MEASURES: Stillbirth mortality, defined as antepartum and intrapartum stillbirths. RESULTS: We included 80 663 babies born to 78 085 women; 3107 were stillborn. Stillbirth mortality by country were: 7.3% (Benin), 1.9% (Malawi), 1.6% (Tanzania) and 4.9% (Uganda). The largest contributor to stillbirths was Robson group 10 (preterm birth, 28.2%) followed by Robson group 3 (multipara with cephalic term singleton in spontaneous labour, 25.0%). The risk of dying was highest in births complicated by malpresentations, such as nullipara breech (11.0%), multipara breech (16.7%) and transverse/oblique lie (17.9%). CONCLUSIONS: Our findings indicate that group 10 (preterm birth) and group 3 (multipara with cephalic term singleton in spontaneous labour) each contribute to a quarter of stillbirth mortality. High mortality risk was observed in births complicated by malpresentation, such as transverse lie or breech. The high mortality share of group 3 is unexpected, demanding case-by-case investigation. The high mortality rate observed for Robson groups 6-10 hints for a need to intensify actions to improve labour management, and the categorisation may support the regular review of labour progress.

"Are all referrals necessary?" Experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania.

BACKGROUND: Intrapartum continuity of care to reduce maternal morbidity and mortality relies heavily on a functional and effective referral system between tiers of care. Capacity building of providers in managing intrapartum referrals is expected to improve the efficiency of the referral system, but this does not always work in practice. This study explored the experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania. METHODS: An exploratory qualitative study was conducted at Amana Regional Referral Hospital and Muhimbili National Hospital in Dar es Salaam. Maternity healthcare providers were purposively recruited based on cadre, working experience of more than three years in the maternity wards. An in-depth interview guide which involved questions and probes was used to conduct eleven interviews. Data was thematically analyzed. RESULTS: Three major themes emerged, namely: 1) causes of referrals are beyond medical indications; 2) limited maternity healthcare provider capability at referring facilities; and 3) limited communication between referring and receiving facilities. According to maternity healthcare professionals, referrals were seen as a way to minimize blame and a clinical management tool to prevent difficulties. They advocated for more understanding of the skill set among maternity healthcare providers, but some had negative perceptions towards performing their responsibilities. CONCLUSIONS: Skills gaps among maternity healthcare providers at referring hospitals influenced referral decision-making and service provision. There was hostility between referring and receiving hospitals. Capacity-strengthening strategies such as ongoing skills training and changes in attitudes toward referrals require improvements. The referring hospital should only consider referrals as a last resort after other case management has been completed.

Two Randomized Trials of Low-Dose Calcium Supplementation in Pregnancy.

BACKGROUND: The World Health Organization recommends 1500 to 2000 mg of calcium daily as supplementation, divided into three doses, for pregnant persons in populations with low dietary calcium intake in order to reduce the risk of preeclampsia. The complexity of the dosing scheme, however, has led to implementation barriers. METHODS: We conducted two independent randomized trials of calcium supplementation, in India and Tanzania, to assess the noninferiority of a 500-mg daily dose to a 1500-mg daily dose of calcium supplementation. In each trial, the two primary outcomes were preeclampsia and preterm birth, and the noninferiority margins for the relative risks were 1.54 and 1.16, respectively. RESULTS: A total of 11,000 nulliparous pregnant women were included in each trial. The cumulative incidence of preeclampsia was 3.0% in the 500-mg group and 3.6% in the 1500-mg group in the India trial (relative risk, 0.84; 95% confidence interval [CI], 0.68 to 1.03) and 3.0% and 2.7%, respectively, in the Tanzania trial (relative risk, 1.10; 95% CI, 0.88 to 1.36) - findings consistent with the noninferiority of the lower dose in both trials. The percentage of live births that were preterm was 11.4% in the 500-mg group and 12.8% in the 1500-mg group in the India trial (relative risk, 0.89; 95% CI, 0.80 to 0.98), which was within the noninferiority margin of 1.16; in the Tanzania trial, the respective percentages were 10.4% and 9.7% (relative risk, 1.07; 95% CI, 0.95 to 1.21), which exceeded the noninferiority margin. CONCLUSIONS: In these two trials, low-dose calcium supplementation was noninferior to high-dose calcium supplementation with respect to the risk of preeclampsia. It was noninferior with respect to the risk of preterm live birth in the trial in India but not in the trial in Tanzania. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov number, NCT03350516; Clinical Trials Registry-India number, CTRI/2018/02/012119; and Tanzania Medicines and Medical Devices Authority Trials Registry number, TFDA0018/CTR/0010/5).

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data.

INTRODUCTION: Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity. METHODS: Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators. RESULTS: This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda. DISCUSSION: Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Facilitators and barriers of implementation of routine postnatal care guidelines for women: A systematic scoping review using critical interpretive synthesis.

Background: Postnatal care (PNC) has the potential to prevent a substantial burden of maternal and newborn morbidity and mortality. This scoping review aimed to identify and synthesise themes related to facilitators and barriers of implementation of guidelines on routine PNC for women (postpartum care) in all settings. Methods: This is a scoping review guided by the standard principles of Arksey & O'Malley's framework. We used the critical interpretive synthesis method to synthesise the whole body of evidence. We searched four databases (Medline, Embase, Global Health, CINAHL Plus) using a combination of search terms comprising four key concepts: postnatal care, routine care, guidelines and implementation. No restrictions on country or language of publication were applied. We excluded studies not presenting findings about PNC for women. We thematically charted the themes of studies included based on title and abstract screening. All studies included after full text screening were described and their results synthesised using the socio-ecological model framework. We did not conduct a risk of bias analysis or quality assessment of included studies. Results: We identified a total of 8692 unique records and included 43 studies which identified facilitators and barriers to implementing routine guidelines in provision of PNC to women. Three quarters of studies pertained to PNC provision in high-income countries. Specific facilitators and barriers were identified and thematically presented based on whether they affect the provision of PNC or the intersection between provision of PNC and its use by women and families. We applied a critical global health lens to synthesise three constructs in the literature: finding a balance between standardisation and individualisation of PNC, the fragmented PNC provision landscape complicating the experiences of women with intersecting vulnerabilities, and the heavy reliance on the short postpartum period as an opportunity to educate and retain women and newborns in the health system. Conclusions: This interpretive synthesis of evidence shows that the fragmented and narrow nature of PNC provision presents specific challenges to developing, adapting and implementing routine PNC guidelines. This results in a lack of linkages to social support and services, fails to address intersecting vulnerabilities and inequities among women, and negatively influences care seeking. There is a lack of evidence on how processes of individualising PNC provision can be applied in practice to support health workers in providing woman-centered PNC in various global settings. Registration: https://www.protocols.io/private/C99DA688881F11EBB4690A58A9FEAC02.

Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020.

BACKGROUND: Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland. METHODS: Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage. RESULTS: Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases. CONCLUSION: Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.

HIV burden and the global fast-track targets progress among pregnant women in Tanzania calls for intensified case finding: Analysis of 2020 antenatal clinics HIV sentinel site surveillance.

BACKGROUND: For successful HIV response, updated information on the burden and progress toward HIV elimination targets are required to guide programmatic interventions. We used data from the 2020 HIV sentinel surveillance to update on the burden and factors associated with HIV infection, HIV status awareness, and ART coverage among pregnant women in Tanzania mainland. METHODOLOGY: We conducted the surveillance in 159 antenatal clinics (ANC) from all 26 regions of Tanzania's mainland from September to December 2020. This cross-sectional study included all pregnant women (≥15 years) on their first ANC visit in the current pregnancy during the survey period. Routine HIV counselling and testing were done at the facility. A multivariable logistic regression model accounting for the survey design was used to examine factors associated with HIV infections. RESULTS: 38,783 pregnant women were enrolled (median age (IQR) = 25 (21-30) years). HIV prevalence was 5.9% (95%CI: 5.3% - 6.6%), ranging from 1.9% in the Manyara region to 16.4% in the Njombe region. Older age, lower and no education, not being in a marital union, and living in urban or semi-urban areas were associated with higher odds of HIV infection. HIV status awareness among women who tested positive was 70.9% (95% CI: 67.5%- 74.0%). ART coverage among those aware of their status was 91.6% (86.5%- 94.9%). Overall, 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for HIV knew their HIV status and were on ART. CONCLUSION: HIV is increasingly prevalent among pregnant women in Tanzania mainland especially among older, those with lower or no formal education, those outside marital union, and pregnant women living in urban and semi-urban areas. Behind the global fast-target to end HIV/ AIDS, about a third of pregnant women living with HIV initiating ANC were not on ART. Interventions to increase HIV testing and linkage to care among women of reproductive age should be intensified.

Community-based transport system in Shinyanga, Tanzania: A local innovation averting delays to access health care for maternal emergencies.

In achieving the sustainable development goal 3.1, Tanzania needs substantial investment to address the three delays which responsible for most of maternal deaths. To this end, the government of Tanzania piloted a community-based emergency transport intervention to address the second delay through m-mama program. This study examined secondary data to determine the cost-effectiveness of this intervention in comparison to the standard ambulance system alone. The m-mama program was implemented in six councils of Shinyanga region. The m-mama program data analyzed included costs of referral services using the Emergency Transportation System (EmTS) compared with the standard ambulance system. Analysis was conducted using Microsoft Excel, whose data was fed into a TreeAge Pro Healthcare 2022 model. The cost and effectiveness data were discounted at 5% to make a fair comparison between the two systems. During m-mama program implementation a total of 989 referrals were completed. Of them, 30.1% used the standard referral system using ambulance, while 69.9% used the EmTS. The Emergency transport system costed USD 170.4 per a completed referral compared to USD 472 per one complete referral using ambulance system alone. The introduction of m-mama emergency transportation system is more cost effective compared to standard ambulance system alone in the context of Shinyanga region. Scaling up of similar intervention to other regions with similar context and burden of maternal mortality may save cost of otherwise normal emergency ambulance system. Through lessons learned while scaling up, the intervention may be improved and tailored to local challenges and further improve its effectiveness.

Epidemiology of syphilis infections among pregnant women in Tanzania: Analysis of the 2020 national representative sentinel surveillance.

BACKGROUND: Syphilis has detrimental effects on the health of the mother and that of both fetuses and newborns exposed in utero or at delivery. Understanding its local epidemiology is essential for policies, planning, and implementation of targeted preventive interventions. Using data from the 2020 National Sentinel Surveillance of pregnant women attending antenatal clinics (ANCs) in Tanzania we determined the prevalence and determinants of syphilis among pregnant women in Tanzania mainland. METHODOLOGY: The ANC surveillance was conducted in 159 ANC sites from all 26 regions of Tanzania's mainland from September to December 2020. It included all pregnant women 15 years and above on their first ANC visit in the current pregnancy during the survey period. Counseling for syphilis was done using standard guidelines at the ANC and testing was done using rapid SD Bioline HIV/Syphilis Duo test kits. Analysis was done using both descriptive statistics to determine the prevalence and characteristics of syphilis, whereas, logistic regressions were used to examine the independent association between syphilis and dependent variables. RESULTS: A total of 38,783 women [median age (Interquartile range (IQR)) = 25 (21-30) years] participated in the surveillance. Of them, 582 (1.4%) tested positive for syphilis. A wide regional variation was observed with the highest burden in Kagera (4.5%) to the lowest burden in Kigoma (0.3%). The odds of syphilis infections were higher among older women and those with no formal education. Compared with primigravids, women with 1-2, those with 3-4 and those with more than four previous pregnancies had 1.8 (aOR = 1.8, 95% CI: 1.2-2.5), 2.1 (aOR = 2.1, 95% CI: 1.4-3.1) and 2.6 (aOR = 2.6, 95% CI: 1.7-3.9) higher odds of syphilis infection respectively. CONCLUSION: Syphilis is still prevalent among pregnant women in Tanzania with a wide regional disparity. Efforts to prevent new infections, screen pregnant women, and treat those infected should be strategized to include all regions and renewed emphasis on regions with high burden, and importantly among women who are multipara, with a low level of education, and advanced age.

Correction: No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women.

[This corrects the article DOI: 10.1371/journal.pgph.0000345.].

Community perceptions and experiences on the events leading to facility maternal death; a verbal autopsy qualitative study.

BACKGROUND: Tanzania Maternal Death Surveillance and Response (MDSR) system introduced in 2015 emphasizes review of facility maternal deaths with little community involvement. Involving the community in deaths enquiry can help to make better strategies to prevent future deaths. We aimed to explore family members (caregivers) perceptions and experiences on the events leading to facility maternal deaths to inform future community involvement in MDSR. METHODS: Narrative interviews were conducted with 20 caregivers who cared for women who died in childbirth to investigate into delays and health care seeking experience. The unstructured questions on perceptions and experiences of events leading to death were administered together with standard verbal autopsy questionnaire. Two regions, Lindi and Mtwara of Southern Tanzania were selected for the study in 2018. Narrative thematic analysis was used for data analysis. RESULTS: Three main themes evolved: 'Prepared for birth but not ready for complications', 'Disconnect between caregivers and providers' and 'The bitter impact of maternal deaths. Caregivers made efforts to prepare for birth but their preparation were severely inadequate when complications that necessitated referral occurred. Decision to seek care was made jointly between the pregnant woman, husband and other family members. Caregivers tried with little success in communicating with heathcare providers regarding their admitted patients. They also experienced emotions of grief such as denial, anger, depression, bargaining and acceptance once maternal deaths occurred. Caregivers (mostly old women) were left with the burden of caring for the newborns and other children left by the deceased mother. CONCLUSION: Caregivers' perceptions and experiences of maternal deaths events provide valuable information for community interventions on birth preparedness, decision making, communication and providers' accountability. Maternal deaths bring far reaching mental, social and economic consequences to the family and society.

Associations of Diet Quality, Socioeconomic Factors, and Nutritional Status with Gestational Weight Gain among Pregnant Women in Dar es Salaam, Tanzania.

Background: Gestational weight gain (GWG) is a modifiable factor associated with maternal and child health outcomes, but the relationship between diet quality and GWG has not been evaluated using metrics validated for low-income and middle-income countries (LMICs). Objective: This study aimed to investigate relationships between diet quality, socioeconomic characteristics, and GWG adequacy using the novel Global Diet Quality Score (GDQS), the first diet quality indicator validated for use across LMIC. Methods: Weights of pregnant women enrolled between 12 and 27 wk of gestation (N = 7577) were recorded in Dar es Salaam, Tanzania, from 2001 to 2005 during a prenatal micronutrient supplementation trial. GWG adequacy was the ratio of measured GWG to Institute of Medicine-recommended GWG, categorized into severely inadequate (<70%), inadequate (70 to <90%), adequate (90 to <125%), or excessive (≥125%). Dietary data were collected using 24-h recalls. Multinomial logit models were used to estimate relationships between GDQS tercile, macronutrient intake, nutritional status, and socioeconomic characteristics and GWG. Results: GDQS scores in the second [relative risk (RR): 0.82; 95% confidence interval (CI): 0.70, 0.97] tercile were associated with lower risk of inadequate weight gain than those in the first tercile. Increased protein intake was associated with higher risk of severely inadequate GWG (RR: 1.06; 95% CI: 1.02, 1.09). Nutritional status and socioeconomic factors were associated with GWG: underweight prepregnancy BMI (in kg/m2) with a higher risk of severely inadequate GWG (RR: 1.49; 95% CI: 1.12, 1.99), overweight or obese BMI with a higher risk of excessive GWG (RR: 6.80; 95% CI: 5.34, 8.66), and a higher education (RR: 0.61; 95% CI: 0.42, 0.89), wealth (RR: 0.68; 95% CI: 0.48, 0.80), and height (RR: 0.96; 95% CI: 0.95, 0.98) with a lower risk of severely inadequate GWG. Conclusions: Dietary indicators showed few associations with GWG. However, stronger relationships were revealed between GWG, nutritional status, and several socioeconomic factors.This trial was registered at clinicaltrials.gov as NCT00197548.

Neonatal and perinatal mortality in the urban continuum: a geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania.

INTRODUCTION: Recent studies suggest that the urban advantage of lower neonatal mortality in urban compared with rural areas may be reversing, but methodological challenges include misclassification of neonatal deaths and stillbirths, and oversimplification of the variation in urban environments. We address these challenges and assess the association between urban residence and neonatal/perinatal mortality in Tanzania. METHODS: The Tanzania Demographic and Health Survey (DHS) 2015-2016 was used to assess birth outcomes for 8915 pregnancies among 6156 women of reproductive age, by urban or rural categorisation in the DHS and based on satellite imagery. The coordinates of 527 DHS clusters were spatially overlaid with the 2015 Global Human Settlement Layer, showing the degree of urbanisation based on built environment and population density. A three-category urbanicity measure (core urban, semi-urban and rural) was defined and compared with the binary DHS measure. Travel time to the nearest hospital was modelled using least-cost path algorithm for each cluster. Bivariate and multilevel multivariable logistic regression models were constructed to explore associations between urbanicity and neonatal/perinatal deaths. RESULTS: Both neonatal and perinatal mortality rates were highest in core urban and lowest in rural clusters. Bivariate models showed higher odds of neonatal death (OR=1.85; 95% CI 1.12 to 3.08) and perinatal death (OR=1.60; 95% CI 1.12 to 2.30) in core urban compared with rural clusters. In multivariable models, these associations had the same direction and size, but were no longer statistically significant. Travel time to the nearest hospital was not associated with neonatal or perinatal mortality. CONCLUSION: Addressing high rates of neonatal and perinatal mortality in densely populated urban areas is critical for Tanzania to meet national and global reduction targets. Urban populations are diverse, and certain neighbourhoods or subgroups may be disproportionately affected by poor birth outcomes. Research must capture, understand and minimise risks specific to urban settings.

Understanding maternity care providers' use of data in Southern Tanzania.

INTRODUCTION: Health information management system data is collected for national planning and evaluation but is rarely used for healthcare improvements at subnational or facility-level in low-and-middle-income countries. Research suggests that perceived data quality and lack of feedback are contributing factors. We aimed to understand maternity care providers' perceptions of data and how they use it, with a view to co-design interventions to improve data quality and use. METHODS: We based our research on constructivist grounded theory. We conducted 14 in-depth interviews, two focus group discussions with maternity care providers and 48 hours of observations in maternity wards to understand maternity providers' interaction with data in two rural hospitals in Southern Tanzania. Constant comparative data analysis was applied to develop initial and focused codes, subcategories and categories were continuously validated through peer and member checks. RESULTS: Maternity care providers found routine health information data of little use to reconcile demands from managers, the community and their challenging working environment within their daily work. They thus added informal narrative documentation sources. They created alternative narratives through data of a maternity care where mothers and babies were safeguarded. The resulting documentation system, however, led to duplication and increased systemic complexity. CONCLUSIONS: Current health information systems may not meet all data demands of maternity care providers, or other healthcare workers. Policy makers and health information system specialists need to acknowledge different ways of data use beyond health service planning, with an emphasis on healthcare providers' data needs for clinical documentation.

Fear of childbirth: validation of the Kiswahili version of Wijma delivery expectancy/experience questionnaire versions A and B in Tanzania.

BACKGROUND: Fear of childbirth is common both before and after childbirth, often leading to complications in mother and new-born. The Wijma Delivery Expectancy/Experience Questionnaires (W-DEQ) are commonly used to measure fear of childbirth among women before (version A) and after childbirth (version B). The tools are not yet validated in the Tanzanian context. This study aimed to validate the reliability, validity, and factorial structure of their Kiswahili translations. METHODS: A longitudinal study was conducted in six public health facilities in the Pwani region, Tanzania. In all, 694 pregnant and 625 postnatal women were concurrently selected and responded to W-DEQ-A and W-DEQ-B. Validation involved: translating the English questionnaires into Kiswahili; expert rating of the relevancy of the Kiswahili versions' items; computing content validity ratio; piloting the tools; data collection; statistical analysis with reliability evaluated using Cronbach's alpha and the intraclass correlation coefficient. Tool validity was assessed using factor analysis, convergent and discriminant validity. Exploratory factor analysis and confirmatory factor analysis were conducted on data collected using W-DEQ-A and W-DEQ-B, respectively. RESULTS: Exploratory factor analysis revealed seven factors contributing to 50% of the total variation. Four items did not load to any factor and were deleted. The factors identified were: fear; lack of self-efficacy; lack of positive anticipation; isolation; concerns for the baby; negative emotions; lack of positive behaviour. The factors correlated differently with each other and with the total scores. Both Kiswahili versions with 33 items had good internal consistency, with Cronbach's alphas of .83 and .85, respectively. The concerns for the baby factor showed both convergent and discriminant validity. The other six factors showed some problems with convergent validity. The final model from the confirmatory factor analysis yielded 29 items with good psychometric properties (χ2/df = 2.26, p = < .001, RMSEA = .045, CFI = .90 and TLI = .81). CONCLUSIONS: The Kiswahili W-DEQ-A-Revised and W-DEQ-B-Revised are reliable tools and measure fear of childbirth with a multifactorial structure, encompassing seven factors with 29 items. They are recommended for measuring fear of childbirth among pregnant and postnatal Tanzanian women. Further studies are needed to address the inconsistent convergent validity in the revised versions and assess the psychometric properties of W-DEQ-A among pregnant women across gestational ages.

Health workers' experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework.

BACKGROUND: In-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers' experiences of the HMS BAB training. METHODS: Our qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation. RESULTS: Overall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational. CONCLUSION: The HMS BAB training has great potential to improve health workers' competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures.

Gestational weight gain during the second and third trimesters and adverse pregnancy outcomes, results from a prospective pregnancy cohort in urban Tanzania.

BACKGROUND: Appropriate gestational weight gain (GWG) is important for optimal pregnancy outcomes. This study prospectively evaluated the associations between GWG during the second and third trimesters of pregnancy and adverse pregnancy outcomes in an urban Tanzanian pregnancy cohort. METHODS: We used data from a randomized clinical trial conducted among pregnant women recruited by 27 weeks of gestation in Dar es Salaam, Tanzania (N = 1230). Women's gestational weight was measured at baseline and at monthly antenatal visits. Weekly GWG rate during the second and third trimesters was calculated and characterized as inadequate, adequate, or excessive, in conjunction with measured or imputed early-pregnancy BMI status according to the 2009 Institute of Medicine (IOM) GWG guidelines. We used multivariable Poisson regression with a sandwich variance estimator to calculate risk ratios (RR) for associations of GWG with low birth weight, preterm birth, small for gestational age (SGA), and large for gestational age (LGA). Degree of appropriate GWG defined using additional metrics (i.e., percentage of adequacy, z-score) and potential effect modification by maternal BMI were additionally evaluated. RESULTS: According to the IOM guidelines, 517 (42.0%), 270 (22.0%), and 443 (36.0%) women were characterized as having inadequate, adequate, and excessive GWG, respectively. Overall, compared to women with adequate GWG, women with inadequate GWG had a lower risk of LGA births (RR = 0.54, 95% CI: 0.36-0.80) and a higher risk of SGA births (RR = 1.32, 95% CI: 0.95-1.81). Women with inadequate GWG as defined by percentage of GWG adequacy had a higher risk of LBW (OR = 1.93, 95% CI: 1.03-3.63). In stratified analyses by early-pregnancy BMI, excessive GWG among women with normal BMI was associated with a higher risk of preterm birth (RR = 1.59, 95% CI: 1.03-2.44). CONCLUSIONS: A comparatively high percentage of excessive GWG was observed among healthy pregnant women in Tanzania. Both inadequate and excessive GWGs were associated with elevated risks of poor pregnancy outcomes. Future studies among diverse SSA populations are warranted to confirm our findings, and clinical recommendations on optimal GWG should be developed to promote healthy GWG in SSA settings. TRIAL REGISTRATION: This trial was registered as "Prenatal Iron Supplements: Safety and Efficacy in Tanzania" (NCT01119612; http://clinicaltrials.gov/show/NCT01119612 ).

Pregnancy is a critical lifetime event for both mother and the offspring, with implications in short-term and long-term health consequences. Gestational weight gain (GWG) is an important modifiable factor for pregnancy outcomes related to infant body size and weight and prematurity. Countries in sub-Saharan Africa (SSA) have long had poor rates of insufficient GWG and pregnancy complications associated with insufficient GWG. Nevertheless, some SSA countries are experiencing economic transitions accompanied with changes in lifestyle and nutrition, which might impact pregnancy experiences, including GWG and pregnancy outcomes. This study aimed to characterize recent GWG patterns and the associations of both inadequate and excessive GWG with adverse pregnancy outcomes, using an urban pregnancy cohort in Tanzania. This study found that 42.0%. 22.0%, and 36.0% of women had insufficient, adequate, and excessive GWG, respectively. Insufficient GWG was associated with higher risks of small infant size and low infant body weight, and excessive GWG was associated with higher risk of preterm birth, particularly among women with body mass index 18.5­25.0 kg/m². Results from the present study highlight that both insufficient and excessive GWG are of potential public health concerns in urban centers of SSA, concerning upward trends in obesity and possibly obesity-related pregnancy consequences. Local public health practitioners should continue to advocate longitudinal GWG monitoring and care among African pregnant women, and optimal GWG with feasible and effective clinical guidelines should be developed to prevent both over- and under-gaining of maternal weight during pregnancy.

Tale of 22 cities: utilisation patterns and content of maternal care in large African cities.

INTRODUCTION: Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities. METHODS: We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC. RESULTS: The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%-99% and 29%-94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance. CONCLUSION: This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts.

'We are not going to shut down, because we cannot postpone pregnancy': a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic.

INTRODUCTION: Referral hospitals in sub-Saharan Africa are located in crowded urban areas, which were often epicentres of the COVID-19 pandemic. This paper prospectively assesses how maternal healthcare was provided in six referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the COVID-19 pandemic. METHODS: Mixed-methods design using three data sources: (1) qualitative data from repeated rounds of semi-structured interviews conducted between July 2020 and February 2021 with 22 maternity skilled heath personnel (SHP) on perceptions of care provision; (2) quantitative monthly routine data on caesarean section and labour induction from March 2019 to February 2021; and (3) timeline data of COVID-19 epidemiology, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on timeline analysis, and triangulated during reporting. RESULTS: We identified three periods: first wave, slow period and second wave. The first wave was challenging for SHP given little knowledge about COVID-19, lack of infection prevention and control training, and difficulties reaching workplace. Challenges that persisted beyond the first wave were shortage of personal protective equipment and no rapid testing for women suspected with COVID-19. We noted no change in the proportion of caesarean sections during the pandemic, and a small increase in the proportion of labour inductions. All hospitals arranged isolation areas for women suspected/confirmed with COVID-19 and three hospitals provided care to women with suspected/confirmed COVID-19. Breastfeeding was not discouraged and newborns were not separated from mothers confirmed with COVID-19. Care provision was maintained through dedication of SHP, support from hospital management and remote communication between SHP. CONCLUSION: Routine maternal care provision was maintained in referral hospitals, despite first wave challenges. Referral hospitals and SHP contributed to guideline development for pregnant women suspected/confirmed with COVID-19. Maternity SHP, women and pregnancy must always be included in priority setting when responding to health system shocks, including outbreaks.

Associations between Gestational Weight Gain Adequacy and Neonatal Outcomes in Tanzania.

INTRODUCTION: Gestational weight gain (GWG) is associated with fetal and newborn health; however, data from sub-Saharan Africa are limited. METHODS: We used data from a prenatal micronutrient supplementation trial among a cohort of human immunodeficiency virus-negative pregnant women in Dar es Salaam, Tanzania to estimate the relationships between GWG and neonatal outcomes. GWG adequacy was defined as the ratio of the total observed weight gain over the recommended weight gain based on the Institute of Medicine body mass index-specific guidelines. Neonatal outcomes assessed were stillbirth, perinatal death, preterm birth, low birthweight, macrosomia, small-for-gestational age (SGA), large-for-gestational age (LGA), stunting at birth, and microcephaly. Modified Poisson regressions with robust standard error were used to estimate the relative risk of newborn outcomes as a function of GWG adequacy. RESULTS: Of 7,561 women included in this study, 51% had severely inadequate (<70%) or inadequate GWG (70 to <90%), 31% had adequate GWG (90 to <125%), and 18% had excessive GWG (≥125%). Compared to adequate GWG, severely inadequate GWG was associated with a higher risk of low birthweight, SGA, stunting at birth, and microcephaly, whereas excessive GWG was associated with a higher risk of LGA and macrosomia. CONCLUSION: Interventions to support optimal GWG are needed and may contribute to preventing adverse neonatal outcomes.