A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania

Sunday Dominico; Florina Serbanescu; Nguke Mwakatundu; Mkambu Godfrey Kasanga; Paul Chaote; Leonard Subi; Godson Maro; Neena Prasad; Alicia Ruiz; Wilfred Mongo; Karen Schmidt; Samantha Lobis

doi:10.9745/GHSP-D-21-00485

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Program to Reduce Maternal Deaths in Tanzania: Interventions, Implementation, Duration, and Timeline
Abbreviations: CEmONC, comprehensive emergency obstetric and newborn care; CME, continuing medical education; CDC, Centers for Disease Control and Prevention; CHWs, community health workers; CPAC, comprehensive postabortion care; FP, family planning; HBB, Helping Babies Breathe; HCs, health centers; KMC, kangaroo mother care; SBA, skilled birth attendance.

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TABLE 1.

Program to Reduce Maternal Deaths in Tanzania: Maternal Health Strategies, Interventions, and Scope

Strategy and Interventions	Scope
Decentralize CEmONC from hospitals to health centers
Upgrade (construction of operating theaters and other renovations) and equip health centers to provide CEmONC	6 health centers upgraded (Group 1) 7 health centers upgraded (Group 2)
Support task sharing of CEmONC	AMOs recruited to provide obstetric surgery NMWs and clinical officers recruited to provide anesthesia
Train associate clinicians and nurses to deliver CEmONC and all providers in the maternity to provide basic EmONC (BEmONC)	CEmONC (including obstetric surgery): 33 AMOs trained Theater management: 14 NMWs trained Anesthesia: 53 NMWs and 1 clinical officer trained BEmONC: 160 health providers trained (2 AMOs, 129 NMWs, and 29 clinical officers/assistants)
Provide computers and mobile phones with CUG network connections to increase communication among health providers and clinical experts, at no expense to providers	Computers: to Group 1 health centers Mobile phones with CUG: to Group 1 and 2 health centers
Sustain availability of good-quality CEmONC
Support and mentor associate clinicians and nurses to deliver CEmONC (AMOs in obstetric surgery and NMWs and clinical officers in anesthesia) and all providers in the maternity to provide BEmONC	Providers supported: approximately 350 health providers in maternity wards at 13 upgraded health centers Supportive supervision and mentorship visits: 2011–2014, monthly visits to supported health centers; 2015–2018, quarterly visits to supported health centers
Provide continuing medical education to supported health centers to sustain and expand health providers' knowledge and skills	In-person: 12 CME in-person workshops conducted 2011–2019 on 6 topics: AVD, infection prevention, obstetric anesthesia, hemorrhage, criterion-based audits, neonatal resuscitation With information communication technology: 6 e-learning modules developed and disseminated to supported health centers: cesarean delivery, spinal anesthesia, assisted vaginal delivery, management of postpartum hemorrhage, hypertensive disorders of pregnancy, and neonatal resuscitation
Conduct clinical audits of maternal and neonatal deaths, cesarean deliveries, and near misses to monitor and improve quality of care	In supported health centers: 2011–2014, conducted monthly; 2015–2018, conducted quarterly
Provide emergency call system and conduct weekly teleconference for supported facilities to increase health providers' access to clinical advice from senior obstetricians	Emergency call system: Program obstetricians provided 24/7 telesupport to health providers 2014–2019 Weekly teleconferences: Program obstetricians facilitated conference calls Jan. 2013–Oct. 2018
Train providers to plan, budget, and manage EmONC services	Leadership and management: 95 health facility managers (“in-charges^{^a}”) trained Budget planning: 104 in-charges trained
Train health providers to maintain biomedical equipment, budget for new equipment, and do minor repairs of existing equipment	Providers from all supported health centers
Create/adapt and distribute job aids to supported facilities	Job aid topics: respectful maternity care, antenatal protocol, active management of the third stage of labor, HBB, postpartum hemorrhage, eclampsia, management of shock, vacuum extraction, breech delivery, shoulder dystocia, infection prevention and control, WHO IMPAC guidelines, Tanzanian national EmONC treatment guidelines
Introduce new evidence-based clinical interventions	AVD with vacuum in all supported hospitals, health centers, and dispensaries Tranexamic acid in all supported hospitals, health centers, and dispensaries beginning in 2018
Work with government officials to address human resource shortages	Recruited retired nurse-midwives to rejoin workforce; trained medical attendants (providers without official nursing training), as part of the maternity ward team, in skilled birth attendance
Build staff houses at health facilities to help retain health providers in rural areas and to ensure they are living close to health facilities	Constructed or renovated 18 two-family staff houses at 5 health centers and 3 hospitals
Improve newborn care
Introduce HBB in supported facilities	189 providers trained at 3 supported hospitals and 12 health centers
Train providers to promote and support women to use KMC and make minor renovations to better accommodate KMC in supported facilities	264 providers trained at 3 supported hospitals and 12 health centers; rooms renovated and equipped in 2 district hospitals and 10 health centers
Improve quality of obstetric care in dispensaries
Renovate and equip dispensaries for routine obstetric care and BEmONC	18 dispensaries in 7 districts
Train dispensary health providers to provide routine obstetric care and elements of BEmONC	39 health providers (enrolled nurses, NMWs, and clinical officers) trained initially; more than 85 additional providers trained over time
Link health centers and affiliated dispensaries for supervision and mentorship, including provision of motorcycles to facilitate supervision and mentorship visits	8 supported health centers, each equipped with a motorcycle for transport of mentors, provided continuous supportive supervision to 18 dispensaries
Strengthen referral systems
Facilitate stakeholders to create and disseminate referral guidelinesIncrease preparedness for obstetric emergencies in communities and health facilities	Pilot: One supported health center and 5 affiliated dispensaries in 1 district Replication areas: 4 additional health centers and 14 affiliated dispensaries in 2 districts
Support communities to set up and manage emergency health funds for transporting women with obstetric emergencies to health facilities	Pilot: April 2016–March 2017, 1,137 households and 204 individuals in 11 villages contributed a total of 4,285,700 TZS ($1,948 USD) Replication areas: Nov. 2017–Dec. 2018, 24 villages contributed approximately 200,000–560,000 TZS (US$85–US$240) and 70 women benefited from these funds
Organize local transport providers to be ready to transport women with obstetric emergencies when needed	Bodaboda and other taxi drivers mobilized in 5 catchment areas (pilot and replication areas)
Improve experience of care for women delivering at facilities
Introduce birth companionship for facility births	Piloted in 9 supported health facilities (1 district hospital and 8 health centers); partitions added to labor rooms to increase audio and visual privacy
Increase demand for facility delivery and improve birth preparedness
Create and manage multimedia communication campaigns	2 region-wide campaigns with maternal health focus (implemented in 2014, 2016, and 2018); 1 additional campaign with focus on family planning
Train and support CHWs to provide maternal and reproductive health education, mobilize and link communities with health services, and help communities be more prepared for obstetric emergencies	139 CHWs supported (63 supported by Thamini Uhai and 76 supported by other program partners) 2014–2019: CHWs conducted hundreds of program-related outreach events 2017–2018: CHWs made more than 14,000 visits to pregnant women
Support and sustain good quality EmONC at regional, district, and community levels
Strengthen hospitals to back up and serve as resources for health centers	Construction of new operating theaters and renovation of maternity wards at 3 supported hospitals
Include regional and district level health officials in routine supervision and mentorship visits to supported facilities	Approximately 50 district council and regional health officials participated
Form and train a regional mentorship team	1 regional mentorship team created with 36 members (obstetrician-gynecologist, medical officers, AMOs, and NMWs).
Strengthen capacity of district councils to plan, budget, manage, and support EmONC service delivery	16 district council members trained
Improve quality and use of data for decision making through training of providers and district and regional councils	60 individuals from hospitals, health centers, and regional and district councils trained in data for decision making (a series of 4 workshops), ICD-10 codes and maternal mortality (1 workshop), and data quality (1 workshop)
Train technicians to repair biomedical equipment	4 electrical technicians from districts with supported facilities
Train regional and district council officials to conduct maternal and perinatal death surveillance and response	Approximately 30 people (representing the regional and all 8 district councils) trained in 1 workshop to become members of the Regional Maternal and Perinatal Death Surveillance and Response team
Urge government officials at the national, regional, and district levels to send more health providers to Kigoma, increase budget ceiling for health centers offering CEmONC and sustain good-quality service delivery after project end	National: frequent meetings with the Ministry of Health, PO-RALG, and relevant members of parliament Regional: routine meetings with regional health management team members and regional medical officer District: routine meetings with district health management councils and district medical officers
Strengthen accountability for good-quality service delivery	Identify and engage champions (local council members, members of parliament)
Share information with communities so that they can contribute to sustaining good-quality service delivery after project end	Conducted 83 meetings with communities in catchment areas surrounding supported health facilities.
Use media to promote program achievements, advocate for sustainability of program activities, and elevate maternal mortality as a priority in Tanzania	2013–2019: an average of 4 news opportunities staged per year; news events drew 7–14 media houses and generated on average 8–15 mentions in print, online, television, and/or radio, making a total of 20–50 mentions annually; Facebook posts drew 5,532 followers; Jamii Forums, a popular Tanzanian website, reached more than 378,000 people and drew more than 270 contributions from audience members; and Twitter followers are 956 and 1,503 messages tweeted

Abbreviations: AMO, assistant medical officer; AVD, assisted vaginal delivery; BEmONC, basic emergency obstetric and neonatal care; CEmONC, comprehensive emergency obstetric and neonatal care; CHWs, community health workers; CME, continuing medical education; CUG, closed user group; EmONC, emergency obstetric and neonatal care; HBB, Helping Babies Breathe; IMPAC, Integrated Management of Pregnancy and Childbirth; KMC, kangaroo mother care; NMW, nurse-midwife; PO-RALG President's Office, Regional Administration and Local Government; TZS, Tanzanian shilling (2018 average exchange rate: 1 USD=2,200 TZS).
↵a A health facility in-charge is a health worker that is responsible for the management of daily facility operations in addition to clinical duties.

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TABLE 2.

Population, Births, and Health System, Kigoma Region, 2013, 2016, and 2018

	2013	2016	2018
Population and births
Total population	2,179,000	2,339,684	2,453,336
Population in rural areas, %	82.8	83.6	84.1
Women of reproductive age (15–49 years)	485,803	526,441	572,463
Expected annual number of live births	87,450	91,014	100,287
Health workforce
Number of health workers providing skilled care at birth^{^a}	989	1,544	1,621
Density of health workers providing skilled care at birth^{^a} (per 10,000 population)	4.5	6.6	6.6
Health care facility types
Regional hospitals	1	1	1
District hospitals	2	2	2
Other hospitals (all private)	2	3	3
Health centers with surgical care	8	12	16
Health centers without surgical care	15	13	11
Dispensaries providing maternity care^{^b}	99	143	164
Heath facility ownership
Government	119	161	184
Private/faith-based	8	13	13
Health facilities supported by the program
Governmental hospitals	3	3	3
Health centers supported (groups 1 and 2)	6	12	13
Dispensaries receiving predominantly EmONC support^{^b}	0	17	18
Dispensaries receiving predominantly family planning support^{^b}	0	49	49
Health facilities providing EmONC^{^c,^d}
Basic EmONC	0	0	1
Basic EmONC w/o AVD (BEmONC-1)	2	3	5
Comprehensive EmONC	8	8	8
Comprehensive EmONC w/o AVD (CEmONC-1)	1	1	7

Abbreviations: AVD, assisted vaginal delivery; EmONC, emergency obstetric and neonatal care.
↵a Includes obstetrician/gynecologists, surgeons, medical doctors, assistant medical officers, clinical officers/assistants, nurse-midwives, advanced practice nurses, and nurse assistants/medical attendants.
↵b All program-supported dispensaries were upgraded for essential maternal and newborn care and family planning services; 18 dispensaries received additional support, mentorship, and supported supervision for basic EmONC; 49 dispensaries received additional support, mentorship, and supervision for family planning activities, including outreach activities.
↵c EmONC includes a set of evidence-based lifesaving interventions or “signal functions” that the World Health Organization recommends for reducing maternal and neonatal mortality.⁴⁴ Basic EmONC interventions include administration of parenteral antibiotics, uterotonics, or anticonvulsants; manual removal of placenta; removal of retained products; assisted vaginal delivery; and basic neonatal resuscitation. Comprehensive EmONC interventions include 2 additional services: ability to perform obstetric surgery (e.g., cesarean delivery) and blood transfusion. Facilities were classified based on whether they had, within the previous 3 months, performed each of these interventions. Because assisted vaginal delivery—using either forceps or vacuum extractor—is relatively uncommon in Tanzania, some facilities were classified as fully providing EmONC care even if they did not perform assisted vaginal deliveries within the past 3 months.
↵d A minimum of 25 EmONC facilities including at least 5 fully functional CEmONC facilities are recommended for the 2018 population size of Kigoma.⁴⁵^,⁴⁶

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TABLE 3.

Selected Health Facility Indicators by Facility Type and Program Support Status, Kigoma Region, 2013,^{^a} 2016, and 2018

Characteristic	Kigoma Region			Total Hospitals			Total Health Centers			Total Dispensaries			Hospitals						Health Centers									Dispensaries
	Kigoma Region			Total Hospitals			Total Health Centers			Total Dispensaries			PS			NPS			PS Group 1			PS Group 2			NPS			PS EmONC			PS FP			NPS
	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018
Number of health facilities^{^b}	127	174	197	5	6	6	23	25	27	99	143	164	3	3	3	2	3	3	6	6	6	6	6	7	11	13	14	11	17	18	37	49	49	51	77	97
General facility infrastructure
Availability of electricity	75.6	72.4	91.9	100.0	100.0	100.0	87.0	80.0	81.5	71.7	69.9	93.3	100.0	100.0	100.0	100.0	100.0	100.0	83.3	100.0	100.0	83.3	83.3	85.7	90.9	69.2	71.4	72.7	47.1	100.0	73.0	77.6	93.9	70.6	70.1	91.8
Availability of clean and safe water	70.9	81.0	92.9	100.0	100.0	100.0	91.3	96.0	100.0	64.6	77.6	91.5	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	83.3	100.0	90.9	100.0	100.0	72.7	94.1	94.4	67.6	67.3	89.8	60.8	80.5	91.8
Availability of essential drugs
No stock-out last 12 months of antibiotics	39.4	48.9	92.9	100.0	100.0	100.0	69.6	80.0	88.9	29.3	41.3	93.3	100.0	100.0	100.0	100.0	100.0	100.0	50.0	83.3	100.0	83.3	66.7	100.0	72.7	84.6	78.6	27.3	35.3	100.0	27.0	36.7	91.8	31.4	45.5	92.8
No stock-out last 12 months of magnesium sulfate	26.0	87.4	89.3	80.0	100.0	83.3	73.9	84.0	96.3	12.1	87.4	88.4	100.0	100.0	66.7	50.0	100.0	100.0	100.0	100.0	100.0	50.0	66.7	100.0	72.7	84.6	92.9	27.3	82.4	100.0	13.5	87.8	89.8	7.8	88.3	85.6
No stock-out last 12 months of uterotonics	73.2	89.7	99.0	100.0	100.0	100.0	95.7	96.0	96.3	66.7	88.1	99.4	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	100.0	100.0	100.0	85.7	90.9	100.0	100.0	100.0	88.2	100.0	62.2	87.8	98.0	62.7	88.3	100.0
Routine maternal care
Labor and delivery services available 24/7	92.1	97.7	97.5	100.0	100.0	100.0	100.0	96.9	100.0	89.9	97.9	97.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	100.0	100.0	100.0	100.0	90.9	100.0	100.0	89.2	100.0	91.8	90.2	96.1	99.0
AMTSL performed routinely (confirmed)	62.2	40.2	95.9	100.0	100.0	100.0	87.0	68.0	96.3	54.5	32.9	95.7	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	33.3	100.0	72.7	69.2	92.9	63.6	35.3	94.4	45.9	30.6	95.9	58.8	33.8	95.9
Availability and use of partographs	20.5	36.2	78.7	100.0	100.0	100.0	60.9	56.0	77.8	7.1	30.1	78.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	33.3	33.3	85.7	54.5	46.2	71.4	0.0	29.4	94.4	2.7	26.5	81.6	11.8	32.5	73.2
Neonatal care
Providers initiate immediate skin-to-skin contact	NA	97.7	99.5	NA	83.3	100.0	NA	100.0	100.0	NA	97.9	99.4	NA	100.0	100.0	NA	66.7	100.0	NA	100.0	100.0	NA	100.0	100.0	NA	100.0	100.0	NA	100.0	100.0	NA	98.0	100.0	NA	97.4	99.0
Providers promote KMC	NA	67.8	69.0	NA	83.3	100.0	NA	72.0	88.9	NA	66.4	64.6	NA	100.0	100.0	NA	66.7	100.0	NA	66.7	100.0	NA	83.3	100.0	NA	69.2	78.6	NA	41.2	61.1	NA	59.2	73.5	NA	76.6	60.8
Forms and protocols
Availability of maternal death reviews forms	4.7	12.1	32.5	60.0	66.7	100.0	8.7	28.0	70.4	1.0	7.0	23.8	66.7	100.0	100.0	50.0	33.3	100.0	33.3	66.7	100.0	0.0	16.7	71.4	0.0	15.4	57.1	0.0	0.0	16.7	2.7	8.2	28.6	0.0	7.8	22.7
Availability of perinatal death reviews forms	1.6	10.9	33.0	20.0	33.3	100.0	4.3	28.0	74.1	0.0	7.0	23.8	33.3	66.7	100.0	0.0	0.0	100.0	16.7	66.7	100.0	0.0	16.7	71.4	0.0	15.4	64.3	0.0	0.0	11.1	0.0	8.2	28.6	0.0	7.8	23.7
Availability of triage protocol/algorithim	29.1	48.9	61.4	40.0	50.0	83.3	47.8	48.0	88.9	24.2	49.0	56.1	33.3	66.7	66.7	50.0	33.3	100.0	66.7	33.3	100.0	33.3	50.0	85.7	45.5	53.8	85.7	18.2	35.3	61.1	24.3	42.9	53.1	25.5	55.8	56.7
Availability of IMPAC guidelines	NA	8.6	81.7	NA	66.7	83.3	NA	44.0	70.4	NA	0.0	83.5	NA	66.7	66.7	NA	66.7	100.0	NA	66.7	83.3	NA	16.7	71.4	NA	46.2	64.3	NA	0.0	100.0	NA	0.0	85.7	NA	0.0	79.4
Availability of HBB implementation guidelines	NA	79.9	93.4	NA	100.0	100.0	NA	84.0	100.0	NA	78.3	92.1	NA	100.0	100.0	NA	100.0	100.0	NA	50.0	100.0	NA	83.3	100.0	NA	100.0	100.0	NA	58.8	94.4	NA	81.6	95.9	NA	80.5	89.7

Abbreviations: AMTSL, active management of the third stage of labor; EmONC, emergency obstetric and neonatal care; FP, family planning; HBB, Helping Babies Breathe; IMPAC, Integrated Management of Pregnancy and Childbirth; KMC, kangaroo mother care; NA, not available; PS, program-supported; NPS, non-program-supported throughout the program implementation.
↵a Indicators for year 2013 for facilities that started to receive support from the program during 2013–2017 (group 2 health centers and dispensaries) reflect pre-intervention status.
↵b The number of health facilities providing maternity care increased from 2013 and 2018 and significance testing is not applicable.

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TABLE 4.

Provision of EmONC in Hospitals, Health Centers, and Dispensaries by Program Support Status, Kigoma Region, 2013, 2016, and 2018^{^a}

Characteristic	Kigoma Region			Total Hospitals			Total Health Centers			Total Dispensaries			Hospitals						Health Centers									Dispensaries
	Kigoma Region			Total Hospitals			Total Health Centers			Total Dispensaries			PS			NPS			PS Group 1			PS Group 2			NPS			PS EmONC			PS FP			NPS
	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018	2013	2016	2018
No. of health facilities^{^b}	127	174	197	5	6	6	23	25	27	99	143	164	3	3	3	2	3	3	6	6	6	6	6	7	11	13	14	11	17	18	37	49	49	51	77	97
Monthly no. of deliveries	3,181	4,612	7,099	970	1,163	1,169	1,042	1,447	2,126	1,170	2,002	3,804	820	892	763	149	271	406	490	580	641	106	359	629	446	508	857	137	276	709	556	767	1,323	477	959	1,772
Monthly no. of obstetric complications treated	481	622	768	322	375	403	149	239	290	9	8	75	258	301	283	64	74	121	65	87	89	7	58	92	77	94	109	2	1	25	1	2	28	6	4	22
Signal function
Parenteral antibiotics	80.3	67.2	99.5	100.0	100.0	100.0	95.7	92.0	100.0	75.8	61.5	99.4	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	100.0	100.0	83.3	100.0	90.9	100.0	100.0	72.7	58.8	100.0	70.3	55.1	100.0	80.4	66.2	99.0
Uterotonic drugs	81.1	70.7	100.0	100.0	100.0	100.0	100.0	88.0	100.0	75.8	66.4	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	100.0	100.0	84.6	100.0	100.0	47.1	100.0	78.4	63.3	100.0	68.6	72.7	100.0
Anticonvulsants	29.1	91.4	92.9	100.0	100.0	100.0	82.6	88.0	100.0	13.1	91.6	91.5	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	66.7	66.7	100.0	81.8	92.3	100.0	27.3	88.2	100.0	16.2	89.8	93.9	7.8	93.5	88.7
Manual removal of placenta	11.0	8.6	10.7	80.0	100.0	100.0	43.5	28.0	51.9	0.0	1.4	0.6	100.0	100.0	100.0	50.0	100.0	100.0	66.7	16.7	50.0	16.7	0.0	71.4	45.5	46.2	42.9	0.0	0.0	5.6	0.0	0.0	0.0	0.0	2.6	0.0
Removal of retained products	13.4	16.7	58.9	100.0	100.0	100.0	52.2	84.0	85.2	0.0	1.4	53.0	100.0	100.0	100.0	100.0	100.0	100.0	66.7	100.0	100.0	16.7	83.3	100.0	63.6	76.9	71.4	0.0	0.0	88.9	0.0	0.0	59.2	0.0	2.6	43.3
Assisted vaginal delivery	10.2	6.9	6.1	80.0	83.3	50.0	30.4	28.0	33.3	2.0	0.0	0.0	100.0	100.0	66.7	50.0	66.7	33.3	83.3	83.3	66.7	0.0	0.0	42.9	18.2	15.4	14.3	0.0	0.0	0.0	0.0	0.0	0.0	3.9	0.0	0.0
Neonatal resuscitation	33.9	34.5	80.7	100.0	100.0	100.0	87.0	88.0	100.0	18.2	22.4	76.8	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	83.3	100.0	81.8	84.6	100.0	27.3	17.6	94.4	13.5	26.5	81.6	19.6	20.8	71.1
Obstetric surgery	10.2	9.8	10.7	100.0	100.0	100.0	34.8	44.0	55.6	0.0	0.0	0.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	83.3	83.3	0.0	66.7	100.0	18.2	15.4	21.4	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
Blood transfusion	11.0	6.9	11.2	100.0	100.0	100.0	39.1	24.0	59.3	0.0	0.0	0.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	66.7	83.3	0.0	0.0	100.0	27.3	15.4	28.6	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
Average number of SFs	2.8	3.1	4.7	8.6	8.8	8.5	5.7	5.6	6.9	1.8	2.4	4.2	9.0	9.0	8.7	8.0	8.7	8.3	8.3	7.3	7.8	3.8	4.7	8.1	5.4	5.3	5.8	2.3	2.1	4.9	1.8	2.3	4.3	1.8	2.6	4.0
EmONC status
CEmONC	6.3	4.6	4.1	80.0	83.3	50.0	17.4	12.0	18.5	0.0	0.0	0.0	100.0	100.0	66.7	50.0	66.7	33.3	33.3	16.7	16.7	0.0	0.0	42.9	18.2	15.4	7.1	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
CEmONC w/o AVD	0.8	0.6	3.6	0.0	16.7	50.0	4.3	0.0	14.8	0.0	0.0	0.0	0.0	0.0	33.3	0.0	33.3	66.7	16.7	0.0	16.7	0.0	0.0	28.6	0.0	0.0	7.1	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
CEmONC w/o MRP	0.8	0.6	1.5	0.0	0.0	0.0	4.3	4.0	11.1	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	16.7	16.7	33.3	0.0	0.0	0.0	0.0	0.0	7.1	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
BEmONC	0.0	0.0	0.5	0.0	0.0	0.0	0.0	0.0	3.7	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	16.7	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	5.6	0.0	0.0	0.0	0.0	0.0	0.0
BEmONC w/o AVD	1.6	1.7	2.5	0.0	0.0	0.0	8.7	12.0	14.8	0.0	0.0	0.6	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	16.7	0.0	0.0	9.1	23.1	28.6	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
BEmONC w/o MRP	0.0	1.1	0.0	0.0	0.0	0.0	0.0	8.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	33.3	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0

Abbreviations: AVD, assisted vaginal delivery; BEmONC, basic emergency obstetric and neonatal care; CEmONC, comprehensive emergency obstetric and neonatal care; EmONC, emergency obstetric and neonatal care; FP, family planning; MRP, manual removal of the placenta; PS, program-supported; NPS, non-program-supported; SFs, signal functions; w/o, without.
↵a Unless otherwise stated, the figures in this table represent percentages of facilities with a selected characteristic.
↵b The number of health facilities providing maternity care increased from 2013 and 2018 and significance testing is not applicable.

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TABLE 5.

Pregnancy Outcomes and Maternal and Perinatal Health Indicators by Health Facility Type, Kigoma Region, 2013 and 2018

	Kigoma Region			Hospitals			Health Centers			Dispensaries
	2013	2018	% Change	2013	2018	% Change	2013	2018	% Change	2013	2018	% Change
Number of health facilities	174	197	13%	6	6	0%	25	27	8%	143	164	15%
Maternal outcomes
Number of facility deliveries	38,177	85,187	123%	11,637	14,022	20%	12,505	25,517	104%	14,035	45,648	225%
Number of direct obstetric complications^{^a}	5,769	9,217	60%	3,869	4,837	25%	1,793	3,482	94%	107	898	739%
Number of cesarean deliveries	2,290	4,471	95%	1,793	2,889	61%	497	1,582	218%	0	0	N/A
Number of maternal deaths (direct and indirect)	114	148	30%	89	91	2%	22	41	86%	3	16	433%
Number of direct maternal deaths	102	129	26%	79	78	-1%	20	39	95%	3	12	300%
Perinatal outcomes
Number of births delivered in facilities	38,637	86,162	123%	11,822	14,270	21%	12,695	25,918	104%	14,120	45,974	226%
Number of live births delivered in facilities	37,606	85,054	126%	11,237	13,780	23%	12,328	25,427	106%	14,041	45,847	227%
Number of stillbirths delivered in facilities	1,031	1,101	7%	585	489	-16%	367	486	32%	79	126	59%
Number of intrapartum stillbirths delivered in facilities	556	520	-6%	320	267	-17%	191	187	-2%	45	66	47%
Number of predischarge neonatal deaths	404	649	61%	260	316	22%	129	296	129%	15	37	147%
Number of perinatal deaths (stillbirths and predischarge neonatal deaths)	1,435	1,750	22%	845	805	-5%	496	782	58%	94	163	73%
	Kigoma Region			Hospitals			Health Centers			Dispensaries
	2013	2018	Sig. Level^{^b}	2013	2018	Sig. Level^{^b}	2013	2018	Sig. Level^{^b}	2013	2018	Sig. Level^{^b}
Maternal indicators
Institutional delivery rate,^{^c,^d} %	48.8	84.9	***	13.5	14.0	***	14.7	25.4	***	20.6	45.5	***
Population cesarean delivery rate,^{^d} %	2.6	4.5	***	2.1	2.9	***	0.6	1.6	***	0.0	0.0	N/A
Met need for EmONC, %	44.0	61.3	***	29.5	32.2	***	13.7	23.1	***	0.8	6.0	***
Direct obstetric case fatality rate, %	1.8	1.4	**	2.0	1.6	NS	1.1	1.1	NS	2.8	1.3	NS
Facility MMR (maternal deaths in facilities per 100,000 live births in facilities)	303.1	174.0	***	792.0	660.4	NS	178.5	161.2	NS	21.4	34.9	NS
Perinatal indicators
Stillbirth rate (per 1,000 live births and stillbirths)	26.7	12.8	***	49.5	34.3	***	28.9	18.8	***	5.6	2.7	***
Intrapartum stillbirth rate (per 1,000 live births and stillbirths)	14.4	6.0	***	27.1	18.7	***	15.0	7.2	***	3.2	1.4	***
Predischarge neonatal mortality rate (per 1,000 live births)	10.7	7.6	***	23.1	22.9	NS	10.5	11.6	NS	1.1	0.8	NS
Perinatal mortality rate (per 1,000 live births and stillbirths)	37.1	20.3	***	71.5	56.4	***	39.1	30.2	***	6.7	3.5	***

Abbreviations: DHIS, district health information systems, EmONC, emergency obstetric and neonatal care; MMR, maternal mortality ratio; N/A, not applicable; Sig. Level, significance level.
↵a Includes antepartum, intrapartum, and postpartum hemorrhage, eclampsia/preeclampsia, puerperal sepsis, obstructed labor/uterine rupture, other direct obstetric complications (e.g., embolism, anesthetic complications), and first trimester complications related to all pregnancy losses.
↵b Asterisks indicate significance levels calculated with a z-statistic as follows: ***=P <.01, **=P <.05, *=P<.1, NS=not significant.
↵c The institutional delivery rate in 2013 includes imputations using DHIS-reported number of deliveries for missing months of outcomes, which were primarily in dispensaries. All other indicators were calculated without these imputations, as DHIS only contains aggregate data.
↵d The institutional delivery rate and the cesarean delivery rate use the expected annual number of live births in the regional population as denominators, as shown in Table 2.

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TABLE 6.

Pregnancy Outcomes and Maternal and Perinatal Health Indicators by Facility Type and Program Support, Kigoma Region, 2013 and 2018

	Kigoma Region						Hospitals						Health Centers						Dispensaries
	PS			NPS			PS			NPS			PS^{^a}			NPS			PS EmONC			PS FP			NPS
	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}	2013	2018	% Change/ Sig. Level^{^b}
Number of health facilities	81	83	2%	93	114	23%	3	3	0%	3	3	0%	12	13	8%	13	14	8%	17	18	6%	49	49	0%	77	97	26%
Maternal outcomes
Number of facility deliveries	25,313	48,768	93%	12,864	36,419	183%	9,844	9,151	-7%	1,793	4,871	172%	7,153	15,237	113%	5,352	10,280	92%	1,642	8,505	418%	6,674	15,875	138%	5,719	21,268	272%
Number of direct obstetric complications^{^c}	3,997	6,200	55%	1,772	3,017	70%	3,096	3,390	9%	773	1,447	87%	868	2,176	151%	925	1,306	41%	20	301	1405%	15	333	2120%	72	264	267%
Number of cesarean deliveries	1,637	3,061	87%	653	1,410	116%	1,382	2,026	47%	411	863	110%	255	1,035	306%	242	547	126%	0	0	N/A	0	0	N/A	0	0	N/A
Total number of maternal deaths	96	101	5%	18	47	161%	79	68	-14%	10	23	130%	15	28	87%	7	13	86%	0	2	N/A	2	3	50%	1	11	1000%
Total number of direct maternal deaths	85	88	4%	17	41	141%	69	58	-16%	10	20	1%	14	26	86%	6	13	117%	0	2	N/A	2	2	0%	1	8	700%
Perinatal outcomes
Number of newborns delivered in facilities	25,634	49,378	93%	13,003	36,784	183%	9,987	9,315	-7%	1,835	4,955	170%	7,275	15,487	113%	5,420	10,431	92%	1,663	8,553	414%	6,709	16,023	139%	5,748	21,398	272%
Number of live births delivered in facilities	24,870	48,585	95%	12,736	36,469	186%	9,487	8,921	-6%	1,750	4,859	178%	7,039	15,148	115%	5,289	10,279	94%	1,652	8,518	416%	6,692	15,998	139%	5,697	21,331	274%
Number of stillbirths delivered in facilities	764	791	4%	267	310	16%	500	393	-21%	85	96	13%	236	338	43%	131	148	13%	11	35	218%	17	25	47%	51	66	29%
Number of intrapartum stillbirths delivered in facilities	415	381	-8%	141	139	-1%	274	221	-19%	46	46	0%	123	130	6%	68	57	-16%	7	15	114%	11	15	36%	27	36	33%
Number of predischarge neonatal deaths	299	471	58%	105	178	70%	225	255	13%	35	61	74%	71	199	180%	58	97	67%	1	8	700%	2	9	350%	12	20	67%
Number of perinatal deaths (stillbirths and predischarge neonatal deaths)	1,063	1,262	19%	372	488	31%	725	648	-11%	120	157	31%	307	537	75%	189	245	30%	12	43	258%	19	34	79%	63	86	37%
Maternal indicators
Institutional delivery rate,^{^d,^e} %	31.2	48.6	***	17.6	36.3	***	11.3	9.1	***	2.2	4.9	***	8.4	15.2	***	6.3	10.3	***	2.3	8.5	***	9.2	15.8	***	9.1	21.2	***
Population cesarean delivery rate,^{^e} %	1.9	3.1	***	0.7	1.4	***	1.6	2.1	***	0.5	0.9	***	0.3	1.0	***	0.3	0.5	***	0.0	0.0	N/A	0.0	0.0	N/A	0.0	0.0	N/A
Met need for EmONC, %	30.5	41.2	***	13.5	20.1	***	23.6	25.8	***	5.9	11.0	***	6.6	14.5	***	7.1	10.0	***	0.2	2.3	***	0.1	2.5	***	0.5	2.0	***
Direct obstetric case fatality rate, %	2.1	1.4	***	1.0	1.4	NS	2.2	1.7	NS	1.3	1.4	NS	1.6	1.2	NS	0.6	1.0	NS	0.0	0.7	N/A	13.3	0.6	NS	1.4	3.0	NS
Facility MMR (maternal deaths in facilities per 100,000 live births in facilities)	386.0	207.9	***	141.3	128.9	NS	832.7	762.2	NS	571.4	473.3	NS	213.1	184.8	NS	132.4	126.5	NS	0.0	23.5	N/A	29.9	18.8	NS	17.6	51.6	NS
Perinatal indicators
Stillbirth rate (per 1,000 live births and stillbirths)	29.8	16.0	***	20.5	8.4	***	50.1	42.2	**	46.3	19.4	***	32.4	21.8	***	24.2	14.2	***	6.6	4.1	NS	2.5	1.6	NS	8.9	3.1	***
Intrapartum stillbirth rate (per 1,000 live births and stillbirths)	16.2	7.7	***	10.8	3.8	***	27.4	23.7	NS	25.1	9.3	***	16.9	8.4	***	12.5	5.5	***	4.2	1.8	NS	1.6	0.9	NS	4.7	1.7	***
Predischarge neonatal mortality rate (per 1,000 live births)	12.0	9.7	**	8.2	4.9	***	23.7	28.6	**	20.0	12.6	**	10.1	13.1	**	11.0	9.4	NS	0.6	0.9	NS	0.3	0.6	NS	2.1	0.9	*
Perinatal mortality rate (per 1,000 live births and stillbirths)	41.5	25.6	***	28.6	13.3	***	72.6	69.6	NS	65.4	31.7	***	42.2	34.7	***	34.9	23.5	***	7.2	5.0	NS	2.8	2.1	NS	11.0	4.0	***

Abbreviations: DHIS, district health information systems; EmONC, emergency obstetric and neonatal care; FP, family planning; MMR, maternal mortality ratio; PS, program-supported; NPS, non-project-supported; Sig. Level, significance level.
↵a Includes group 1 and 2 health centers.
↵b Asterisks indicate significance levels calculated with a z-statistic as follows: ***=P<.01, **=P<.05, *=P<.1, NS=not significant.
↵c Includes antepartum, intrapartum and postpartum hemorrhage, eclampsia/preeclampsia, puerperal sepsis, obstructed labor/uterine rupture, other direct obstetric complications (e.g. embolism, anesthetic complications), and first trimester complications related to all pregnancy losses.
↵d The institutional delivery rate in 2013 includes imputations using DHIS-reported number of deliveries for missing months of outcomes, which were primarily in dispensaries. All other indicators were calculated without these imputations, as DHIS only contains aggregate data.
↵e The institutional delivery rate and the cesarean delivery rate use the expected annual number of live births in the regional population as denominators, as shown in Table 2.