ACCESSING SAFE DELIVERIES IN TANZANIA
Background information
Accessing Safe Deliveries in Tanzania (ASDIT) is the project implemented by Tanzanian Training Centre for International Health (TTCIH) based in Ifakara and Dalhousie University of Canada. This project is funded by the Canadian government through its Innovating for Maternal and Child Health for Africa (IMCHA) program. The overarching goal of this project is to reduce maternal and neonatal morbidity and mortality in Tanzania by means of enhancing safe deliveries through supporting comprehensive emergency obstetric and neonatal care services at the health centre (HC) level.With maternal mortality ratio (MMR) at 554 per 100,000 live births, neonatal mortality rate at 19 per 1,000 livebirths in 2015 and only 10% – 13% of health facilities providing the full set of basic emergency obstetric and neonatal care (BEmONC) or comprehensive emergency obstetric and neonatal care (CEmONC) signal functions, Tanzania needs to expand the number of facilities providing these services in more remote areas.[1, 2] This project introduced/ strengthened CEmONC services in five health centres located in underserved rural areas in Morogoro region in 2016 – 2019 using associate clinicians.
Research Questions
- To what extent does CEmONC implementation in health centres alter unmet need for emergency obstetrical and newborn services, and change maternal and newborn morbidity & mortality rates in the study health centres?
- How does post-training mentorship, continuous supportive supervision, and continuing education impact on CEmONC delivery in health centres?
Project Sites
The ASDIT project has two control and five intervention health centres in Morogoro region, which are Gairo HC – in Gairo district, Kibati and Melela HCs in Mvomero district, Ngerengere HC in Morogoro district and St. Joseph HC in Kilosa district. The control health centres are Mlimba and Mkamba HCs in Kilombero district.
Interventions
Human Resources Capacity Building
Training of staff from five health centres in CEmONC and anaesthesia were carried out in various periods. The first group of 20 care providers that included teams of associate clinicians and nurse-midwives were conducted from April – October 2016. Assistant medical officers (AMO) were trained in CEmONC and clinical officers and nurse/ midwives were trained in anaesthesia. Other training programs were held during implementation of the project.
eHealth Strategies
Six eLearning modules were developed and uploaded on stand-alone computers in all supported health centres to reinforce CEmONC skills and knowledge. Computers that did not require continuous internet access since this is not available to most of the health centres. In 2019 the modules were uploaded on the care providers’ mobile phones through mobile Moodle app. The project established mobile based-teleconsultation services in all these facilities. All health centres were equipped with the mobile phones (handsets) enabled with Closed User Group (CUG) service. CUG is a token prepaid service which allows users to call more experienced project team for consultation for free.
Supportive Supervision and Mentorship
These activities were conducted on quarterly basis and included: clinical audits for C-sections, maternal and deaths and morbidities, fresh stillbirth admitted with audible fetal heart beats, early neonatal deaths.
Key Achievements
The key achievements after four years of implementation of the intervention are as follows:
1. Provision of CEmONC services in health centres
All five health centres are now providing CEmNOC services as planned. Only two of these health centres provided CEmONC services before the intervention. The quality of CEmONC services was strengthened in the two facilities that provided the services before the intervention.
2. Health facility deliveries
The mean monthly health facility deliveries has increased by 157% from the baseline (before intervention) i.e. July 2014 – June 2016, in the intervention health centres compared to 42% in the control facilities
Figure 1. The mean monthly health facility deliveries before and during the intervention period.
3. Referral Rates for Reasons Related to Pregnancy and Childbirth Complications
Comparing with the figures before the intervention, referral rates (RR) decreased in both groups (Table 1). While RR decreased from 8.4% to 1.7% in the control HCs, it decreased from 5.4% to 3.5% in the intervention group in the year three.
Significance: Referring women with pregnancy and childbirth complications to distant hospitals leads to delay appropriate intervention. Delay is usually contributed by poor roads, poor availability of transport and queues/ congestion in the referral hospitals. Thus, reducing referrals for reasons related to pregnancy and childbirth complications suggests reduction of maternal and newborn mortality and morbidity. Referring a pregnant woman increases also the cost to the family, the referring institution and the health sector at large. The costs include running costs for the ambulances, payments made to the escorting nurses etc.
Table 1. Referral rates for reasons related to pregnancy and childbirth complications before and during the intervention period.
| Baseline:
Jul ’14 – Jun ’16 |
Year 1:
Jul ’16 – Jun ’17 |
Year 2:
Jul ’17 – Jun ’18 |
Year 3:
Jul ’18 – Jun ’19 |
|
| Control HCs | 8.4% | 1.5% | 1.1% | 1.7% |
| Intervention HC | 5.4% | 7.6% | 1.9% | 3.5% |
4. Maternal and Perinatal Mortality and Morbidity
Maternal Mortality
Maternal mortality decreased in both groups but more in the control group from 108 per 100,000 live births at baseline to 45 during the intervention period, and from 145 to 137 in the intervention group. The proportion of women who died from complications of pregnancy and child birth (case fatality rate) decreased slightly from 4% to 35 in the intervention group and from 5% to 2% in the control group (Table 2).
Table 2. Case fatality rate before and after the intervention in the control and intervention health centres
| Maternal deaths | Severe morbidities | Case fatality rates | |
| Intervention HC | |||
| Baseline | 6 | 135 | 4% |
| Intervention periodṪ | 18 | 559 | 3% |
| Control HCs | |||
| Baseline | 6 | 125 | 5% |
| Intervention period | 6 | 295 | 2% |
Note: Ṫ two deaths were due to complications of spinal anaesthesia
Perinatal Mtality
While stillbirth rate decreased in the control group from 18 per 100,000 births at baseline to 14 by year three of the intervention, it did change in the intervention group (Fig. 2). Following introduction of CEmONC services, the facilities started to receive more obstetric emergencies from the surrounding lower facilities. Some had severely distressed fetus and intrauterine fetal deaths. The low stillbirth rate at the baseline could also have been contributed by poor documentation before the intervention that was observed during data collection.
Figure 2. Stillbirth and very early neonatal death rates before and after intervention in the control and intervention health centres.
5. Safety of Obstetric Surgeries at the Health Centres
Selection of anaesthesia: Although general anaesthesia is also safe, the risk ratio compared with regional anaesthesia has been reported to be 1.7. Use of regional anaesthesia for caesarean delivery is associated with improved maternal safety, as it eliminates fatal complications of aspiration, failed intubation and inadequate ventilation. All facilities provided either spinal anaesthesia or ketamine for all obstetric surgeries. General anaesthesia under intubation was not practiced. Obstetric surgeries included c-sections, laparotomy for ruptured uterus and ectopic pregnancies, cervical and severe perineal tears (third and fourth degrees). While the control health centres decreased the proportion of C-sections performed under ketamine by 20%, the intervention group decreased by almost 48% (Table 3). Except where the diagnoses were not well established, all obstetric haemorrhagic conditions requiring surgery were performed using ketamine.
Table 3. Proportions of obstetric surgical interventions performed under ketamine before and during the intervention period.
| C-Sections | Laparotomy for ruptured uterus | Laparotomy for ruptured ectopic pregnancy | |
| Control HCs | |||
| · Baseline period | 383 (81%) | 1 (100%) | 0 (0%) |
| · Intervention period | 494 (65%) | 8 (89%) | 7 (100%) |
| Intervention HCs | |||
| · Baseline period | 144 (83%) | 0 (0%) | 0 (0%) |
| · Intervention period | 870 (44%) | 29 (81%) | 31 (89%) |
Safety of C-sections: Of the 2046 C-sections performed during the intervention period, only one death was attributed to intraoperative haemorrhage and two to complications of anaesthesia. The risk of dying (maternal deaths) from complications of C-section in ASDIT supported health facilities was 1.5 per 1,000 caesarean deliveries. The risk of dying (maternal deaths) from complications of anaesthesia was 1 per 1000 CS which is lower than the 2.5–3.7 per 1000 caesarean deliveries reported in Nigeria in 2008 and 2.1 per 1000 caesarean deliveries in Zimbabwe in 2005.[3, 4] Given the critical shortage of anaesthetists at present, it is unrealistic to expect that a trained physician anaesthetist can staff every remote healthcare facility. Until then, associate clinicians will remain the backbone and hope of anaesthesia in rural areas. Associate clinicians already play a vital role in the provision of CS and anesthesia, but greater numbers are needed.
Justification of C-sections: Out of 668 C-sections that were audited, 536 (80%) were performed with justifiable indications. Justification of 24 (4%) audited C-sections was unclassified because of inadequate documentation.
6. Uptake Innovation
In collaboration with our project team, the government through the Ministry of health, community development, gender, elderly and children (MOHCDGEC) developed a four months competency-based curriculum for CEmONC training program. Having noted the impact of introducing CEmONC on health services delivery, the government has started to scale up the services to other health centres in the country. As of today, the government is upgrading over 320 health centres for CEmONC services provision.
Conclusions
The 3-4 month training program in maternal and newborn emergency care (including surgery and anaesthesia) is a safe, effective and an immediate solution that is currently saving lives of mothers and babies in rural Tanzania. This education program can be used to meet the demand for maternal and newborn emergency services in rural areas in Africa.