When Iringa’s women speak about maternal health care, the community listens. The messages they deliver are helping boost women’s access to and use of antenatal care services. They’re particularly effective because the women themselves identified the pressing barriers they face. With community support, they also designed strategies to overcome them.

This success is the result of an innovative implementation research project carried out in Kilolo and Mufindi districts by the University of Dar es Salaam, Tanzania, and the HealthBridge Foundation, Canada, in collaboration with Iringa Municipal Council’s Health Department. Funding was provided by the Innovating for Maternal and Child Health Care in Africa (IMCHA) initiative.

Why women don’t seek early care

Improving maternal and child health (MCH) is urgent in Tanzania where deaths of mothers during childbirth increased 20% and newborn deaths 60% between 2012 and 2015. These figures translate to 30 women and 49 newborns dying every day from birth-related complications.

Tanzania has worked to reverse this trend through national policies, health sector reforms, and targeted plans and programs. But as the research team pointed out, the improvements don’t always respond to local needs. In Iringa, one of the most pressing is to increase the use of antenatal services. Tanzanian Ministry of Health guidelines recommend at least four visits for uncomplicated pregnancies, with the first during the first 12 weeks of gestation. However, only 27% and 17% of women in Kilolo and Mufindi, respectively, attend before their fourth month of pregnancy.

Why this delay?

Through focus group discussions and interviews with women and men and local healthcare providers and officials in 20 villages in each district, researchers determined that, beyond the lack of transportation to reach often-distant health facilities, poor understanding of the importance of antenatal care (ANC) looms large.

Home-grown strategies to improve maternal and child health care

The project is finding ways to surmount these hurdles. As an entry point, the research team set up Women’s Participatory Learning and Action Groups (WPLAG) in the 20 villages to identify and prioritize barriers to their poor maternal health outcomes, then strategize about how to solve them.

The groups identified four main reasons: home deliveries; low participation of men in ANC; late ANC attendance, if at all; and poor birth spacing. The WPLAG suggested many strategies to overcome them, such as:

- using women’s groups and champions to educate other women on how best to share information with their partners during pregnancy and childbirth;

- partnering with Community Health Workers (CHWs) to educate the community on the importance of early ANC and to visit pregnant women to encourage them to give birth at the health facility;

- identifying male champions in each village to deliver key health messages to men wherever they gather – bars, football matches, and other social gatherings;

- improving the capacity of existing health facility governing committees to educate health providers about their roles and ways to better engage with the communities and village health workers.

Health system issues ̶ disrespectful language and behaviour on the part of the health providers; delays in providing appropriate care; lack of facilities and equipment; and shortage of drugs and supplies ̶ require a different kind of intervention. The research showed that health facility governing committees had difficulty planning and implementing services, leading to the neglect of the poorest and most vulnerable.

In May 2018, the research team trained committee members from the 12 dispensaries in the project area. All were shocked at the poor MCH indicators and low participation in ANC. They committed themselves to collaborate with women’s groups and promised to work closely with the community and health facilities to overcome gender barriers to MCH, including setting an example by accompanying their own wives to the clinics.

The power of action research

Key messages have been developed and women, male champions, and community leaders have started implementing the selected strategies in their respective villages. The project team is documenting how this is unfolding. It has already presented some of its work to local and national stakeholders, including the Ministry of Health, and published results in peer-reviewed journals on topics such as male involvement to break barriers to MCH.

The research team points out that this project is one of few in Tanzania to have used an action research approach to involve communities in the changes they want to see in the health sector. As one participant noted: “This approach has empowered us to diagnose our problems and design strategies to address them. This is a very innovative way of engaging communities.”

“We have demonstrated how stakeholders were able to design culturally acceptable strategies,” said the project team, increasing the odds that the interventions will continue beyond the end of the project in 2020.