An assessment of the health system's capacity for major structural birth defects care in Tanzania using anorectal malformations as a tracer condition: A multi-phase, mixed-methods study protocol.

backgroundStructural birth defects cause disproportionate neonatal and under-five morbidity and mortality in low- and middle-income countries, where 90-95% of births and associated deaths occur; however, health-system readiness for prevention uptake, early detection, and management remains poorly understood. Anorectal malformations account for 33-40% of the paediatric surgical workload in sub-Saharan Africa, making it a tracer condition for evaluating Tanzania's 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.

methodsThis 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's 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's 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's exact tests. Phase IV will test feasibility of a preoperative anorectal malformation checklist at Muhimbili National Hospital, examining practicality and acceptability (non-parametric comparisons). DISCUSSION: This study will produce a system-level appraisal of Tanzania's 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.