Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results.

BACKGROUND: In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed. OBJECTIVE: Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania. METHODS: A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used 'wedge sampling' protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the 'Real Accountability: Data Analysis for Results Coverage Survey to women 15-49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD. RESULTS: Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [-0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019. CONCLUSIONS: Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

The fear of social stigma experienced by men: a barrier to male involvement in antenatal care in Misungwi District, rural Tanzania.

BACKGROUND: Evidence has shown that male involvement is associated with improved maternal health outcomes. In rural Tanzania, men are the main decision makers and may determine women's access to health services and ultimately their health outcomes. Despite efforts geared towards enhancing male participation in maternal health care, their involvement in antenatal care (ANC) remains low. One barrier that impacts men's participation is the fear and experience of social stigma. This study, builds on previous findings about men's perspectives in attending antenatal care appointments in Misungwi district in Tanzania, examining more closely the fear of social stigma amongst men attending ANC together with their partners. METHODS: Twelve individual interviews and five focus group discussions were conducted using semi-structured questionnaires with fathers and expectant fathers. In-depth interviews were conducted with health providers, volunteer community health workers and village leaders. Interviews were audiotaped, and transcripts were transcribed and translated to English. Transcripts were organized in NVivo V.12 then analyzed using thematic approach. RESULTS: Three main themes were found to create fear of social stigma for men: 1. Fear of HIV testing; 2. Traditional Gender Norms and 3. Insecurity about family social and economic status. CONCLUSION: Respondent's experiences reveal that fear of social stigma is a major barrier to attend ANC services with their partners. Attention must be given to the complex sociocultural norms and social context that underly this issue at the community level. Strategies to address fear of social stigma require an understanding of the real reasons some men do not attend ANC and require community engagement of community health workers (CHWs), government officials and other stakeholders who understand the local context.

Female respondent acceptance of computer-assisted personal interviewing (CAPI) for maternal, newborn and child health coverage surveys in rural Uganda.

INTRODUCTION: High maternal and child mortality continues in low- and middle-income countries (LMIC). Measurement of maternal, newborn and child health (MNCH) coverage indicators often involves an expensive, complex, and lengthy household data collection process that is especially difficult in less-resourced settings. Computer-assisted personal interviewing (CAPI) has been proposed as a cost-effective and efficient alternative to traditional paper-and-pencil interviewing (PAPI). However, the literature on respondent-level acceptance of CAPI in LMIC has reported mixed outcomes. This is the first study to prospectively examine female respondent acceptance of CAPI and its influencing factors for MNCH data collection in rural Southwest Uganda. METHODS: Eighteen women aged 15-49 years were randomly selected from 3 rural villages to participate. Each respondent was administered a Women's Questionnaire with half of the survey questions asked using PAPI techniques and the other half using CAPI. Following this PAPI/CAPI exposure, semi-structured focus group discussions (FGDs) assessed respondent attitudes towards PAPI versus CAPI. FGD data analysis involved an immersion/crystallization method (thematic narrative analysis). RESULTS: The sixteen FGD respondents had a median age of 27 (interquartile range: 24.8, 32.3) years old. The majority (62.5%) had only primary level education. Most respondents (68.8%) owned or regularly used a mobile phone or computer. Few respondents (31.3%) had previously seen but not used a tablet computer. Overall, FGDs revealed CAPI acceptance and the factors influencing CAPI acceptability were 'familiarity', 'data confidentiality and security', 'data accuracy', and 'modernization and development'. DISCUSSION: Female survey respondents in our rural Southwest Ugandan setting found CAPI to be acceptable. Global health planners and implementers considering CAPI for health coverage survey data collection should accommodate influencing factors during survey planning in order to maximize and facilitate acceptance and support by local stakeholders and community participants. Further research is needed to generate best practices for CAPI implementation and LMIC; higher quality, timely, streamlined and budget-friendly collection of MNCH indicators could help direct and improve programming to save lives of mothers and children.

Drugs for some but not all: inequity within community health worker teams during introduction of integrated community case management.

BACKGROUND: The Ugandan health system now supports integrated community case management (iCCM) by community health workers (CHWs) to treat young children ill with fever, presumed pneumonia, and diarrhea. During an iCCM pilot intervention study in southwest Uganda, two CHWs were selected from existing village teams of two to seven CHWs, to be trained in iCCM. Therefore, some villages had both 'basic CHWs' who were trained in standard health promotion and 'iCCM CHWs' who were trained in the iCCM intervention. A qualitative study was conducted to investigate how providing training, materials, and support for iCCM to some CHWs and not others in a CHW team impacts team functioning and CHW motivation. METHODS: In 2012, iCCM was implemented in Kyabugimbi sub-county of Bushenyi District in Uganda. Following seven months of iCCM intervention, focus group discussions and key informant interviews were conducted alongside other end line tools as part of a post-iCCM intervention study. Study participants were community leaders, caregivers of young children, and the CHWs themselves ('basic' and 'iCCM'). Qualitative content analysis was used to identify prominent themes from the transcribed data. RESULTS: The five main themes observed were: motivation and self-esteem; selection, training, and tools; community perceptions and rumours; social status and equity; and cooperation and team dynamics. 'Basic CHWs' reported feeling hurt and overshadowed by 'iCCM CHWs' and reported reduced self-esteem and motivation. iCCM training and tools were perceived to be a significant advantage, which fueled feelings of segregation. CHW cooperation and team dynamics varied from area to area, although there was an overall discord amongst CHWs regarding inequity in iCCM participation. Despite this discord, reasonable personal and working relationships within teams were retained. CONCLUSIONS: Training and supporting only some CHWs within village teams unexpectedly and negatively impacted CHW motivation for 'basic CHWs', but not necessarily team functioning. A potential consequence might be reduced CHW productivity and increased attrition. CHW programmers should consider minimizing segregation when introducing new program opportunities through providing equal opportunities to participate and receive incentives, while seeking means to improve communication, CHW solidarity, and motivation.

Breastfeeding difficulties and exclusivity among late preterm and term infants: results from the all our babies study.

OBJECTIVE: To compare breastfeeding difficulties attributable to the baby and mother/milk and exclusive breastfeeding between a group of late preterm (LP) infants and term infants. METHODS: We utilized data from a prospective community-based cohort (n=2977) in Calgary, Alberta, and performed bivariate and multivariable analyses to identify demographic, obstetric, maternal and infant health indicators that were independently associated with term status and breastfeeding outcomes. RESULTS: Multivariable analyses found that LP status was an independent risk factor for breastfeeding difficulties attributable to the baby (OR 1.72, 95% CI 1.24-2.38), but not for difficulties due to mother/milk (defined as not producing enough milk or having flat or inverted nipples). Among women who were breastfeeding at hospital discharge, mothers of LP infants were less likely to report exclusive breastfeeding at 4 months (OR 0.67, 95% CI 0.46-0.97), after controlling for household income level, mode of delivery and postpartum maternal physical health. CONCLUSIONS: Mothers of LP infants need increased support to establish successful breastfeeding outcomes and to ensure that these infants receive the full benefits of breast milk.