Limited integration of contextual factors in maternal
care contributes to slow progress towards
achieving MDG5 in sub-Sahara Africa. In Ngorongoro,
rural Tanzania, the maternal mortality
ratio is high with 642 maternal deaths/100,000
live births. Skilled birth attendants (SBAs) assist
only 7% of deliveries. This study, undertaken
from 2009 to 2011, used Participatory Action
Research involving local stakeholders (Maasai
women and men, traditional birth attendants
(TBAs), hospital staff) to examine reasons for
low utilization of SBAs and moreover to develop
proposals how to integrate contextual factors
and local needs in the health care system. Interviews,
observations and literature study were
also conducted. Thaddeus and Maine’s Three
Delays model is used to structure the analysis.
Delaying factors in decision making at home:
negative perceptions by the community on
availability and quality of care in the hospital;
discontinuity of care by TBAs; food and financial
insecurity; desired nearness to cattle and
family; limited recognition of maternal deaths;
limited male health education and suboptimal
birth preparedness. Delaying factors in reaching
the hospital: vehicle and road limitations. Delaying
factors in receiving hospital care: limited
(human) resources and limited knowledge sharing
at the hospital. Community members and
health workers proposed: increasing food/financial
security; tailoring male health education;
combining TBA/SBA care to provide continuous,
culturally appropriate labour support; creating
separate maternity wards; increasing the number
and training of staff; ensuring continuous
availability of Emergency Obstetric Care. Applying
solutions to increase hospital utilization
seems complex as collaborative actions by multiple
actors and institutions are needed to create
both a needs based and clinically sound continuum
of maternal care. To follow-up this process
of integrating local solutions into the maternal
care system, we suggest to adapt the
WHO Strategic Approach—a top-down framework
for the implementation of innovations—to
fit this bottom-up approach.