SaferBirths bundle of care protocol: a stepped-wedge cluster implementation project in 30 public health-facilities in five regions, Tanzania

Background The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival. Methods The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live. Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99. Discussion Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope. Trial registration Name of Trial Registry: ISRCTN Registry. Trial registration number: ISRCTN30541755. Date of Registration: 12/10/2020. Type of registration: Prospectively Registered.publishedVersio

How much time do health services spend on antenatal care? Implications for the introduction of the focused antenatal care model in Tanzania

BACKGROUND: Antenatal care (ANC) is a widely used strategy to improve the health of pregnant women and to encourage skilled care during childbirth. In 2002, the Ministry of Health of the United Republic of Tanzania developed a national adaptation plan based on the new model of the World Health Organisation (WHO). In this study we assess the time health workers currently spent on providing ANC services and compare it to the requirements anticipated for the new ANC model in order to identify the implications of Focused ANC on health care providers' workload. METHODS: Health workers in four dispensaries in Mtwara Urban District, Southern Tanzania, were observed while providing routine ANC. The time used for the overall activity as well as for the different, specific components of 71 ANC service provisions was measured in detail; 28 of these were first visits and 43 revisits. Standard time requirements for the provision of focused ANC were assessed through simulated consultations based on the new guidelines. RESULTS: The average time health workers currently spend for providing ANC service to a first visit client was found to be 15 minutes; the provision of ANC according to the focused ANC model was assessed to be 46 minutes. For a revisiting client the difference between current practise and the anticipated standard of the new model was 27 minutes (9 vs. 36 min.). The major discrepancy between the two procedures was related to counselling. On average a first visit client was counselled for 1:30 minutes, while counselling in revisiting clients did hardly take place at all. The simulation of focused ANC revealed that proper counselling would take about 15 minutes per visit. CONCLUSION: While the introduction of focused ANC has the potential to improve the health of pregnant women and to raise the number of births attended by skilled staff in Tanzania, it may need additional investment in human resources. The generally anticipated saving effect of the new model through the reduction of routine consultations may not materialise because the number of consultations is already low in Tanzania with a median of only 4 visits per pregnancy. Special attention needs to be given to counselling attitudes and skills during the training for Focused ANC as this component is identified as the major difference between old practise and the new model. Our estimated requirement of 46 minutes per first visit consultation matches well with the WHO estimate of 40 minutes

Setting an emergency obstetric care unit local initiatives, availability of resources and good will are the main ingredients of success: A lesson from Mkuranga District Hospital, Tanzania

Mkuranga District Hospital is 50 km South of Dar-Es-Salaam city serving a population of about 196,0004. Before June 2004, all obstetric patients with complications from this district were referred to Dar-Es-Salaam as the hospital had no comprehensive emergency obstetric care (CEmOC) skilled personnel. In June 2004, a project was started using local manpower and resources to impart knowledge for CEmOC. The aim was to reduce referrals to Dar es Salaam and hence delays in receiving CEmOC.Methodology: Hospital staffs were trained on CEmOC which included the use of partography and management of common obstetric emergencies. The list of lacking essential equipments for of CEmOC was made and submitted to the district management for purchases. Weekly visit by the project manager was arranged for monitoring of the project.Results: There was a three to four fold increase in the monthly-number of deliveries in the hospital and referrals decreased sharply. Almost all major obstetric intervention were performed in the hospital and only 20% of patients were referred.Conclusion: The findings from this project show that using local initiatives, resources and advocacy can give a good outcome of obstetric services

Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity

BACKGROUND: Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. METHODS: We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). RESULTS: Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. CONCLUSION: This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed

The Situation of Safe Surgery and Anaesthesia in Tanzania : A Systematic Review

Background: Improvement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed. Methods: A systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing. Results: 1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain. Conclusions: Despite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania

Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity

<div><p>Background</p><p>Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO’s Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael’s Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (<u>G</u>uideline-driven, <u>R</u>esearch priorities, <u>E</u>vidence synthesis, <u>A</u>pplication of evidence, and <u>T</u>ransfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these.</p><p>Methods</p><p>We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers).</p><p>Results</p><p>Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators.</p><p>Conclusion</p><p>This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.</p></div

Summary of indicators and guideline implementation research activities and outcomes in four countries.

<p>Summary of indicators and guideline implementation research activities and outcomes in four countries.</p

Knowledge-to-Action Cycle (Reproduced with permission from[38]).

<p>Reprinted from Straus SE, Tetroe J, Graham I. Knowledge translation in health care: moving from evidence to practice. 2nd ed. BMJ Books, Wiley, 2013. under a CC BY license, with permission from Wiley, original copyright 2013.</p