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Background: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned. Methods: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries. Results: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1. Conclusions: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries.
Assisted vaginal delivery in Tanzania had been all but abandoned in 2008 when Thamini Uhai began implementation. Obstetric forceps was never popular and although national guidelines recognized VE as a sanctioned obstetric procedure, its utilization was often not considered [10, 11]. Quality improvement audits in two Tanzanian hospitals suggested that fear of HIV contributed to the reluctance to use VE [11, 12].2 A guiding principle to capacity building was that all associate clinicians who were going to engage in surgery also needed the skills to use a vacuum extractor. Before implementing VE training at project sites, advocacy efforts strategically began with clinical training at the two largest medical training centres in the country: Muhimbili Medical School and Bugando Teaching Hospital, where the country’s leading obstetrician/gynaecologists worked. International experts teamed up with local champions to conduct these trainings. Some participants expressed reservations while paediatricians in some regions, at least, spoke against the practice. Nevertheless, the outcome of this early attempt to elicit the support of local leaders in the field was one of strong endorsement by the Ministry of Health and it fostered a favourable climate for including VE in the toolbox of obstetric skills. The task-shifting strategy that Thamini Uhai embraced builds on a long history in Tanzania of working with AMOs for surgery [13] and nurse-midwives and clinical officers for anaesthesia. The 3 months of EmONC training for teams of surgeons and anaesthetists has been described elsewhere [14]. It also included skills-building in VE, removal of retained products, manual removal of placenta, cervical and perineal repairs, and adult and neonatal resuscitation. This training was followed by weeklong Continuing Medical Education (CME) sessions that focused on specific topics that were identified as requiring further confidence- and skills-building such as VE. CMEs were conducted at the five hospitals in the three regions. Two rounds of VE CMEs have taken place, one in 2012 and the other in 2016. The CME focused on a review of the partograph and VE. Trainees used anatomical models for practice but had relatively few opportunities themselves to perform a vacuum-assisted delivery on a patient, but all observed the procedure being performed. Between nine and 14 individuals made up a batch for a CME session. The training used both soft and metal cups and the project distributed Malmström extractors and Kiwi equipment. The training was considered competency-based in the context of anatomical models and followed a protocol adapted from the American College of Obstetricians and Gynecologists. Training in VE also included how to treat complications such as postpartum haemorrhage and perineal lacerations, if they occurred. Because all sites had an operating theatre (OT), if vacuum-assisted delivery was not successful, a woman was transferred to the OT for caesarean delivery. Multiple activities were put in place to support the newly trained AMOs, nurse-midwives and clinical officers, and to improve the quality of care. These included supportive supervision and clinical audits. Obstetrician/gynaecologists or experienced AMOs and an expert anaesthetist visited each site monthly, spending two to three-days at each site, providing on-the-job coaching and hands-on mentoring. The project established weekly teleconferences allowing staff to discuss specific cases with clinicians as well as closed user group networks enabling each facility to make calls for free within the network. The closed user groups facilitated specialists to be ‘on call’ so that emergency consultations were possible day and night; in Kigoma, they created a “WhatsApp” group. The supportive supervision and clinical audit visits were helpful in identifying when a CME was warranted as staff rotated and others were transferred. In addition to the hands-on CMEs, eLearning sessions were developed. In the case of VE, the trainers adopted WHO’s video on VE and translated it into Swahili. The supervisory teams also reviewed the contents of a monthly monitoring form that tracked aggregated service statistics – births, maternal and neonatal deaths, intrapartum stillbirths, near misses, and audits of all caesareans, which were used for quality improvement purposes and immediate feedback [8]. The data extracted from these forms were used in the analyses below. When retrieving this information, staff had no contact with patients and no names were captured on the form. Given that the primary purpose of the data was for internal quality improvement and feedback for the staff and to document high level changes over time, neither patient consent nor Institutional Review Board approval was sought. However, the Ministry of Health and Social Welfare, the Regional and District health management teams and medical directors of participating facilities granted permission and approval of project activities. In 2015 four additional health centres were selected for C-EmONC upgrading in Kigoma and began receiving a similar package of interventions that the other sites received, including training in VE for AMOs and nurse-midwives. For this paper, the monitoring counts were used to calculate percentages, rates and ratios, for example, the ratio of the number of caesareans to VE procedures. No statistical tests were used.
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