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-chargesa”) 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.