Study protocol : improving newborn survival in rural southern Tanzania : a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening

Child mortality has declined substantially in many countries including Tanzania, but newborn mortality remains high and around 3 million babies die every year in the first 28 days of life. Community-based approaches with home visits in the first week of life have shown great potential to reduce newborn mortality. INSIST aimed1 to develop, implement and evaluate an integrated, two-part strategy that combines interventions at community level with health system strengthening in rural Southern Tanzania to reduce newborn mortality. The community intervention focused around interpersonal communication through home visits in pregnancy and the early neonatal period by a village-based "agent of change". Key messages focused on hygiene during delivery, immediate and exclusive breastfeeding, and identification and extra care for babies born small because of low birth weight or prematurity. Extra care for babies born small included skin-to-skin care for small babies and referral to hospital for very small babies. The community intervention was implemented in six poor rural districts in Southern Tanzania, with 65 of the 132 wards within these districts randomized to receive the community intervention. In addition, a health system quality-improvement package was implemented in all health facilities of one district. Data collection for the evaluation included i) a baseline household survey in 2007 of all 243,000 households in 5 of the 6 study districts to estimate baseline mortality and prevalence of newborn care behaviours, ii) an adequacy survey in 2011 in a representative sample of 5,000 households to estimate coverage of home visits and prevalence of newborn care behaviours, and iii) an endline household survey in 2013 in a representative sample of 200,000 households to estimate newborn and maternal mortality and prevalence of newborn care behaviours. The final analysis was based on "intention to treat", comparing newbor

Staff experiences of Providing Maternity Services in Rural Southern Tanzania -- A Focus on Equipment, Drug and Supply Issues.

The poor maintenance of equipment and inadequate supplies of drugs and other items contribute to the low quality of maternity services often found in rural settings in low- and middle-income countries, and raise the risk of adverse maternal outcomes through delaying care provision. We aim to describe staff experiences of providing maternal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies. Focus group discussions and in-depth interviews were conducted with different staff cadres from all facility levels in order to explore experiences and views of providing maternity care in the context of poorly maintained equipment, and insufficient drugs and other supplies. A facility survey quantified the availability of relevant items. The facility survey, which found many missing or broken items and frequent stock outs, corroborated staff reports of providing care in the context of missing or broken care items. Staff reported increased workloads, reduced morale, difficulties in providing optimal maternity care, and carrying out procedures that carried potential health risks to themselves as a result. Inadequately stocked and equipped facilities compromise the health system's ability to reduce maternal and neonatal mortality and morbidity by affecting staff personally and professionally, which hinders the provision of timely and appropriate interventions. Improving stock control and maintaining equipment could benefit mothers and babies, not only through removing restrictions to the availability of care, but also through improving staff working conditions

Health System Support for Childbirth care in Southern Tanzania: Results from a Health Facility Census.

Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2--3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage

"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania.

Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels. Methods: EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses. Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.Children’s Investment Fund Foundation (CIFF)Swedish Research CouncilUnited States Agency for International DevelopmentSaving Newborn Lives/Save the ChildrenWHOBill & Melinda Gates Foundatio

STUDY PROTOCOL: Improving newborn survival in rural southern Tanzania: a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening

Child mortality has declined substantially in many countries including Tanzania, but newborn mortality remains high and around 3 million babies die every year in the first 28 days of life. Community-based approaches with home visits in the first week of life have shown great potential to reduce newborn mortality. INSIST aimed1 to develop, implement and evaluate an integrated, two-part strategy that combines interventions at community level with health system strengthening in rural Southern Tanzania to reduce newborn mortality. The community intervention focused around interpersonal communication through home visits in pregnancy and the early neonatal period by a village-based “agent of change”. Key messages focused on hygiene during delivery, immediate and exclusive breastfeeding, and identification and extra care for babies born small because of low birth weight or prematurity. Extra care for babies born small included skin-to-skin care for small babies and referral to hospital for very small babies. The community intervention was implemented in six poor rural districts in Southern Tanzania, with 65 of the 132 wards within these districts randomized to receive the community intervention. In addition, a health system quality-improvement package was implemented in all health facilities of one district. Data collection for the evaluation included i) a baseline household survey in 2007 of all 243,000 households in 5 of the 6 study districts to estimate baseline mortality and prevalence of newborn care behaviours, ii) an adequacy survey in 2011 in a representative sample of 5,000 households to estimate coverage of home visits and prevalence of newborn care behaviours, and iii) an endline household survey in 2013 in a representative sample of 200,000 households to estimate newborn and maternal mortality and prevalence of newborn care behaviours. The final analysis was based on “intention to treat”, comparing newbor