Figures & Tables
Figures
A family planning campaign poster shows a supportive partner escorting a pregnant woman at term to a health facility for delivery and states: “For safety and reliability, please deliver in a health care facility.” © 2018 ABC Bros Co Ltd.
- FIGURE 1
Program Logic Model
Abbreviations: GoT, Government of Tanzania; EmONC, emergency obstetric and newborn care; MRH, maternal and reproductive health; MMR, maternal mortality ratio.
aPartnership is GoT, communities, health facilities/providers, donors, implementing partners, and evaluator.
bMRH services is EmONC, skilled birth attendance, newborn care, family planning, and comprehensive postabortion care.
cQuality in terms of clinical services and women's experience of care.
- FIGURE 2
Snapshot of Major Program-Supported Interventions by Level of Health System
Abbreviations: CPAC, comprehensive postabortion care; EmONC, emergency obstetric and newborn care; LARC, long-acting reversible contraceptive.
aIn select catchment areas/facilities.
bIn a subset of 18 dispensaries.
- FIGURE 3
Evaluation Methods
Source: CDC evaluation reports23,24,29–36,40
Tables
- TABLE 1.
Key Maternal and Reproductive Health Population-Based Indicators for Tanzania (2004, 2010 and 2015/16), Western Zone (2004, 2010, 2015/16), and Kigoma Region (2004, 2010, 2014, 2015/6 and 2018), Women Aged 15–49 Years
Tanzania Western Zonea Kigoma Regionb 2004d 2010e 2015/16f 2004d 2010e 2015/16f 2004d 2010e 2014g 2015/16g 2018h Populationc 34,443,603 42,360,831 48,283,107 4,633,738 5,635,918 6,398,886 1,674,047 2,028,202 2,179,000 2,339,684 2,453,336 % Urban (women aged 15–49 years) 28.4 28.5 36.3 N/A N/A N/A N/A N/A 19.7 N/A 24.0 % Literate (women aged 15–49 years) 67.3 72.2 76.8 55.2 62.0 65.1 64.8 71.7 69.1 69.0 69.4 Total fertility rate (births per woman) 5.7 5.4 5.2 7.3 7.1 6.7 N/A N/A 6.7 N/A 6.3 Currently using any method of contraception (women in union) 26.4% 34.4% 38.4% 12.8% 20.1% 22.8% 19.8% 25.2% 20.6% 24.1% 26.3% Currently using modern contraception (women in union)i 20.0% 27.4% 32.5% 8.7% 14.6% 19.3% 12.2% 14.4% 15.6% 17.5% 21.0% Attended at least 4 antenatal care visits 61.5% 42.8% 50.6% N/A N/A N/A N/A N/A 42.1% N/A 57.7% Delivered in a health facility 47.1% 50.2% 62.6% 45.5% 36.5% 49.7% 39% 33.3% 47.1% 46.1% 77.0% Delivered by cesarean section 3.2% 4.5% 5.9% 1.8% 2.8% 3.2% 1.9% 2.0% 3.5% 4.0% 5.2% Perinatal mortality rate (per 1,000 births)j 42 36 39 28 29 32 N/A N/A 29 N/A 32 Maternal mortality ratio (per 100,000 live births) 578 454 556 N/A N/A N/A N/A N/A N/A N/A N/A Under-5 mortality rate (per 1,000 live births) 112 81 67 138 98 69 N/A N/A 56 N/A 48 Abbreviation: N/A, data not available.
↵a Includes Tabora, Shinyanga, and Kigoma regions.
↵b Regional estimates from national Demographic and Health Surveys conducted in 2004, 2010, and 2015/16 are based on small samples (200–500 women); maternal mortality at subnational level not available due to small sample sizes.
↵c Population projections based on the 2002 and 2012 census rounds.21
↵d Source: 2004 Tanzania Demographic and Health Survey.3
↵e Source: 2010 Tanzania Demographic and Health Survey.22
↵f Source: 2015–2016 Tanzania Demographic and Health Survey.17
↵g Source: 2014 Kigoma Reproductive Health Survey.23
↵h Source: 2018 Kigoma Reproductive Health Survey.24
↵i Modern contraception includes male or female sterilization, intrauterine contraceptive devices, injectables, implants, pills, male or female condoms, diaphragms, foam or jelly, lactational amenorrhea method, and emergency contraception.
↵j Stillbirths and early neonatal deaths that occurred in the 5 years before the survey per 1,000 total births (stillbirths and live births).
- TABLE 2.
Strategies and Interventions by Phase and Level of Implementation (Activities Conducted by Program Unless Otherwise Noted)
Phase 1 (2006–2012) Phase 2 (2012–2015) Phase 3 (2015–2019) Increase and sustain availability of high-quality MRH services RHMT/CHMTs -Reviewed and approved all activities and materials (e.g., job aids, campaign content)
-Participated in supportive supervision and mentorship visits to facilities
-Participated in CME workshopsThe R/CHMTs were involved in all aspects of facility upgrades and planning provider training -Improved FP commodities stock management and provided a buffer stock of all commodities in case of stock-outs
-Provided training of trainers in FP-Formed a regional mentorship team
-Provided training and technical support to improve quality of MRH data; use data for decision making, planning and budgeting; and conduct MPDSR
-Supported to train district-based biomedical technicians to repair medical equipment
-Participated in research studies (e.g., birth companionship, EmONC, and refugee communities)
-Worked toward including additional MRH service delivery costs identified through the Program into budgets (e.g., cost of providing routine onsite supervision and mentorships visits)Hospitals (N=3)
-Provided routine supportive supervision and mentorship
-Conducted routine clinical audits
-Participated in CME workshops-Provided some EmONC equipment, supplies, and medications Not applicable -Made minor renovations as needed
-Provided training and supported health providers to deliver high-quality CEmONC
-Built staff houses for maternity staff-Provided training and supported health providers to deliver high-quality: CEmONC, LARC, PMs, and CPAC
-Installed technical infrastructure and provided training in using e-learning system
-Linked to toll-free closed user group mobile phone network for emergency calls and teleconferences-Provided training and supported health providers to deliver high-quality CEmONC, LARC, PMs and CPAC, HBB,a respectful maternity care
-Provided training on improving quality of MRH data and using data for decision making, budgeting, and planning
-Introduced birth companionship in 1 hospitalHealth centers (N=6)
-Constructed 6 operating theaters and renovated maternity wards as needed
-Provided EmONC equipment, supplies, and medications
-Provided training and supported non-doctors to provide obstetric surgery and nurse-midwives/clinical officers to provide anesthesia
-Provided monthly supportive supervision and mentorship visits
-Conducted monthly clinical audits
-Provided CME workshops as needed (e.g., on assisted vaginal delivery, infection prevention)(N=12)
-Constructed operating theaters in 5 additional health centers and renovated maternity wards as needed; provided technical assistance on upgrade of 1 additional health center
-Provided EmONC & FP equipment, supplies, and medications
-Provided training and supported health providers in CEmONC, SBA, LARC, PMs, and CPAC
-Provided quarterly supportive supervision and mentorship visits
-Conducted quarterly clinical audits
-Provided CME workshops as needed
-Linked to toll-free closed user group mobile phone network for emergency calls and teleconferences
-Installed technical infrastructure and provided training in use of e-learning system
-With a focus on improving quality of EmONC, introduced weekly teleconferences, emergency call system, and e-learning platform
-Provided training and support to use COPE
-Provided technical support for FP service days(N=13)
-Provided training and supported health providers in CEmONC, SBA, LARC, PMs, CPAC, use of simulations with mannequins to regularly refresh skills, respectful maternity care.
-Provided quarterly supportive supervision and mentorship visits
-Conducted quarterly clinical audits
-Provided CME workshops as needed
-Continued weekly teleconferences, emergency call system, and e-learning platform
-Introduced HBB and KMCb
-Provided training and support to use COPEc
-Provided technical support for FP service days
-Provided training to improve quality of MRH data and how to use data for decision making, budgeting, and planning
-During critical shortages, provided essential EmONC equipment, supplies, and medications
-Introduced birth companionship in 8 health centersDispensaries Not applicable Not applicable (N=67)
-Renovated 67 dispensaries
-Provided equipment, supplies, and medications for some BEmONC, SBA, LARC, and CPAC
-Provided training for health providers in BEmONC and skilled birth attendance (N=18)
-LARC (N=67); and CPAC (N=35)
-Provided monthly supportive supervision and mentorship visits, in partnership with closest health center in-charge
-Provided training and support to use COPE
-Provided CME workshops as needed
-Provided technical support for FP service daysImprove and sustain access to MRH services RHMT/CHMTs Not applicable Participated in development and implementation of referral guidelines Hospitals Not applicable Participated in development and implementation of referral guidelines Health centers Not applicable Developed and implemented referral guidelines in partnership with catchment area around 1 health center Developed and implemented referral guidelines in partnership with catchment areas around 3 health centers Dispensaries Not applicable Developed referral guidelines in partnership with catchment areas around 5 dispensaries Developed referral guidelines in partnership with catchment areas around 18 dispensaries -Provided technical support for FP outreach
-Provided technical support for FP weeksCommunities Not applicable -In partnership with health center and dispensaries in catchment area: developed referral guidelines; started emergency scheme funds; organized local transport providers to provide care to women during obstetric emergencies
-Provided technical support for FP weeks
-Integrated FP service delivery with other community events (e.g., immunization mobile teams)Create and sustain demand for MRH services RHMT/CHMTs Not applicable -Participated in the design and development of all multimedia communication campaigns to increase demand and utilization of services
-Involved in the selection of 139 community members who were trained by the program as CHWs
-Teamed up with program staff in conducting routine supportive supervision to CHWsHospitals Not applicable Participated in campaigns Health centers Not applicable -Participated in campaigns
-Provided capacity building and support to facility in-charges to supervise CHWs
-Provided training to facilities to facilitate the process of community members being led in “walk throughs” to learn about services providedDispensaries Not applicable -Participated in campaigns
-Provided capacity building and support to facility in-charges to supervise CHWsCommunities Not applicable -Exposed to 2 multimedia campaigns focusing on importance of facility delivery, birth preparedness, and FP -Exposed to 1 multimedia campaign focusing on importance of facility delivery, birth preparedness, and birth companionship
-Promoted the use of birth companions during facility deliveries-Supported CHWs to promote and educate women and communities on MRH
-Provided support to CHWs to conduct outreach events
-Provided support to cultural troops
-Facilitated the collection of testimonies from satisfied clients
-Worked with 2 CBOs to provide reproductive health education for adolescents in schoolsAbbreviations: BEmONC, basic emergency obstetric and newborn care; CBOs, community-based organizations; CEmONC, comprehensive emergency obstetric and newborn care; CHMT, council health management teams; CHWs, community health workers; CME, continuing medical education; COPE, client-oriented, provider-efficient; CPAC, comprehensive postabortion care; EmONC, emergency obstetric and newborn care; FP, family planning; HBB, helping babies breathe; KMC, kangaroo mother care; LARC, long-acting reversible contraceptive; MPDSR, maternal and perinatal death surveillance and response; MRH, maternal and reproductive health; PM, permanent methods; RHMT, regional health management team; SBA, skilled birth attendance.
↵a Helping Babies Breathe is a training curriculum designed to improve neonatal resuscitation skills through hands-on learning and practice using the NeoNatalie newborn simulator; the training was designed to specifically meet the needs of resource-limited settings.37
↵b Kangaroo mother care is a method of care initially designed for preterm and low birthweight infants that involves the infant being held to the mother's chest for skin-to-skin contact (usually in sessions of minimum 1 hour, several times per day), early exclusive breastfeeding, and early discharge from the health facility. It is initiated in health facilities by specially trained health care providers and can continue at home.38
↵c Client-oriented, provider-efficient is an approach that helps health care staff continuously improve the quality and efficiency of services provided at their facility and make services more responsive to clients' needs.39
- TABLE 3.
Selected Facility and Population-Based Indicators Documented by External Monitoring, Kigoma Region, 2013/2014 and 2018a,b
Indicators From Facility-Based Surveys 2013 2018 % Change Significancec Institutional maternal mortality ratio (per 100,000 live births) 303 174 -43 *** Predischarge neonatal mortality rate (per 1,000 live births) 10.7 7.6 -29 *** Institutional intrapartum stillbirth rate (per 1,000 births) 14.4 6.0 -58 *** Number of BEmONC facilitiesd 2 6 +200 NA Number of CEmONC facilitiesd 9 15 +67 NA Indicators from population-based surveys (RHS) 2014 2018 % Change Significancec Contraceptive prevalence all methods (current use among married women aged 15–49 years) 20.6 26.3 +28 *** Contraceptive prevalence modern methods (current use among married women aged 15–49) 15.6 21.0 +35 *** Prevalence of implant and IUD use (current use among married women aged 15–49 years) 2.1 9.4 +348 *** Unmet need for contraception (married women aged 15–49 years) 39.2 35.1 -11 *** Abbreviations: BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; IUD, intrauterine device; RHS,, reproductive health survey.
↵a Source: CDC evaluations in health facilities30,31 and population-based surveys.23,24,29
↵b Baseline/endline population-based indicators were measured in mid-2014 (2014 RHS)23 and mid-2018 (2018 RHS).24
↵c Asterisks indicate significance level of the difference between baseline and endline outcomes for all facilities combined, using a z-statistic test for rates and proportions to calculate the p-value of the difference, as follows: *** = P<.01. NA=Not applicable.
↵d Include facilities with provision of lifesaving interventions that constitute EmONC that performed these interventions in the last 3 months: BEmONC interventions include administration of parenteral antibiotics, uterotonics, or anticonvulsants; manual removal of placenta; removal of retained products; assisted vaginal delivery; and basic neonatal resuscitation. CEmONC interventions include 2 additional services: ability to perform obstetric surgery (e.g., C- section) and blood transfusion; BEmONC and CEmONC facilities may or may not have performed assisted vaginal delivery in past 3 months (i.e., BEmONC-1 and CEmONC-1). According to the World Health Organization—which recommends at least 5 EmONC facilities per 500,000 population, including at least 1 CEmONC facility—by 2018 Kigoma achieved a sufficient number of CEmONC facilities but is still lagging behind in BEmONC facilities.9
