Increasing utilisation of good quality maternity services is necessary to reduce maternal and newborn deaths and disability in low- and middle-income countries (LMIC) through the provision of skilled care, medication and clinical procedures, including emergency obstetric care (EmOC), to prevent and treat complications [1–5].
Health systems can only provide good quality maternity care if facilities have sufficient and skilled staff who have access to functioning equipment, and sufficient drugs and supplies . The quality of maternity services is variable and often poor in LMIC [7–9]. Reasons for this include management issues , insufficient and inadequately skilled staff [10–12], high staff turnover and absenteeism [7, 13] and poorly maintained equipment and stocks of drugs and other items [12, 14]. The latter is itself an important direct contributor to the delay in women receiving timely and appropriate maternity care upon reaching a facility (known as the Phase 3 delay), which increases the risk of maternal and newborn mortality through delayed treatment of obstetric complications .
Although previous studies have reported women’s views of their maternity care [16, 17] and staff views regarding general working conditions , few have reported staff views of providing maternity care in LMIC, despite these being key to understanding staff motivation and working conditions.
Here we examine the experiences of professional staff providing maternal care in public rural health facilities in Southern Tanzania, focusing on issues arising in the context of poorly maintained equipment and insufficient key drugs and other supplies. We also aim to quantify the availability of functioning equipment and medical supplies.
Tanzanian health system
The Tanzanian public health system comprises a network of dispensaries, health centres and hospitals. Health sector reform, since 1994, is characterized by decentralization with devolution , integration of vertical programs, promotion of private-public mix, and a sector wide approach. It also includes joint donor financing directly to districts through “basket funding” since 2001.
Council Health Management Teams (CHMTs) are responsible for health services in their district . Each CHMT is headed by a District Medical Officer (DMO), who answers to the local government and is supported by the regional medical officer .
Ordering and equipment maintenance systems
The purchase and distribution of drugs and equipment are mandated to the Medical Stores Department (MSD), a semiautonomous organisation under the Ministry of Health and Social Welfare . Drug distribution changed in the mid 2000s to a “pull” system where facilities order according to their needs via the DMO’s office, which distributes items to facilities . While facilities are allowed to purchase drugs from user fees and community health funds, lengthy bureaucracy undermines this option.
The Tanzania demographic and health survey 2010 reported a maternal mortality ratio (MMR) of 454/100,000 deliveries and a neonatal mortality rate (NMR) of 26/1000 live births ; such levels warrant intensive reduction strategies. Southern Tanzania is largely rural: 39% of the population lives under the poverty line  and the MMR and NMR are higher than the national average (MMR: 731 in 2007 (unpublished data), NMR: 47 in 2004 ).
A national medicine supply assessment reported high availability of drugs in general (median availability of twenty tracer drugs in health facilities was 89%) but stock management was poor, with frequent and long-lasting stock outs . For maternal care, a national health service provision assessment in 2006 showed there was much room for improvement . Although antenatal care (ANC) was available in nearly all government facilities, fewer than half had all essential equipment, drugs and supplies for basic ANC, including blood pressure machine, foetoscope, and iron and folic acid tablets. While delivery services were widely available, basic items for conducting normal deliveries were available in only one in eight of those facilities.
The availability of items required for maternity care has been found to be lower in the Southern Zone of Tanzania compared to others nationally . Despite this, assessments of the quality of reproductive health services in Lindi region in 1999 and 2007  found improvements in the availability of equipment for maternal and neonatal care, such as scissors (availability increased from 34% of facilities in 1999 to 84% in 2007) and needle holders (increased from 23% in 1999 to 73% in 2007). Furthermore availability of some supplies greatly improved between the two surveys, e.g. syphilis test kits (from 0% to 54%) and intravenous kits (from 5% to 38%). Nevertheless, availability of other key items remained problematic, e.g. functioning blood pressure machines and working sterilisers were found in only half of facilities. Shortages and stock outs also remained common .
The availability of EmOC was well below international recommendations, often due to unavailability of parenteral anticonvulsants or assisted vaginal delivery . Eighteen percent of hospitals provided comprehensive EmOC . The coverage of EmOC in the Southern Zone of Tanzania was 0.7 facilities/500,000 people for basic emergency care, which is well below the United Nations recommended level of 4 facilities/500,000 people . Data from 2000–2002 gave a rate for major obstetric interventions, essentially caesarean section, of 1.8% of expected births, indicating deficiencies in access to life-saving comprehensive EmOC in rural areas .
Despite these challenges, staff in rural health facilities in Tanzania provide ANC to the majority of pregnant women (95%) and assist many deliveries (41%) . In the study area nearly all (99%) pregnant women attend ANC at least once , and over half of women deliver in a health facility [22, 28], mainly public facilities .