Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania-A qualitative study of health workers' perspectives.
Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities.



In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories.



'It is like rain' was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers' access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of 'things going as intended', as a sign of good quality care.



Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.
Department of Public Health sciences, Global health - Health Systems and Policy Research, Widerströmska huset, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden. ulrika.baker@ki.se.|Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Nobels allé 12, 141 83, Huddinge, Sweden. ulrika.baker@ki.se.
Ulrika
U
Baker
Ifakara Health Institute, Plot 463 Kiko Avenue, Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
Farida
F
Hassan
Department of Public Health sciences, Global health - Health Systems and Policy Research, Widerströmska huset, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.|Department for Disease Control, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK.
Claudia
C
Hanson
Ifakara Health Institute, Plot 463 Kiko Avenue, Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
Fatuma
F
Manzi
Department for Disease Control, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK.
Tanya
T
Marchant
Department of Public Health sciences, Global health - Health Systems and Policy Research, Widerströmska huset, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.|International Maternal and Child Health, Uppsala University, Drottninggatan 4, 751 85, Uppsala, Sweden.|Makerere School of Public Health, Kampala, Uganda.
Stefan
S
Swartling Peterson
Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Nobels allé 12, 141 83, Huddinge, Sweden.
Ingrid
I
Hylander
D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D006282:Health Personnel / Q000523:psychology*; D006295:Health Resources; D006297:Health Services Accessibility; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services / Q000592:standards*; D011247:Pregnancy; D036301:Qualitative Research; D011787:Quality of Health Care; D019035:Rural Health Services / Q000592:standards*; D013636:Tanzania
District health services; Grounded theory; Health workers; Maternal and newborn health; Quality of care; Sub Saharan Africa