Effects of helping mothers survive bleeding after birth in-service training of maternity staff : a cluster-randomized trial and mixed-method evaluation

Background: Postpartum Haemorrhage (PPH) causes a significant amount of morbidity and mortality among mothers giving birth in sub-Saharan Africa, Tanzania included. One root cause is the insufficient health worker skills to address postpartum haemorrhage. To combat this in-service training using competency-based simulation is proposed. Aim: To assess the effectiveness of the Helping Mothers Survive Bleeding After Birth (HMS BAB) in-service training of maternity staff on PPH related health outcomes, and health workers’ skills. The thesis also assessed health workers’ perceptions of the training and facility preparedness to support care of women with PPH in Tanzania. Methods: Study I was conceptualised as a cluster-randomized trial. Interrupted time-series analysis was used to compare the following PPH related health outcomes i) PPH near miss and ii) PPH case fatality between 10 intervention and 10 comparison clusters. Study II was a before-after study of health workers (n=636), and assessed skills change immediately and ten months after the training, as well as the association between health workers’ characteristics and skill change. Study III was a qualitative study using seven Focus Group Discussions (FGD) of health workers to explore their perceptions of the training implementation. A deductive theory-driven analysis informed by integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. Study IV explored health workers (FGDs, n=7) and health managers (In-depth interviews, n=12) perceptions of health facility preparedness to support care given to women with PPH. The data was analysed using thematic analysis. Results: There was a significant decline of severe PPH cases in intervention clusters compared to the comparison clusters observed immediately after the intervention. This was sustained in the post-intervention period (Study I). A small reduction in PPH case fatality was observed in intervention clusters during the post-intervention period. Health workers’ skills were significantly improved immediately after the training with a small decline at ten-months follow up (Study II). In Study III health workers reported positive perceptions of the training: the content, the training technique, use of simulated scenarios and peer practice facilitators enhanced learning. Challenges to successful training were related to organization of the training and allocating time for weekly skill practices. In Study IV health workers reported poor facility preparedness with inconsistencies and insufficiencies of resources, including few and overwhelmed maternity staff. This constrained their ability to use the new skills and to provide quality PPH-care. Additional challenges on human interactions such as communication, collaborations and leadership were highlighted. Conclusion: The HMS BAB one-day training followed by eight weekly drills was effective in reducing PPH morbidities and mortality and improved health workers skills. Implementational challenges included i) organizational aspects of in-facility training, and ii) protected time for health workers to engage in weekly drills. Health providers voiced their struggle to put their new knowledge into practice highlighting insufficiencies in health facility readiness, such as lack of drugs and blood products

Health workers' experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework

BACKGROUND: In-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers' experiences of the HMS BAB training. METHODS: Our qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation. RESULTS: Overall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational. CONCLUSION: The HMS BAB training has great potential to improve health workers' competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures

Effect of maternal vitamin D3 supplementation on maternal health, birth outcomes, and infant growth among HIV-infected Tanzanian pregnant women: study protocol for a randomized controlled trial

Background: Vitamin D has significant immunomodulatory effects on both adaptive and innate immune responses. Observational studies indicate that adults infected with HIV with low vitamin D status may be at increased risk of mortality, pulmonary tuberculosis, and HIV disease progression. Growing observational evidence also suggests that low vitamin D status in pregnancy may increase the risk of adverse birth and infant health outcomes. As a result, antiretroviral therapy (ART) adjunct vitamin D3 supplementation may improve the health of HIV-infected pregnant women and their children. Methods/design The Trial of Vitamins-5 (ToV5) is an individually randomized, double-blind, placebo-controlled trial of maternal vitamin D3 (cholecalciferol) supplementation conducted among 2300 HIV-infected pregnant women receiving triple-drug ART under Option B+ in Dar es Salaam, Tanzania. HIV-infected pregnant women of 12–27 weeks gestation are randomized to either: 1) 3000 IU vitamin D3 taken daily from randomization in pregnancy until trial discharge at 12 months postpartum; or 2) a matching placebo regimen. Maternal participants are followed-up at monthly clinic visits during pregnancy, at delivery, and then with their children at monthly postpartum clinic visits. The primary efficacy outcomes of the trial are: 1) maternal HIV disease progression or death; 2) risk of small-for-gestational age (SGA) births; and 3) risk of infant stunting at 1 year of age. The primary safety outcome of the trial is incident maternal hypercalcemia. Secondary outcomes include a range of clinical and biological maternal and child health outcomes. Discussion The ToV5 will provide causal evidence on the effect of vitamin D3 supplementation on HIV progression and death, SGA births, and infant stunting at 1 year of age. The results of the trial are likely generalizable to HIV-infected pregnant women and their children in similar resource-limited settings utilizing the Option B+ approach. Trial registration ClinicalTrials.gov identifier: NCT02305927. Registered on 29 October 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2157-3) contains supplementary material, which is available to authorized users

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

BackgroundPersistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.MethodsWe conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.ResultsThe percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.ConclusionsAddressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed

Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania.

BackgroundShared decision-making between clinicians and pregnant women with prior cesarean on the subsequent mode of delivery improves trial of labor rates, and reduces the number of repeat cesarean sections and their related complications. However, this practice is insufficient worldwide and the factors influencing it are still unknown. The study aimed at determining the proportion of pregnant women involved in shared decision-making and its associated factors in Dar es Salaam.MethodsA cross-sectional analytical study among 350 pregnant women with one prior cesarean section. Data was collected using a structured questionnaire and SPSS 23 was used for analysis. A score of 80 or higher on the nine-item Shared Decision-Making Questionnaire (SDM-Q9) was used to calculate the proportion of women, and the associated factors were obtained using a logistic regression model. P value of ResultsThe proportion of pregnant women involved in shared decision making was 38%. Factors that were significantly associated with sharing decision making were; having low level of education (AOR 0.55 95% CI 0.33-0.91), being married/having partner (AOR 2.58 95% CI 1.43-4.63), having a companion who had active participation (AOR 3.31 95% CI 1.03-10.6) and being familiar with the clinician (AOR 5.01 95% CI 1.30-19.2).ConclusionTo promote practice of shared decision making in our setting, encouragement of socially vulnerable pregnant women's participation in decision-making by health care professionals, encouragement of companion participation during antenatal care and promotion of personal continuity of care to improve familiarity to clinicians are needed

COVID-19 vaccine hesitancy among pregnant women attending public antenatal clinics in Dar es Salaam, Tanzania

ABSTRACTThe COVID-19 pandemic has claimed over six million lives and caused significant morbidities globally. The development and use of COVID-19 vaccines is a key strategy in ending this. There is a general public hesitancy on vaccine uptake, including pregnant women who are at high risk of severe forms of the disease and death when infected with the virus. To determine the magnitude of hesitancy toward COVID-19 vaccines and the associated factors among pregnant women attending public antenatal clinics in Dar es Salaam‬. This was a cross-sectional analytical study conducted among 896 pregnant women attending antenatal clinics at public health facilities in Dar es Salaam. A structured interviewer-based questionnaire, in an electronic form, was used. The analysis was done by a multivariable linear regression model using STATA 16 to obtain factors associated with vaccine hesitancy, and P < .05 was considered significant. The proportion of pregnant women with vaccine hesitancy was 45%. Hesitancy was higher among unemployed pregnant women (AOR 2.16 (95% CI 1.36–3.42) and the self-employed group (AOR 1.62 (95% CI 1.07–2.44). It was also higher among pregnant women with poor attitudes to COVID-19 vaccines (AOR 2.44 (95% CI 1.75–3.39) and women who had low perceived benefits of the vaccines (AOR 2.57 (95% CI 1.83–3.60). COVID-19 vaccine-targeted interventions should aim at the provision of knowledge on COVID-19 and the COVID-19 vaccine and address poor attitudes and perceptions that pregnant women have on these vaccines

Exploring women’s experiences of care during hospital childbirth in rural Tanzania: a qualitative study

Abstract Background Women’s childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women’s childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user’s needs. Aim This study aimed to explore women’s childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania. Methods This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization’s Quality of Care framework on experiences of care domains. Results Three themes emerged from the data: (1) Women’s experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were. Conclusion The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women’s needs

Labour outcomes among low-risk women using WHO next-generation partograph versus WHO composite partograph: A quasi-experimental study

Background: Partogram is an important tool in the management of labor and delivery. Its correct use, has been shown to decrease maternal and newborn adverse events including deaths. In Tanzania, composite partograph is used as a standard of care. Recently, the World Health Organization (WHO) released Labour Care Guide (LCG), a next generation partograph which emphases on woman centered care. This study aimed to compare maternal and newborn outcomes among low-risk pregnant women who were monitored by using WHO LCG versus those who were monitored by using composite partograph. Methodology: This Quasi Experimental Study on LCG, was conducted at Mnazi Mmoja and Vijibweni hospitals in Dar es salaam, Tanzania. The following outcomes were compared as depicted in the WHO quality of care framework: mode of delivery, Post-Partum Hemorrhage, labour augmentation, duration of labor, maternal death, APGAR, admission to Neonatal Intensive Care Unit and perinatal death. Statistical analysis was done by using Statistical Package for Social Sciences. Stepwise logistic regression was done to identify factors associated with dichotomous outcomes. Adjusted Odds Ratio, and 95% confidence interval were used to present the results.P value \u3c0.05 was considered significant Results: A total of 482 women were enrolled; 241 in the intervention and 241 in the comparison group. There was no difference regarding maternal and newborn outcomes among women in the two study groups; Post-Partum Hemorrhage (p=0.69), Perineal trauma (p=0.65) and maternal death; APGAR score at 5 minutes (p=0.41), need for NICU admission (p= 0.80) and perinatal death (p=0.33). Parity of 3 and above was associated with better maternal outcome AOR= 3.05, 95%CI:1.40- 6.65; p=0.005 while augmentation of labour was associated with less chances of better maternal outcome AOR=0.33,95% CI: 0.16- 0.68: p= 0.003. Cesarean section was ssociated with less chances of better maternal outcome AOR=0.33,95% CI: 0.16- 0.68: p= 0.003. Cesarean section was associated with poor newborn outcome AOR= 0.43, 95% CI: 0.19- 0 .96; p=0.04. Conclusion: From this study, monitoring labour in low-risk women using WHO LCG had similar maternal and newborn outcome when compared with use of a composite partograph.Large studies powered to compare maternal and newborn outcomes including high risk pregnant women in busy labour ward are highly recommended