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Background In many countries, rates of facility-based childbirth have increased substantially in recent years. However, insufficient attention has been paid to the acceptability and quality of maternal health services provided at facilities and, consequently, maternal health outcomes have not improved as expected. Disrespect and abuse during childbirth is increasingly being recognized as an indicator of overall poor quality of care and as a key barrier to achieving improved maternal health outcomes, but little evidence exists to describe the scope and magnitude of this problem, particularly in urban areas in low-income countries. Methods This paper presents findings from an assessment of the prevalence of disrespectful and abusive behaviors during facility-based childbirth in one large referral hospital in Dar es Salaam, Tanzania. Client reports of disrespect and abuse (D&A) were obtained through postpartum interviews immediately before discharge from the facility with 1914 systematically sampled women and from community follow-up interviews with 64 women four to six weeks post-delivery. Additionally, 197 direct observations of the labor, delivery, and postpartum period were conducted to document specific incidences of disrespect and abuse during labor and delivery, which we compared with women’s reports. Results During postpartum interviews, 15 % of women reported experiencing at least one instance of D&A. This number was dramatically higher during community follow-up interviews, in which 70 % of women reported any experience of D&A. During postpartum interviews, the most common forms of D&A reported were abandonment (8 %), non-dignified care (6 %), and physical abuse (5 %), while reporting for all categories of D&A, excluding detention and non consented care, was above 50 % during community follow-up interviews. Evidence from direct observations of client-provider interactions during labor and delivery confirmed high rates of some disrespectful and abusive behaviors. Conclusions This study is one of the first to quantify the prevalence of disrespect and abuse during facility-based childbirth in a large public hospital in an urban setting. The difference in respondent reports between the two time periods is striking, and more research is needed to determine the most appropriate methodologies for measuring this phenomenon. The levels and types of disrespect and abuse reported here represent fundamental violations of women’s human rights and are symptomatic of failing health systems. Action is urgently needed to ensure acceptable, quality, and dignified care for all women.

Natural resource extraction projects are often accompanied by complex environmental and social-ecological changes. In this paper, we evaluated the association between commodity extraction and the incidence of diseases. We retrieved council (district)-level outpatient data from all public and private health facilities from the District Health Information System (DHIS2). We combined this information with population data from the 2012 national population census and a geocoded list of resource extraction projects from the Geological Survey of Tanzania (GST). We used Poisson regression with random effects and cluster-robust standard errors to estimate the district-level associations between the presence of three types of commodity extraction (metals, gemstone, and construction materials) and the total number of patients in each disease category in each year. Metal extraction was associated with reduced incidence of several diseases, including chronic diseases (IRR = 0.61, CI: 0.47–0.80), mental health disorders (IRR = 0.66, CI: 0.47–0.92), and undernutrition (IRR = 0.69, CI: 0.55–0.88). Extraction of construction materials was associated with an increased incidence of chronic diseases (IRR = 1.47, CI: 1.15–1.87). This study found that the presence of natural resources commodity extraction is significantly associated with changes in disease-specific patient volumes reported in Tanzania’s DHIS2. These associations differed substantially between commodities, with the most protective effects shown from metal extraction.

Background There is emerging evidence that disrespect and abuse (D&A) during facility-based childbirth is prevalent in countries throughout the world and a barrier to achieving good maternal health outcomes. However, much work remains in the identification of effective interventions to prevent and eliminate D&A during facility-based childbirth. This paper describes an exploratory study conducted in a large referral hospital in Dar es Salaam, Tanzania that sought to measure D&A, introduce a package of interventions to reduce its incidence, and evaluate their effectiveness. Methods After extensive consultation with critical constituencies, two discrete interventions were implemented: (1) Open Birth Days (OBD), a birth preparedness and antenatal care education program, and (2) a workshop for healthcare providers based on the Health Workers for Change curriculum. Each intervention was designed to increase knowledge of patient rights and birth preparedness; increase and improve patient-provider and provider-administrator communication; and improve women’s experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery. Results Comparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women’s knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality. Conclusions Collectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.

Introduction To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2‐year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. Methods A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed‐up to July 2021. Kaplan−Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow‐up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. Results Participants were followed‐up to 6 years for a median of 3 years (IQR: 0.1–4). The overall ART attrition rate was 13.8 per 100 person‐years (95% CI: 13.5–14.1), highest in the first year of enrolment at 27.1 (26.3–27.9), thereafter declined to 9.5 (8.9–10.1) in year 3 and 2.7 (2.1–3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38–1.92) as compared to 30‐39 year‐olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16–1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher‐level health facilities. Conclusions ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.

Male partner participation improves uptake, retention and outcomes of prevention of mother-to-child transmission of HIV (PMTCT) services. However, in patriarchal settings few men accompany their partners to antenatal care (ANC) and PMTCT services. We explored whether community leaders can improve male partner participation in ANC and PMTCT. We integrated initiatives to increase male partner participation in routine ANC care in six health facilities (attending about 4,500 new pregnant women per quarter) in Dar es Salaam, Tanzania in 2015/16. These initiatives were adapted from a best performing health facility, on male partner participation in ANC and PMTCT, referred to as the \"best practice site\". At the six purposively selected intervention sites, we sensitized and garnered commitment from healthcare providers to provide couple friendly services. We then worked with the providers to sensitize and engage community leaders to integrate and promote male partner participation initiatives in their routine community activities. We assessed change in male partner participation in ANC and PMTCT using the proportion of women testing for HIV together with their partners (i.e. couple HIV testing) by quarter. We used 203 ANC facilities (attending about 31,000 new pregnant women per quarter) in the same area as control sites. After one year, couple HIV testing in the six intervention sites had tripled from 11.9% at baseline to 36.0% (p<0.001) while there was very little change (from 17.7% to 18.3%) in the 203 control sites (p = 0.07). Statistically significant improvements in couple testing were observed in four of the six intervention sites (6.7% to 19.1%; 9.3% to 74.6%; 46.2% to 95.2%; and 4.7% to 15.1% respectively. p<0.001 for all sites). Two of these four sites, located in the same administrative district as the best practice site, achieved remarkably high couple HIV testing (95.2% and 74.6%). This may be attributable to the greater engagement and active participation of the community leaders in these two sites compared to the other four. Effective engagement and functional partnerships between healthcare providers and community leaders can contribute to improve male partner participation in ANC and PMTCT services. PMTCT programs should capitalize on community leaders, in addressing low male partner participation in ANC and PMTCT, in order to improve effective uptake, retention and outcomes of HIV prevention and treatment services among pregnant and breastfeeding women, their partners, infants and families.

Background: The UNAIDS estimate of the risk of mother-to-child transmission of HIV(MTCT) in Tanzania remains unacceptably high at 11%, despite 84% coverage of lifelong antiretroviraltreatment (ART) for the prevention of MTCT (PMTCT). ART is known to reduceMTCT to <2%, however its outcomes in routine healthcare have not been readily evaluated.This PhD thesis aimed to contribute knowledge on the outcomes of use of lifelong ART forPMTCT in routine healthcare in Dar es Salaam, Tanzania, and opportunities for improvement.Methods: Two prospective cohort studies were conducted to evaluate maternal and infantoutcomes of lifelong ART for PMTCT. The studies involved 15,586 (study I) and 13,790(study II) pregnant women who enrolled in routine PMTCT care between 2014 to 2017 andwere followed up until 2021. Study outcomes were viral suppression [<400 viral copies/ mL](study I) and MTCT [infant testing HIV positive by polymerase chain reaction or antibody testat ≥18 months old] (study II), and their determinants. Study III was a 1-year implementationstudy that evaluated the effect of engaging community leaders to improve male involvement inantenatal care (ANC) and couple HIV testing in six intervention facilities compared to 203control facilities. Study IV was a cluster randomized implementation study involving 23intervention and 24 control facilities to evaluate the effect of peer mother services in improvingretention in care, viral suppression and MTCT among women on lifelong ART for PMTCT.Results: In study I, we observed 88.2% (95% CI: 87.8% to 88.7%) viral suppression amongwomen on lifelong ART for PMTCT in routine care. Viral suppression improved on longerduration in care from 85.1% at 0-11 months to 90.6% at 36+ months since PMTCT enrolment.The risk of virologic failure was 76% higher in women aged <20 versus 30–39 years old; 28%higher in women starting PMTCT care in third versus first trimester; and 33% higher in womenwith advanced versus early stage HIV. Conversely, virologic failure was 19% lower amongwomen at ANC clinics with high versus low couple HIV testing coverage. In study II we founda low MTCT risk of 1.8% (95% CI: 1.5% to 2.1%) by 18 months post-partum. The odds ofMTCT were 2-3 times higher in women who started PMTCT care late in second/ third versusfirst trimester and twice as high in women with advanced versus early stage HIV. The odds ofMTCT were 69% lower among women who started ART before pregnancy. In study III, thecommunity-leaders intervention improved couple HIV testing from 11.9% to 36.0% (p<0.0001) at the intervention facilities compared to no change at the control facilities. In studyIV, the peer-mother intervention, compared to control, resulted in significantly higher one-yearART retention (78.0% versus 73.6%) and higher viral suppression among ART naïve womenat baseline (90.8% versus 88.1%). However, no significant difference was observed on MTCT.Conclusion: The findings of this thesis reaffirm the effectiveness of lifelong ART in achievingand sustaining high (>90%) maternal viral suppression and low (<2%) risk of MTCT in routinehealthcare. The findings indicate that adolescent mothers, late care seekers and women withadvanced HIV remain vulnerable to poor outcomes. The findings also highlight need for andopportunities to strengthen male involvement and peer mother engagement to further improveoutcomes of lifelong ART for PMTCT in routine healthcare.

The need for HIV treatment among children in Tanzania, as in most of sub-Saharan Africa, is compelling. At the end of 2009, approximately 160,000 children aged zero to fourteen in Tanzania were living with HIV. Even with successful roll out of prevention of mother to child transmission programs in Tanzania, there were nearly 29,000 perinatal infections in 2009. As of December 2010, only 18% of these were enrolled in HIV treatment programs. Without antiretroviral therapy (ART), one-half of HIV-infected children will die before their second birthday. Due to numerous efforts to scale-up pediatric HIV services, care and treatment for HIV-nfected children is now available at a number of sites in Dar es Salaam, elsewhere in Tanzania and in numerous other resource-constrained countries. As with adults, effective combination ART has made HIV a manageable chronic illness for many children and investments in their future have followed.