How Mistimed and Unwanted Pregnancies Affect Timing of Antenatal Care Initiation in three Districts in Tanzania

Early antenatal care (ANC) initiation is a doorway to early detection and management of potential complications associated with pregnancy. Although the literature reports various factors associated with ANC initiation such as parity and age, pregnancy intentions is yet to be recognized as a possible predictor of timing of ANC initiation. Data originate from a cross-sectional household survey on health behaviour and service utilization patterns. The survey was conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania on 910 women of reproductive age who had given birth in the past two years. ANC initiation was considered to be early only if it occurred in the first trimester of pregnancy gestation. A recently completed pregnancy was defined as mistimed if a woman wanted it later, and if she did not want it at all the pregnancy was termed as unwanted. Chisquare was used to test for associations and multinomial logistic regression was conducted to examine how mistimed and unwanted pregnancies affect timing of ANC initiation. Although 49.3% of the women intended to become pregnant, 50.7% (34.9% mistimed and 15.8% unwanted) became pregnant unintentionally. While ANC initiation in the 1st trimester was 18.5%, so was 71.7% and 9.9% in the 2nd and 3rd trimesters respectively. Multivariate analysis revealed that ANC initiation in the 2nd trimester was 1.68 (95% CI 1.10‒2.58) and 2.00 (95% CI 1.05‒3.82) times more likely for mistimed and unwanted pregnancies respectively compared to intended pregnancies. These estimates rose to 2.81 (95% CI 1.41‒5.59) and 4.10 (95% CI 1.68‒10.00) respectively in the 3rd trimester. We controlled for gravidity, age, education, household wealth, marital status, religion, district of residence and travel time to a health facility. Late ANC initiation is a significant maternal and child health consequence of mistimed and unwanted pregnancies in Tanzania. Women should be empowered to delay or avoid pregnancies whenever they need to do so. Appropriate counseling to women, especially those who happen to conceive unintentionally is needed to minimize the possibility of delaying ANC initiation.\u

Tanzanian lessons in using non-physician clinicians to scale up comprehensive emergency obstetric care in remote and rural areas

UNLABELLED\ud \ud ABSTRACT:\ud \ud BACKGROUND\ud \ud With 15-30% met need for comprehensive emergency obstetrical care (CEmOC) and a 3% caesarean section rate, Tanzania needs to expand the number of facilities providing these services in more remote areas. Considering severe shortage of human resources for health in the country, currently operating at 32% of the required skilled workforce, an intensive three-month course was developed to train non-physician clinicians for remote health centres.\ud \ud METHODS\ud \ud Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara, Tanzania. The required key competencies were identified, taught and objectively assessed. The training involved hands-on sessions, lectures and discussions. Participants were purposely selected in teams from remote health centres where CEmOC services were planned. Monthly supportive supervision after graduation was carried out in the upgraded health centres\ud \ud RESULTS\ud \ud A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and 2 from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. During training, participants performed 278 major obstetric surgeries, 141 manual removal of placenta and evacuation of incomplete and septic abortions, and 1161 anaesthetic procedures under supervision. The first 8 months after introduction of CEmOC services in 3 health centres resulted in 179 caesarean sections, a remarkable increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate (OR: 0.4; 95% CI: 0.1-1.7) and reduced obstetric referrals (OR: 0.2; 95% CI: 0.1-0.4)). There were two maternal deaths, both arriving in a moribund condition.\ud \ud CONCLUSIONS\ud \ud Tanzanian AMOs, clinical officers, and nurse-midwives can be trained as a team, in a three-month course, to provide effective CEmOC and anaesthesia in remote health centres