International Journal of Health Policy and Management

International Journal of Health Policy and Management

Bottlenecks Analysis in the Intervention of Improving Maternal Health in Rural Areas of Tanzania: A Convergent Mixed-Method Approach

Document Type : Original Article

Authors
Hyeyun Kim 1, 2
Jiye Kim 2
Seohyeon Lee 2
Minkang Cho 2
Hyekyeong Kim 3
1 Korea Institute for Health and Social Affairs, Sejong, Republic of Korea
2 Department of Health Convergence, Graduate School of Ewha Womans University, Seoul, Republic of Korea
3 Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea
10.34172/ijhpm.8355
Abstract
Background 
Achieving universal health coverage for maternal health (MH) requires a health system that ensures the availability, accessibility, acceptability, and effective use of services. The study aimed to identify bottlenecks that hinder project outcomes of MH in the rural districts of Tanzania.
 
Methods 
This study employed a convergent mixed-method approach to conduct the bottleneck analysis. Quantitative data were collected to identify indicators of MH utilization, with source including Tanzanian health statistics, health facilities and the women in reproductive age (WRA) survey. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with WRA, their families, community health workers (CHWs), and healthcare personnel (HP) to gain insight into factors influencing healthcare utilization from both a demand and an environmental perspective. Following the Tanahashi steps, the quantitative data were analyzed using descriptive statistics and the qualitative data were analyzed using a thematic approach. The findings from both were integrated to identify bottlenecks toward effective coverage and how bottlenecks affected the utilization of MH services.
 
Results 
Community awareness and acceptance were observed to be high, however only a limited number of individuals had received MH services. Utilization rates for antenatal care (ANC) and postnatal care (PNC) were 17.4% and 22.0%, respectively. This suggests that efforts to enhance awareness may be inadequate to change social norms and lead to health behaviors. Furthermore, even when women utilize the service, they may not do so in a timely or consistent manner due to low service quality or unsatisfactory experiences.
 
Conclusion 
To strengthen the logic model, contextual factors such as provider attitudes, service quality, supportive family, and community climate need to be considered to ensure that WRAs are satisfied with and continue to access services. With building supply-side infrastructure, ongoing efforts to change stakeholders’ perceptions of MH services and utilization patterns will be needed to improve the coverage of MH services. 
Keywords
Bottleneck
Maternal Health
Intervention
Mixed-Method
  1. Kananura RM, Kiwanuka SN, Ekirapa-Kiracho E, Waiswa P. Persisting demand and supply gap for maternal and newborn care in eastern Uganda: a mixed-method cross-sectional study. Reprod Health. 2017;14(1):136. doi:1186/s12978-017-0402-6
  2. Baker U, Peterson S, Marchant T, et al. Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania. Bull World Health Organ. 2015;93(6):380-389. doi:2471/blt.14.141879
  3. WHO, UNICEF, UNFPA, The World Bank and the United Nations. Trends in Maternal Mortality: 1990 to 2013. 2014. Geneva: World Health Organization; 2014.
  4. Ministry of Health and Social Welfare. National Integrated Community Maternal, Newborn and Child Health Guidelines. Reproductive and Child Health Section. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare; 2008.
  5. Tarekegn SM, Lieberman LS, Giedraitis V. Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy Childbirth. 2014;14:161. doi:1186/1471-2393-14-161
  6. Koblinsky M, Moyer CA, Calvert C, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet. 2016;388(10057):2307-2320. doi:1016/s0140-6736(16)31333-2
  7. Ministry of Health and Social Welfare, United Republic of Tanzania. Health Sector Strategic Plan III July 2009-June 2015. 2009.
  8. Chowdhury MAK, Karim F, Hasan MM, et al. Bottleneck analysis of maternal and newborn health services in hard-to-reach areas of Bangladesh using 'TANAHASHI' framework': an explanatory mixed-method study. PLoS One. 2022;17(5):e0268029. doi:1371/journal.pone.0268029
  9. Sharma G, Mathai M, Dickson KE, et al. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S2. doi:1186/1471-2393-15-s2-s2
  10. United Nations. The Sustainable Development Goals Report. United Nations; 2021.
  11. Banke-Thomas OE, Banke-Thomas AO, Ameh CA. Factors influencing utilisation of maternal health services by adolescent mothers in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2017;17(1):65. doi:1186/s12884-017-1246-3
  12. Lassi ZS, Middleton PF, Bhutta ZA, Crowther C. Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis. Glob Health Action. 2016;9:31408. doi:3402/gha.v9.31408
  13. Mhlanga M, Mutseyekwa F, Zvinavashe M, Haruzivishe C. Predictors on utilization of maternal, newborn and child health services among rural women in Manicaland Zimbabwe. Cent Afr J Med. 2016;62(9-12):63-71.
  14. Martinez DE, Cooper DJ. Seeing through the logical framework. International Journal of Voluntary and Nonprofit Organizations. 2020; 31:1239-1253. doi:1007/s11266-020-00223-8
  15. Sartorius RH. The logical framework approach to project design and management. Eval Pract. 1991;12(2):139-147. doi:1177/109821409101200204
  16. Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295-303.
  17. Datta V, Srivastava S, Garde R, et al. Combining bottleneck analysis and quality improvement as a novel methodology to improve the quality of neonatal care in a northeastern state of India: a feasibility study. Int Health. 2019;11(1):52-63. doi:1093/inthealth/ihy062
  18. O’Connell TS, Sharkey A. Reaching Universal Health Coverage Through District Health System Strengthening: Using a Modified Tanahashi Model Sub-Nationally to Attain Equitable and Effective Coverage. New York: UNICEF; 2013.
  19. Fetters MD, Tajima C. Joint displays of integrated data collection in mixed methods research. Int J Qual Methods. 2022;21:16094069221104564. doi:1177/16094069221104564
  20. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. Health Serv Res. 2013;48(6 Pt 2):2134-2156. doi:1111/1475-6773.12117
  21. Creswell JW, Clark VL. Designing and Conducting Mixed Methods Research. Thousand Oaks, CA: SAGE Publications; 2017.
  22. Burgess RG. In the Field: An Introduction to Field Research. London: Allen & Unwin; 1984.
  23. Morse JM. Strategies for sampling. In: Morse JM, ed. Qualitative Nursing Research: A Contemporary Dialogue. Newbury Park, CA: SAGE Publications; 1991:127-145. doi:4135/9781483349015.n16
  24. Villar J, Bergsjø P. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. Geneva: World Health Organization; 2002.
  25. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol. 2001;15 Suppl 1:1-42. doi:1046/j.1365-3016.2001.0150s1001.x
  26. Lawn J, Kerber K. Opportunities for Africa’s Newborns: Practical Data, Policy and Programmatic Support for Newborn Care in Africa. Cape Town: Partnership for Maternal, Newborn and Child Health; 2006.
  27. Ministry of Health and Social Welfare Tanzania. The National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child & Adolescent Health in Tanzania (2016-2020). https://www.prb.org/wp-content/uploads/2018/05/National-Road-Map-Strategic-Plan-to-Accelerate-Reduction-of-Maternal-Newborn-and-Child-Deaths-in-Tanzania-2016-2020-One-Plan-II.pdf. Published March 2015. Accessed March 3, 2017.
  28. Marra K, Espinosa I. Bottlenecks and barriers to effective coverage of early childhood health and development interventions in Guatemala: a scoping review. Rev Panam Salud Publica. 2020;44:e105. doi:26633/rpsp.2020.105
  29. de Paoli MM, Manongi R, Klepp KI. Factors influencing acceptability of voluntary counselling and HIV-testing among pregnant women in Northern Tanzania. AIDS Care. 2004;16(4):411-425. doi:1080/09540120410001683358
  30. Mrisho M, Schellenberg JA, Mushi AK, et al. Factors affecting home delivery in rural Tanzania. Trop Med Int Health. 2007;12(7):862-872. doi:1111/j.1365-3156.2007.01855.x
  31. Falnes EF, Moland KM, Tylleskär T, de Paoli MM, Leshabari SC, Engebretsen IM. The potential role of mother-in-law in prevention of mother-to-child transmission of HIV: a mixed methods study from the Kilimanjaro region, northern Tanzania. BMC Public Health. 2011;11:551. doi:1186/1471-2458-11-551
  32. Pembe AB, Mbekenga CK, Olsson P, Darj E. Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members. Glob Health Action. 2017;10(1):1364888. doi:1080/16549716.2017.1364888
  33. Wang W, Mallick L, Allen C, Pullum T. Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. PLoS One. 2019;14(6):e0217853. doi:1371/journal.pone.0217853
  34. Simen-Kapeu A, Seale AC, Wall S, et al. Treatment of neonatal infections: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S6. doi:1186/1471-2393-15-s2-s6
  35. McCollum R, Taegtmeyer M, Otiso L, et al. Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya. Int J Equity Health. 2019;18(1):65. doi:1186/s12939-019-0967-5
  36. Liu G, Segrè J, Gülmezoglu A, et al. Antenatal corticosteroids for management of preterm birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S3. doi:1186/1471-2393-15-s2-s3
  37. Lama S, Krishna AK. Barriers in utilization of maternal health care services: perceptions of rural women in Eastern Nepal. Kathmandu Univ Med J (KUMJ). 2014;12(48):253-258. doi:3126/kumj.v12i4.13730
  38. Applying Evaluation Criteria Thoughtfully. Paris: OECD Publishing; 2021. doi:10.1787/543e84ed-en
  39. Dickson KE, Simen-Kapeu A, Kinney MV, et al. Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries. Lancet. 2014;384(9941):438-454. doi:1016/s0140-6736(14)60582-1
  40. Hoey L. “Show me the numbers”: examining the dynamics between evaluation and government performance in developing countries. World Dev. 2015;70:1-12. doi:1016/j.worlddev.2014.12.019
International Journal of Health Policy and Management
Volume 14, Issue 1
2025
Pages 1-12

  • Received Date 22 November 2023
  • Revised Date 06 January 2025
  • Accepted Date 18 January 2025
  • First Published Date 19 January 2025
  • Published Date 01 December 2025