"It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania

Objective: To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania.

Design: A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis.

Setting: This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care.

Participants: Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility.

Findings: Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility.

Key conclusions: The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities.

Implications for practice: Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision.

Trial registration number: NCT04685668 Date of initial trial registration: December 28th, 2020.