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Background: One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians. Methods: A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge. Results: The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 – June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 – June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49–58%) to 77% (95% CI 74–80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1%) to 1.1% (95% CI 0.7–1.6%) in the intervention group and from 3.3% (95% CI 1.2–7.0%) to 0.8% (95% CI 0.2–1.7%) in the control group. Conclusions: When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.
This was a prospective cohort study of CEmONC implementation in five health centres chosen because they were far from the nearest hospital and represented the different funding and governance models for health centres in Tanzania (Fig. (Fig.1).1). As reported elsewhere, Morogoro region had 15 health centres that were either already offering CEmONC or were ready to do so once staff were trained [12]. The first category included three publicly-funded HCs that had never provided CEmONC services. They had the proper infrastructure (maternity and neonatal wards, a functioning operating theatre and ability to provide emergency blood transfusions) but their staff had not received CEmONC training. This group typified the HCs that the Ministry of Health would have to upgrade as it implements its national goal of 50% of health centres in Tanzania offering CEmONC. Two of the three (Kibati and Ngerengere) HCs were randomly allocated to the intervention. The second category had nine publicly-funded HCs and were already providing CEmONC. Using simple random sampling, two of the nine (Mlimba and Mkamba HCs) were allocated to be control sites and two (Gairo and Melela HCs) to the intervention in order to study how CEmONC services could be strengthened. The third category contained three HCs affiliated with faith-based organizations. They receive both public and faith-based organization funding and are a permanent and integral part of the Tanzanian health system. One of the three (St. Joseph HC) was randomly allocated to the intervention. Unlike many studies where control centres are chosen to be comparable to intervention centres, we chose two facilities primarily to track secular trends, i.e., changes in epidemiology and health services practices that occurred independently of the ASDIT intervention. Again, unlike many studies, we purposefully chose our five intervention HCs to be different from each other in order to understand the variation in experience according to how facilities were funded and administered. With the exception of Kilosa district, none had ready access to a district hospital. Before the intervention, women with emergency obstetric complications requiring surgical intervention in the four health centres were referred to either a nearby faith-based hospital or a regional referral hospital in Morogoro urban. The distance from these health centres to the nearest district hospital ranged from 35 km to 80 km. Map of Morogoro region indicating the geographical locations of the project health centres and the nearest hospitals Face-to-face training in CEmONC and anaesthesia: Twenty six associate clinicians from five health centres were trained in teams for three months in CEmONC and anaesthesia. From each health centre, four to six associate clinicians were trained. Assistant medical officers (advanced associate clinicians) were trained in CEmONC while clinical officers (associate clinicians) and nurse-midwives (ordinary diploma holders) were trained in anaesthesia and postoperative care of mothers and newborns. In Tanzania, clinical officers are mid-level professionals trained in a three-year post-secondary clinical medicine program and are not licensed to perform major surgery. Assistant medical officers are clinical officers with an additional two-year training program in clinical medicine, which includes three months of surgery and three months of obstetrics. They function as general practitioners and are licensed to perform major surgery independently, including caesarean sections. Although both often lack hands-on experience in surgery and obstetrics at the time of graduation, university graduate medical doctors go through a one-year internship training whereas assistant medical doctors do not. The project team adopted and revised the CEmONC and anaesthesia training curricula designed at Tanzanian Training Centre for International Health (TTCIH) and St. Francis Referral Hospital (SFRH) described elsewhere [13]. The main emphasis of both training curricula included the use of underlying principles in obstetric and anaesthetic care; appropriate decision making and clinical reasoning skills, and acquisition of clinical management skills in these areas. Both training programs were full time and took place at SFRH, a busy facility, to enhance hands-on practice and acquisition of skills. The educational curricula were implemented by teams of obstetricians, pediatricians and anaesthetists working at SFRH and TTCIH. Post-training capacity building: Following training, the research team implemented teleconsultation, quarterly on-site supportive supervision and continuous mentorship via telephone and social media to reinforce skills and knowledge. Care providers at the health centres were linked to obstetricians for virtual consultation when there were maternal complications. Supportive supervision and mentorship visits at the health centres included clinical audits of charts with clinicians for all mothers who died or had significant morbidities. The objective of the audit was to determine the causes and assess the factors that contributed to the maternal deaths based on the “three delays model” [14]. The level of delay was determined for each case with a purpose of developing the action plans for intervention. Based on the three delays model the following were explored: Delay in deciding to seek care: This included delay in seeking treatment at any time during antenatal care, up to and including the intrapartum period. The use of local herbs during labour and use of a traditional birth attendant before coming to the facility was also reviewed. Delay in arriving at a functional health facility: Any delay in transport from home once a decision had been made. Delay providing adequate care: This included any delay in referring from a facility that could not provide emergency obstetric care (e.g., a dispensary) or any delay in receiving adequate care at the receiving facility. The maternal mortality audit allowed the team to assess the quality of care and decision making in order to improve care. The audit team was composed of an obstetrician, an assistant medical officer with anaesthesiology training, a paediatrician, care providers working at the supported HCs and senior midwives from the regional and council health management teams. The data were collected using a mobile data collection app called CommCare. Data were collected from the logbooks for Health Management Information System (HMIS), operating theatre logbooks and individual case files, which included partographs. The key dependent variables included the number of deliveries, number and types of maternal morbidities (women with obstetric complications) and maternal deaths. Variables for maternal death audits were the causes of maternal deaths and level(s) of delay using the three delays model. The audit team reviewed the case notes and partographs to establish the duration of the complication before admission to ascertain the delay in seeking care or reaching the facility, if she sought care at the traditional birth attendant before coming to the health facility and the appropriateness of the treatment provided at the health facility. The appropriateness of management was judged by comparing it with the national management guidelines. Strategies for uptake of the educational and mentoring programs and sustainability of the interventions in these health centres have been described elsewhere [12]. Data were extracted from the server into Microsoft Excel and analyzed using Stata (version 15). Tests of proportion were performed to compare the incidences of morbidities and case fatality rates during the baseline and intervention periods. The level of significance was set at a p-value of 0.05. The annual number of expected births in each catchment population was calculated using crude birth rate (annual live births per 1000 population), multiplied by the population during the year of interest. Of these births, 15% were estimated to be complicated [4, 15]. The met need for emergency obstetric care was determined as a proportion of pregnant women expected to have complications who were admitted for treatment [16].
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