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Kidanto, Hussein L.
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Makokha-Sandell, H., Mgaya, A., Belachew, J., Litorp, H., Kidanto, H. L. & Essén, B. (2020). Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam. Sexual & Reproductive HealthCare, 25, Article ID 100533.
Åpne denne publikasjonen i ny fane eller vindu >>Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam
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2020 (engelsk)Inngår i: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 25, artikkel-id 100533Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background: Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored.

Method: During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use.

Findings: Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students.

Conclusion: This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.

sted, utgiver, år, opplag, sider
ELSEVIER IRELAND LTD, 2020
Emneord
Vacuum extraction, Caesarean section, Tanzania, Low-income setting
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-424042 (URN)10.1016/j.srhc.2020.100533 (DOI)000577442600003 ()32505920 (PubMedID)
Tilgjengelig fra: 2020-11-02 Laget: 2020-11-02 Sist oppdatert: 2020-11-02bibliografisk kontrollert
Mgaya, A. H., Kidanto, H. L., Nystrom, L. & Essén, B. (2019). Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting. International Journal of Gynecology & Obstetrics, 144(2), 199-209
Åpne denne publikasjonen i ny fane eller vindu >>Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting
2019 (engelsk)Inngår i: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 144, nr 2, s. 199-209Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objective: To evaluate the impact of a criteria-based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes.

Methods: A cross-sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013-November 2013 and July 2015-June 2016). Outcomes of fetal distress (baseline CBA, n=248; re-audit, n=251) and obstructed labor (baseline CBA, n=260; re-audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification.

Results: Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09-0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02-1.63) and non-referred (OR 2.78, 95% CI 1.98-3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56-0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25-0.39), and non-referred preterm pregnancies (OR 0.26, 95% CI 0.18-0.36).

Conclusion: Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

Emneord
Cesarean delivery, Criteria-based audit, Fetal distress, Low-resource setting, Obstructed labor, Robson classification
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-374421 (URN)10.1002/ijgo.12726 (DOI)000454953100012 ()30499099 (PubMedID)
Forskningsfinansiär
Swedish Research Council
Tilgjengelig fra: 2019-01-29 Laget: 2019-01-29 Sist oppdatert: 2020-07-13bibliografisk kontrollert
Kamala, B. A., Mgaya, A. H., Ngarina, M. M. & Kidanto, H. L. (2018). Predictors of low birth weight and 24-hour perinatal outcomes at Muhimbili National Hospital in Dar es Salaam, Tanzania: a five-year retrospective analysis of obstetric records. Pan African Medical Journal, 29, Article ID 220.
Åpne denne publikasjonen i ny fane eller vindu >>Predictors of low birth weight and 24-hour perinatal outcomes at Muhimbili National Hospital in Dar es Salaam, Tanzania: a five-year retrospective analysis of obstetric records
2018 (engelsk)Inngår i: Pan African Medical Journal, E-ISSN 1937-8688, Vol. 29, artikkel-id 220Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Introduction: the global prevalence of low birth weight (LBW) is 16%, representing more than 20 million infants worldwide, of which 96% are born in low-income countries. This study aimed to determine the prevalence, predictors and perinatal outcomes of LBW newborns.

Methods: we conducted a retrospective analysis of data obtained from the hospital's obstetric and neonatal database. Descriptive statistics and multivariate logistic regression were performed with 95% confidence intervals (CI).

Results: the prevalence of LBW was 21% (n = 8,011) and two-thirds of these were delivered at term. Seven percent of newborns were stillbirths and 2% died within 24hrs after birth. Logistic regression revealed that primigravida and grand multiparity were associated with LBW (OR: 1.25, 95%CI: 1.15-1.37; and OR: 1.21, 95%CI: 1.01-1.25, respectively). Having <4 antenatal care (ANC) visits was associated with increased odds of LBW (OR: 1.74, 95%CI: 1.59-1.87). Regression models revealed an independent association between LBW and increased odds of stillbirths (OR = 7.20, 95%CI 6.71-7.90), low Apgar score (OR = 3.42, 95%CI: 3.12-3.76) and early neonatal deaths (OR = 1.82, 95%CI: 1.51-2.19).

Conclusion: the prevalence of LBW was high and was associated with extreme maternal age groups, grand multiparity, low maternal education, low number of ANC visits and obstetrics risks factors and complications. Both LBW and prematurity were independently associated with poor perinatal outcome. Future interventions should focus on improving the quality of ANC and integrating peripartum emergency obstetric and neonatal care.

Emneord
Low-birth-weight, perinatal outcomes, intra-uterine growth restriction
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-356099 (URN)10.11604/pamj.2018.29.220.15247 (DOI)000431602600002 ()
Tilgjengelig fra: 2018-07-19 Laget: 2018-07-19 Sist oppdatert: 2023-07-07bibliografisk kontrollert
Åhman, A., Edvardsson, K., Kidanto, H. L., Ngarina, M., Small, R. & Mogren, I. (2018). 'Without ultrasound you can't reach the best decision': Midwives' experiences and views of the role of ultrasound in maternity care in Dar Es Salaam, Tanzania. Sexual & Reproductive HealthCare, 15, 28-34
Åpne denne publikasjonen i ny fane eller vindu >>'Without ultrasound you can't reach the best decision': Midwives' experiences and views of the role of ultrasound in maternity care in Dar Es Salaam, Tanzania
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2018 (engelsk)Inngår i: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 15, s. 28-34Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objective: To explore Tanzanian midwives' experiences and views of the role of obstetric ultrasound in relation to clinical management of pregnancy, and in situations where maternal and fetal health interests conflict.

Method: In 2015, five focus group discussions were conducted with midwives (N = 31) at three public referral hospitals in the Dar es Salaam region as part of the CROss Country Ultrasound Study (CROCUS).

Results: Ultrasound was described as decisive for proper management of pregnancy complications. Midwives noted an increasing interest in ultrasound among pregnant women. However, concerns were expressed about the lack of ultrasound equipment and staff capable of skilful operation. Further, counselling regarding medical management was perceived as difficult due to low levels of education among pregnant women.

Conclusion: Ultrasound has an important role in management of pregnancy complications. However, lack of equipment and shortage of skilled healthcare professionals seem to hamper use of obstetric ultrasound in this particular low-resource setting. Increased availability of obstetric ultrasound seems warranted, but further investments need to be balanced with advanced clinical skills' training as barriers, including power outages and lack of functioning equipment, are likely to continue to limit the provision of pregnancy ultrasound in this setting.

sted, utgiver, år, opplag, sider
ELSEVIER IRELAND LTD, 2018
Emneord
Pregnancy, Obstetric ultrasound, Prenatal diagnosis, Tanzania, Midwives, Qualitative study
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-348099 (URN)10.1016/j.srhc.2017.11.007 (DOI)000424721100006 ()29389498 (PubMedID)
Forskningsfinansiär
Västerbotten County CouncilSwedish Research CouncilForte, Swedish Research Council for Health, Working Life and Welfare
Tilgjengelig fra: 2018-04-11 Laget: 2018-04-11 Sist oppdatert: 2018-04-11bibliografisk kontrollert
Misaeli, C. G., Kamala, B. A., Mgaya, A. & Kidanto, H. L. (2017). Factors associated with women's intention to request caesarean delivery in Dar es Salaam, Tanzania. Sajog-South African Journal Of Obstetrics And Gynaecology, 23(2), 56-62
Åpne denne publikasjonen i ny fane eller vindu >>Factors associated with women's intention to request caesarean delivery in Dar es Salaam, Tanzania
2017 (engelsk)Inngår i: Sajog-South African Journal Of Obstetrics And Gynaecology, ISSN 0038-2329, Vol. 23, nr 2, s. 56-62Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background. In the past decade, the rate of caesarean section (CS) has increased dramatically in many parts of the world. At Muhimbili National Hospital (MNH) there has been a dramatic rise in the caesarean section rate over the past decade.

Objective. To determine the incidence of maternal request for CS and factors associated with intention to request caesarean section at the MNH antenatal clinic.

Methods. We conducted a cross-sectional study from August to October 2014. A structured questionnaire gathered participants' background and obstetric information, perceptions and opinions regarding a request for caesarean section, and the respective reasons for the request. Confidence intervals were calculated and a p-value <0.05 was considered significant.

Results. The incidence of CS on maternal request was about 6%. The intention to request for CS in the index pregnancy was 8%. Higher-level education and formal-sector employment had higher odds for requesting CS (p=0.01 and p=0.05, respectively). Half of the participants agreed that maternal request for CS should be allowed; more private patients agreed that it could affect the doctor-patient relationship (p=0.02); more private patients agreed that request for CS was due to fear of losing a child (p=0.03). Previous history of CS was an independent predictor of maternal request for caesarean section (OR 1.7; 95% CI 1.7-15.4) and (OR 5.8; 95% CI 1.6-20.1), respectively.

Conclusion. Maternal requests for CS exist at the national referral hospital in Tanzania. This was associated with factors other than women's preferences, including perceived fear of child loss and events associated with previous CS.

Emneord
Caesarean section, intent to request, predictors
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-335747 (URN)10.7196/SAJOG.2017.v23i2.1158 (DOI)000410852700006 ()
Tilgjengelig fra: 2017-12-08 Laget: 2017-12-08 Sist oppdatert: 2017-12-08bibliografisk kontrollert
Mgaya, A., Hinju, J. & Kidanto, H. L. (2017). Is time of birth a predictor of adverse perinatal outcome?: A hospital-based cross-sectional study in a low-resource setting, Tanzania. BMC Pregnancy and Childbirth, 17, Article ID 184.
Åpne denne publikasjonen i ny fane eller vindu >>Is time of birth a predictor of adverse perinatal outcome?: A hospital-based cross-sectional study in a low-resource setting, Tanzania
2017 (engelsk)Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, artikkel-id 184Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background: Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods: A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients' socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results: Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50-1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45-0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07-2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07-2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31-2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3-2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7-8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1-2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02-2.6, p = 0.004, for abnormal breech deliveries). Conclusion: Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

Emneord
Perinatal outcome, Time of birth, Quality of care, Low-resource setting
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-327374 (URN)10.1186/s12884-017-1358-9 (DOI)000403082900003 ()28606111 (PubMedID)
Tilgjengelig fra: 2017-08-10 Laget: 2017-08-10 Sist oppdatert: 2017-11-29bibliografisk kontrollert
Kamala, B., Mgaya, A., Ngarina, M. & Kidanto, H. L. (2017). Predictors of low birthweight and 24-hour survival rate at Muhimbili National Hospital in Dar es Salaam: A 5-year retrospective analysis of obstetric records. British Journal of Obstetrics and Gynecology, 124, 20-20
Åpne denne publikasjonen i ny fane eller vindu >>Predictors of low birthweight and 24-hour survival rate at Muhimbili National Hospital in Dar es Salaam: A 5-year retrospective analysis of obstetric records
2017 (engelsk)Inngår i: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 124, s. 20-20Artikkel i tidsskrift, Meeting abstract (Annet vitenskapelig) Published
sted, utgiver, år, opplag, sider
John Wiley & Sons, 2017
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-377544 (URN)000418193700035 ()
Tilgjengelig fra: 2019-02-21 Laget: 2019-02-21 Sist oppdatert: 2019-02-21bibliografisk kontrollert
Mgaya, A., Kidanto, H. L., Nystrom, L. & Essén, B. (2016). Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania. PLOS ONE, 11(11), Article ID e0166619.
Åpne denne publikasjonen i ny fane eller vindu >>Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
2016 (engelsk)Inngår i: PLOS ONE, E-ISSN 1932-6203, Vol. 11, nr 11, artikkel-id e0166619Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-312977 (URN)10.1371/journal.pone.0166619 (DOI)000389472400035 ()27893765 (PubMedID)
Merknad

Contributed equally to this work with: Andrew H. Mgaya, Hussein L. Kidanto, Lennarth Nystrom, Birgitta Essén

Tilgjengelig fra: 2017-02-10 Laget: 2017-02-10 Sist oppdatert: 2021-06-14bibliografisk kontrollert
Litorp, H., Rööst, M., Kidanto, H. L., Nyström, L. & Essén, B. (2016). The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania. International Journal of Gynecology & Obstetrics, 133(2), 183-187
Åpne denne publikasjonen i ny fane eller vindu >>The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania
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2016 (engelsk)Inngår i: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 133, nr 2, s. 183-187Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objective: To investigate if multiparous individuals who had undergone a previous cesarean delivery experienced an increased risk of severe maternal outcomes or adverse perinatal outcomes compared with multiparous individuals who had undergone previous vaginal deliveries. Methods: An analytical cross-sectional study at a university hospital in Dar es Salaam, Tanzania, enrolled multiparous participants of at least 28 weeks of pregnancy between February 1 and June 30, 2012. Data were collected from patients' medical records and the hospital's obstetric database. Odds ratios (OR) and 95% confidence intervals (Cl) were calculated to compare outcomes among patients who had or had not undergone previous cesarean deliveries. Results: A total of 2478 patients were enrolled. A previous cesarean delivery resulted in no increase in the risk of severe maternal outcomes (OR0.86, 95% CI 0.58-1.26; P = 0.46), and decreased risk of stillbirth (OR 0.42, 95% CI 0.29-0.62, P < 0.001), and intrapartum stillbirth and neonatal distress (OR 0.58, 95% CI 038-0.87, P = 0.007). Conclusion: Previous cesarean delivery was not a risk factor for severe maternal outcomes or adverse perinatal outcomes. The present study was conducted at a referral institution, where individuals with previous cesarean deliveries may constitute a healthy group. Additionally, there could be differences between the study groups in terms of healthcare-seeking behavior, referral mechanisms, intrapartum monitoring, and clinical decision making.

Emneord
Cesarean section, Low-income countries, Maternal near-miss, Previous scar, Tanzania
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-298233 (URN)10.1016/j.ijgo.2015.10.009 (DOI)000375739500012 ()26868073 (PubMedID)
Forskningsfinansiär
Swedish Society for Medical Research (SSMF)
Tilgjengelig fra: 2016-07-01 Laget: 2016-07-01 Sist oppdatert: 2017-11-28bibliografisk kontrollert
Litorp, H., Mgaya, A., Mbekenga, C. K., Kidanto, H. L., Johnsdotter, S. & Essén, B. (2015). Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting. Social Science and Medicine, 143, 232-240
Åpne denne publikasjonen i ny fane eller vindu >>Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
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2015 (engelsk)Inngår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, s. 232-240Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

Emneord
Tanzania; Caesarean section; Low-resource setting; Attitudes; Caregivers; Transparency
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-238477 (URN)10.1016/j.socscimed.2015.09.003 (DOI)000364245600027 ()26364010 (PubMedID)
Forskningsfinansiär
Swedish Research Council
Tilgjengelig fra: 2014-12-15 Laget: 2014-12-12 Sist oppdatert: 2017-12-05bibliografisk kontrollert
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