Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019

Introduction Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city's facility births. Methods Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. Results Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). Conclusions This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.Research into fetal development and medicin

CANCER OF THE CERVIX: KNOWLEDGE AND ATTITUDES OF FEMALE PATIENTS ADMITTED AT MUHIMBILI NATIONAL HOSPITAL, DAR ES SALAAM

Objectives: To determine the level of knowledge of basic symptoms of cancer of thecervix among Tanzanian females and to determine causes of late presentation withadvanced disease among cancer patients.Design: Hospital based cross-sectional study.Setting: Muhimbili National Hospital, Dar es Salaam, Tanzania.Subjects: Eighty nine cervical cancer patients and 178 controls were interviewedbetween August 1999 and January 2000. Data was analyzed using Epi-Infoversion 6.04.Results: At Muhimbili National Hospital most patients are admitted in very advancedstages of the disease (Stage IIb and IV). We determined, using a structured questionnaire,knowledge of basic symptoms of cancer of the cervix, attitude and reasons for latepresentation among female patients admitted at Muhimbili National Hospitalgynaecological ward. The mean age of cases was 48.8 (SD11.1) years and the mean paritywas 6.7 years were comparable to that of control, which were 45 years(SD10.8) andmean parity of 6.6 respectively. Mean age in years at marriage was lower for cases17.5(SD 2.9) than controls 18.8(SD3.5). Majority of cases (50.6%) and controls (23.6%)were illiterate, and 21.3% of cases and 33.7% of controls had incomplete primaryeducation. Majority of both cases (47.23%) and controls (56.7%) had no routinegynaecological examination and they did not find it necessary. More than 90% of thecases were in advanced stages of the disease (stage IIb-IV).Conclusion: Both cases and controls had low knowledge of basic symptoms of cancerof the cervix and as a result most of those who happen to have problems reportedlate with advanced disease

MATERNAL MORTALITY AT MUHIMBILI NATIONAL HOSPITAL, TANZANIA, 1999 - 2005: LEVELS, CAUSES AND CHARACTERISTICS

Objectives:To determine the levels, direct causes and characteristics of maternal mortality at Muhimbili National Hospital in Tanzania. Methods: We used hospital data recorded systematically and routinely from 1999 to 2005. The outcome of interest was a maternal death that occurred at the hospital before discharge. We used descriptive analyses characterizing the outcome variable by maternal and obstetric factors. Results: We found a maternal mortality ratio of 512 per 100,000 live births (95%CI, 465/100,000 - 559/100,000 livebirths) during the study period. Yearly maternal mortality ratios have been rising gradually over time. The top three direct obstetric causes of maternal deaths include eclampsia, 108 (23.5%), postpartum hemorrhage, 107 (23.3%) and anaemia in pregnancy, 52 (11.3%). Conclusions:Although the current hospital-based data suggest underestimation of maternal mortality ratio, the observed constant maternal mortality risk calls for further strengthening of emergency obstetric care to reduce direct obstetric causes of maternal deaths

LEVELS, TRENDS AND RISK FOR EARLY NEONATAL MORTALITY AT MUHIMBILI NATIONAL HOSPITAL, TANZANIA, 1999 - 2005

Objective: To determine the magnitude, trend and to assess risk factors for early neonatal mortality in one of the referral hospitals in Tanzania Methods: We used logistic regression analyses with data from the Maternity Unit of Muhimbili National Hospital, Tanzania, adjusting for possible confounding factors. Results: We found early neonatal mortality rate of 20 per 1000 live births (95%CI, 19/1000 - 21/1000). Results indicated the reduced risk of 0.8 (95% CI, 0.7 - 0.9) per 10 years increase of maternal age at delivery. We also found a reduced risk of neonatal mortality by increase in birth weight of the infant (OR = 0.87: 95%CI, 0.87-0.88 per 100 grams increase). Male born babies were found to have an elevated risk (OR = 1.4, 95%CI, 1.3 - 1.5) of early neonatal mortality as compared to females and the risk of neonatal mortality among offspring of women who have history of neonatal death was 1.9 times (95%CI, 1.1 - 3.1) as compared to those without a history of neonatal death. Conclusions: Hospital-based data understate the magnitude of early neonatal mortality but maternal age and history of previous neonatal death should be used as markers for such undesired birth outcome

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen - safe and respectful clinical childbirth care - is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study)

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained. Trial registration number: NCT0468566