Neonatal Survival in Rural Tanzania : Home Deliveries, Neonatal Mortality and Subsequent Help and Health Seeking Behaviour for the Newborn by Mothers in Rural Tanzania

It is unlikely that the fourth Millennium Development Goal (MDG 4: reduce child mortality) will be attained without considerable decline in neonatal mortality. About 4.0 million of the annual 10.8 million global deaths in children younger than 5 years occur in the first month of life. Worldwide, the average neonatal mortality is estimated to be 33 per 1000 live births. Nearly all neonatal deaths (99%) occur in low and middle income countries and about half occur at home. Three quarters of all neonatal deaths occur in the first week of life, suggesting the need for early care. Based on data from the Demographic and Health Survey (DHS) 2004/5, between 2000 and 2004 Tanzania reported a dramatic reduction in mortality in infants and children under 5 years of age, with overall under five mortality dropping from 147 to 112 per 1000 live births and infant mortality dropping from 99 to 68 per 1000 live births. However, the reduction in the neonatal mortality rate was much smaller and not statistically significant, from 40 to 32 per 1000 live births. The major direct causes of neonatal deaths globally are infections (36%), preterm birth (28%), asphyxia (23%) and remaining, 14% are due to indirect causes such as low birth weight, poverty and maternal complications in labour which carry a high risk of neonatal death. The general aim of this study was to evaluate the magnitude and determinants of neonatal mortality, home deliveries, and subsequent help and health seeking Summary XIII behaviour for the newborn by mothers in rural Tanzania. Quantitative data were collected in a cross-sectional household and health facility surveys carried out in five districts in southern Tanzania between July and October 2004 to generate baseline information before evaluation of an intervention on malaria (IPTi). Qualitative data were collected using in-depth interview, focus group discussion (FGD), case studies and through participant observation. This was implemented through the network of village-based informants (watoa taarifa) in 8 villages of Lindi rural and Tandahimba districts, southern Tanzania. Main findings: The present study revealed key areas for strengthening both the health system and the community. The 2004 health facility survey revealed particular problems with staff absences and drug stock shortages. Staff absences were common, with only about two-thirds of all employed staff present on the day of the survey. A group of seven essential oral treatments was found in less than half of all facilities. Only about one-fifth of all facilities had a supply of clean water. Data from the 2004 household survey revealed that 38% of all women had personally experienced a child death: this shows how common child deaths are in this area as well as in much of sub-Saharan Africa, where it is no great shock when a child dies. Neonatal and infant mortality were 43.2 and 76.4 per 1000 live births respectively. More surprisingly perhaps, we found little evidence that neonatal mortality rates were associated with maternal education, in contrast to Summary XIV the post-neonatal period, when mortality rates were 50% higher for mothers with no formal education compared with those who had had at least one year of schooling. We also found that children living over 5km from a health facility had lower vaccine coverage, fewer nets, more anaemia, poorer care-seeking and higher infant mortality than those living closer. Data from the qualitative research revealed that women are forced to prepare materials for childbirth and some set aside money for emergencies. Home deliveries are due in part to transport cost, poor quality of care in health facilities and lack of privacy. Most home births are assisted by unskilled attendants, which contribute to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Despite many good essential newborn care practices, we also found risky behaviour for the newborn in relation to resuscitation, drying and warming, breastfeeding, cord care, skin care and eye care. Many newborns are denied colostrum and are fed sweetened warm water before breastfeeding or as a supplemental feed. A positive attitude towards antenatal and postnatal care can offer important opportunities for better integration the health system and the community by encouraging women to deliver with a skilled attendant. Efforts to improve antenatal and postnatal care should therefore focus on increasing geographical and economic access while observing cultural sensitivity. Summary XV This thesis has revealed key areas for strengthening both the health system and the community. The findings emphasize the need for a systematic approach to overcome health-system constraints, for community based programmes and for scaling-up effective low-cost interventions which are already available. Behaviour change communication strategies capitalizing on common and positive themes in local beliefs about pregnancy and newborn care practices are key steps to improve maternal and newborn health. Women’s access to income must be addressed strongly, as it might strengthen their bargaining power to influence place and timing of accessing skilled delivery. Promoting female education, especially primary and higher education, as well as continued health education, accompanied by a suitable and effective health care delivery system should lead to sustainable safer motherhood practices. Zusammenfassung XVI Zusammenfassung Ohne eine deutliche Abnahme der Sterblichkeitsrate bei Neugeborenen ist das Erreichen des vierten Millenniumsentwicklungsziels (MDG 4) zur Reduktion der Kindersterblichkeit unwahrscheinlich. Rund 37% der weltweit jährlich 10,8 Millionen Todesfälle bei Kindern unter 5 Jahren ereignen sich im ersten Lebensmonat. Die durchschnittliche Sterblichkeitsrate in den ersten 28 Tagen wird auf 33 pro 1000 Lebendgeburten geschätzt. Beinahe alle diese Todesfälle (99%) ereignen sich in Entwicklungs- und Schwellenländern, und etwa die Hälfte aller Säuglinge stirbt zu Hause. Zwei Drittel all dieser Neugeborenen sterben in der ersten Woche nach der Geburt, eine Tatsache, die auf die Notwendigkeit von früher Pflege verweist. Wie eine Studie zur Demographie und Gesundheit in Tansania (Demographic and Health Survey (DHS)) aufzeigt, konnte Tansania zwischen den Jahren 2000 und 2004 einen erheblichen Rückgang der Sterblichkeit bei Säuglingen und Kleinkindern unter 5 Jahren verzeichnen: die Sterblichkeitsrate bei Kindern unter 5 Jahren sank von 147 auf 112 pro 1000 Lebendgeburten, bei Säuglingen fiel sie von 99 auf 68 pro 1000 Lebendgeburten. Die Reduktion der Sterblichkeitsrate bei Neugeborenen fiel dagegen sehr viel geringer aus (von 40 auf 32 Lebendgeburten) und ist statistisch nicht signifikant. Die weltweit häufigsten direkten Ursachen, die zum Tod von Neugeborenen führen, sind Infektionskrankheiten (36%), Frühgeburt (28%) und Erstickungstod (23%). Die restlichen 14% der Todesfälle werden durch indirekte Faktoren wie Zusammenfassung XVII zum Beispiel Untergewicht bei der Geburt, Armut und Geburtskomplikationen verursacht, wobei speziell letztere ein hohes Risiko für Säuglingstod bergen. Ziel dieser Studie ist es, das Ausmass der Sterblichkeit bei Neugeborenen zu evaluieren, und Faktoren für die Wahl des Geburtsortes sowie die medizinische Behandlung im ländlichen Raum Tansanias besser zu verstehen. Von Juli 2004 bis Oktober 2004 wurden in einer Querschnittstudie in Haushalten und Gesundheitszentren quantitative Daten in fünf verschiedenen Distrikten in Südtansania erhoben. Diese Daten lieferten Basisinformationen für eine später durchgeführte Malariaintervention (IPTi). Qualitative Daten wurden in Form von Tiefeninterviews, Fokusgruppendiskussionen, Fallstudien und durch teilnehmende Beobachtung erhoben. Für die Datenerhebung wurde ein Netzwerk lokaler Informanten in acht Dörfern (watoa taarifa) in den beiden ländlichen Distrikten Lindi und Tandahimba im südlichen Tansania eingerichtet. Die vorliegende Arbeit macht auf die Notwendigkeit von Verbesserungsmassnahmen sowohl im Gesundheitssystem als auch in der Gesellschaft aufmerksam. Die im Jahr 2004 durchgeführte Studie in den Gesundheitszentren verdeutlicht vor allem die durch Personalabsenzen und fehlende Medikamente verursachten Probleme. Personalabsenzen sind alltäglich, und nur rund zwei Drittel der angestellten Personen waren während des Besuchs in den Gesundheitszentren anwesend. Eine Gruppe von sieben essentiellen oralen Medikamenten war in weniger als der Hälfte aller Zusammenfassung XVIII Gesundheitszentren vorhanden. Nur ein Fünftel aller Gesundheitszentren verfügte über Wasser. Die Haushaltsumfrage im Jahr 2004 ergab, dass 38% aller Frauen den Tod mindestens eines ihrer Kinder erlebt hatten, was die Häufigkeit und Normalität dieses Ereignisses in der Region und in Afrika südlich der Sahara verdeutlicht. Die Sterblichkeit bei Neugeborenen und Säuglingen liegt bei 43,2 bzw. 76,4 Todesfällen pro 1000 Lebendgeburten. Während in der postnatalen Phase die Säuglingssterblichkeit bei Müttern ohne Schulbildung 50% höher ist als bei Müttern, die mindestens ein Jahr lang die Schule besuchten, kann ein solcher Zusammenhang für die neonatale Phase überraschenderweise nicht aufgezeigt werden. Die Haushaltsstudie zeigt weiter auf, dass die Impfrate und Bettnetzdichte für Kinder, die weiter als 5km vom Gesundheitszentrum entfernt leben, niedriger ist als für Kinder, die in der Nähe von Gesundheitszentren wohnen. Kinder, die weiter entfernt leben, leiden ausserdem häufiger an Anämie, werden weniger häufig behandelt, und die Säuglingsterblichkeit ist höher. Die qualitativen Daten verdeutlichen, dass von den Frauen erwartet wird, für die Geburt notwendige Utensilien selbst zu besorgen sowie Geld für den Notfall vorzubereiten. Teilweise sind auch hohe Transportkosten, das marode Gesundheitssystem und fehlende Privatsphäre Gründe für Hausgeburten. Bei den meisten Hausgeburten werden die Frauen von Laien unterstützt, die im Notfall nicht über das notwendige Wissen verfügen, um der Mutter oder dem Zusammenfassung XIX Säugling ausreichend medizinische Hilfe leisten zu können. Die Nabelschnur wird mit der Verwundbarkeit des Säuglings gegenüber übernatürlichen Kräften und Hexerei assoziiert. Grosse Sorgfalt wird daher darauf verwendet, sowohl die Mutter als auch das Kind vor bösen Geistern zu schützen, bis die Nabelschnur abfällt. Neben korrektem Verhalten wurden auch riskante Praktiken rund um die Reanimation, das Trocknen, Wärmen und Stillen des Neugeborenen sowie rund um die Behandlung der Nabelschnur, der Haut und der Augen des Säuglings beobachtet. Viele der Neugeborenen erhalten keine Vormilch und werden stattdessen zusätzlich mit gesüsstem warmem Wasser gefüttert. Eine positive Einstellung bezüglich Geburtsvor- und nachsorge kann Möglichkeiten für eine verbesserte Kooperation zwischen dem Gesundheitssystem und der Gesellschaft bieten. Anstrengungen zur Verbesserung der Geburtsvor- und nachsorge sollten sich daher auf einen guten geographischen und ökonomischen Zugang konzentrieren, und dabei kulturelle Sensitivität als zentrales Element integrieren. Die vorliegende Doktorarbeit zeigt Interventionsmöglichkeiten sowohl im Gesundheitssystem als auch in der Gesellschaft auf. Die Resultate verdeutlichen die Notwendigkeit für einen systematischen Ansatz, der die Schwächen des Gesundheitssystems angeht, für gesellschaftsbasierte Programme und für die Verbreitung (up-scaling) von bestehenden effektiven und kosteneffizienten Interventionen. Kommunikationsstrategien, die auf Verhaltensveränderungen Zusammenfassung XX abzielen und allgemein bekannte positive Themen in den lokalen Vorstellungen rund um Schwangerschaft und Pflege von Neugeborenen nützen, bilden die Basis zur Verbesserung der Mütter- und Kindgesundheit. Der Zugang der Frauen zu ökonomischen Ressourcen muss betont werden, da damit deren Möglichkeit, Ort und Zeit des Zugangs zu professioneller Pflege zu bestimmen, verbessert werden kann. Die Förderung von Frauenbildung, vor allem Grundschul- und höhere Bildung aber auch bezüglich Gesundheit, zusammen mit einem Angebot an angemessenen und effektiven Gesundheitsangeboten, sollte zu nachhaltigen Praktiken rund um Schwangerschaft und Geburt führen

: the case of institutional review boards in Tanzania.

Masters Degree. University of KwaZulu-Natal, Pietermaritzburg.Background Independent ethics review is one of the fundamental principles of research ethics. The body of literature has documented increasing bureaucratic delays associated with ethics review, which has impacted the start of research activities. This study aimed to determine the extent of variability in turnaround times for protocol review among different institutional review boards (IRBs) within Tanzania. It also assessed the challenges and experiences of submitting and reviewing protocols after introducing the tablet PC, from the perspectives of Ifakara Health Institute IRB (IHI-IRB) members and investigators. Methods This cross-sectional study employed a mixed-methods approach which consisted of qualitative and quantitative approaches. The quantitative data were obtained retrospectively from databases of seven selected IRBs in Tanzania. Purposive sampling was used to select seven IRBs for inclusion in the study. Seven IRB secretaries and their assistants from five institutions were interviewed to respond to the research questions. In addition, 19 in-depth interviews were conducted with IRB members and investigators to explore their experiences of using tablet PCs in reviewing protocols and in submitting electronic proposals, respectively. This study was conducted in mainland Tanzania and Zanzibar. Quantitative secondary data were analysed using Stata software (quantitative data analysis software, version 10). Qualitative data were categorised in an Excel spreadsheet and analysed using thematic analysis. Results The median time for ethics review across the visited sites was 32 days and ranged from 1 to 396 days. Qualitative results found that eleven thematic issues emerged from in-depth interviews with IRB members and the secretariat in the visited study areas. Generally, looking into the procedures for submission of protocols to the secretariat of the IRB, these were more or less the same across IRB institutions in Tanzania. However, investigators sometimes failed to adhere to the submission checklist and guidelines which resulted in delays in the timeous review of protocols. Most of the IRB members and investigators preferred electronic submission for its ease of use and reduced burdens associated with paper-based submissions, such as printing, distribution and misplacing of protocols. Conclusion Data from this study suggest that there is an urgent need to address the issues raised in order to improve the turnaround time of protocol review in Tanzania. Investigators should adhere to the submission checklist and guidelines to avoid delays in the ethics approval process. Ethics review boards need to invest in technology and system strengthening to facilitate timeous processing of ethics applications

Understanding home-based neonatal care practice in rural southern Tanzania.

In order to understand home-based neonatal care practices in rural Tanzania, with the aim of providing a basis for the development of strategies for improving neonatal survival, we conducted a qualitative study in southern Tanzania. In-depth interviews, focus group discussions and case studies were used through a network of female community-based informants in eight villages of Lindi Rural and Tandahimba districts. Data collection took place between March 2005 and April 2007. The results show that although women and families do make efforts to prepare for childbirth, most home births are assisted by unskilled attendants, which contributes to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Some neonates are denied colostrum, which is perceived as dirty. Behaviour-change communication efforts are needed to improve early newborn care practices

Determinants of Home Delivery among Women Aged 15-24 Years in Tanzania

This research article published by International Journal of Maternal and Child Health and AIDS, Volume 9, Issue 2, 2020Background: The United Nation’s Sustainable Development Goal number 3 aims at reducing the maternal mortality rate by less than 70/100,000 live births globally and 216/100,000 live births in developing regions by 2030. Despite several interventions in Tanzania, maternal mortality has increased from 454/100,000 live births in 2010 to 556/100,000 live births in 2015. Home delivery and maternal young age contribute to maternal deaths. Reducing home deliveries among women aged 15-24 years may likely decrease the prevalence of maternal deaths in Tanzania. This study investigated the determinants of home delivery among women aged 15- 24 years in rural and mainland districts of Tanzania. Methods: This study uses a mixed-methods approach using data collected as part of the evaluation of government and UNICEF interventions in 13 districts of Tanzania mainland from October and November 2011. Results from the secondary analysis were supplemented by qualitative data collected between February and April 2019 from four rural districts: Bagamoyo, Tandahimba, Magu, and Moshi. Results: A total of 409 adolescents and young women who delivered one year before the quantitative data collection were included in the final analysis. A quarter of them gave birth at home. Having at least four antenatal care (ANC) visits (OR=0.23, 95% CI: 0.12-0.41, p<0.01), planning place of delivery (OR=0.22, 95%CI: 0.14-0.36 p<0.01), and knowledge of the danger signs during pregnancy (OR=0.36, 95% CI: 0.22- 0.57, p<0.01) were significantly associated with the place of delivery. Conclusion and Global Health Implications: Maternal level of education, number of ANC visits attended, planned place of delivery, and knowledge of danger signs during pregnancy were the determinants of the choice of place of delivery among women aged 15-24 years in Tanzania. Understanding these risk factors is important in designing programs and interventions to reduce maternal deaths from women of this age group which contributes about 18% of all maternal deaths in Tanzania

Understanding home-based neonatal care practice in rural southern Tanzania

In order to understand home-based neonatal care practices in rural Tanzania, with the aim of providing a basis for the development of strategies for improving neonatal survival, we conducted a qualitative study in southern Tanzania. In-depth interviews, focus group discussions and case studies were used through a network of female community-based informants in eight villages of Lindi Rural and Tandahimba districts. Data collection took place between March 2005 and April 2007. The results show that although women and families do make efforts to prepare for childbirth, most home births are assisted by unskilled attendants, which contributes to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Some neonates are denied colostrum, which is perceived as dirty. Behaviour-change communication efforts are needed to improve early newborn care practice

Clean Home-Delivery in Rural Southern Tanzania: Barriers, Influencers, and Facilitators

The study explored the childbirth-related hygiene and newborn care practices in home-deliveries in Southern\ud Tanzania and barriers to and facilitators of behaviour change. Eleven home-birth narratives and six focus group discussions were conducted with recently-delivering women; two focus group discussions were conducted with birth attendants. The use of clean cloth for delivery was reported as common in the birth narratives; however, respondents did not link its use to newborn’s health. Handwashing and wearing of gloves by birth attendants varied and were not discussed in terms of being important for newborn’s health, with few women giving reasons for this behaviour. The lack of handwashing and wearing of gloves was most commonly linked to the lack of water, gloves, and awareness. A common practice was the insertion\ud of any family member’s hands into the vagina of delivering woman to check labour progress before calling the birth attendant. The use of a new razor blade to cut the cord was near-universal; however, the cord was usually tied with a used thread due to the lack of knowledge and the low availability of clean thread. Applying something to the cord was near-universal and was considered essential for newborn’s health. Three hygiene practices were identified as needing improvement: family members inserting a hand into\ud the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting\ud substances on the cord. Little is known about families conducting internal checks of women in labour, and more research is needed before this behaviour is targeted in interventions. The use of clean thread as cord-tie appears acceptable and can be addressed, using the same channels and methods that were used for successfully encouraging the use of new razor blade

Cluster-randomized study of intermittent preventive treatment for malaria in infants (IPTi) in southern Tanzania: evaluation of impact on survival.

BACKGROUND\ud \ud Intermittent Preventive Treatment for malaria control in infants (IPTi) consists of the administration of a treatment dose of an anti-malarial drug, usually sulphadoxine-pyrimethamine, at scheduled intervals, regardless of the presence of Plasmodium falciparum infection. A pooled analysis of individually randomized trials reported that IPTi reduced clinical episodes by 30%. This study evaluated the effect of IPTi on child survival in the context of a five-district implementation project in southern Tanzania. [Trial registration: clinical trials.gov NCT00152204].\ud \ud METHODS\ud \ud After baseline household and health facility surveys in 2004, five districts comprising 24 divisions were randomly assigned either to receive IPTi (n = 12) or not (n = 12). Implementation started in March 2005, led by routine health services with support from the research team. In 2007, a large household survey was undertaken to assess the impact of IPTi on survival in infants aged two-11 months through birth history interviews with all women aged 13-49 years. The analysis is based on an "intention-to-treat" ecological design, with survival outcomes analysed according to the cluster in which the mothers lived.\ud \ud RESULTS\ud \ud Survival in infants aged two-11 months was comparable in IPTi and comparison areas at baseline. In intervention areas in 2007, 48% of children aged 12-23 months had documented evidence of receiving three doses of IPTi, compared to 2% in comparison areas (P < 0.0001). Over the three years of the study there was a marked improvement in survival in both groups. Between 2001-4 and 2005-7, mortality rates in two-11 month olds fell from 34.1 to 23.6 per 1,000 person-years in intervention areas and from 32.3 to 20.7 in comparison areas. In 2007, divisions implementing IPTi had a 14% (95% CI -12%, 49%) higher mortality rate in two-11 month olds in comparison with non-implementing divisions (P = 0.31).\ud \ud CONCLUSION\ud \ud The lack of evidence of an effect of IPTi on survival could be a false negative result due to a lack of power or imbalance of unmeasured confounders. Alternatively, there could be no mortality impact of IPTi due to low coverage, late administration, drug resistance, decreased malaria transmission or improvements in vector control and case management. This study raises important questions for programme evaluation design

Development of behaviour change communication strategy for a vaccination-linked malaria control tool in southern Tanzania.

BACKGROUND\ud \ud Intermittent preventive treatment of malaria in infants (IPTi) using sulphadoxine-pyrimethamine and linked to the expanded programme on immunization (EPI) is a promising strategy for malaria control in young children. As evidence grows on the efficacy of IPTi as public health strategy, information is needed so that this novel control tool can be put into practice promptly, once a policy recommendation is made to implement it. This paper describes the development of a behaviour change communication strategy to support implementation of IPTi by the routine health services in southern Tanzania, in the context of a five-year research programme evaluating the community effectiveness of IPTi.\ud \ud METHODS\ud \ud Mixed methods including a rapid qualitative assessment and quantitative health facility survey were used to investigate communities' and providers' knowledge and practices relating to malaria, EPI, sulphadoxine-pyrimethamine and existing health posters. Results were applied to develop an appropriate behaviour change communication strategy for IPTi involving personal communication between mothers and health staff, supported by a brand name and two posters.\ud \ud RESULTS\ud \ud Malaria in young children was considered to be a nuisance because it causes sleepless nights. Vaccination services were well accepted and their use was considered the mother's responsibility. Babies were generally taken for vaccination despite complaints about fevers and swellings after the injections. Sulphadoxine-pyrimethamine was widely used for malaria treatment and intermittent preventive treatment of malaria in pregnancy, despite widespread rumours of adverse reactions based on hearsay and newspaper reports. Almost all health providers said that they or their spouse were ready to take SP in pregnancy (96%, 223/242). A brand name, key messages and images were developed and pre-tested as behaviour change communication materials. The posters contained public health messages, which explained the intervention itself, how and when children receive it and safety issues. Implementation of IPTi started in January 2005 and evaluation is ongoing.\ud \ud CONCLUSION\ud \ud Behaviour Change Communication (BCC) strategies for health interventions must be both culturally appropriate and technically sound. A mixed methods approach can facilitate an interactive process among relevant actors to develop a BCC strategy