Implementation and evaluation of a health facility quality improvement intervention for maternal and neonatal health in Southern Tanzania

MUHTASARI Mojawapo ya matatizo yanayoikumba sekta ya afya Tanzania ni pamoja na vifo vya akina mama vinavyohusiana na uzazi na vya watoto wachanga. Juhudi za kuongeza ubora wa utoaji wa huduma za afya zimewekwa hususan katika eneo la afya ya mama na mtoto ili kutokomeza vifo hivi na kuhakikisha maisha yenye afya kwa kila mtoto mchanga na uzazi salama. Katika Tanzania takriban kila mwanamke mjamzito anahudhuria huduma za kliniki ya wajawazito angalau mara moja kwenye ujauzito wake, ingawa idadi ya uhudhuriaji kliniki ya wajawazito ni kubwa, kiwango cha ubora wa huduma kitolewacho wakati wa mahudhurio hayo bado hakiridhishi. Vilevile, mwamko wa kujifungua kwenye vituo vya kutolea huduma za afya hauendani na mwamko wa akina mama kuhudhuria kliniki ya wajawazito. Asilimia ya akina mama wanaojifungua kwenye vituo vya kutolea huduma za afya ni karibu nusu ya asilimia ya mahudhurio ya wajawazito kwenye vituo hivyo hivyo kwa ajili ya kliniki. Lakini pia ubora wa huduma za kujifungulia kituoni kwa idadi hiyo ndogo ya akina mama bado hairidhishi. Utafiti uliojikita kwenye “Kuboresha Uhai wa Mtoto Mchanga Kusini mwa Tanzania” ulibuniwa ili kupata taswira kuhusu namna ya kuimarisha mfumo wa afya kupitia jamii na vituo vya kutolea huduma za afya ili kutatua matatizo haya. Utafiti huu ulitekelezwa katika Halmashauri za Wilaya sita za mikoa ya Lindi na Mtwara, kusini mwa Tanzania. Eneo hili ni moja kati ya maeneo ambayo yanachangia kwa kiasi kikubwa kitaifa vifo vya watoto wachanga na vya akina mama wajawazito au mara tu baada ya kujifungua. Utafiti wa kizamivu ulifanyika katika kuandaaa, kutekeleza na kutathmini afua kwenye vituo vya kutolea huduma za afya kwa kutumia mbinu ya kuimarisha ubora katika Halmashauri ya Wilaya ya Ruangwa, Mkoa wa Lindi tangu mwaka 2010 mpaka 2011. Mbinu ya kuimarisha ubora iliyotumika ilitekelezwa kwa kuleta pamoja timu za watoa Huduma za Afya kutoka vituo tofauti tofauti vya kutolea huduma za afya, ambao wana lengo moja katika kufanya kazi kwa pamoja kwa kuzingatia utaratibu maalumu ili kuboresha utoaji huduma za uzazi kwa akina mama wajamzito na watoto wachanga. Mbinu hii ilifanya kazi kupitia washiriki kutoa mawazo yenye kuleta mabadiliko ya kuboresha mfumo uliopo, kufuatilia utekelezaji wa mabadiliko mara kwa mara kupitia ukusanyaji wa takwimu, kushirikishana uzoefu na kujifunza. Mada walizofanyia kazi zilijumuisha ushauri juu ya maandalizi ya kujifungua, mama kujifungulia kituoni, namna ya kutumia grafu ya uchungu, huduma baada ya kujifungua pamoja na chanjo. Ili kuweza kujifunza kama mbinu hii inafanya kazi na ni kwa namna gani iliweza kuleta mafanikio katika utoaji huduma, utafiti huu wa kizamivu unalenga kuelezea utekelezaji wa afua na kutathmini mtazamo wa watoa huduma za afya juu ya afua ya uimarishaji ubora kwa kupitia “qualitative study”. Utafiti huu una malengo matatu: 1.) Kuelezea uandaaji na utekelezaji wa afua ya uimarishaji ubora iliyotumika kwenye mradi wa INSIST; 2.) Kufanya mapitio ya tathmini ya mbinu za uimarishaji ubora wa afya barani Afrika - Kusini mwa Jangwa la Sahara kwa kupitia hatua kwa hatua tafiti zilizochapishwa; 3.) Kuelewa vikwazo na viwezeshi vya utekelezaji wa afua ya uimarishaji ubora miongoni mwa watoa huduma za afya katika Halmashauri ya Wilaya ya Ruangwa. Matokeo yanalenga katika kuchangia ushahidi wa kisayansi kuhusu na kwa namna gani afua za uimarishaji ubora zinavyoweza kupunguza maradhi na vifo vya mama wajawazito na watoto wachanga nchini Tanzania. Matokeo yetu yameashiria kwamba inawezekana kutumia mbinu za kuboresha utoaji huduma ili kuboresha mfumo wa afya kwenye ngazi za vituo vya afya na zahanati. Tofauti kati ya kada mbalimbali na viwango vya elimu vya watoa huduma za afya haileti kipingamizi kwenye matumizi ya mbinu za kuboreshaji utoaji huduma. Matumizi ya mbinu za uboreshaji utoaji huduma zilihamasisha na kuongezea ujuzi watoaji huduma za afya. Utoaji ushauri fasaha wakati wa ujauzito uliwaongezea uelewa mama wajawazito na familia zao kuhusu maswala ya ujauzito na kuwatia nguvu ya kuwasaidia kufanya maamuzi yakinifu kuhusu kujifungualia kwenye vituo vya kutolea huduma za afya. Kwa kumalizia, matokeo ya utafiti huu yametoa mafunzo yenye maslahi ambayo ni muhimu kuzingatia wakati wa kupanga tafiti za aina hii, zitakazo fanyika kwenye mazingira yanayofanana na ya Halmashauri ya Wilaya ya Ruangwa. Mapokeo ya mbinu za uimarishaji ubora katika mfumo wa afya haubagui uimarishaji wa mfumo wa afya bali unawezesha. Tunahitaji kuwa na uwiano katika kuwafikishia huduma za afya kwa wananchi na kuwapa huduma zenye ubora wa hali ya juu. SUMMARY Maternal and neonatal deaths are still major public health problems in Tanzania. Efforts to improve quality of healthcare delivery have been put in place especially in the area of maternal and neonatal health in order to reduce the number of deaths and to ensure healthy living for every woman and child. In Tanzania, almost every pregnant woman receives antenatal care at least once, however, despite this high coverage, the quality of services provided during the antenatal care is low. In addition, the number of institutional deliveries is not proportional to the level of antenatal care, i.e. the number of facility deliveries constitute almost half of the total number of at least one antenatal visit. Furthermore, the quality of care of these few facility deliveries is also a problem. Thus, a study focusing on "Improving Newborn Survival in Southern Tanzania(INSIST)" was designed to implement and evaluate cost effectiveness of interventions to improve neonatal survival in rural southern Tanzania.This setting is among the areas that accounts for the highest national maternal and neonatal mortality and morbidity. This PhD thesis focused on contributing to a better understanding of the development, implementation and evaluation of a health facility intervention using a quality improvement (QI) approach in Ruangwa district, Lindi region from 2010 to 2011. The following three objectives were achieved: 1.) To describe the development and implementation of the QI intervention used in INSIST project; 2.) To review evaluation of QI approaches in sub Saharan Africa through a systematic review of published literature; 3.) To understand barriers and facilitators of the QI intervention implementation among health care providers in Ruangwa district. Our findings demonstrated that it is feasible to apply QI techniques in improving health systems performance at dispensary and health center levels. The differences in healthcare cadres and level of education was not a barrier in using QI techniques. Use of QI methods motivated and built capacity of healthcare providers. Proper counselling sessions during pregnancy improved knowledge of pregnant women and their families on pregnancy related issues and empowered them to make informed decisions such as delivering their babies in healthcare facilities. In conclusion, this thesis reports a case that shares interesting and powerful lessons from the real-time project implementation experience that are worth taking into consideration when planning for future studies in similar settings. The use of QI methods facilitates the strengthening of health systems as we seek to balance high coverage of services with high quality of providing them

Improving Tanzanian childbirth service quality.

Purpose The purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania. Design/methodology/approach A QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs. Findings Median monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months. Research limitations/implications The time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures. Originality/value Healthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings

Improving institutional childbirth services in rural Southern Tanzania: a qualitative study of healthcare workers' perspective.

OBJECTIVE: To describe health workers' perceptions of a quality improvement (QI) intervention that focused on improving institutional childbirth services in primary health facilities in Southern Tanzania. DESIGN: A qualitative design was applied using in-depth interviews with health workers. SETTING: This study involved the Ruangwa District Reproductive and Child Health Department, 11 dispensaries and 2 health centres in rural Southern Tanzania. PARTICIPANTS: 4 clinical officers, 5 nurses and 6 medical attendants from different health facilities were interviewed. RESULTS: The healthcare providers reported that the QI intervention improved their skills, capacity and confidence in providing counselling and use of a partograph during labour. The face-to-face QI workshops, used as a platform to refresh their knowledge on maternal and newborn health and QI methods, facilitated peer learning, networking and standardisation of care provision. The onsite follow-up visits were favoured by healthcare providers because they gave the opportunity to get immediate help, learn how to perform tasks in practice and be reminded of what they had learnt. Implementation of parallel interventions focusing on similar indicators was mentioned as a challenge that led to duplication of work in terms of data collection and reporting. District supervisors involved in the intervention showed interest in taking over the implementation; however, funding remained a major obstacle. CONCLUSIONS: Healthcare workers highlighted the usefulness of applying a QI approach to improve maternal and newborn health in rural settings. QI programmes need careful coordination at district level in order to reduce duplication of work

The reliability of a newborn foot length measurement tool used by community volunteers to identify low birth weight or premature babies born at home in southern Tanzania.

BACKGROUND: Low birthweight babies need extra care, and families need to know whether their newborn is low birthweight in settings where many births are at home and weighing scales are largely absent. In the context of a trial to improve newborn health in southern Tanzania, a counselling card was developed that incorporated a newborn foot length measurement tool to screen newborns for low birth weight and prematurity. This was used by community volunteers at home visits and shows a scale picture of a newborn foot with markers for a 'short foot' (<8 cm). The tool built on previous hospital based research that found newborn foot length <8 cm to have sensitivity and specificity to identify low birthweight (<2500 g) of 87% and 60% respectively. METHODS: Reliability of the tool used by community volunteers to identify newborns with short feet was tested. Between July-December 2010 a researcher accompanied volunteers to the homes of babies younger than seven days and conducted paired measures of newborn foot length using the counselling card tool and using a plastic ruler. Intra-method reliability of foot length measures was assessed using kappa scores, and differences between measurers were analysed using Bland and Altman plots. RESULTS: 142 paired measures were conducted. The kappa statistic for the foot length tool to classify newborns as having small feet indicated that it was moderately reliable when applied by volunteers, with a kappa score of 0.53 (95% confidence interval 0.40 - 0.66) . Examination of differences revealed that community volunteers systematically underestimated the length of newborn feet compared to the researcher (mean difference -0.26 cm (95% confidence interval -0.31-0.22), thus overestimating the number of newborns needing extra care. CONCLUSIONS: The newborn foot length tool used by community volunteers to identify small babies born at home was moderately reliable in southern Tanzania where a large number of births occur at home and scales are not available. Newborn foot length is not the best anthropometric proxy for birthweight but was simple to implement at home in the first days of life when the risk of newborn death is highest

Effect of home-based counselling on newborn care practices in southern Tanzania one year after implementation: a cluster-randomised controlled trial.

BACKGROUND: In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation. METHODS: All 132 wards in the 6-district study area were randomised to intervention or comparison groups. Starting in 2010, in intervention areas trained volunteers made home visits during pregnancy and after childbirth to promote recommended newborn care practices including hygiene, breastfeeding and identification and extra care for low birth weight babies. In 2011, in a representative sample of 5,240 households, we asked women who had given birth in the previous year both about counselling visits and their childbirth and newborn care practices. RESULTS: Four of 14 newborn care practices were more commonly reported in intervention than comparison areas: delaying the baby's first bath by at least six hours (81% versus 68%, OR 2.0 (95% CI 1.2-3.4)), exclusive breastfeeding in the three days after birth (83% versus 71%, OR 1.9 (95% CI 1.3-2.9)), putting nothing on the cord (87% versus 70%, OR 2.8 (95% CI 1.7-4.6)), and, for home births, tying the cord with a clean thread (69% versus 39%, OR 3.4 (95% CI 1.5-7.5)). For other behaviours there was little evidence of differences in reported practices between intervention and comparison areas including childbirth in a health facility or with a skilled attendant, thermal care practices, breastfeeding within an hour of birth and, for home births, the birth attendant having clean hands, cutting the cord with a clean blade and birth preparedness activities. CONCLUSIONS: A home-based counselling strategy using volunteers and designed for scale-up can improve newborn care behaviours in rural communities of southern Tanzania. Further research is needed to evaluate if, and at what cost, these gains will lead to improved newborn survival. TRIAL REGISTRATION: Trial Registration Number NCT01022788 (http://www.clinicaltrials.gov, 2009)

Effectiveness of a Home-Based Counselling Strategy on Neonatal Care and Survival: A Cluster-Randomised Trial in Six Districts of Rural Southern Tanzania.

BACKGROUND: We report a cluster-randomised trial of a home-based counselling strategy, designed for large-scale implementation, in a population of 1.2 million people in rural southern Tanzania. We hypothesised that the strategy would improve neonatal survival by around 15%. METHODS AND FINDINGS: In 2010 we trained 824 female volunteers to make three home visits to women and their families during pregnancy and two visits to them in the first few days of the infant's life in 65 wards, selected randomly from all 132 wards in six districts in Mtwara and Lindi regions, constituting typical rural areas in Southern Tanzania. The remaining wards were comparison areas. Participants were not blinded to the intervention. The primary analysis was an intention-to-treat analysis comparing the neonatal mortality (day 0-27) per 1,000 live births in intervention and comparison wards based on a representative survey in 185,000 households in 2013 with a response rate of 90%. We included 24,381 and 23,307 live births between July 2010 and June 2013 and 7,823 and 7,555 live births in the last year in intervention and comparison wards, respectively. We also compared changes in neonatal mortality and newborn care practices in intervention and comparison wards using baseline census data from 2007 including 225,000 households and 22,243 births in five of the six intervention districts. Amongst the 7,823 women with a live birth in the year prior to survey in intervention wards, 59% and 41% received at least one volunteer visit during pregnancy and postpartum, respectively. Neonatal mortality reduced from 35.0 to 30.5 deaths per 1,000 live births between 2007 and 2013 in the five districts, respectively. There was no evidence of an impact of the intervention on neonatal survival (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.9-1.2, p = 0.339). Newborn care practices reported by mothers were better in intervention than in comparison wards, including immediate breastfeeding (42% of 7,287 versus 35% of 7,008, OR 1.4, CI 1.3-1.6, p < 0.001), feeding only breast milk for the first 3 d (90% of 7,557 versus 79% of 7,307, OR 2.2, 95% CI 1.8-2.7, p < 0.001), and clean hands for home delivery (92% of 1,351 versus 88% of 1,799, OR 1.5, 95% CI 1.0-2.3, p = 0.033). Facility delivery improved dramatically in both groups from 41% of 22,243 in 2007 and was 82% of 7,820 versus 75% of 7,553 (OR 1.5, 95% CI 1.2-2.0, p = 0.002) in intervention and comparison wards in 2013. Methodological limitations include our inability to rule out some degree of leakage of the intervention into the comparison areas and response bias for newborn care behaviours. CONCLUSION: Neonatal mortality remained high despite better care practices and childbirth in facilities becoming common. Public health action to improve neonatal survival in this setting should include a focus on improving the quality of facility-based childbirth care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01022788

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

EN-BIRTH Data Collector Training - Handbook and Manual

The EN-BIRTH study aims to validate selected newborn and maternal indicators for routine facility-based tracking of coverage and quality of care for use at district, national and global levels. The item contains the EN-BIRTH_Trainer's Manual (14 June 2017) and EN-BIRTH_Training Handbook (23 May 2017)