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  • 1.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mgaya, Andrew
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mbekenga, Columba K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Malmo Univ, Fac Hlth & Soc, S-20506 Malmo, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, p. 232-240Article in journal (Refereed)
    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.

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  • 2.
    Mbekenga, Columba K
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Striving to Promote Family Health after Childbirth: Studies in Low-Income Suburbs of Dar es Salaam, Tanzania2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Deeper understanding of family health and support after childbirth from the perspective of first-time parents and their informal support network is needed. Postpartum experiences and health concerns of first-time mothers and fathers and, discourses on sexuality and informal support after childbirth were explored in low-income, suburban areas in Ilala, Dar es Salaam, Tanzania. Individual qualitative interviews with first-time mothers (n=10) and fathers (n=10), and 14 focus group discussions with first-time parents (n=40) and informal support persons (n=42) provided the data, which were analyzed through qualitative content and discourse analysis.

    First-time parents’ areas of concern were newborn care and hygiene, infant feeding, handling crying infant, maternal nutrition and hygiene, uncertain body changes for the mother and, sexuality. The mothers were burdened with caring responsibilities and fathers felt neglected and excluded from the care of the mother and infant after childbirth, both by the families and the health care system. Sexuality after childbirth created tension between new parents due to the understanding that abstinence would protect child health during the breastfeeding period, which could be several years. Women’s adherence to sexual abstinence was more emphasized compared to men’s. Men’s engagement with other sex partners and the risk of contraction HIV was a threat to family health.

    First-time parents drew on support from both informal and formal sources. Informal support networks played a major role in providing information, materials, guidance and supervision while conveying stereotypic gender norms. Contradictions in the messages to parents within and between the support systems created uncertainties that might have negative implications for family health. Poor parents and those who did not adherence to the social norms were less likely to get informal support than others were.

    There is a need for information and practical guidance on basic aspects of care for the mother and infant, male involvement, and the importance of social support to first-time parents, as new parents face physical, social and relational challenges after childbirth. The link between the health care system and informal networks need to be strengthened to enable them to complement each other in promoting family health after child health.

    List of papers
    1. Joy, struggle and support: postpartum experiences of first-time mothers in a Tanzanian suburb
    Open this publication in new window or tab >>Joy, struggle and support: postpartum experiences of first-time mothers in a Tanzanian suburb
    2011 (English)In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 24, no 1, p. 24-31Article in journal (Refereed) Published
    Abstract [en]

    The first-time mothers enjoyed motherhood and the respectful status it implied. To understand and handle the infant's needs and own bodily changes were important during postpartum. The tradition of abstaining from sex up to 4 years during breastfeeding was a concern as male's faithfulness was questioned and with HIV a threat to family health. Partner relationship changed towards shared parental and household work and the man's active participation was appreciated. Support from family members and others in the neighbourhood were utilised as a resource by the mothers. In instances of uncertainties on how to handle things, their advice was typically followed. The new mothers generally had good experiences of health care during the childbearing period. However, they also experienced insufficiencies in knowledge transfer, disrespectful behaviour, and unofficial fees. KEY CONCLUSIONS AND IMPLICATION FOR PRACTICE: The mothers' perspective of postpartum revealed that they actively searched for ways to attain infants' and own health needs, and family health in general. Prolonged sexual abstinence was considered a risk for the partner having other sexual partners and contracting HIV. The mothers relied heavily on the informal support network, which sometimes meant risking family health due to misinformation and harmful practices. Health care and informal support systems should complement each other to attain adequate support for the families postpartum.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-150899 (URN)10.1016/j.wombi.2010.06.004 (DOI)000208666500005 ()20674528 (PubMedID)
    Available from: 2011-04-07 Created: 2011-04-07 Last updated: 2017-12-11Bibliographically approved
    2. Postpartum experiences of first-time fathers in a Tanzanian suburb: A qualitative interview study
    Open this publication in new window or tab >>Postpartum experiences of first-time fathers in a Tanzanian suburb: A qualitative interview study
    2010 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 27, no 2, p. 174-180Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVES: to explore postpartum experiences of first-time fathers in a multicultural, low-income, suburban Tanzanian setting. DESIGN, SETTING AND PARTICIPANTS: individual qualitative interviews with ten first-time fathers, four to ten weeks post partum in Ilala suburb, Dar es Salaam, Tanzania. FINDINGS: these first-time fathers enjoyed fatherhood and revealed a sincere concern for the well-being of the mother and infant during the postpartum period. They described themselves as active in mother and infant care and household chores; however, they were limited by breadwinning responsibilities. The families were supported by relatives or laypersons. The mothers' and infants' nutrition had high priority but poverty was an obstacle. Timing of resumption of sex after childbirth was problematic as traditions prescribed abstinence while the woman is breast feeding. The risk of contracting HIV to the family was a concern. Reproductive and child health care often excluded fathers and gave unclear information. CONCLUSION: these new fathers struggled to gain confidence and experience while engaging in family matters during post partum. Changing gender roles in the suburban Tanzanian society in general and their personal experiences of transition to fatherhood both facilitated and made the postpartum period problematic. The health sector does not respond with respect to fathers' concerns for family health and needs for support. RECOMMENDATIONS: these findings call for programmes on gender relations, which are supporting constructive masculinities and facilitate new fathers' active participation and responsibilities in parenting, family health and their relations with their partners. Such programmes should not only target people in childbearing age but also their potential support persons. Health workers should welcome fathers and discuss strategies for good family health during post partum. Counselling couples together could facilitate their support for each other in optimising health post partum.

    Keywords
    Post partum, Fathers, Experiences, Qualitative, Interviews, Tanzania
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-129615 (URN)10.1016/j.midw.2009.03.002 (DOI)000289071200011 ()20385433 (PubMedID)
    Available from: 2010-08-19 Created: 2010-08-19 Last updated: 2022-01-28Bibliographically approved
    3. Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania
    Open this publication in new window or tab >>Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania
    Show others...
    2011 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 11, p. 98-Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND:

    In Tanzania, and many sub-Saharan African countries, postpartum health programs have received less attention compared to other maternity care programs and therefore new parents rely on informal support. Knowledge on how informal support is understood by its stakeholders to be able to improve the health in families after childbirth is required. This study aimed to explore discourses on health related informal support to first-time parents after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

    METHODS:

    Thirteen focus group discussions with first-time parents and female and male informal supporters were analysed by discourse analysis.

    RESULTS:

    The dominant discourse was that after childbirth a first time mother needed and should be provided with support for care of the infant, herself and the household work by the maternal or paternal mother or other close and extended family members. In their absence, neighbours and friends were described as reconstructing informal support. Informal support was provided conditionally, where poor socio-economic status and non-adherence to social norms risked poor support. Support to new fathers was constructed as less prominent, provided mainly by older men and focused on economy and sexual matters. The discourse conveyed stereotypic gender roles with women described as family caretakers and men as final decision-makers and financial providers. The informal supporters regulated the first-time parents' contacts with other sources of support.

    CONCLUSIONS:

    Strong and authoritative informal support networks appear to persist. However, poverty and non-adherence to social norms was understood as resulting in less support. Family health in this context would be improved by capitalising on existing informal support networks while discouraging norms promoting harmful practices and attending to the poorest. Upholding stereotypic notions of femininity and masculinity implies great burden of care for the women and delimited male involvement. Men's involvement in reproductive and child health programmes has the potential for improving family health after childbirth. The discourses conveyed contradicting messages that may be a source of worry and confusion for the new parents. Recognition, respect and raising awareness for different social actors' competencies and limitations can potentially create a health-promoting environment among families after childbirth.

    Keywords
    informal support, first-time parents, postpartum, sexuality, qualitative, Tanzania
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-150871 (URN)10.1186/1471-2393-11-98 (DOI)000298852600001 ()
    Available from: 2011-04-07 Created: 2011-04-06 Last updated: 2017-12-11Bibliographically approved
    4. Prolonged sexual abstinence after childbirth: gendered norms and perceived family health risks. Focus group discussions in a Tanzanian suburb
    Open this publication in new window or tab >>Prolonged sexual abstinence after childbirth: gendered norms and perceived family health risks. Focus group discussions in a Tanzanian suburb
    Show others...
    2013 (English)In: BMC International Health and Human Rights, E-ISSN 1472-698X, Vol. 13, no 1, p. 4-Article in journal (Refereed) Published
    Abstract [en]

    Background

    Prolonged sexual abstinence after childbirth is a socio-cultural practice with health implications, and is described in several African countries, including Tanzania. This study explored discourses on prolonged postpartum sexual abstinence in relation to family health after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

    Methods

    Data for the discourse analysis were collected through focus group discussions with first-time mothers and fathers and their support people in Ilala, Dar es Salaam, Tanzania.

    Results

    In this setting, prolonged sexual abstinence intended at promoting child health was the dominant discourse in the period after childbirth. Sexual relations after childbirth involved the control of sexuality for ensuring family health and avoiding the social implications of non-adherence to sexual abstinence norms. Both abstinence and control were emphasised more with regard to women than to men. Although the traditional discourse on prolonged sexual abstinence for protecting child health was reproduced in Ilala, some modern aspects such as the use of condoms and other contraceptives prevailed in the discussion.

    Conclusion

    Discourses on sexuality after childbirth are instrumental in reproducing gender-power inequalities, with women being subjected to more restrictions and control than men are. Thus, interventions that create openness in discussing sexual relations and health-related matters after childbirth and mitigate gendered norms suppressing women and perpetuating harmful behaviours are needed. The involvement of males in the interventions would benefit men, women, and children through improving the gender relations that promote family health.

     

    Keywords
    sexual abstinence, first-time parents, gender relations, childbirth, FGD, Tanzania
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-150869 (URN)10.1186/1472-698X-13-4 (DOI)000317465400001 ()23316932 (PubMedID)
    Available from: 2011-04-07 Created: 2011-04-06 Last updated: 2024-01-17Bibliographically approved
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  • 3.
    Mbekenga, Columba K
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Christensson, Kyllike
    Karolinska Institute, Stockholm, Sweden.
    Lugina, Helen
    Weill Bugando University College of Health Sciences, Mwanza, Tanzania.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Joy, struggle and support: postpartum experiences of first-time mothers in a Tanzanian suburb2011In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 24, no 1, p. 24-31Article in journal (Refereed)
    Abstract [en]

    The first-time mothers enjoyed motherhood and the respectful status it implied. To understand and handle the infant's needs and own bodily changes were important during postpartum. The tradition of abstaining from sex up to 4 years during breastfeeding was a concern as male's faithfulness was questioned and with HIV a threat to family health. Partner relationship changed towards shared parental and household work and the man's active participation was appreciated. Support from family members and others in the neighbourhood were utilised as a resource by the mothers. In instances of uncertainties on how to handle things, their advice was typically followed. The new mothers generally had good experiences of health care during the childbearing period. However, they also experienced insufficiencies in knowledge transfer, disrespectful behaviour, and unofficial fees. KEY CONCLUSIONS AND IMPLICATION FOR PRACTICE: The mothers' perspective of postpartum revealed that they actively searched for ways to attain infants' and own health needs, and family health in general. Prolonged sexual abstinence was considered a risk for the partner having other sexual partners and contracting HIV. The mothers relied heavily on the informal support network, which sometimes meant risking family health due to misinformation and harmful practices. Health care and informal support systems should complement each other to attain adequate support for the families postpartum.

  • 4.
    Mbekenga, Columba K
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pembe, Andrea B
    Dept of Obstetrics and Gynaecology, School of Medicine, Muhimbili, University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Christensson, Kyllike
    Karolinska Institute, Stockholm, Sweden.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania2011In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 11, p. 98-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    In Tanzania, and many sub-Saharan African countries, postpartum health programs have received less attention compared to other maternity care programs and therefore new parents rely on informal support. Knowledge on how informal support is understood by its stakeholders to be able to improve the health in families after childbirth is required. This study aimed to explore discourses on health related informal support to first-time parents after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

    METHODS:

    Thirteen focus group discussions with first-time parents and female and male informal supporters were analysed by discourse analysis.

    RESULTS:

    The dominant discourse was that after childbirth a first time mother needed and should be provided with support for care of the infant, herself and the household work by the maternal or paternal mother or other close and extended family members. In their absence, neighbours and friends were described as reconstructing informal support. Informal support was provided conditionally, where poor socio-economic status and non-adherence to social norms risked poor support. Support to new fathers was constructed as less prominent, provided mainly by older men and focused on economy and sexual matters. The discourse conveyed stereotypic gender roles with women described as family caretakers and men as final decision-makers and financial providers. The informal supporters regulated the first-time parents' contacts with other sources of support.

    CONCLUSIONS:

    Strong and authoritative informal support networks appear to persist. However, poverty and non-adherence to social norms was understood as resulting in less support. Family health in this context would be improved by capitalising on existing informal support networks while discouraging norms promoting harmful practices and attending to the poorest. Upholding stereotypic notions of femininity and masculinity implies great burden of care for the women and delimited male involvement. Men's involvement in reproductive and child health programmes has the potential for improving family health after childbirth. The discourses conveyed contradicting messages that may be a source of worry and confusion for the new parents. Recognition, respect and raising awareness for different social actors' competencies and limitations can potentially create a health-promoting environment among families after childbirth.

    Download full text (pdf)
    fulltext
  • 5.
    Mbekenga, Columba K
    et al.
    Department of Community Health Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Pembe, Andrea B
    Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Christensson, Kyllike
    Department of Women's and Children's health, Karolinska Institute, Stockholm, Sweden.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Prolonged sexual abstinence after childbirth: gendered norms and perceived family health risks. Focus group discussions in a Tanzanian suburb2013In: BMC International Health and Human Rights, E-ISSN 1472-698X, Vol. 13, no 1, p. 4-Article in journal (Refereed)
    Abstract [en]

    Background

    Prolonged sexual abstinence after childbirth is a socio-cultural practice with health implications, and is described in several African countries, including Tanzania. This study explored discourses on prolonged postpartum sexual abstinence in relation to family health after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

    Methods

    Data for the discourse analysis were collected through focus group discussions with first-time mothers and fathers and their support people in Ilala, Dar es Salaam, Tanzania.

    Results

    In this setting, prolonged sexual abstinence intended at promoting child health was the dominant discourse in the period after childbirth. Sexual relations after childbirth involved the control of sexuality for ensuring family health and avoiding the social implications of non-adherence to sexual abstinence norms. Both abstinence and control were emphasised more with regard to women than to men. Although the traditional discourse on prolonged sexual abstinence for protecting child health was reproduced in Ilala, some modern aspects such as the use of condoms and other contraceptives prevailed in the discussion.

    Conclusion

    Discourses on sexuality after childbirth are instrumental in reproducing gender-power inequalities, with women being subjected to more restrictions and control than men are. Thus, interventions that create openness in discussing sexual relations and health-related matters after childbirth and mitigate gendered norms suppressing women and perpetuating harmful behaviours are needed. The involvement of males in the interventions would benefit men, women, and children through improving the gender relations that promote family health.

     

    Download full text (pdf)
    fulltext
  • 6.
    Mukwenda, Annamagreth M.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mbekenga, Columba K
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Univ Hlth & Allied Sci, Sch Nursing, Dept Community Hlth Nursing, Dar Es Salaam, Tanzania..
    Pembe, Andrea
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Univ Hlth & Allied Sci, Sch Med, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Women's experiences of having had, and recovered from, eclampsia at a tertiary hospital in Tanzania2017In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 30, no 2, p. 114-120Article in journal (Refereed)
    Abstract [en]

    Background: Eclampsia is a major cause of maternal and perinatal mortality that requires advanced care and long hospital stays with uncertain outcomes for mother and baby. Care of eclamptic women is particularly challenging in low-income settings. Standards for medical care for eclampsia are established but the psychosocial needs of women are under-researched. Aim: To explore and describe women's experiences of having had, and recovered from, eclampsia at a tertiary hospital in Tanzania. Methods: Qualitative semi-structured interviews were held with a purposive sample of 10 women recovering from eclampsia. Thematic analysis informed the interpretation of the data. Findings: The women had experienced eclamptic seizure as painful and unreal as they were unable to control their body or actions despite sensing what happened. At hospital they felt being cared for and recovered but concerned because they had not been provided with enough information about the disorder. Being separated from the baby during hospitalisation was troublesome and they worried about infant feeding and health. The women experienced being connected to God and they were grateful for being alive and having recovered. However, they expressed fears over the possible recurrence of eclampsia in future pregnancies and wanted information about prevention strategies. Conclusion: Experiencing eclampsia is painful and gives a sense of bodily disconnectedness. It involves worrisome separation from the newborn, not being adequately informed and concerns over future health. More holistic care would benefit eclamptic women and their newborns.

  • 7.
    Pembe, Andrea
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili University of Health and Allied Sciences, School of Medicine, Department of Obstetrics and Gynaecology.
    Mbekenga, Columba K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Aga Khan University, School of Nursing and Midwifery.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian University of Science and Technology, NTNU, Department of Public Health and Nursing; St Olav's Hospital, Department of Obstetrics and Gynaecology.
    Why do women not adhere to advice on maternal referral in rural Tanzania?: Narratives of women and their family members2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1364888Article in journal (Refereed)
    Abstract [en]

    Background: In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice.

    Objective: To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community.

    Methods: Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process.

    Results: In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives' advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral.

    Conclusions: Declining maternal referral advice centred around the pregnant women's position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals.

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