Achieving progress in maternal and neonatal health through integrated and comprehensive healthcare services – experiences from a programme in northern Tanzania

An integrated and comprehensive hospital/community based health programme is presented, aimed at reducing maternal and child mortality and morbidity. It is run as part of a general programme of health care at a rural hospital situated in northern Tanzania. The purpose was through using research and statistics from the programme area, to illustrate how a hospital-based programme with a vision of integrated healthcare may have contributed to the lower figures on mortality found in the area. Such an approach may be of interest to policy makers, in relation to the global strategy that is now developed in order to meet the MDGs 4 and 5. The hospital provides reproductive and child health services, PMTCT-plus, comprehensive emergency obstetric care, ambulance, radio and transport services, paediatric care, an HIV/AIDS programme, and a generalised healthcare service to a population of approximately 500 000. We describe these services and their potential contribution to the reduction of the maternal and neonatal mortality ratios in the study area. Several studies from this area have showed a lower maternal mortality and neonatal mortality ratio compared to other studies from Tanzania and the national estimates. Many donor-funded programmes focusing on maternal and child health are vertical in their framework. However, the hospital, being the dominant supplier of health services in its catchment area, has maintained a horizontal approach through a comprehensive care programme. The total cost of the comprehensive hospital programme described is 3.2 million USD per year, corresponding to 6.4 USD per capita. Considering the relatively low cost of a comprehensive hospital programme including outreach services and the lower mortality ratios found in the catchment area of the hospital, we argue that donor funds should be used for supporting horizontal programmes aimed at comprehensive healthcare services. Through a strengthening of the collaboration between government and voluntary agency facilities, with clinical, preventive and managerial capabilities of the health facilities, the programmes will have a more sustainable impact and will achieve greater progress in the reduction of maternal and neonatal mortality, as opposed to vertical and segregated programmes that currently are commonly adopted for averting maternal and child deaths. Thus, we conclude that horizontal and comprehensive services of the type described in this article should be considered as a prerequisite for sustainable health care delivery at all policy and decision-making levels of the local, national and international health care delivery pyramid

Barriers to Implementing Emergency Obstetric Care in Northern Tanzania: Balancing Quality and Quantity

Background: Improving obstetric care is one key factor for the achievement of the millennium development goals concerning maternal and child mortality. Earlier studies of barriers to implementation of health policies, including plans to improve obstetric care, show that there is a major shortfall in the provision and utilization of services in a developing country such as Tanzania. Only scattered evidence exists on how these findings relate to the health system itself and the ability of the system to provide minimum quality care. Aims: The main objective of this thesis is to evaluate health system barriers to facility utilization and facility deliveries of adequate quality through the use of EmOC as a monitoring tool in a resource poor environment such as northern Tanzania. The thesis attempts to contribute to increased understanding of the importance of quality in balance with quantity of health services to improve utilization of services in the community. Material and methods: The study was conducted in six districts in northern Tanzania, and included all facilities in each district (n=129). Each facility in the study districts was assessed in terms of its supply of Emergency Obstetric Care (EmOC) services using pretested and validated assessment guidelines developed by UNICEF/WHO/UNFPA. Data were collected using a facility survey tool including information relevant specifically to the EmOC indicators. Other data sources were the national health management information systems, official planning documents, population surveys and administrative records. Results: Overall there is a very low availability of Basic Emergency Obstetric Care (BEmOC) units in the study area (1.6/500,000 people). Comparatively there is a high availability of Comprehensive Emergency Obstetric Care (CEmOC) units (4.6/500,000 people). There is a large urban / rural variation. The overall provision of Caesarian sections was 4.6%, also lower than the UN guidelines stipulate (5% – 15 %). On average 1.7 BEmOC qualified staff were available at dispensary level and 7.3 BEmOC qualified staff available at health center level. There were on average only 2.5 CEmOC qualified staff at first referral levels. Compared to global figures the availability of staff per population in Tanzania is very low. There is considerable bypassing of services. Delivering mothers seek perceived quality services, often provided only in urban areas, or by voluntary agencies in rural areas. Discussion: Using the EmOC tool was useful to assess availability and utilization of health services. Our data suggest that one of the most important determinants of access to quality care is not the knowledge of the mother or her ability to get to a facility, but the lack of quality care provided at the facility. Of concern is the total provision of good-quality services, accessible to all but not necessarily with the same overall coverage, given the severe resource constraints. The issue at stake is not coverage, but health care quality, accessibility and trust. A high coverage of inadequate quality is not pro-poor

Barriers to Implementing Emergency Obstetric Care in Northern Tanzania: Balancing Quality and Quantity

Background: Improving obstetric care is one key factor for the achievement of the millennium development goals concerning maternal and child mortality. Earlier studies of barriers to implementation of health policies, including plans to improve obstetric care, show that there is a major shortfall in the provision and utilization of services in a developing country such as Tanzania. Only scattered evidence exists on how these findings relate to the health system itself and the ability of the system to provide minimum quality care. Aims: The main objective of this thesis is to evaluate health system barriers to facility utilization and facility deliveries of adequate quality through the use of EmOC as a monitoring tool in a resource poor environment such as northern Tanzania. The thesis attempts to contribute to increased understanding of the importance of quality in balance with quantity of health services to improve utilization of services in the community. Material and methods: The study was conducted in six districts in northern Tanzania, and included all facilities in each district (n=129). Each facility in the study districts was assessed in terms of its supply of Emergency Obstetric Care (EmOC) services using pretested and validated assessment guidelines developed by UNICEF/WHO/UNFPA. Data were collected using a facility survey tool including information relevant specifically to the EmOC indicators. Other data sources were the national health management information systems, official planning documents, population surveys and administrative records. Results: Overall there is a very low availability of Basic Emergency Obstetric Care (BEmOC) units in the study area (1.6/500,000 people). Comparatively there is a high availability of Comprehensive Emergency Obstetric Care (CEmOC) units (4.6/500,000 people). There is a large urban / rural variation. The overall provision of Caesarian sections was 4.6%, also lower than the UN guidelines stipulate (5% – 15 %). On average 1.7 BEmOC qualified staff were available at dispensary level and 7.3 BEmOC qualified staff available at health center level. There were on average only 2.5 CEmOC qualified staff at first referral levels. Compared to global figures the availability of staff per population in Tanzania is very low. There is considerable bypassing of services. Delivering mothers seek perceived quality services, often provided only in urban areas, or by voluntary agencies in rural areas. Discussion: Using the EmOC tool was useful to assess availability and utilization of health services. Our data suggest that one of the most important determinants of access to quality care is not the knowledge of the mother or her ability to get to a facility, but the lack of quality care provided at the facility. Of concern is the total provision of good-quality services, accessible to all but not necessarily with the same overall coverage, given the severe resource constraints. The issue at stake is not coverage, but health care quality, accessibility and trust. A high coverage of inadequate quality is not pro-poor

Actual clinical leadership: a shadowing study of charge nurses and doctors on-call in the emergency department

Background: The provision of safe, high quality healthcare in the Emergency Department (ED) requires frontline healthcare personnel with sufficient competence in clinical leadership. However, healthcare education curriculum infrequently features learning about clinical leadership, and there is an absence of experienced doctors and nurses as role models in EDs for younger and less experienced doctors and nurses. The purpose of this study was to explore the activities performed by clinical leaders and to identify similarities and differences between the activities performed by charge nurses and those performed by doctors on-call in the Emergency Department after completion of a Clinical Leadership course. Methods: A qualitative exploratory design was chosen. Nine clinical leaders in the ED were shadowed. The data were analyzed using a thematic analysis. Results: The analysis revealed seven themes: receiving an overview of the team and patients and planning the shift; ensuring resources; monitoring and ensuring appropriate patient flow; monitoring and securing information flow; securing patient care and treatment; securing and assuring the quality of diagnosis and treatment of patient; and securing the prioritization of patients. The last two themes were exclusive to doctors on-call, while the theme “securing patient care and treatment” was exclusive to charge nurses. Conclusions: Charge nurses and doctors on-call perform multitasking and complement each other as clinical leaders in the ED. The findings in this study provide new insights into how clinical leadership is performed by charge nurses and doctors on-call in the ED, but also the similarities and differences that exist in clinical leadership performance between the two professions. Clinical leadership is necessary to the provision of safe, high quality care and treatment for patients with acute health needs, as well as the coordination of healthcare services in the ED. More evaluation studies of this Clinical Leadership course would be valuable.publishedVersio

High potential of escalating HIV transmission in a low prevalence setting in rural Tanzania

Background: Previous surveillance among antenatal clinic (ANC) attendees within the remote rural Manyara and Singida regions in Tanzania identified an imminent but still, relatively low HIV epidemic. We conducted a population-based HIV study to identify risk factors and validate the representativeness of ANC-based estimates. Methods: Using a two-stage cluster sampling approach, we enrolled and then interviewed and collected saliva samples from 1,698 adults aged 15–49 years between December 2003 and May 2004. We anonymously tested saliva samples for IgG antibodies against HIV using Bionor HIV-1&2 assays ®. Risk factors for HIV infection were analysed by multivariate logistic regression using the rural population of the two regions as a standard. Results: The prevalence of HIV in the general population was 1.8% (95%CI: 1.1–2.4), closely matching the ANC-based estimate (2.0%, 95% CI: 1.3–3.0). The female to male prevalence ratio was 0.8 (95%CI 0.4–1.7). HIV was associated with being a resident in a fishing community, and having recently moved into the area. Multiple sexual partners increased likelihood of HIV infection by 4.2 times (95% CI; 1.2–15.4) for men. In women, use of contraceptives other than condoms was associated with HIV infection (OR 6.5, 95% CI; 1.7–25.5), while most of the population (78%) have never used condoms. Conclusion: The HIV prevalence from the general population was comparable to that of pregnant women attending antenatal clinics. The revealed patterns of sexual risk behaviours, for example, close to 50% of men having multiple partners and 78% of the population have never used a condom; it is likely that HIV infection will rapidly escalate. Immediate and effective preventive efforts that consider the socio-cultural contexts are necessary to reduce the spread of the infection

Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour

\ud Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour. We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza. Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines. This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.\u

Rethinking Nursing Care: An Ethnographic Approach to Nurse-Patient Interaction in the Context of a HIV Prevention Programme in Rural Tanzania.

While care has been described as the essence of nursing, it is generally agreed that care is a complex phenomenon that remains elusive. Literature reviews highlight the centrality of nurse-patient interactions in shaping care. In sub-Saharan Africa, where there is a critical shortage of health workers, nurses remain the core of the health workforce, but the quality of the patient care they provide has been questioned. OBJECTIVE: The study explored how care is shaped, expressed and experienced in nurses' everyday communication among HIV positive women in Tanzania. STUDY CONTEXT: Data were collected through a prevention of mother-to-child transmission of HIV programme with a comprehensive community component conducted by a church-run hospital in rural Tanzania. The population is largely agro-pastoral, the formal educational level is low and poverty is rampant. METHODS: An ethnographic approach was employed. Nurses and women enrolled in the prevention of mother-to-child transmission of HIV programme were followed closely over a period of nine months in order to explore their encounters and interactions. FINDINGS AND DISCUSSION: The way care is shaped, expressed and experienced is not globally uniform, and the expectations of what quality care involves differ between settings. In this study the expectations of nurses' instructions and authority, combined with nurses' personal engagement were experienced as caring interactions. The findings from this study demonstrate that the quality of nursing care needs to be explored within the specific historical, socio-cultural context in which it is practised

Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study

<p>Abstract</p> <p>Background</p> <p>Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.</p> <p>Methods</p> <p>A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.</p> <p>Results</p> <p>An increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).</p> <p>Conclusion</p> <p>Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.</p

What do District Health Planners in Tanzania think about improving priority setting using 'Accountability for Reasonableness'?

<p>Abstract</p> <p>Background</p> <p>Priority setting in every health system is complex and difficult. In less wealthy countries the dominant approach to priority setting has been Burden of Disease (BOD) and cost-effectiveness analysis (CEA), which is helpful, but insufficient because it focuses on a narrow range of values – need and efficiency – and not the full range of relevant values, including legitimacy and fairness. 'Accountability for reasonableness' is a conceptual framework for legitimate and fair priority setting and is empirically based and ethically justified. It connects priority setting to broader, more fundamental, democratic deliberative processes that have an impact on social justice and equity. Can 'accountability for reasonableness' be helpful for improving priority setting in less wealthy countries?</p> <p>Methods</p> <p>In 2005, Tanzanian scholars from the Primary Health Care Institute (PHCI) conducted 6 capacity building workshops with senior health staff, district planners and managers, and representatives of the Tanzanian Ministry of Health to discussion improving priority setting in Tanzania using 'accountability for reasonableness'. The purpose of this paper is to describe this initiative and the participants' views about the approach.</p> <p>Results</p> <p>The approach to improving priority setting using 'accountability for reasonableness' was viewed by district decision makers with enthusiastic favour because it was the first framework that directly addressed their priority setting concerns. High level Ministry of Health participants were also very supportive of the approach.</p> <p>Conclusion</p> <p>Both Tanzanian district and governmental health planners viewed the 'accountability for reasonableness' approach with enthusiastic favour because it was the first framework that directly addressed their concerns.</p

Helping Mothers Survive Bleeding After Birth: retention of knowledge, skills, and confidence nine months after obstetric simulation-based training

Background: It is important to know the decay of knowledge, skills, and confidence over time to provide evidence-based guidance on timing of follow-up training. Studies addressing retention of simulation-based education reveal mixed results. The aim of this study was to measure the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care in order to understand the impact of training on these components. Methods: An educational intervention study was carried out in 2012 in a rural referral hospital in Northern Tanzania. Eighty-nine healthcare workers of different cadres were trained in "Helping Mothers Survive Bleeding After Birth", which addresses basic delivery skills including active management of third stage of labour and management of postpartum haemorrhage (PPH). Knowledge, skills, and confidence were tested before, immediately after, and nine months after training amongst 38 healthcare workers. Knowledge was tested by completing a written 26-item multiple-choice questionnaire. Skills were tested in two simulated scenarios "basic delivery" and "management of PPH". Confidence in active management of third stage of labour, management of PPH, determination of completeness of the placenta, bimanual uterine compression, and accessing advanced care was self-assessed using a written 5-item questionnaire. Results: Mean knowledge scores increased immediately after training from 70 % to 77 %, but decreased close to pre-training levels (72 %) at nine-month follow-up (p = 0.386) (all p-levels are compared to pre-training). The mean score in basic delivery skills increased after training from 43 % to 51 %, and was 49 % after nine months (p = 0.165). Mean scores of management of PPH increased from 39 % to 51 % and were sustained at 50 % at nine months (p = 0.003). Bimanual uterine compression skills increased from 19 % before, to 43 % immediately after, to 48 % nine months after training (p = 0.000). Confidence increased immediately after training, and was largely retained at nine-month follow-up. Conclusions: Training resulted in an immediate increase in knowledge, skills, and confidence. While knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. These findings indicate a need for continuation of training. Future research should focus on the frequency and dosage of follow-up training