empowering nurses to improve maternal health outcomes

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Empowering Nurses to Improve

Maternal Health Outcomes

Paper 1 rom the Ethics, Payments, and

Maternal Survival project

By Paula Tibandebage*, Tausi Kida** Maureen Mackintosh***and Joyce Ikingura****

*Research on Poverty Alleviation (REPOA), Dar es Salaam, Tanzania

** Economic and Social Research Foundation (ESRF), Dar es Salaam, Tanzania

***The Open University, Milton Keynes, UK

****National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania

Working Paper 13/1


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Published or: REPOAP.O. Box 33223, Dar es Salaam, Tanzania157 Mgombani Street, Regent EstateTel: +255 (0) 22 2700083 / 2772556Fax: +255 (0) 22 2775738Email: [email protected]: www.repoa.or.tz

Design: FGD Tanzania Ltd

Suggested Citation:Paula Tibandebage, Tausi Kida, Maureen Mackintosh and Joyce Ikingura Empowering Nurses toImprove Maternal Health Outcomes.

Working Paper 13/1, Dar es Salaam, REPOA

Suggested Keywords:

Maternal Health Care, Maternal Health Survival, Ethics, payments, Empowering nurses

REPOA, 2013

ISBN: 978-9987-615-44-5

All rights reserved. No part o this publication may be reproduced or transmitted in any orm or byany means without the written permission o the copyright holder or the publisher.

Ethics, Payments, and Maternal Survival project - Paper 1


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Acknowledgements

We are grateul to our hard-working interviewers, who also worked on translation: Samwel Ebenezeri,Magdalena Shirima, Tumaini Mashina, Onike Mcharo, Caritas Pesha, and especially Cornel Jahari,who managed the eldwork and assisted in supervising data entry and cleaning. We are also verygrateul to all the women and men who gave time to the household interviews, and to the nurses,midwives, doctors, clinical ocers, traditional birth attendants and other proessional sta whoanswered our questions, oten under great time pressure. We are most grateul to the advisers orthis project Pro. Siriel Massawe, Mr. Gustav Moyo, Dr. Sebalda Leshabari, Pro. Pam Smith andMs. Rachel Celia or their invaluable advice at all stages o the research.This work was supportedbythe Wellcome Trust [WT094966MA], to whom we are most grateul. The content o this paper isthe sole responsibility o the authors.


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Table of Contents

Acknowledgements .......................................................................................................... iii

Table of Contents ............................................................................................................. iv

Abstract ............................................................................................................................. v

Acronyms .......................................................................................................................... vi

1.0 Introduction ............................................................................................................. 1

2.0 Theory and Method ................................................................................................ 2

2.1 Empowerment and the Management o Maternal Care .................................... 2

2.2 Project Methods .............................................................................................. 4

3.0 Findings ................................................................................................................... 6

3.1 A Tale o Two Hospitals .................................................................................... 6

3.1.1 Staff Shortages and Work Pressure ....................................................... 6

3.1.2 Complaints About Staff Rudeness ......................................................... 7

3.1.3 Supply Shortages and Informal Payments ............................................. 9

3.1.4 Support and Incentives for Midwives ..................................................... 12

3.1.5 Reputations and Interactions ................................................................. 13

3.2 Two Government Health Centres ..................................................................... 14

3.2.1 A Crisis of Supplies ............................................................................... 14

3.2.2 Bribery and Abuse ................................................................................ 16

3.2.3 DisIncentives and Staff Morale .............................................................. 18

4.0 Discussion ............................................................................................................... 20

5.0 Conclusion and Implications for Policy and Practice ......................................... 21

References ........................................................................................................................ 22

Publications by REPOA .................................................................................................... 24


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Abstract

To what extent is the disempowerment o nurses/nurse midwives and other maternal health-careproessionals an important actor contributing to poor perormance in the provision o maternalhealth care, and thereore a contributory actor in poor maternal health outcomes? This paperaddresses this question by using a systematic analysis o part o a data set rom a research projectEthics, payments, and maternalsurvival. Drawing on concepts o empowerment rom the nursingliterature, we analyse qualitative data rom interviews with sta in two hospitals and two healthcentres, and with women in sampled households who had sought maternal health care in the veyears preceding the eldwork in a single urban district in Tanzania.

We show that in the hospitals, stang shortages were a key organisational constraint generatingpressure on sta and contributing to poor behaviour towards women during delivery. In one o the

hospitals, however, good management ensured a much better quality o care than in the otherhospital. In two health centres, supply shortages were the main organisational constraint experiencedby sta. In one health centre, sta morale, management and care were very poor, while in the othermuch more isolated setting, continuing relationships between the sta and community helped toreduce abusive behaviour towards women who were coming to deliver.

The lack o capacity or emergency care at the health-centre level, including transport or reerrals,was a disempowering actor or nurses/nurse midwives in both health centres. As a way orwardwe consider the role o management in promoting an empowering environment or maternalhealth workers as key to improving the perormance o available sta. Good management would

involve, among other things, a system that values and promotes good proessional behaviour whilesanctioning bad behaviour, and promotes a more fexible, participatory and communicative systemo management. Capacity building or both management and sta in this area would be required.


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Acronyms

D&C Dilation and Curettage

DG Director General

EN Enrolled Nurse

FBO Faith-Based Organisation

MDG Millennium Development Goal

MOHSW Ministry o Health and Social Welare

MSD Medical Stores Department

Obs & Gynae Obstetrics and Gynaecology

PPH Post-Partum Haemorrhage

RN Registered Nurse

TDHS Tanzania Demographic and Health Survey

URT United Republic o Tanzania

WEO Ward Executive Ocer

WHO World Health Organisation


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1 IntroductionWith 2015, the target year or the Millennium Development Goals (MDGs) only three years away,

Tanzania is still a long way rom attaining its goal o reducing the Maternal Mortality Rate (MMR)to meet MDG 5. The MDG 5 target or Tanzania was to reduce MMR to 265 deaths per 100,000live births. The Tanzania Demographic and Health Survey (TDHS 2010) estimates MMR during theten-year period prior to the survey to be 454 deaths per 100,000 live births. This is lower than the2004/05 estimate o 578 maternal deaths per 100,000 live births, but this gure was higher than the1996 gure o 529 deaths per 100,000 live births (TDHS 1996, TDHS 2004/05, TDHS 2010).

There are numerous interlocking reasons or this policy ailure. One such actor is the documentedcrisis o availability and perormance o health workers in the health system as a whole (Mastad,2006; Mastad and Mwisongo, 2011). This paper uses a systematic analysis o part o a data set

rom a research project Ethics, payments, and maternal survival to explore the extent to whichthe disempowerment o nurses/nurse midwives is a actor contributing to poor perormance inthe provision o maternal health care, and thereore a contributing actor in poor maternal healthoutcomes.


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2 Theory and MethodThis paper draws on two sets o literature: literature on empowerment o nurses and quality o care,and some o the large literature on the management and quality o maternal care. In this section wediscuss some key aspects o these works and also briefy outline the eldwork method o the projectrom which the ndings are drawn.

2.1 Empowerment and the Management of Maternal Care

The work o nurses/nurse-midwives poses some specic challenges in the provision o maternalhealth care. Managing pregnancy requires close attention and obtaining and providing goodinormation. The birth process is risky, and crises can arise rapidly and unexpectedly. As we

document below, labour wards in hospitals are requently very busy, highly pressured places.Midwives work autonomously or much o their working lives, at a highly responsible job that caninvolve pain and emotion.

An element o the nursing literature argues that empowerment o nurses is a valuable attribute thatis essential to the eective unctioning o a health care system (Palmier, 1998). Chandler (1986) wasamong the rst to describe the process o empowerment in nursing. In her work (Chandler, 1992)she distinguished between power and empowerment, noting that empowerment enables one toact, whereas power connotes having control, infuence, or domination over something or someone.Empowerment is a process through which power is acquired (Kerner, 1993). The argument thusimplies that a lack o empowerment a situation o rustration and constraint undermines theability o nurses to provide sae and good quality nursing care in order or the patients to achievetheir maximum level o wellness (Manoijlovich, 2007). Empowerment has been viewed as havinga potential role to play in proessional development in nursing, and there is a substantial body oliterature on the subject (Fletcher 2006, Bradbury-Jones 2007; Kuokkannen and Leino-Kilpi 2000).

Power, as Chandlers denition implies, is a complex attribute; control and infuence may be usedor good or ill. Hence, the empowerment o nurses must be within a context that not only enablesnurses to do their job well in terms o delivery o good quality health care, but which also constrainsthe misuse o power. Such constraints may include management systems that penalise abusivebehaviour and organisational cultures that value good perormance.

The nursing literature draws on a variety o theoretical approaches to empowerment. The theory ostructural empowermentproposes that organisational eectiveness requires opportunity and powerin organisations to be available to all employees (Manojlovich, 2005a). Kanter (1993) argues thatemployees work behaviour arises rom conditions and situations in the workplace and not rompersonal attributes (Laschinger and Havens, 1996).

Degner (2005) argues that empowered employees are more committed to an organisation, moreaccountable or their work, and better able to ull job demands in an eective manner. Otherstudies have shown that structural empowerment contributes to job satisaction (Manoijlovich,

2005b). Kanters theory has been widely applied to the practice o proessional nursing, showinghow workplace structures that acilitate access to resources can empower nurses to accomplishtheir work in more meaningul ways (Kluska et al2004; Siu et al. 2005). Other empowering actorsidentied in other studies include participative management, job enrichment, less bureaucracy, andinvolving sta in decision-making (Krawer and Schmalenberg, 1993).

Thereore, this theoretical perspective places the responsibility or the behaviour o an employeeentirely on the organisation and its management. According to Kanter (1993), structural empowerment


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is promoted in work environments that provide employees with access to inormation about theorganisation, support in perorming the job and in decision-making, the opportunity to learn anddevelop, and access to the resources needed by employees. Applying Kanters theory, Hajbagheryet al. (2005), identied having authority, proessional sel-condence in the application o knowledgeand skills, and orms o collective power o nurses as important to empowerment. We exploreour data or evidence on a case study basis that organisational and management support andacilitation o midwives in these ways are associated with positive patients perceptions o maternalcare.

A second theoretical approach, psychological empowerment moves the ocus away rom theorganisation towards personal attributes, motivation, and psychological experience (Manoijlovich,

2007). Conger and Kanungo (1988) viewed empowerment as a motivational construct as wellas a personal attribute. This perspective recognises that some individuals will try to do their jobeectively even in disempowering environments. It sees individuals as being able to shape theirwork role. Spreitzer (1995) denes psychological empowerment as a motivational construct whichis maniested in our cognitions: meaning, competence, sel-determination, and impact. Meaningrequires similarity between a nurses belies, values, behaviour, and job requirements. Competencereers to condence in ones abilities to perorm the job. Sel-determination reers to a eeling ocontrol that is exerted over ones work. Finally, impact is a sense o being able to infuence importantorganisational outcomes (Laschinger et al. 2001). Psychological empowerment thereore interactswith the characteristics o the work environment.

Meaning and values can be both rooted in and undermined by the culture o the organisation withinwhich a nurse works. Furthermore, midwiery is a clinical eld that links to deep-rooted emotionsand the generation o human lie. Teamwork and mutual support can be important elements o the

job, and collaboration between midwives and the women they care or is important to patientssaety. We search our data or nurse midwives sense o condence, sel-determination and impact,and their explanation o their eelings.

A third perspective, Relational theoryseeks to understand empowerment in the nursing proessionin relation to history and patriarchal structures within which nurses nd themselves (Harden, 1996).It acknowledges the patriarchal nature o medicine and the health-care industry in general and theoppressive nature o the relationships it can generate (Chinn, 1995; Sampselle, 1990). Indeed, it hasbeen argued that nurses are an oppressed group by class and gender perspectives (Lovell, 1982;Ford and Walsh, 1994). Drawing on liberal eminism, Wuse (1994) argues that an environment thatpromotes reciprocal proessional relationships would be a more eective empowering environmentor nurses. Fletcher (2006) sees relationships which can be built through dialogue and sel-awarenessas having the potential to break cycles o disempowerment or nurses.

This third theoretical perspective links values and organisational culture to nurses historicalexperience o working relationships. Health care organisations are requently hierarchical, devaluingteamwork among nurses and other non-medical clinicians. The literature on organisational culture

in health care is inconclusive on the link between culture and perormance (Scott et al. 2003; Davieset al. 2007). Yet the idea that culture infuences perormance has enduring intuitive appeal (Scottet al. 2003:115). We explore our evidence or discussion o the relationships between midwives,supervisors, and doctors, and how these relationships are associated with institutional perormanceas perceived by patients.


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Drawing rom this set o theoretical rameworks, we use case studies o our health acilities toexplore workplace and individual actors that may empower nurses/nurse midwives to deliver qualitymaternal health care, and those actors that may infuence and sustain bad behaviour.

2.2 Project Methods

The sample and data collection instruments

Fieldwork or the project was undertaken in our districts located in two contrasting regions oTanzania. In each region, the research included one urban and one rural district. Three wards ineach district and then two streets or villages in each ward were chosen that displayed contrasting

economic circumstances. Finally ten households were selected randomly along those streets orvillages. Households where no woman was pregnant and/or no woman had given birth in the lastve years were replaced. A total o 240 households were selected, sixty in each district.

Interviews with heads o households or their representatives in these 240 households collectedbasic data on the households socio-economic conditions, while interviews with women collecteddata on payments and maternal care, including birth experiences. In the sampled households alleligible women were interviewed. In total, interviews were conducted with 248 women who hadgiven birth in the last ve years and/or were currently pregnant. The ve-year cut-o point wasapplied to limit recall problems. The interviews captured inormation on the womens experiences oantenatal care, care at birth, and post-natal care, including payments made and their perceptionso the quality o care they received.

In addition, the eldwork also included health care acility interviews that were conducted with healthworkers in 59 health care acilities in the selected districts. The health care acilities in the surveywere at dierent levels and were drawn rom three sectors public, private, and those owned byaith-based organisations (FBOs). In total, 11 hospitals, 16 health centres, and 32 dispensaries werevisited. Interviewees included medical directors and clinicians in-charge, managers responsible ormaternal care, and midwives. Some traditional birth attendants were also interviewed.

Semi-structured questionnaires with provisions or in-depth probing were used in both household

and health acility interviews. In addition, or household interviews a separate structured questionnairewas used to capture the households socio-economic characteristics. Fieldwork was undertaken inSeptember and October 2011. This paper uses interviews conducted at three public acilities andone non-prot acility in one o the urban districts.

Data analysis

Qualitative data on womens maternal health care experiences were coded and sorted intothemes by using Nvivo sotware. Systematic analyses were carried out to identiy patterns andcommonalities and/or dierences in experiences. Patton (2002) explains this method o qualitativedata analysis in detail. Background data or health acilities and households were analysed with

Stata sotware using descriptive methods such as graphs and cross tabulations. We triangulateddata sources, e.g. responses rom women and responses rom maternal health workers, so asto identiy similarities or divergences in their responses regarding issues o payment and what isconsidered ethical maternal care. We also triangulated quantitative data, e.g. on payments, withqualitative data to assess whether issues emerging rom the qualitative interviews were consistentwith the quantitative ndings.


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Ethical considerations

This study was undertaken with the approval o the National Health Research Ethics ReviewCommittee. In conducting primary data collection and analysing the ndings, eorts were made toensure anonymity and objectivity. Respondents were inormed about the objectives o the study,and their inormed consent was obtained. Participants were assured o anonymity during the dataanalysis and in the presentation o the ndings. Accordingly, data were coded to protect identitiesand ensure privacy.


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3 FindingsIn this section we examine our acilities in detail: two hospitals and two health centres. For eachacility, we triangulate our evidence rom: those in charge o acilities and maternity care; Nurse-midwives working in those acilities, and women who have given birth in the same acilities. Wesystematically compare the evidence or empowerment and disempowerment o nurses andmidwives and the evidence o womens experiences o care while they were giving birth in thoseacilities.

3.1 A tale of two hospitals

We rst compare two hospitals in the same city. Hospital A is an FBO-owned and run reerral

hospital. It charges ormally or its maternal health-care services except or emergency admissions,and is attending a large number o deliveries, including sel-reerrals. Hospital B is a government-owned regional hospital. Like hospital A, hospital B also receives large numbers o women ordelivery; many are reerred by lower-level health acilities, others reer themselves or come aterthe lower-level acilities close; and others are women with pregnancy complications or emergencycases.

Two actors are common to both hospitals: rst, sta shortages and resultant work pressure onnurses and midwives, and second, patients complaints about sta rudeness.

3.1.1 Staff shortages and work pressure

In Hospital A, the major problem pointed out by all the sta interviewed was overwork in maternitywards due to shortage o nurse-midwives:

For maternity care you need sta, but we have a very high shortage o sta. Nursein-charge, maternity

The stang level is very small. We are so much overworked. Nurse-Midwife

One interviewee careully explained the eect that such understang can have on the ability onurses to ensure patients saety:

Yes, there are serious sta shortages in maternity. Example o the labour ward: Atnight, the ward has 1 RN [registered nurse] and 2 ENs [enrolled nurses, rom a shortertraining course]. It is dangerously low. The ward needs ve. Suppose, as usual, youhave a caesarean section? A nurse has to go to the theatre with that patient. Then youhave at any one moment, say, a delivery, one person waiting who needs monitoring,and one ante-natal admission. How should the two remaining people divide up? Who isorganising the medications? It is not sae. And these are long shits Nurse manager,maternity

In Hospital B, exactly the same core problem was mentioned by all the interviewed sta: a shortageo sta, and thereore overwork:

Here it is heavy duty deliveries are at all times. We have two wards but stang isbasically or one ward. Maternity in-charge


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It is hard to work in the maternity ward. In seven days we get only one day o. And thisis when you have had a night shit. So we are so much overworked and exhausted.Nursemidwife

Data rom these two hospitals show that both have sta shortages, but the situation appearedworse in Hospital B.

Hospital A, as a reerral hospital or several regions, has two specialist obstetrics and gynaecologyregistrars per shit, plus consultants (eight in total) on call. The labour ward has seven deliverybeds and there are seven admissions and waiting beds or risky pregnancies. In addition, thereare 45 post-natal beds. There are 25-30 deliveries a day. A high proportion o the maternity cases

are reerred emergencies, averaging around 30 in 24 hours, including obstructed labour, severehypertension and eclampsia, Post-Partum Haemorrhage (PPH), post-natal complications andsevere anaemia, caesarean section complications, puerperal sepsis, post-delivery eclampsia, andcardiomyopathy. The hospital has a total o 10 registered nurses and nine enrolled nurses withmidwiery training assigned to the labour ward, plus other nursing sta or the post-natal ward whichhandled many emergencies; the nurse manager quoted above noted that the worst sta shortagesor the labour ward occurred at night.

Hospital B is a regional hospital which or a long time has also been serving as a district hospitalbecause there is no district hospital in the area. The hospital has only two obstetrics and gynaecologist

consultants. The labour ward has 10 active labour beds and our delivery beds, 11 ante-natal beds,and 46 post-natal beds. There are about 40 deliveries a day on average, sometimes with womendoubling up in beds. There are ve to eight emergency cases a week. In total, the hospital has 23qualied nurses working in maternity care, o whom only eight are registered nurses; the rest havelower levels o training. A morning shit typically has 8 eight nurses and a night shit has our, hal owhom are in the labour ward.

3.1.2 Complaints about staff rudeness

Women who had given birth in both o these hospitals had some complaints about sta rudeness.Some women who described their experience o delivery at Hospital A complained o delays inbeing attended to, the use o abusive language, or nurses being rude:

The services were not good. I was not happy about the care I received during deliveryat Hospital A. Labour pain started at home, uterine fuid started to run out, I took ataxi which rushed me to the hospital which I reached at ve pm. Ater I arrived andin-patient charges were paid, then I was given a bed where I waited to deliver. At twothirty am my labour advanced too much. I called or a nurse several times, but no onecame to help. I continued calling while struggling in bed up to three am when I delivered(alone) This was dangerous or my lie and my childs lie. Woman 23

The nurses at the hospital are very harsh, especially when you seek advice rom them;

instead o responding politely, they will shout at you harshly. The attendants are ew.Woman 34

Both the nurse in charge o maternity and the nurse-midwie recognised that the heavy workloadcould have a spill over eect:


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Sometimes the nurses eel stressed and overworked, and this can have implicationson the relationship with patients! Maternity in-charge

There were many more such complaints by women who had given birth at Hospital B; this is anexample:

They are so rude/harsh and do not have good hearts to help pregnant women whoare really in need at the time o giving birth. They are harsh when attending pregnantwomen when they need help. Woman 13

In each hospital there were also women who had not been subjected to abusive language. In

Hospital B:

The doctors are experienced and do respect mothers; this is why most o us do returnthere. Woman 18

The delivery service I got was good because I was never abused or shouted at duringdelivery. Woman 1

Furthermore, some o the women interviewed did recognise the problem o the shortage o nursesin Hospital B. A woman who acknowledged that the quality o care she got was not good, and who

regretted coming to deliver at the hospital ater delivering alone and unaided in the ward, said:

What I learned rom that experience is that the nurses are overwhelmed by work. Thewomen who had come or delivery on that day were many compared to the number onurses/service providers who were on duty. Woman 3

The word overwhelmed recurred in the data rom both hospitals. There was an acknowledgedinterconnection between extreme pressure o work and the use o bad language by midwives. InHospital A the nurse manager or maternity said that A nurse cannot use abusive language, this isnot proessional. However, she also pointed out that the shortages o sta on a hectic ward canbe severe. Nurses are human beings. When one midwie nds hersel struggling with three dicult

deliveries, then we need to give support, not just blame.

In Hospital B the acility management also seemed to be aware o what was going on, and wassympathetic as to why such behaviour might be happening. The doctor in-charge said that inthe context o the number o deliveries the nurses are trying to cope with and the level ocomplications:

You cant blame the nurses At the moment we deliver 40-70 cases (in 24 hours)with only three nurses (per shit); they will burn out. Facility in-charge

However, there was no acknowledgement rom the Hospital B management that this was nonethelessunacceptable behaviour.

At this point, the similarities between the evidence rom the two hospitals end. Big dierencesappear in the data in terms o a number o key issues related to the empowerment o sta. Theseinclude dierences in the availability o supplies or midwiery in the two hospitals; dierences inmanagement support or sta as expressed in incentives and technical support rom medical sta;and dierences in sta behaviour in terms o demands or inormal payments.


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3.1.3 Supply shortages and informal paymentsThe two issues o supplies availability and inormal payments turned out to be closely linked in thepatients accounts. Many women told stories o being asked or inormal payments in Hospital Band linked those accounts o bribery to delays and abuse by sta:

People who delivered at Hospital B say that they are poorly treated as ollows: treatedbadly; nurses care or patients they know rst; some mothers delivering while on thebenches; mothers dying beore attended by doctors. Woman 1

Services at Hospital B are poor ... I you do not have money they do not care oryou, i.e. one patient delivered on the foor because she did not have money to bribe anurse. Woman 28

I gave Tshs. 5000 to the nurse who assisted me during delivery. I gave it to her beorethe baby was born because I was scared and I was conused by the labour pains andthe women in the labour ward who kept saying that i you give something to the nurse,at least you get someone to pay attention to you. So I did give money and I was giventhe services Yes, it was much better than beore I had given something or comparedto the women who did not have anything to give. And there were very many women onthat day. Woman 37

The service is not good at all, I was not satised with it because the attendants areater money; they do not attend patients with a clean heart; they do not care about themothers.- They harass and abuse us.- They are corrupt.- You can only get supplies ater giving gits (corruption)

Actually the service I got rom that attendant was because I paid or it; the amount Ipaid (Tshs. 4000) aected the kind o services I got, because i I had nothing, it meansI would not have been attended. Woman 40

One woman had been treated well, but had seen the problems experienced by others:

I thank God that I received good care, although some o the nurses use abusivelanguage, and i you do not have money to give a nurse or you do not have a nursewho knows you, you will get a lot o problems and they will not take care o you. Theyshould give us good care; also there should be air treatment between those who haveand those who have not. Woman 27

Responses given by women who had sought delivery care at Hospital A were mixed but mostlypositive, indicating that they had not been asked to make inormal payments or to bring their ownsupplies:

The services I got at Hospital A during delivery were good even i I could not pay Tshs.15,000; I am sure they would attend to me and I could pay ater services. Woman 1Even though I prepared mysel and bought requirements like gloves, they were notused in the hospital. They used hospital supplies. Woman 10


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One woman (Woman 12)said she was very pleased with the care she received while giving birth;she said the care was excellent because the birth attendant was present throughout and was readyto receive the baby ater delivery. She said she would go to Hospital A or delivery again even i shedid not have money. She said the amount she was charged was the same as in Hospital B, andnothing extra was paid or supplies or asked or as a git.

Another woman contrasted this hospital with Hospital B:

The service is good; however, in my opinion Tsh. 10,000 or admission and in-patientcare makes everyone able to go there. Even those with no money would be able todeliver at Hospital A. Here in this city we have a hospital called B, but its services are

very poor. You nd a mother delivering hersel at Hospital B; it is torture. Attendants donot care or patients. Woman 35

The acility sta at Hospital B said little about inormal payments. The maternity in-charge admittedthat women coming to deliver sometimes gave gits, but insisted that she had not seen or heard osta demanding anything rom patients. However, a nurse-midwie admitted in general terms thatasking or bribes was common:

Asking or bribes is a common problem even though the services are supposed to beree. Most o the women whom we assist to deliver give us thank you in monetary terms

(which is not much). They give Tshs. 1000 to 5000 and give us vitenge (abric), chicken,sh etc. Nurse midwife

At Hospital A the management claimed to be keen to take measures to sanction inappropriatebehaviour such as corruption and mishandling o patients:

There is zero tolerance o thet. There is also zero tolerance o abusive language andbribery. Complaints are taken very seriously, and documentation and evidence sought.

Thet and bribery can lead to sackings, and in the past they have. The older governmentemployees can be sacked, not only hospital employees; it has happened. There hasbeen no recent case o bribery ound on the maternity wards. Nurse manager,maternity

For midwives to ask or money, this is not common. It is not a practice, and themanagement is very rm on this. Nurse midwife

The womens evidence supports these claims.

In both hospitals the data regarding essential supplies showed that many o the required supplieswere available within the acility. Interviewees in the health acilities were asked about the currentavailability o six essentials or handling normal in-patient delivery and 15 requirements or assisted

delivery and emergencies1. The sta in Hospital A stated that they had all o these. The Hospital B

1 The list was compiled on the basis o expert advice. The six normal delivery essentials were: clean latex or sterilegloves; disinecting solution; delivery bed; scissors or blade; cord clamp or tie; suction apparatus (bulb or machine).The emergency requirements were: syringes and needles; sutures; intravenous solution and perusion set; injectableoxytocic medication; oral valium or magnesium sulphate; injectable valium or magnesium sulphate; injectable antibioticor gentamicin; injectable hydralazine; injectable ergometrine or methergine or misoprostol; vacuum extractor or assistedlabour; vacuum aspirator or D&C kit; blood transusion capabilities; capability or caesarean section; capable MOavailable/on call; anaesthetist/nurse-anaesthetist available/on call.


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sta said they lacked oral valium or magnesium sulphate, a vacuum extractor or assisted labour, avacuum aspirator, and a Dilation and Curettage (D&C) kit, and they were unable to say whether aninjectable antibiotic was available on the day o the interview; the other items were all available.

In Hospital A, the qualitative evidence rom sta supported the availability o all essential supplies,with a commitment that started at the top:

The DG is a gynaecologist and is always arguing or women. I you run out o something,he wants to know why it wasnt ordered well in advance! ... I you dont make a goodestimate, or enough gloves or example, it is your ault I you dont have the rightsupplies, you have to go to the administration and explain why. Nurse manager,

maternity

Supplies are there, no problem. Nurse in-charge, maternity

The womens interviews also supported this claim; there were no complaints about missingsupplies:

Even though I prepared mysel and bought requirements like gloves, they were notused in the hospital. They used hospital supplies. Woman 10

The service was good. All the requirements were available or instance, I was told bynurses during ANC to prepare mysel with our pairs o gloves, threads, and mackintosh,but all were not used. They used the hospital supplies. Woman 26

In Hospital B the acility in-charge also did not identiy severe problems in terms o the availabilityo medicines and other medical supplies. They were using cost-sharing money to ll in gaps arisingrom major shortages in the Medical Stores Department (MSD). People are pushed here by lack osupplies elsewhere, he said. A nurse midwie diered in her opinion; it was the shortage o sta thatreceived most emphasis rom her:

To work in [this] hospital labour ward is a hard job; this is mainly because we have a

shortage o sta and we do not have adequate supplies. Nursemidwife

When we run short o supplies, e.g. gauze, then delivery procedure is a problem, orwhen we run short o cord ties then we have to do it in an unproessional way, andover-bleeding can occur. Nurse midwife

The women interviewed also diered in their experiences o the availability o supplies, and thereseems to have been some link between inormal payments and access to supplies, as suggestedby a quotation above. One woman said that she had bought syringes and gloves rom the pharmacyor the nurse midwives to use at the time o delivery, because the supplies are not available in the

hospital (Woman 13). However, others said:

Medical health supplies and medicine are available at the acility. Woman 36

I did not buy supplies; everything was available at the hospital. Woman 16


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3.1.4 Support and incentives for midwivesAs experienced by the patients, the weight o evidence shows that Hospital A is achieving a higherquality o care when compared to Hospital B. What makes the dierence? The literature reviewedwould suggest that support or sta may be a dierentiating actor, and we asked nurse midwivesabout the support they received and questioned all interviewees about the incentives or the sta.

In Hospital A it was clear that the management was supportive o sta who, despite constraints ooverwork due to shortages o nurse midwives, nonetheless elt valued and supported in doing their

job:

Supervision/administration is acilitating, even i you go there to report a shortage osupplies they do their best to assist. Nurse in-charge, maternityThe hospital recognises and values the work I do. Nurse midwife

The relationship between health workers is generally good and we work as a team.Nurse midwife

We asked about medical back-up when required:

The technical support system is very ecient; on any shit there is an intern (rst on

call), a resident (second on call), and a specialist (third on call). Nurse midwife

In Hospital B it was evident that sta working in the labour ward elt that the management was notbeing very supportive:

Even i you complain about shortages, management does not seem to see this as aproblem. Generally, management does not seem to recognise and appreciate the worknurses do, and so sometimes nursing and midwiery are not given the required priority.Maternity in-charge

Another challenging task is the relationship between midwives and doctors on call.Doctors who are on call are not available most o the time. I cannot explain the reasonsor the doctors not to be available. We have two doctors (specialist Obs & Gynae), butwhen we have emergencies they are most o the time not available. Nurse midwife

It is very hard to get technical support rom the medical doctors; last year was worse;at least now we have two new ones, but it is a common phenomenon or us whenseeking technical help or a medical doctor not to be around or unexplained reasons.Nurse midwife

However, the acility in-charge reported that there were currently two medical specialists includinghimsel, and that they had to do six to eight caesareans a day.

We also asked about incentives, in the sense o nancial and practical support or sta. In HospitalA the salaries o many hospital sta were paid by the government, and there were complaints aboutsalary delays, low salaries, and non-payment o allowances. Still, the hospital management wasmaking eorts to provide some incentives:


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O the private patients payments, a percentage goes or incentives to sta. The restgoes to a basket und or supplies. Nurse manager, maternity

The government is not giving any allowance, but Hospital A is giving some allowancesto the sta in maternity just to motivate them. Nurse in-charge, maternity

They pick us up when we are coming to work, and they provide us with tea, which isvery helpul. Nursemidwife

In Hospital B the acility in-charge said that he was trying to provide minimal incentives or nurses,such as tea and bread. He said that a fat-rate extra duty allowance was paid to the sta, but there

was a lack o unds or other incentives. The block grant could be used, but that had just been cutby 30 per cent. He recognised that:

The nurses need support, mentally and physically; they cant work around the clock.Facility in-charge

According to a nurse midwie:

We work in a very dicult environment; we do not have any kind o incentives. We donot have night allowances; even extra duties allowance is not paid. Midwife.

3.1.5 Reputations and Interactions

Some women interviewed compared the two hospitals and explained their choice between them.The conditions at each hospital, and their reputation, infuenced both their own and the othersdemands or services, as did conditions at the lower-level acilities. Both hospitals received womenwho chose to go there, women or whom it was the only choice when lower-level acilities ailedthem, women reerred as emergencies, and in the case o Hospital A private patients.

In Hospital A sta recognised that women chose to deliver there in order to avoid Hospital B. Thehospital director expressed rustration:

I cannot tell Hospital B what to do. Women say why should I go to Hospital B anddie?. Facility in-charge

The nurse manager explained:

There are several dierent types o admissions. There are large numbers o reerrals.Some people sel-reer; they say they dont like Hospital B. Nurse manager,maternity

One woman interviewed had decided to go to Hospital A or delivery because she did not trust

the services oered at Hospital B. She delivered at Hospital A despite being reerred to deliver atHospital B. She had changed her mind because she did not trust Hospital B, particularly bearing inmind that she was living with HIV. She said that at Hospital B the nurses were not careul enough,and she eared that her child could get HIV i she had to deliver at that acility. It was better, she said,to pay in order to secure the lie o my child (Woman 12).


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However, there were women who said they received good maternity services at Hospital B, citingcheap or ree services and the experienced sta:

I chose to deliver at Hospital B because their services are good, less expensive, and incase o emergency, one could get all such services there. Woman 14

3.2 Two Government Health Centres

In this section we compare and contrast two government health centres. Health Centre C is in anurbanised area o a city, while Health Centre D is located in the most remote part o the municipality,

where the social and physical environment is basically rural. Both aced some very similar constraints,to which they were responding in distinctive ways.

Neither health centre unlike the two hospitals was acing a severe stang constraint. There wasa real eort by the government to improve health centre stang in 2011, and both health centreshad received new sta. The in-charge at Health Centre C was very pleased to have gained newpersonnel, with the health centre being well staed as a result; there were two assistant medicalocers, eight clinical ocers, and 11 nurses, o whom three were doing midwiery. Health CentreD also seemed reasonably satised with its stang level; there were three clinical ocers and sixnurses, including one RN and two other nurse midwives. Three nurses did midwiery and all didante-natal care. Neither health centre had a theatre, so they could not do caesarean sections, andnor did they have blood bank acilities.

3.2.1 A crisis of supplies

However, both health centres were acing recurrent supply shortages in terms o assets or maternalcare. O the six requirements or normal delivery (see ootnote 1), Health Centre C stated that theyhad no gloves and no suction apparatus, although Health Centre D stated that all these wereavailable at the time o the visit. O the 11 requirements or dealing with emergencies that could beused at a health centre without a theatre or blood bank2, When visited, Health Centre C had onlysutures and intravenous solution rom this list. Health Centre D had six items; the missing itemswere sutures, oral valium or magnesium sulphate, injectable hydralazine, a vacuum extractor or

assisted labour, a vacuum aspirator, and a D&C kit.

According to the acility in-charge at Health Centre C, the lack o supplies was a severe problem.The last supply o medicines to the acility had been in mid-May 2012, which was about our monthsbeore our visit in September. There were repeated stock outs o essential medicines and suppliesor maternity, such as surgical gloves, delivery kits, and oxytocin. Supply was irregular, and otenthey did not get sucient quantities o what they had ordered.

Supply shortages made it dicult or Health Centre C to handle complications they would otherwisehave been able to deal with, such as Post Partum Haemorrhage (PPH). Thereore, women who

came to deliver were told to bring supplies such as gloves and even oxcytocin. The acility had noambulance o its own, and the service rom the only ambulance serving all acilities in the city wasnot reliable. Hence, reerred emergency patients had to pay or transport rom the health centre to

2 Syringes and needles; sutures; intravenous solution and perusion set; injectable oxytocic medication; oral valium ormagnesium sulphate; injectable valium or magnesium sulphate; injectable antibiotic or gentamicin; injectable hydralazine;injectable ergometrine or methergine or misoprostol; vacuum extractor or assisted labour; vacuum aspirator or D&C kit;blood transusion capabilities.


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hospital. The health centre reerred women largely to Hospital B, but also to Hospital A or morecomplicated cases.

When asked what happened i women were unable to pay or transport, the in-charge said:

I a reerral patient needs to pay or transport and does not have money then she willhave to wait until the ambulance rom the city arrives. Even i she is bleeding there is noway. She will have to wait. Facility in-charge

The problem o supply shortages was also pointed out by both the nurse in charge o maternalservices and the midwie. The nurse in charge o maternal services, who put the number o deliveries

they handled per month at between 48 and 52, said:

The main challenge is shortage o supplies, which makes it hard sometimes to do ourjobs eectively. The main issue is shortage o gloves, antiseptic. Sterilisation processis also poor; we are using boiling methods using kerosene equipment. The electricalsteriliser is not working properly The main disincentive to midwives is the shortage osupplies and sterilisation equipment. Nurse in-charge, maternity

The nurse in charge o maternity at Health Centre C elt she had little infuence on the availability osupplies:

As an in-charge I do not have much infuence to ensure availability o the key supplies.We report almost every day in our morning reports but my infuence is limited. Nursein-charge, maternity

A midwie also conrmed the severe shortage o supplies, saying patients were asked to bringsupplies such as gloves, oxytocin, syringes, and sometimes inusion solution. The midwie said theshortage o supplies was putting them at risk. She said their job had become risky since the 1980s,especially with the prevalence o HIV:

I there are no essential supplies you are worried because you could be at risk andalso you do not have peace o mind. As midwives we should try to cope with thesituation and do our job since this is a job that requires one to have a calling. However,we should push or improvements to be made in making more resources available.Nurse midwife

This midwie said that i she was younger and had the opportunity to change jobs, she would doso.

Health Centre D also experienced recurrent supply shortages. In particular, a shortage o gloveswas said to be a critical problem. The in-charge said they oten experienced delays in receiving

supplies, and the MSD did not bring what was ordered:

They might bring more supplies o items that we do not need and bring less o thosewe need most. For example, they might bring only one box o gloves (ty pairs) andexpect it to last or three months. The last time we received supplies was in May; this isSeptember. Facility in-charge


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The nurse midwie also pointed out that the glove shortage was a crisis:

No single pair o gloves has been received in kit in the last six months, while we havean average o between 30-50 deliveries per month. Usually a kit comes with only onebox o 50 pairs o gloves or three months. The gloves issue is a crisis. One womancan use an average o up to three pairs o gloves. They last only one week. So we arecompelled to ask them to bring gloves because it is risky to handle without protection.Ergometrine is also not sucient or the cases o PPH. Only one or two boxes in a kitis not sucient. Nurse midwife

Asked about the ordering system, the nurse midwie said yes, they do order things themselves, but

what is put in the kit is oten quite dierent rom what was ordered.

3.2.2 Bribery and abuse

In both health centres women conrmed that there was a lack o supplies, and they oten linked thisto demands or money and abusive behaviour.

Few women indicated that they had gone to deliver at Health Centre C. Those who had done soexpressed dissatisaction with the services they received, and oten associated bad services withnot being able to give money to sta:

No, in government hospitals I never got services ethically. The nurses are abusive/insulting and chase women away. For instance, at Health Centre C I was told, dontcome back here you are disturbing us, you got pregnant out o your own pleasure come back ater two months. Woman 10

One woman had been reerred to Hospital B by Health Centre C on the grounds that the healthcentre had no gloves. However, she thought that the reerral was actually because she did not givemoney to sta:

I was not asked to pay anything, but this might have contributed to the reusal atHealth Centre C. Woman 16

Furthermore, this woman compared the quality o service at the health centre during her mostrecent delivery in 2010 with that during her preceding delivery, saying that services were good backthen and medicines and supplies were available.

When asked about bribery, the acility in-charge at Health Centre C said that it did not occur.However, she went on to say that such practices were dicult to prove, giving the impression thatnothing could be done to control the problem:

This happens but it is hard to have evidence or it. It is also common or patients to give

thank yous. You have no control over this. Someone has given out willingly. Facilityin-charge

A nurse midwie at the same health centre acknowledged that women sometimes give them gits,but went on to say that this did not make them treat those who gave gits better than those whodid not. Ater all, they give gits ater getting services, she said. However, one o the womeninterviewed said she gave a git o Tshs. 2000 in thanks, so that she would get a good service thenext time she comes.


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In the case o Health Centre D, women conrmed that they had encountered the problem oinadequate supplies:

The services at Health Centre D are not good, because they lack some importantservices or pregnant women, something which is dangerous to us. For example, I didnot get olic acid or blood anaemia, a blood pressure test, tests or dizziness, untilI was directed to get those services at [a government dispensary]. So I request thegovernment to work on that and make sure that the mentioned services are availableat [Health Centre D]. At the acility, even the water or cleaning is a problem. Gloves arealso a problem ... In 2006, in my rst delivery, the bleeding was so heavy and you canimagine the acility had no injection or that, until it stopped by itsel. It is a problem.

Woman 42

Also the water or cleaning is a problem; the patients have to walk to the nearby source To me, all I saw was chaos. Woman 43

It is a very dicult time when one wants to go or a delivery service because everything,all supplies and medicines, you need to buy, and or me, I really could not aord it untilI had to borrow some cash rom my riends. Woman 45

Giving her opinion at the end o the interview, one woman said:

I think there is a shortage o supplies because everyone who goes or delivery isrequested to buy supplies, especially gloves, so the government should take necessarymeasures or this. Woman 50

However, while payments or supplies seemed universal at this health centre, not all women atHealth Centre D had experienced abusive language or bribery. The same woman said:

I was lucky to get a nurse with polite language to help me through delivery. Woman50

On the issue o bribes, the in-charge at Health Centre D acknowledged the problem, but like thein-charge in Health Centre C, he said it was done in a very secretive way and it was thereore hardto get evidence. There was no indication o measures being taken to address this problem. Thenurse midwie seemed uneasy about commenting on the issue but she did indicate that sometimeswomen give something as thanks or being attended well. She gave examples:

Women can sometimes bring you sh, sweet potatoes, or vegetables. So or us whoare in a rural setting, women are very riendly; they are always bringing something.Nurse midwife

However, only two women said they had to make inormal payments to nurses at Health Centre D,and they took this as a condition or getting good care:

The nurse also told me to give her 5000 shillings, the amount which was said to be orkerosene. I oered this ater delivery. Each woman who delivers there has to contribute5000 shillings though they say it is or kerosene, but we know it is like a git, becauseeven those who go and deliver during the day contribute the same. Woman 56


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The midwie who we ound during the aternoon was so rude, but the one who helpedme to deliver was so kind and polite and she took good care o me. But the problemwas the money I paid, but it helped me. I I did not have money they would not helpme. Woman 63

A ew more women said the nurses at Health Centre D were rude and harsh without relating thisto inormal payments. Most o the women who said they received good care knew someone at thehealth acility, or said that their husband was well known locally, and they attributed their good careto this:

I went to Health Centre D because it is near my home. I believe that Health Centre D

does not provide a good service, but because I know someone there (the in-charge),that is why I went to that acility. Also because they took good care o me The serviceI received was ethical because I was attended by people who already knew me andsome were my tribe mates. Woman 47

Actually Health Centre D is near my home, but again that is not enough, becausethe doctor o the acility (Dr. XY) and I are good riends. Thus, I always opt to go toHealth Centre D or services. So to me, as long as I know someone in the acility, I willalways get good treatment. I also know one nurse at the acility who is my riend, sheis called ...i, who is really a riend to me and she is always helping me once I go there

or service. Woman 44

In this rural location, personal relationships strongly aected the behaviour between sta andpatients.

3.2.3 Disincentives and staff morale

Sta in both health centres complained about the conditions o work. In Health Centre D the nursemidwie explained how poor and inadequate the inrastructure is:

Work conditions are not good. The labour ward is too small and has no partition. Weare doing manual vacuum aspiration (MVA) using a screen which has to be borrowedrom the doctor in-charges oce. Nurse Midwife

Summarising all this as one o the disincentives in her working lie, a nurse midwie in Health CentreD said:

No support and supplies. This is rustrating or me since I am unable to do my job well.The situation can be stressul as you are oten eeling helpless. Nurse Midwife

In Health Centre C there seemed to be little initiative by acility management to promote stamotivation, which is an important actor in job perormance. Asked whether there were incentives

or sta, the acility in-charge said there were none. The acility had budgeted or small incentivessuch as tea or sta, but they had not received the budgeted money. The in-charge expressedrustration, saying:

It is hard to cope as an in-charge in this situation and continue to encourage the sta.Facility in-charge


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The nurse in-charge also elt that the promotion system was unclear and reported this as ademotivating actor or sta.

Sta at Health Centre D ound the remote location challenging. The rural setting created additionalconstraints or sta, including very poor housing conditions and associated acts o robbery in stahouses, as well as belies and practices o witchcrat:

This is a hard area to work. There is a widespread belie in witchcrat, and robbery.Most health workers preer not to work here. We do not have enough security and themunicipality does not pay or it. The ward level has not enough money to nance thisservice. We need to enhance our security. We cannot use our user ee und or this

as it is not enough. We only collect about 300,000 per year rom user ees. Facilityin-charge

The acility was not providing any incentives to the sta. The in-charge said he could only try tolive by example and encourage the sta, because this was a hard place to work. Members o stawere not getting any allowances, including hardship allowance, and new sta had not been paid thesettling-in allowance to which they were entitled. A nurse midwie gave examples o the severity othe problem o not getting allowances and other entitlements:

No monetary incentives, e.g. no longer being paid overtime. This is the third year ithas not been paid. There are new recruits who have not even been paid subsistenceallowance. They are still staying in town. When you want to go on leave, no travelallowance is paid. There is no promotion I was last promoted in 2004. Our acility in-charge was last promoted in 1999. Nurse midwife

Regarding the channels o communication between management and sta, Health Centre Dseemed to have more sta meetings at least once a week, compared with Health Centre C wherethe acility in-charge indicated quarterly meetings. The midwie at Health Centre D said that theyreceived help and support rom the in-charge when needed, noting that this was especially truesince the arrival o two more clinical ocers, giving the acility three in total.

The demoralisation and lack o supplies and inrastructure were causing considerable dangers towomen delivering at the health centres. Health Centre C encouraged women to deliver at HospitalB, and Health Centre D was reerring complicated and emergency maternal cases to Hospital B.However, both health centres aced transport problems. At Health Centre D the lack o transport orreerred women was compounded by the remoteness o the location. In the case o Health CentreC, we have already quoted the in-charge as saying that women who were bleeding would be let towait or long periods or transport, and many women did not have money to pay or transport.

Since neither health centre indeed, no local government health centre in this district had atheatre thereore no capability to undertake emergency surgery, this transport problem could be

atal and also rustrating or some o the sta. For example, at Health Centre D:

One day a woman in her seventh pregnancy arrived at the acility in prolongedlabour. She arrived at ten pm. The phone network was very poor, the women had nocontractions. We called WEO but the vehicle had no uel, and the ambulance we usecomes rom another centre. In the struggle to get help the woman nally died beorea police escort could arrive. Her husband was out in the lake shing and she had twoyoung children in the house. Nurse midwife


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4 DiscussionThe overall ndings o this study show a close interaction between problems o stang and supplies,and those o morale and sta behaviour and perormance. In hospitals shortage o sta, whichwas causing the ew available sta to be overworked, seems to be the key organisational orm odisempowerment; while in the health centres it was supply shortages. However, it is clear rom thendings that while overwork contributed to unproessional behaviour, such as the use o abusivelanguage towards patients, in all our health acilities, and particularly in the hospitals where stashortages were more serious, Hospital A was achieving a higher quality o care as experienced bythe patients. This, the ndings suggest, can be largely attributed to a system o management thatvalues and promotes good proessional behaviour by enorcing sanctions against inappropriatebehaviour. The clear zero tolerance position regarding bribery practices in Hospital A is a case inpoint. Indeed, it has been argued that while autonomy acilitates empowerment o proessionals,

tight rules and procedures are part o a well-balanced management approach to improving theperormance o health workers (Marchal et al. 2010).

Our results also show how severely the shortage o supplies aected sta perormance in the twohealth centres. Implications o the shortage o drugs and essential medical supplies or the qualityo maternal health care have been clearly expressed by both maternity health workers and womenwho were seeking maternity health care. This has also been underscored in other studies. Forexample, in a study by Mathauer and Imlo (2006), health workers indicated that as much as theywould have liked to have higher salaries, what they wanted most was the availability o the meansand materials to enable them to perorm well proessionally.

Furthermore, an absence o incentives was shown to constrain both hospitals and health centres,aecting sta morale and thereore perormance. It is worth noting that non-monetary incentives,such as promotion and career advancement, are among the actors that aected the morale o themidwives. Other studies also show that non-monetary incentives, such as proessional development,appreciation o managers and colleagues, and recognition, are important actors that aect healthworkers perormance (Mathauer and Imlo, 2006; Dieleman et al. 2003; Dieleman and Hammeijer,2008).

Our ndings also indicate the importance o support and eective communication across acilityhierarchies. It was clear rom the responses o midwives and maternity in-charge in the our healthacilities that sta morale and appreciation o management were better in Hospital A, where there wasreal evidence o sta support and where there seemed to be better communication across hierarchylevels (relational empowerment). On the other hand, the act that midwives and the maternity in-charge at Hospital B did not know where to locate the doctors on call in that acility shows how anineective hierarchical system can be disempowering to nurses.

Finally, our results show how resigning themselves or giving up (psychological disempowerment)and not trying to do their best in the given circumstances can worsen the situation. In Hospital Band Health Centre C some sta seemed to have given up on trying to work well. A resigned attitudewas clearly portrayed by the in-charge at Health Centre C. This inhibits processes through which

alternative ways o coping with the situation can be identied. Indeed, such a resigned attitude onthe part o the in-charge in Health Centre C could be a reason why morale seemed to be lowestamong the sta in that acility.


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Conclusion and Implications for

Policy and Practice5This paper has drawn on data rom an exploratory study to examine actors that are disempoweringto nurses and nurse midwives. The motivation or exploring these actors was the persistently highlevel o MMR in Tanzania, which is partly attributed to poor-quality maternal care in health acilities.Maternal health workers oten bear the brunt o complaints rom women seeking maternal healthcare about poor quality-services and patient handling.

Drawing on concepts o empowerment rom the nursing literature, we have attempted to explore theextent to which disempowerment o nurse midwives and other maternal health-care proessionals isan important actor contributing to poor perormance in the provision o maternal health care, andthereore a contributory actor in poor maternal health outcomes.

We have shown how the absence o key empowering actors can contribute to the disempowermento maternal health workers. These range rom actors related to organisational orms odisempowerment, such as shortages o sta and supplies, poor inrastructure, and poor workingenvironments, to those that are generated and sustained by the system o hierarchy within whichhealth care is provided. The role o management in promoting an empowering environment ormaternal health workers cannot be over-emphasised. The ollowing may be considered as measuresthat might contribute to overcoming elements that disempower maternal health workers, in order toenable them to play a more eective role in contributing to better maternal health outcomes.

Provide short-term management training to those in charge o health acilities as well as other health

acility sta to impart knowledge and skills about supportive and participatory management. Thiswill enhance the capacity o health acilities to put in place more participatory and communicativemanagement systems and more fexible and interactive management hierarchies.

It is clear that the absence o incentives aects sta morale. Some o these incentives are non-monetary, and health acility management should commit to promoting these even i nancialresources are a constraint.

The problem o health-worker shortages is acknowledged at the national level, and measures arebeing taken to address it. However, there is a clear need to rethink how the currently availablequalied sta may be empowered to improve perormance.

The severity o supply shortages, especially in lower-level acilities, and its apparent interactionwith acts o bribery and abuse o patients, raises questions as to whether such shortages arearticially created. The underlying causes o such severe supply shortages need to be investigatedby looking into issues o disbursed unds, bureaucratic procedures in the disbursement o unds,delays in placing and receiving orders, supply leakages, etc.


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MoHSW (2011), Health Sector Perormance ProleReport 2010: Tanzania Mainland

Patton, Q. M. (2002). Qualitative Research &Evaluation Methods. 3 Edition. Sage PublicationsInc.

Pillay, R. (2009), Retention strategies or proessionalnurses in South Arica, Leadership in HealthServices,Vol. 22, Issue 1: pp 39 - 57

Palmier, D. (1998). How can the bed side nursetake a leadership role to aect change or theuture? Concern, Saskatchewan Registered Nurses

Association, 2(1),16-7

Ryles, S. M. (1999). A concept analysis oempowerment: Its relationship to mental healthnursing. Journal o Advanced Nursing, 29(3), 600-607.

Sampselle, P.M. (1990)The infuence o eministphilosophy on nursing practice, The Journal ofNursing Scholarship, 22(4): pp 243 47.

Siu, H.M, Laschinger, H.K.S., & Vingilis, E.(2005).The eect o problem-based learning on nursingstudents perceptions o empowerment Journal oNursing Education, 44(10), 459-469.

Spreitzer, G. M. (1995). Psychological empowermentin the workplace: Dimension, measurement, andvalidation. The Academy o Management Journal,

38(5), 1442-1465.

Tibandebage, P. and M. Mackintosh (2005), TheMarket shaping o charges, trust and abuse: Healthcare transactions in Tanzania, Social Science andMedicine, 61: 1385 95.

URT/MOHSW (2007). Report rom the Joint ExternalEvaluation o Health Sector Paper produced by theHealth Sector Reorm Secretariat, Ministry o Healthand Social Welare, Tanzania

WHO (2006), World Health Report 2006: WorkingTogether for Health; Geneva, WHO.

Wuse, J. (1994), Proessionalism and the evolutiono nursing as a discipline: A eminist perspective,

Journal of Professional Nursing, 10(6): 357 367.


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Books

Researching Poverty in Tanzania: problems,

policies and perspectives

Edited by Idris Kikula, Jonas Kipokola, Issa Shivji,Joseph Semboja and Ben Tarimo

Local Perspectives on Globalisation: The African

Case

Edited by Joseph Semboja, Juma Mwapachu andEduard Jansen

Poverty Alleviation in Tanzania: Recent ResearchIssues Edited by M.S.D. Bagachwa

Research Reports

12/4 Factors Affecting Participation in a CivilSociety Network (Nangonet) in Ngara

District

Raphael N.L. Mome

12/3 The Instrumental versus the Symbolic:Investigating Members Participation in Civil

Society Networks in Tanzania

Kenny Manara

12/2 The Effect of Boards on the Performanceof Micronance Institutions: Evidence from

Tanzania and Kenya

By Neema Mori and Donath Olomi

12/1 The Growth of Micro and Small, ClusterBased Furniture Manufacturing Firms and

their Implications for Poverty Reduction inTanzania

Edwin Paul Maede

11/2 Affordability and Expenditure Patterns forElectricity and Kerosene in Urban

Households in Tanzania

Emmanuel Maliti and Raymond Mnenwa

11/1 Creating Space for Child Participation inLocal Governmence in Tanzania: Save the

Children and Childrens CouncilsMeda Couzens and Koshuma Mtengeti

10/5 Widowhood and Vulnerability to HIV andAIDS-related Shocks: Exploring Resilience

Avenues

Flora Kessy, Iddy Mayumana and YosweMsongwe

10/4 Determinants of Rural Income in Tanzania:An Empirical Approach

Jehovaness Aikaeli

10/3 Poverty and the Rights of Children atHousehold Level: Findings from Same and

Kisarawe Districts, Tanzania

Ophelia Mascarenhas and Huruma Sigalla

10/2 Childrens Involvement in Small Business:Does if Build youth Entrepreneurship?

Raymond Mnenwa and Emmanuel Maliti

10/1 Coping Strategies Used by Street Childrenin the Event of Illness

Zena Amury and Aneth Komba

08.6 Assessing the Institutional Frameworkfor Promoting the Growth of MSEs in

Tanzania; The Case of Dar es Salaam

Raymond Mnenwa andEmmanuel Maliti

08.5 Negotiating Safe Sex among YoungWomen: the Fight against HIV/AIDS inTanzania

John R.M. Philemon and Severine S.A.Kessy

08.4 Establishing Indicators for UrbanPoverty-Environment Interaction in Tanzania:

The Case of Bonde la Mpunga, Kinondoni,

Dar es Salaam

Matern A.M. Victor, Albinus M.P. Makalleand Neema Ngware

08.3 Bamboo Trade and Poverty Alleviationin Ileje District, Tanzania

Milline Jethro Mbonile

08.2 The Role of Small Businesses in PovertyAlleviation: The Case of Dar es Salaam,

Tanzania


08.1 Improving the Quality of Human Resources

for Growth and Poverty Reduction: TheCase of Primary Education in Tanzania

Amon V.Y. Mbelle

07.2 Financing Public Heath Care: Insurance,User Fees or Taxes? Welfare Comparisons

in Tanzania

Deograsias P. Mushi

Publications by REPOA


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07.1 Rice Production in the Maswa District,Tanzania and its Contribution to Poverty

Alleviation

Jerry A. Ngailo, Abiud L. Kaswamila andCatherine J. Senkoro

06.3 The Contribution of MicronanceInstitutions to Poverty Reduction in

Tanzania

Severine S.A. Kessy and Fratern M UrioPublications by REPOA

06.2 The Role of Indigenous Knowledge inCombating Soil Infertility and Poverty in the

Usambara Mountains, Tanzania

Juma M. Wickama and Stephen T.Mwihomeke

06.1 Assessing Market Distortions AffectingPoverty Reduction Efforts on Smallholder

Tobacco Production in Tanzania

Dennis Rweyemamu and Monica Kimaro

05.1 Changes in the Upland Irrigation Systemand Implications for Rural PovertyAlleviation. A Case of the Ndiwa Irrigation

System, Wes Usambara Mountains,

Tanzania

Cosmas H. Sokoni and Tamilwai C.Shechambo

04.3 The Role of Traditional Irrigation Systems inPoverty Alleviation in Semi-Arid Areas: The

Case of Chamazi in Lushoto District,

Tanzania

Abiud L. Kaswamila and Baker M. Masuruli

04.2 Assessing the Relative Poverty of Clientsand Non-clients of Non-bank Micro-nance

Institutions. The case of the Dar es Salaam

and Coast Regions

Hugh K. Fraser and Vivian Kazi

04.1 The Use of Sustainable Irrigation forPoverty Alleviation in Tanzania. The Case of

Smallholder Irrigation Schemes in Igurusi,

Mbarali DistrictShadrack Mwakalila and Christine Noe

03.7 Poverty and Environment: Impact analysisof Sustainable Dar es Salaam Project on

Sustainable Livelihoods of Urban Poor

M.A.M. Victor and A.M.P. Makalle

03.6 Access to Formal and Quasi-Formal Creditby Smallholder Farmers and Artisanal

Fishermen: A Case of Zanzibar

Khalid Mohamed

03.5 Poverty and Changing Livelihoods ofMigrant Maasai Pastoralists in Morogoro

and Kilosa Districts

C. Mungongo and D. Mwamupe

03.4 The Role of Tourism in Poverty Alleviation inTanzania

Nathanael Luvanga and Joseph Shitundu

03.3 Natural Resources Use Patterns andPoverty Alleviation Strategies in the

Highlands and Lowlands of Karatu and

Monduli Districts A Study on Linkages and

Environmental Implications

Pius Zebbe Yanda and Ndalahwa FaustinMadulu

03.2 Shortcomings of Linkages Between

Environmental Conservation and PovertyAlleviation in Tanzania

Idris S. Kikula, E.Z. Mnzava and ClaudeMungongo

03.1 School Enrolment, Performance, Genderand Poverty (Access to Education) in

Mainland Tanzania

A.V.Y. Mbelle and J. Katabaro

02.3 Poverty and Deforestation around theGazetted Forests of the Coastal Belt of

TanzaniaGodius Kahyarara, Wilred Mbowe andOmari Kimweri

02.2 The Role of Privatisation in Providing theUrban Poor Access to Social Services: the

Case of Solid Waste Collection Services in

Dar es Salaam Suma Kaare

02.1 Economic Policy and Rural Poverty inTanzania: A Survey of Three Regions

Longinus Rutasitara

01.5 Demographic Factors, HouseholdComposition, Employment and Household

Welfare

S.T. Mwisomba and B.H.R. Kiilu


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01.4 Assessment of Village Level SugarProcessing Technology in Tanzania

A.S. Chungu, C.Z.M. Kimambo and T.A.L.Bali

01.3 Poverty and Family Size Patterns:Comparison Across African Countries

C. Lwechungura Kamuzora

01.2 The Role of Traditional Irrigation Systems(Vinyungu) in Alleviating Poverty in Iringa

Rural District

Tenge Mkavidanda and Abiud Kaswamila01.1 Improving Farm Management Skills for

Poverty Alleviation: The Case of Njombe

District

Aida Isinika and Ntengua Mdoe

00.5 Conservation and Poverty: The Case ofAmani Nature Reserve

George Jambiya and Hussein Sosovele

00.4 Poverty and Family Size in Tanzania:Multiple Responses to PopulationPressure?

C.L. Kamuzora and W. Mkanta

00.3 Survival and Accumulation Strategies atthe Rural-Urban Interface: A Study of Ifakara

Town, Tanzania

Anthony Chamwali

00.2 Poverty, Environment and Livelihood alongthe Gradients of the Usambaras on

TanzaniaAdolo Mascarenhas

00.1 Foreign Aid, Grassroots Participation andPoverty Alleviation in Tanzania:

The HESAWAFiasco S. Rugumamu

99.1 Credit Schemes and WomensEmpowerment for Poverty Alleviation: The

Case of Tanga Region, Tanzania

I.A.M. Makombe, E.I. Temba and A.R.M.Kihombo

98.5 Youth Migration and Poverty Alleviation: ACase Study of Petty Traders (Wamachinga)

in Dar es Salaam

A.J. Liviga and R.D.K Mekacha

98.4 Labour Constraints, Population Dynamicsand the AIDS Epidemic: The Case of Rural

Bukoba District, Tanzania

C.L. Kamuzora and S. Gwalema

98.3 The Use of Labour-Intensive IrrigationTechnologies in Alleviating Poverty in

Majengo, Mbeya Rural District

J. Shitundu and N. Luvanga

98.2 Poverty and Diffusion of TechnologicalInnovations to Rural Women: The Role of

EntrepreneurshipB.D. Diyamett, R.S. Mabala and R. Mandara

98.1 The Role of Informal and Semi-FormalFinance in Poverty Alleviation in Tanzania:

Results of a Field Study in Two Regions

A.K. Kashuliza, J.P. Hella, F.T. Magayaneand Z.S.K. Mvena

97.3 Educational Background, Training and TheirInuence on Female-Operated Informal

Sector EnterprisesJ. ORiordan. F. Swai and A.Rugumyamheto

97.2 The Impact of Technology on PovertyAlleviation: The Case of Artisanal Mining

in Tanzania

B W. Mutagwaba, R. Mwaipopo Akoand A. Mlaki

97.1 Poverty and the Environment: The Case ofInformal Sandmining, Quarrying and

Lime-Making Activities in Dar es Salaam,Tanzania

George Jambiya, Kassim Kulindwa andHussein Sosovele

Working Papers

13/1 Empowering Nurses to Improve MaternalHealth Outcomes

Paper 1 from the Ethics, Payments, and

Maternal Survival projectPaula Tibandebage, Tausi Kida, MaureenMackintosh and Joyce Ikingura


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Special Papers

12/4 Growth with Equity High Economic Growthand Rapid Poverty Reduction: The Case of

Vietnam

Do Duc Dinh

12/3 Why Poverty remains high in Tanzania: Andwhat to do about it?

Lars Osberg and Amarakoon Bandara1

12/2 The Instrumental versus the Symbolic:

Investigating Members Participation in CivilSociety Networks in Tanzania

By Kenny Manara

12/1 The Governance of the Capitation Grant inPrimary Education in Tanzania: Why Civic

Engagement and School Autonomy Matter

By Kenny Manara and Stephen Mwombela

11/1 Tracer Study on two Repoa TrainingCourses: Budget Analysis and Public

Expenditure Tracking SystemOphelia Mascarenhas

10/5 Social Protection of the Elderly in Tanzania:Current Status and Future Possibilities

Thadeus Mboghoina and Lars Osberg

10/4 A Comparative Analysis of PovertyIncidence in Farming Systems of Tanzania


10/3 The Tanzania Energy Sector: The Potential

for Job Creation and Productivity GainsThrough Expanded Electrication

Arthur Mwakapugi, Waheeda Samjiand Sean Smith

10/2 Local Government Finances and FinancialManagement in Tanzania: Empirical

Evidence of Trends 2000 - 2007

Reorms in TanzaniaOdd-Helge Fjeldstad, Lucas Katera, Jamaisami and Erasto Ngalewa

10/1 The Impact of Local GovernmentReforms in Tanzania

Per Tidemand and Jamal Msami

09.32 Energy Sector: Supply and Demand forLabour in Mtwara Region

Waheeda Samji, K.Nsa-Kaisiand Alana Albee

09.31 Institutional Analysis of Nutritionin Tanzania

Valerie Leach and Blandina Kilama

09.30 Inuencing Policy for Children in Tanzania:Lessons from Education, Legislation

and Social Protection

Masuma Mamdani, Rakesh Rajani andValerie Leach with Zubeida Tumbo-Masaboand Francis Omondi

09.29 Maybe We Should Pay Tax After All?

Citizens Views of Taxation in TanzaniaOdd-Helge Fjeldstad, Lucas Katera andErasto Ngalewa

09.28 Outsourcing Revenue Collection to PrivateAgents: Experiences from Local Authorities

in Tanzania

Odd-Helge Fjeldstad, Lucas Katera andErasto Ngalewa

08.27 The Growth Poverty Nexus in Tanzania:

From a Developmental PerspectiveMarc Wuyts

08.26 Local Autonomy and Citizen ParticipationIn Tanzania - From a Local Government

Reform Perspective.

Amon Chaligha

07.25 Children and Vulnerability In Tanzania:A Brief Synthesis

Valerie Leach

07.24 Common Mistakes and Problems inResearch Proposal Writing: An Assessment

of Proposals for Research Grants Submitted

to Research on Poverty Alleviation REPOA

(Tanzania).

Idris S. Kikula and Martha A. S. Qorro

07.23 Guidelines on Preparing Concept Notesand Proposals for Research on Pro-Poor

Growth and Poverty in Tanzania

07.22 Local Governance in Tanzania:Observations From Six Councils 2002-2003

Amon Chaligha, Florida Henjewele, AmbroseKessy and Georey Mwambe

07.21 Tanzanian Non-GovernmentalOrganisations Their Perceptions of

Their Relationship with the Government


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of Tanzania and Donors, and Their Role

and Impact on Poverty Reduction

empowering nurses to improve maternal health outcomes

Documents