Access to Reproductive Healthcare in Tanzania

Abstract

This literature review discusses the connection between access to reproductive healthcare in Tanzania and Tanzanian women’s overall health. The seven published peer-reviewed papers, in addition to a literature reviewed-article, examine both qualitative and quantitative findings that revealed an association between maternal pregnancy-complications, and ergo, high rates of maternal mortality. A variety of concurrent facts, figures, and themes were found among the articles, but the three most notable that contributed to the epidemic include Tanzania’s seemingly impeding geographical environment, the high rates of untrained midwives assisting during pre-partum, post-partum and during delivery, and the obstacles faced by women to access birth control. Though researchers successfully framed these themes as prominent rationales for the poor maternal health of Tanzanian women, the studies failed to provide recommendations, innovations, and suggestions to repair the country’s broken reproductive healthcare system. Further measures could be taken to mend this problem, such as the Tanzanian government providing funds for the transportation of medical supplies and skilled healthcare professionals throughout the country. To address the healthcare complications associated with pregnancy and delivery, schools and community centers could offer classes and educational programs to train midwives. On behalf of mothers and their children, Tanzania could implement free seminars and spread public awareness about different birth control options and where to access them. With these efforts, there is a potential for the maternal mortality rates and reproductive healthcare complications in Tanzania to decrease.

Keywords: access, birth control, contraception, maternal, reproductive healthcare, TanzaniaAccess to Reproductive Healthcare in Tanzania

A limited access to reproductive healthcare has posed critical and long-lasting effects in many developing nations. In Tanzania specifically, the high rate of maternal mortality is one of the most compelling and prevalent reproductive healthcare problems the East African country faces. Reproductive healthcare complications, as well as complexities that these healthcare obstacles pose among Tanzanian women, all account for various medical difficulties, injuries, illnesses, and deaths. It is critical to evaluate women in their child-bearing years (12-51) with limited access to contraception because they have the widest variety of birth control options to utilize, and they engender the population that delivers infants in the face of meager reproductive healthcare measures. The reproductive healthcare-problems in Tanzania have effects that are prolonged further than the timespan of the mother’s pregnancy and delivery. Many studies have been conducted, which illustrate that low contraceptive prevalence in rural regions of Tanzania are related to socioeconomic conditions that foster high fertility (Madulu, N. F. , 1995). This boundary results in Tanzanian women having a high rate of unplanned pregnancies without the means to obtain necessary care and prevent subsequent complications. Further, midwives tend to step in and aid the mother during delivery when women cannot find the means to travel to a healthcare unit, framing further complications. Considering this, many researchers have questioned how access to reproductive healthcare in Tanzania directly affects women’s health. Research included data on Tanzania’s geography and how it contributes to women’s reproductive healthcare; the data explores how skilled healthcare professionals and midwives shape mother-infant healthcare circumstances; and findings investigate the domestic distribution of reproductive healthcare.

Databases, such as PubMed and Science

Direct, were used in order to compile necessary research and findings from the hundreds of articles that have been published on the topic. Seven peer-reviewed articles and one literature reviewed-article were carefully evaluated. These eight pieces included research conducted between 1999 and 2016, and they were exclusively chosen through their inclusion of keywords, such as “Tanzania,” “access,” “reproductive healthcare,” “contraception,” and “birth control. ” Reoccurring facts and figures regarding geographical obstacles, untrained midwives aiding women during delivery, and healthcare complications due to a lack of reproductive healthcare methods, all resulted as themes from the articles assessed.

Limited Access to Healthcare in Rural Regions

The mountainous and rural geography of Tanzania provides obstacles for the country’s natives, who face financial and logistical barriers when in need of transportation and resources. In regards to healthcare, the dispersed mountain ranges make it difficult for vehicles to deliver medical supplies and send skilled healthcare professionals across cities and villages. A peer-reviewed case report conducted by Mandulu, N. F. (1995), investigated the contraception prevalence in the Kondoa District of Tanzania. This locale is in rural, northern Tanzania and is dislocated from populated cities. The investigation found that the low contraceptive prevalence in this district correlates to socioeconomic conditions that foster high fertility (Mandulu, N. F. , 1995). These conditions include subsistence level of production, early marriage, the high value on children, low education levels and discrimination in the distribution of contraception (Mandulu, N. F. , 1995). This study was conducted with 849 women (ages 15 years and older), nine randomly selected villages, one district hospital (the only family planning service available in the district), four health centers, and 42 public dispensaries, all of which were over 10 kilometers away from where a majority of the Kondoa population resides (Madulu, N. F. , 1995).

The result of these geographic obstacles was a short 16% of the child-bearing women obtaining and utilizing birth control. Of this 16%, 6. 8% relied on modern methods and contraceptive prevalence among the respondents was a mere 13. 7% (Madulu, N. F. , 1995). Madulu, N. F. (1995) further deduced that most women abstained from obtaining birth control, even if they were aware of contraception methods, because their husbands banned contraception (13. 3%), they were fearful of the side effects (5. 8%), or they felt pressured to have children (12. 8%). Furthermore, only 2. 6% of these women had an education that surpassed the primary school level (Madulu, N. F. , 1995). The Kondoa District of Tanzania represents geographical and accessibility-related complications that are faced by many other rural and Northern regions in Tanzania. Contraception use among married women in urban areas of the country is 35%, yet in the rural regions, it drops to 31% (Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015-2016. , 2016, 150). According to the World Health Organization (WHO) (2013), women living in urban areas receive timely postnatal care 48% of the time, but those residing in rural environments receive the same care 29% of the time. By being dislocated from major healthcare facilities, skilled healthcare workers, and means of transportation methods, Tanzanians living in rural areas are inherently at a disadvantage.

A peer-reviewed study, conducted by Magoma et al. (2010), qualitatively explored the Maasai and Watemi ethic groups from the Ngorongoro district of Northern Tanzania. From October 2007 to May 2008, Magoma et al. investigated the healthcare system and sociocultural factors that mask the divergent pattern of high antenatal care (ANC) versus the low access of delivery care with a trained assistant. The researchers found that most Maasai women in Ngorongoro delivered their babies at home, assisted by Trained Birth Attendants (TBAs) or by other female relatives and neighbors, if part of the Watemi community. (Magoma et al. , 2010). Women did not obtain skilled delivery assistance and emergency obstetric care primarily due to a unreliable and unaffordable transportation to get to the health units, which were all far away. Other reasons for at-home deliveries were due to a lack of advanced planning for accessing delivery care units, and because both women and men felt as though pregnancies labelled as ‘normal’ during past ANC visits would ensure a successful delivery. Some women even reported there was a failure of providers to communicate about the importance of skilled delivery, or they felt as though their low social status and inability to independently make labor and delivery decisions disqualified them from seeking professional healthcare attention (Magoma et al. , 2010). Only as a last resort, and usually as a result of serious complications, would women travel to delivery care at health units (Magoma et al. , 2010). Ultimately, the largest obstacle to receiving skilled and emergency obstetric, was the limited accessibility and means to plan for transport.

Complications During Delivery

Many times, midwives in Tanzania pass down knowledge solely by word-of-mouth, and continue to perform clinical tasks and operations. However, according to WHO (2013), only 30% of these midwives are professionally trained in institutions. Magoma et al. (2010) concluded in their research that children are often times looked after by relatives or neighbors, rather than their maternal mother. With the mother’s absence, co-wives play a crucial role in the community. These supportive practices go so far as to assist the mother’s during birth, offsetting women’s perceptions of the opportunity costs associated with delivery at health units (Magoma et al. , 2010) A nurse-midwife from Temeke Dar es Salaam even had to assist more than one woman at the same time, thus compromising the quality of care provided. She noted that “sometimes the ward (was) flooded, with some mothers sleeping on the floor. (…) (Midwives) could be supporting one woman to deliver, while at the same time (…) another woman (was) pushing. Therefore, (they had to) tie the cord of the baby (…), quickly change gloves and fast rush to the next woman to assist her delivery” (Mselle, L. T. , Moland, K. M. , Mvungi, A. , Evjen-Olsen, B. , & Kohi, T. W. , 2013, p. 7). Midwives assist with the delivery for over 54% of the child-bearing population, despite their dearth of education (Tanzania: TRENDS, 2018).

Women further expressed concerns about specific routine and lifesaving procedures conducted by healthcare providers during labor, delivery, and postpartum. According to Maasai women, digital vaginal exanimations performed at health units are likely to be painful, damage the baby, and cause labor retraction (Magoma et al. , 2010). Watemi women and men described these exams performed by male providers as dehumanizing (Magoma et al. , 2010). Both communities also evoked a strong fear towards caesarean sections (C-sections), and reported that such episiotomies and repairs of genital tears restrained them from seeking skilled delivery care (Magoma et al. , 2010). These misconceptions are direct results of a lack of education and knowledge regarding reproductive healthcare among both men and women.

The combination of noted fears and lack of knowledge resulted in many infections, maladies, injuries, and deaths during delivery and postpartum. According to a peer-review article by Pembe et al. (2014), there were 10,057 live births, 115 maternal deaths, and hence an MMR of 1,541 per 100,000 live births found in a retrospective review of all maternal death records of cases that occurred in 2011. The direct causes of the maternal deaths included preeclampsia/eclampsia (19. 9%), post-partum hemorrhage (14. 9%), abortion complications (9. 9%), and sepsis (9. 2%) (Pembe et al. , 2014). Indirect causes included anemia (11. 3%), HIV/AIDS (9. 9%), and substandard care factors, which accounted for 116 (82. 3%) of all causes (Pembe et al. , 2014). Though hypertensive disorders of pregnancy, postpartum hemorrhage and anemia are the leading causes of maternal deaths, there are a lack of resources attainable to women to prevent and treat these infirmities despite the complications and lives at stake.

A peer-reviewed article in the Tanzania Journal of Health Research evaluated the high rate of maternal death as a public health concern throughout Tanzania, and found that pregnancy, childbirth, and poor quality of health services contribute to the epidemic. The study analyzed maternal mortality in Tanzania over a 50-year time span, with findings supported by quantitative data and key policy documents, publications technical reports, and available internet-based literature that allowed the researchers to conclude that Tanzania is unacceptably high in maternal mortality rates and are far from reaching their millennium development goals (MGD) (Shija, A. E. , Msovela, J. , & Mboera, L. E. , 2012). The research further noted that 50% of maternal deaths occur within the first 24 hours of delivery, which are attributed to subsequent delivery-complications that are not attended to due to an absence of a skilled birth attendant. These complications include obstetric hemorrhage, pregnancy induced hypertension, obstructed labor, sepsis and abortion complications, which are also supported by Pembe et al. ’s findings (2010), as noted previously (Shija, A. E. , Msovela, J. , & Mboera, L. E. , 2012).

Though a variety of initiatives have been put forward by international forums as a response to the high maternal mortality rate in Tanzania, the HIV/AIDS pandemic and direct obstetric causes still lead the country in indirect causes of maternal death (Shija, Msovela, and Mboera’s, 2012). The researchers further acknowledged that for every woman who dies as a result of pregnancy-related causes, between 20 and 30 more women will develop both short and long-term disabilities, including obstetric distula, a ruptured uterus, or pelvic inflammatory disease (Shija, A. E. , Msovela, J. , & Mboera, L. E. , 2012). These initiatives, such as the Alma-Ata declaration of 1978, the Safe Motherhood global initiative, and the World Summit for Children conference, have raised awareness of the high mortality rate in the country, but they have not successfully decreased the exponentially growing problem (Shija, A. E. , Msovela, J. , & Mboera, L. E. , 2012).

Healthcare Complications due to a Lack of Contraception

According to a literature review by Jacobstein et al. in the International Journal of Gynecology & Obstetrics (2013), “voluntary family planning is one of the most efficacious and cost-effective means of improving individual health, gender equity, family well-being, and national development” (S9). However, many Sub-Saharan African countries, including Tanzania, have limited financial resources and measures to obtain contraception. Only 32% of married women used modern contraceptives in 2015-2016, and among these women who began using birth control in the five years preceding the survey conducted by the Tanzania Demographic Health Survey and Malaria Indicator Survey (2016), one in four women discontinued their method within the first 12 months. Further, the unmet need for family planning has not improved since 1999, as it remained between 22 and 24% (Tanzania Demographic Health Survey and Malaria Indicator Survey, 2016). Progress made towards fixing this ongoing healthcare-problem is evidently minimal both in numbers and qualitative findings.

The reasoning behind why women discontinued their birth control varied according to their method of choice and acquisition. Most women discontinued their contraception because she desired pregnancy (38%), but others discontinued due to method-related side effects and health concerns (26%) (Tanzania Demographic Health Survey and Malaria Indicator Survey, 2016). These women lacked the educational-resources to learn more about their method and other existing methods, leading them to consequently halt their usage of contraception all together. One in ten women became pregnant while using a method (11%), and another one in ten desired a more effective method (9%), but did not have the means to obtain it (Tanzania Demographic Health Survey and Malaria Indicator Survey, 2016). Many times, teenagers and women get pregnant in Tanzania for reasons other than choice; for some, pregnancy occurs due to a limited access to birth control. Other women get pregnant at in their teenage years and consequently face many barriers to pre- and postnatal care. Consequently, many women perform unsafe abortions or deliver babies with complications that threaten their life and their newborns’.

A peer-reviewed article conducted by Jato et al. (1999) reported that Tanzania’s government began to integrate family planning into maternal and child health care services in 1988. However, though initiatives have been implemented, it was recognized that becoming a regular user of modern contraception was a gradual and complex process. Few women adopted contraception immediately, even when exposured to information about family planning (Jato et al. , 1999). According to Tanzania’s demographic survey, the contraceptive prevalence rate among married women in Tanzania is 28%, and among sexually active unmarried women ages 15-29, only 46% are obtaining birth control (Jato et al. , 1999). Yamin et al. (2013) further noted that gender inequalities affect women’s health across their lifespan. Especially in rural regions of Tanzania, and where the lowest socioeconomic levels of inhabitants reside, the fertility rate is highest and the access to contraception is limited excessively. The researchers predict that if efforts to improve reproductive autonomy and contraceptive use were innovated, the number of pregnancies and maternal deaths due to complications would exponentially decrease, and the well-being among living children would be promoted.

Conclusion

Through a close examination of the peer-reviewed articles and the literature-review, a concrete link can be established between Tanzania’s poor maternal reproductive healthcare and obstacles surrounding access produced by geography, attendance of unskilled and uneducated midwives, and limited contraception, thus resulting in healthcare complications. While there have been many studies, initiatives, and organizations that have strived to discover and improve this correlation more work needs to be done. It is necessary to implement education programs to spread awareness of the significance of poor maternal care, importance of reproductive healthcare and the high maternal mortality rate in Tanzania.

The links to these prevalent themes and statistics are investigated, analyzed, and published time-and-time again, but hospitals, trained physicians, medical schools, and government figures need to step in and hold Tanzania accountable for the continuing lack of maternal reproductive healthcare that is available and accessible, given the socioeconomic, geographical, and cultural impediments to access. Limits found in the literature reviewed include the authors’ failure to address further variables, such as cultural and traditional barriers, that Tanzanian inhabitants face. Other barriers include the negligence to address how and when schools’ curriculums address reproductive healthcare, and how this affects both males and females in Tanzania. Reproductive healthcare is a global, widespread issue in today’s society and it is only becoming more consequential. Without intervention and aid, Tanzania’s maternal mortality rate will not decrease, and consequently, STDs, STIs, and birthing complications will not improve, nor will women’s desire and incentive to seek education and contraception.