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

Strategy and InterventionsScope
Decentralize CEmONC from hospitals to health centers
    Upgrade (construction of operating theaters and other renovations) and equip health centers to provide CEmONC6 health centers upgraded (Group 1)
7 health centers upgraded (Group 2)
    Support task sharing of CEmONCAMOs 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 providersComputers: 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 BEmONCProviders 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 skillsIn-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 careIn 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 obstetriciansEmergency 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 servicesLeadership 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 equipmentProviders from all supported health centers
    Create/adapt and distribute job aids to supported facilitiesJob 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 interventionsAVD 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 shortagesRecruited 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 facilitiesConstructed or renovated 18 two-family staff houses at 5 health centers and 3 hospitals
Improve newborn care
    Introduce HBB in supported facilities189 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 facilities264 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 BEmONC18 dispensaries in 7 districts
    Train dispensary health providers to provide routine obstetric care and elements of BEmONC39 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 visits8 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 facilitiesPilot: 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 facilitiesPilot: 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 neededBodaboda 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 birthsPiloted 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 campaigns2 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 emergencies139 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 centersConstruction 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 facilitiesApproximately 50 district council and regional health officials participated
    Form and train a regional mentorship team1 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 delivery16 district council members trained
    Improve quality and use of data for decision making through training of providers and district and regional councils60 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 equipment4 electrical technicians from districts with supported facilities
    Train regional and district council officials to conduct maternal and perinatal death surveillance and responseApproximately 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 endNational: 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 deliveryIdentify 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 endConducted 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 Tanzania2013–2019: 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.