{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:56:51Z","timestamp":1791223011864,"version":"4.1.0"},"reference-count":52,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Structural birth defects cause disproportionate neonatal and under-five morbidity and mortality in low- and middle-income countries, where 90\u201395% of births and associated deaths occur; however, health-system readiness for prevention uptake, early detection, and management remains poorly understood. Anorectal malformations account for 33\u201340% of the paediatric surgical workload in sub-Saharan Africa, making it a tracer condition for evaluating Tanzania\u2019s capacity across primary, secondary, and tertiary prevention levels. Although delayed detection, high postoperative morbidity, and referral dysfunction are documented, the upstream preconception, antenatal, delivery, and postnatal profile, parental lived experience, external benchmarking of paediatric surgical capacity, and feasibility of a context-specific preoperative checklist remain to be quantified within the Tanzanian clinical environment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This multi-phase mixed-methods protocol comprises four phases. In Phase I, all mother-newborn dyads where the infant has an anorectal malformation presenting to Muhimbili National Hospital will be enrolled in a cross-sectional study quantifying preconception, antenatal, delivery, and postnatal prevention uptake; multivariable logistic regression will identify predictors of early detection; the sample size will be derived via Cochran\u2019s formula using finite population correction. Phase II will use descriptive phenomenology through purposive in-depth interviews with parents exploring socio-cultural access determinants, analysed via the Stevick-Colaizzi-Keen method. Phase III will conduct a facility-level survey against the Optimal Resources for Children\u2019s Surgery checklist at four tertiary hospitals; domain-specific and total compliance scores will be calculated, gaps quantified against benchmarks, and centres compared using Friedman tests and chi-square or Fisher\u2019s exact tests. Phase IV will test feasibility of a preoperative anorectal malformation checklist at Muhimbili National Hospital, examining practicality and acceptability (non-parametric comparisons).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This study will produce a system-level appraisal of Tanzania\u2019s capacity to prevent, detect, and manage major structural birth defects using anorectal malformation as a tracer condition. Findings will inform policy, guide resource allocation, and support targeted interventions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0359639","type":"journal-article","created":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:26:54Z","timestamp":1791221214000},"page":"e0359639","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["An assessment of the health system\u2019s capacity for major structural birth defects care in Tanzania using anorectal malformations as a tracer condition: A multi-phase, mixed-methods study protocol"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0361-1099","authenticated-orcid":true,"given":"Masawa K.","family":"Nyamuryekung\u2019e","sequence":"first","affiliation":[{"name":"Aga Khan University Medical College","place":["Dar es Salaam, Tanzania"],"department":["Department of Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kokila","family":"Lakhoo","sequence":"additional","affiliation":[{"name":"University of Oxford","place":["Oxford, United Kingdom"],"department":["Nuffield Department of Surgical Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salome","family":"Maswime","sequence":"additional","affiliation":[{"name":"University of Cape Town","place":["Cape Town, South Africa"],"department":["Global Surgery Division, Department of Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,5]]},"reference":[{"key":"pone.0359639.ref001","doi-asserted-by":"crossref","first-page":"764239","DOI":"10.3389\/fped.2021.764239","article-title":"Generating evidence from contextual clinical research in low- to middle income countries: A roadmap based on theory of change","volume":"9","author":"BS Hasan","year":"2021","journal-title":"Front Pediatr"},{"issue":"2","key":"pone.0359639.ref002","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1002\/bdr2.1972","article-title":"Prevention and awareness of birth defects across the lifespan using examples from congenital heart defects and spina bifida","volume":"114","author":"SL Farr","year":"2022","journal-title":"Birth Defects Res"},{"key":"pone.0359639.ref003","doi-asserted-by":"crossref","first-page":"15741","DOI":"10.18697\/ajfand.91.19125","article-title":"Prevention of birth defects in East Africa: A review of national policies","volume":"20","author":"S Walani","year":"2020","journal-title":"AJFAND"},{"issue":"1","key":"pone.0359639.ref004","doi-asserted-by":"crossref","first-page":"2354002","DOI":"10.1080\/16549716.2024.2354002","article-title":"Action against birth defects: If not now, when?","volume":"17","author":"K Strong","year":"2024","journal-title":"Glob Health Action"},{"issue":"4","key":"pone.0359639.ref005","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1016\/j.clp.2022.08.002","article-title":"Advances in the management of the neonate born with an anorectal malformation","volume":"49","author":"SK King","year":"2022","journal-title":"Clin Perinatol"},{"issue":"7","key":"pone.0359639.ref006","doi-asserted-by":"crossref","first-page":"1263","DOI":"10.1016\/j.jpedsurg.2023.01.051","article-title":"Screening for VACTERL anomalies in children with anorectal malformations: Outcomes of a standardized approach","volume":"58","author":"HME Evans-Barns","year":"2023","journal-title":"J Pediatr Surg"},{"key":"pone.0359639.ref007","doi-asserted-by":"crossref","first-page":"819","DOI":"10.3390\/v15040819","article-title":"Primary, secondary, and tertiary prevention of congenital cytomegalovirus infection","volume":"15","author":"P Sartori","year":"2023","journal-title":"Viruses"},{"issue":"3","key":"pone.0359639.ref008","doi-asserted-by":"crossref","first-page":"224","DOI":"10.4314\/thrb.v13i3.56442","article-title":"Experiences with childhood colostomy at a tertiary hospital in Mwanza, Tanzania","volume":"13","author":"PL Chalya","year":"2011","journal-title":"Tanzania J Hlth Res"},{"issue":"9","key":"pone.0359639.ref009","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2020-004406","article-title":"Paediatric surgical outcomes in sub-Saharan Africa: A multicentre, international, prospective cohort study","volume":"6","author":"PaedSurg Africa Research Collaboration","year":"2021","journal-title":"BMJ Glob Health"},{"issue":"8","key":"pone.0359639.ref010","article-title":"Management and outcomes of gastrointestinal congenital anomalies in low, middle and high income countries: Protocol for a multicentre, international, prospective cohort study","volume":"9","author":"Global PaedSurg Research Collaboration","year":"2019","journal-title":"BMJ Open"},{"key":"pone.0359639.ref011","doi-asserted-by":"crossref","unstructured":"Melkonian V, Vincent SA, Torre LDL, Initiative THPGSR, Olson KE, Ketzer J, et al. 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