Background
Methods
Study design and setting
Informants and data collection
Woman | Age (years) | Marital status | Years in school | Duration with Fistula | Domicile |
---|---|---|---|---|---|
1 | 19 | Single | 7 | 4 months | Morogoro |
2 | 25 | Married | 3 | >1 year | Tanga |
3 | 35 | Single | 7 | 18 years | Kilwa |
4 | 20 | Divorced | 7 | 6 months | Pwani |
5 | 28 | Married | 12 | 2 months | Dar es Salaam |
6 | 30 | Married | 12 | 3 months | Iringa |
7 | 33 | Divorced | 7 | 19 years | Morogoro |
8 | 29 | Divorced | 0 | 10 years | Morogoro |
9 | 35 | Married | 7 | 2 years | Singida |
10 | 40 | Married | 7 | 1 year | Dodoma |
11 | 43 | Separated | 7 | 20 years | Dodoma |
12 | 40 | Single | 7 | 20 years | Singida |
13 | 25 | Divorced | 7 | 8 months | Iringa |
14 | 28 | Divorced | 7 | 12 years | Dodoma |
15 | 29 | Divorced | 0 | 9 years | Dodoma |
16 | 18 | Single | 0 | 3 months | Dodoma |
Semi-structured interviews
Focus group discussion
Data analysis
Codes | Themes | Relevant quotes |
---|---|---|
Pushed without instruction | Missing attention, care, and support | I arrived at the hospital at midnight, but the way I was received was not good. When I walked into the hospital, the labour pains started getting stronger, but nurses did not receive me well.… They told me I should wait for the doctor to come. (Woman 6) |
Bad reception | …you find a woman has been in labour for a long time, but they are relaxed in their offices, providing no assistance. (Husbands’ FGD) | |
Asked to wait | ||
No assistance | ||
Did not check anything on me | There [at the health facility], a woman in labour was calling for help. Nurses were sitting in the office; the woman’s mother and I were sitting outside. Her mother was complaining to the nurse....Why can’t you help my daughter who has been crying for help for a long time? They responded by saying behind the closed door, “Go and help her yourself.” (Community members’ FGD) | |
Sitting in the office chatting | ||
No care | ||
I was alone throughout labour | ||
No help | ||
I was alone and nurses were there but they did not help me..... (Woman 6) | ||
No examination | ||
I stayed for a long time, and each time I called for help the nurse would tell me to lie on my side. (Woman 7) | ||
A young woman pushed without any instructions; she called the midwives for help [but] they did not pay attention. Then the young woman got tired, [and] the baby died in the womb. (Community members’ FGD) | ||
Left alone throughout the night | … they did nothing; they did not check anything on me. I was alone throughout the night; there was no doctor. (Woman 3) | |
I was not assisted in any way; I just pushed on my own. (Woman 7) | ||
They did not do any examination until the third day, when the doctor came in the afternoon. Thereafter, the doctor told me that the foetus had died in the womb. (Woman 1) | ||
I was alone throughout the night; there was no doctor. (Woman 3) | ||
Stayed for long time | ||
Crying for help for a long time | ||
Did nothing on me | ||
They did nothing | ||
Pushed on my own did not pay attention | ||
Push without instruction | ||
Not assisted in any way | ||
No doctor |
Ethical consideration
Results
Users’ experiences | Providers’ experiences |
---|---|
1. Missing necessary services | 1. Lacking supportive supervision and supplies |
2. Missing attention, support and care | 2. Lacking motivation to work effectively |
3. Experiencing physical and verbal abuse |
User perspectives
Missing necessary services
I was alone and nurses were there but they did not help me (…). The following morning at 7am while in the labour ward, I heard the voice of my neighbour at home, I asked her to come in. When she saw the state I was in, she called the doctor, and that is when the services started, until operation (Woman 6).
(…) there are traditional birth attendants (TBAs) who have been trained, why are they not helping in dispensaries? Particularly, when there are many women in labour? These women have been trained, they have acquired skills. They could team up with nurses to help women during labour. They could do just the way they do with elders (jurors) in courts. These TBAs could be given allowances, while nurses keep their salaries; can’t you see that these TBAs will save women’s lives? (A female participant in the community FGD).
(…) When I came back from the theatre, I was told that I had severe anaemia and malaria…my father donated one unit of blood and had to sell his bicycle so that we could get cash to pay for two more units of blood (Woman 16).
Missing attention, support and care
I arrived at the hospital at midnight but the way I was received was not good. When I walked into the hospital, the labour pains started getting stronger, but nurses did not receive me well. When I showed them my clinic card, they complained that I was living nearby (Iringa road) and why did I come to hospital at midnight. They said this was the behaviour of women from town to delay to come to hospital because they know the hospital is near. They told me I should wait for the doctor to come because they had already seen my clinic card (Woman 6).
(…) my wife started labour at 2am, we arrived in hospital at 9am. However, until 3pm, we saw nobody. Could you really say that this ward has health care providers? (…) From 9am until 3pm. (…) by our own effort, we traced the doctor to his house; there we had to beg…while getting abusive language (…). We asked the doctor to tell us if there was no means of helping our patient, she should be discharged, so that we leave early, since it would be best to let her go and die at home rather than die in the facility because her transportation will be very costly (Husbands’ FGD).
Midwives contribute to the occurrence of fistulas (…) you find a woman has been in labour for a long time, but they are relaxed in their offices, providing no assistance (Husbands’ FGD).
There (at the health facility), a woman in labour was calling for help. Nurses were sitting in the office; the woman’s mother and I were sitting outside, her mother was complaining to the nurse…why can’t you help my daughter who is crying for help for a long time? They responded by saying behind the closed door “go and help her yourself’. By then the baby was stuck in the pelvis, could not come out and eventually the baby died right there (Female participant -FGD community members).
Nurses need to be motivated, because they work under very difficult conditions. They do not do overtime which could help them earn extra money; hence, they are less motivated to work. (…) they work for long hours and in a shift, sometimes a nurse is not relieved from duty because another nurse has a problem and did not come on time. But given the nature of the job, the nurse cannot just leave patients behind, although she could be really tired and has to continue working. She otherwise could have gone home and do other income generating activities, but she cannot (…). Nurses are paid less, no incentives/allowances, no payment for extra work done, the government should really look at this (Male participant-FGD community members).
Experiencing physical and verbal abuse
A young woman pushes without any instructions, she calls the midwives for help, they do not pay attention, we were there. Then the young woman got tired, the baby dies in the womb (…). When they approached the woman, they started asking why she did not push, after which they slapped her. I had witnessed this happening to my niece, the baby was well, the mother started calling nurses to help, they never responded, they were just sitting there; later on they started beating her, instead of helping her, until the baby died, we were outside listening to all that was happening (Female participant -FGD community members).
I am afraid, some of the midwives do not practice what they were taught, and should that be the case, then, perhaps they did not get adequate training. Because whereas women are crying in pain asking for help (…) what the midwife does… does not show that she is really nursing patients… she tells the patient “… you will see, when you were making your baby I was not with you (…), keep on crying, when you die we will come to collect your dead body....” I said to myself that this is tragic (Husbands’ FGD).
(…) nurses’ actions were very unprofessional, if they adhered to what they have been trained to do, they could have been very helpful, such that when the doctor comes, he attends those with complications. Without such action, women will continue to die or get fistula in health care facilities (Male participant - FGD community members).
Provider perspectives
Lacking supportive supervision and supplies
If a woman has low haemoglobin level and requires blood transfusion (…), she will be referred to Muhimbili National Hospital (Midwife from Temeke, Dar es Salaam).
(…) the gloves we are given are not enough, so we send the message to the clinics that when women come to deliver, they should bring along cotton wool and gloves. Because if they come and there are no gloves they may not be attended (Nurse-midwife from Temeke, Dar es Salaam).
(…) listen, at this facility, things like gloves we are given only one box. Right now as you can see, there are not as many women in labour as it used to be (…). There are times when during a night shift you could deliver 40 or more babies alone (…) the gloves we are given are not enough,(…) you need to protect yourself, if you put on only one pair of glove, some blood could seep into your fingers. Therefore, if women come at least with gloves and cotton wool, even when the hospital runs out of supplies, we could still help (Nurse-midwife from Temeke, Dar es Salaam).
(…) sometimes while you are assisting one woman to deliver, you could find the other woman has delivered on her own, you may find the head is completely out. What helps is that we put on three or four pairs of gloves at once, in an effort to take care of such cases, because you may be helping one woman and you oversee another one pushing the baby, so what you do is you tie the cord of the baby and give the baby to her mom and you would remove a pair of glove and fast you go help that woman (Nurse-midwife from Temeke Dar es Salaam).
Because of the shortage, I only assess those who are seriously in need of immediate attention, and we have a signboard that we place to identify serious cases, which need close attention (Nurse-midwife from Temeke Dar es Salaam).
A mother who is hypertensive, one with a previous scar, first pregnancy, short stature, and a woman who delivered many times (multipara) (Nurse-midwife from Temeke, Dar es Salaam).
There is critical shortage of staff, for example in our dispensary, we are only two, a clinical officer and I, and we have delivery services. Therefore, sometimes we are forced to stay overnight to help women in labour. Beside I am also supposed to take care of all other units in the dispensary such as injection, antenatal care, children, and dressings. It is not easy (Nurse-midwife from Mboli village, Mpwapwa).
(…) Sometimes the ward is flooded, with some mothers sleeping on the floor. Therefore, you need to be ready and prepared all the time. You could be supporting one woman to deliver, while at the same time you see another woman pushing. Therefore, what you do is to tie the cord of the baby you have just delivered, quickly change gloves and fast rush to the next woman to assist her deliver…and the cycle continues (Nurse-midwife from Temeke Dar es Salaam).
You know, sometimes you need to slap them as a way of forcing them to push the baby! You know in our hospital if you deliver a stillbirth or you get a maternal death …mmh is “kasheshe” (you will be in big trouble) you will be required by administrators to write a statement of what happened and you could even lose a job. Therefore, to avoid all this you need to try to assist women give birth safely (Nurse-midwife from Mpwapwa district).
Lacking motivation to work effectively
(…) you know, it is very important to show appreciation and encourage people…even by just calling them and acknowledging the work they do, it gives courage and it helps (…) (Nurse-midwife from Temeke Dar es Salaam).Another midwife said:Truly, we are working hard and in a difficult situation (…), at least we could have been motivated, you understand (…). For example after a night shift, in the morning when you meet your ‘in charge’, if she could simply say, “ooh you have done a good job”, it encourages, and makes you feel that your work is being appreciated (Nurse-midwife from Temeke, Dar es Salaam).