Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes. PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries. FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers. KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward. IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

Faecal sludge containment characteristics and their implications on safe desludging in unplanned settlements of Dar es Salaam, Tanzania.

In unplanned urban settlements, where onsite sanitation systems are the norm, desludging of faecal sludge (FS) containments is a necessity because of the lack of land space to enable new construction. Poorly designed toilet facilities however may jeopardize the progress towards attainment of safely managed sanitation. This study examined FS characteristics and containment design and their effect on safe desludging with a case of two selected unplanned settlements of Dar es Salaam, Tanzania. The analysis focused on design features for the strength of the containment, access to the containment, and desludging characteristics of the FS. The Desludgeability potential of FS was determined on basis of flow behaviour explained in terms of moisture content and volatile solids. Research results showed that partially lined pits, lack of containment access holes and solid wastes are design and usage features which negatively affect containment strength and potential for safe desludging. The analysis further found that, only 54.8% of containments studied have FS that can be desludged by either mechanized or hand pumps. Pour flush toilets and septic tanks indicated a slightly higher potential for safe desludging compared to traditional pit latrines, however, the difference is not statistically significant (P = 0.180). Thus, safe desludging is a problem across all types of containments. To enhance safe desludging in Dar es Salaam, three key design features and usage ought to be urgently addressed: first, a requirement to ensure that all pits are fully lined inside, second, the mandatory presence of an access hole for FS desludging and third, limitations on solid waste entering the pits.