Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania.

BACKGROUND: Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS: We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS: Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS: Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.

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.

Access to maternal health services: geographical inequalities, United Republic of Tanzania.

OBJECTIVE: To determine if improved geographical accessibility led to increased uptake of maternity care in the south of the United Republic of Tanzania. METHODS: In a household census in 2007 and another large household survey in 2013, we investigated 22 243 and 13 820 women who had had a recent live birth, respectively. The proportions calculated from the 2013 data were weighted to account for the sampling strategy. We examined the association between the straight-line distances to the nearest primary health facility or hospital and uptake of maternity care. FINDINGS: The percentages of live births occurring in primary facilities and hospitals rose from 12% (2571/22 243) and 29% (6477/22 243), respectively, in 2007 to weighted values of 39% and 40%, respectively, in 2013. Between the two surveys, women living far from hospitals showed a marked gain in their use of primary facilities, but the proportion giving birth in hospitals remained low (20%). Use of four or more antenatal visits appeared largely unaffected by survey year or the distance to the nearest antenatal clinic. Although the overall percentage of live births delivered by caesarean section increased from 4.1% (913/22 145) in the first survey to a weighted value of 6.5% in the second, the corresponding percentages for women living far from hospital were very low in 2007 (2.8%; 35/1254) and 2013 (3.3%). CONCLUSION: For women living in our study districts who sought maternity care, access to primary facilities appeared to improve between 2007 and 2013, however access to hospital care and caesarean sections remained low.

Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania-A qualitative study of health workers' perspectives.

BACKGROUND: Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities. METHODS: In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories. RESULTS: 'It is like rain' was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers' access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of 'things going as intended', as a sign of good quality care. CONCLUSIONS: Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.

Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania.

A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention's implementers was undertaken in four villages receiving the intervention to evaluate the intervention's implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.

Birth preparedness and place of birth in Tandahimba district, Tanzania: what women prepare for birth, where they go to deliver, and why.

BACKGROUND: As making preparations for birth and health facility delivery are behaviours linked to positive maternal and newborn health outcomes, we aimed to describe what birth preparations were made, where women delivered, and why. METHODS: Outcomes were tabulated using data derived from a repeated sample (continuous) quantitative household survey of women aged 13-49 who had given birth in the past year. Insights into why behaviours took place emerged from analysis of in-depth interviews (12) and birth narratives (36) with recently delivered mothers and male partners. RESULTS: Five hundred-twenty three women participated in the survey from April 2012-November 2013. Ninety-five percent (496/523) of women made any birth preparations for their last pregnancy. Commonly prepared birth items were cotton gauze (93 %), a plastic cover to deliver on (84 %), gloves (72 %), clean clothes (70 %), and money (42 %). Qualitative data suggest that preparation of items used directly during delivery was perceived as necessary to facilitate good care and prevent disease transmission. Sixty-eight percent of women gave birth at a health facility, 30 % at home, and 2 % on the way to a health facility. Qualitative data suggested that health facility delivery was viewed positively and that women were inclined to go to a health facility because of a perception of: increased education about delivery and birth preparedness; previous health facility delivery; and better availability and accessibility of facilities in recent years. Perceived barriers: were a lack of money; absent health facility staff or poor provider attitudes; women perceiving that they were unable to go to a health facility or arrange transport on their own; or a lack of support of pregnant women from their partners. CONCLUSIONS: The majority of women made at least some birth preparations and gave birth in a health facility. Functional items needed for birth seem to be given precedence over practices like saving money. As such, maintaining education about the importance of these practices, with an emphasis on emergency preparedness, would be valuable. Alongside education delivered as part of focussed antenatal care, community-based interventions that aim to increase engagement of men in birth preparedness, and support agency among women, are recommended.

Unit cost analysis of training and deploying paid community health workers in three rural districts of Tanzania.

BACKGROUND: Tanzania, like other African countries, faces significant health workforce shortages. With advisory and partnership from Columbia University, the Ifakara Health Institute and the Tanzanian Training Centre for International Health (TTCIH) developed and implemented the Connect Project as a randomized cluster experimental trial of the childhood survival impact of recruiting, training, and deploying of a new cadre of paid community health workers (CHW), named "Wawazesha wa afya ya Jamii" (WAJA). This paper presents an estimation of the cost of training and deploying WAJA in three rural districts of Tanzania. METHODS: Costing data were collected by tracking project activity expenditure records and conducting in-depth interviews of TTCIH staff who have led the training and deployment of WAJA, as well as their counterparts at Public Clinical Training Centres who have responsibility for scaling up the WAJA training program. The trial is registered with the International Standard Randomized Controlled Trial Register number ( ISRCTN96819844 ). RESULTS: The Connect training cost was US$ 2,489.3 per WAJA, of which 40.1 % was for meals, 20.2 % for accommodation 10.2 % for tuition fees and the remaining 29.5 % for other costs including instruction and training facilities and field allowance. A comparable training program estimated unit cost for scaling-up this training via regional/district clinical training centres would be US$ 833.5 per WAJA. Of this unit cost, 50.3 % would involve the cost of meals, 27.4 % training fees, 13.7 % for field allowances, 9 % for accommodation and medical insurance. The annual running cost of WAJA in a village will cost US$ 1.16 per capita. CONCLUSION: Costs estimated by this study are likely to be sustainable on a large scale, particularly if existing regional/district institutions are utilized for this program.

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.

Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania.

OBJECTIVE: To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania. METHODS: Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi's model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care. FINDINGS: Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts. CONCLUSION: The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.

Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions.

BACKGROUND: Many low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures. METHODS: We compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system. FINDINGS: The distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the "basic needs" poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the "basic needs" poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard. CONCLUSION: In choosing poverty identification strategies for programmes seeking to enhance health equity it's necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities.

"Why not bathe the baby today?": A qualitative study of thermal care beliefs and practices in four African sites.

BACKGROUND: Recommendations for care in the first week of a newborn's life include thermal care practices such as drying and wrapping, skin to skin contact, immediate breastfeeding and delayed bathing. This paper examines beliefs and practices related to neonatal thermal care in three African countries. METHODS: Data were collected in the same way in each site and included 16-20 narrative interviews with recent mothers, eight observations of neonatal bathing, and in-depth interviews with 12-16 mothers, 9-12 grandmothers, eight health workers and 0-12 birth attendants in each site. RESULTS: We found similarities across sites in relation to understanding the importance of warmth, a lack of opportunities for skin to skin care, beliefs about the importance of several baths per day and beliefs that the Vernix caseosa was related to poor maternal behaviours. There was variation between sites in beliefs and practices around wrapping and drying after delivery, and the timing of the first bath with recent behavior change in some sites. There was near universal early bathing of babies in both Nigerian sites. This was linked to a deep-rooted belief about body odour. When asked about keeping the baby warm, respondents across the sites rarely mentioned recommended thermal care practices, suggesting that these are not perceived as salient. CONCLUSION: More effort is needed to promote appropriate thermal care practices both in facilities and at home. Programmers should be aware that changing deep rooted practices, such as early bathing in Nigeria, may take time and should utilize the current beliefs in the importance of neonatal warmth to facilitate behaviour change.

Protocol for the evaluation of a free health insurance card scheme for poor pregnant women in Mbeya region in Tanzania: a controlled-before and after study.

BACKGROUND: The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012. METHODS: A controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective. DISCUSSION: This evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature.

Current Neonatal Skin Care Practices in Four African Sites.

Data for this study on skin care practices and emollient use in four African sites were collected using in-depth interviews, focus-group discussions and observations. Respondents were mothers, grandmothers, fathers, health workers, birth attendants and people selling skin-care products. Analysis included content and framework analyses.Emollient use was a normative practice in all sites, with frequent application from an early age in most sites. There were variations in the type of emollients used, but reasons for use were similar and included improving the skin, keeping the baby warm, softening/strengthening the joints/bones, shaping the baby, ensuring flexibility and encouraging growth and weight gain. Factors that influenced emollient choice varied and included social pressure, cost, availability and deep-rooted traditional norms. Massage associated with application was strong and potentially damaging to the skin in some sites.Given the widespread use of emollients, the repeated exposure of newborns in the first month of life and the potential impact of emollients on mortality, trials such as those that have been conducted in Asia are needed in a range of African settings.

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).

A community-randomized evaluation of the effect of intermittent preventive treatment in infants on antimalarial drug resistance in southern Tanzania.

BACKGROUND: Intermittent preventive treatment in infants (IPTi) is the administration of sulfadoxine-pyrimethamine (SP) at 2, 3, and 9 months of age to prevent malaria. We investigated the influence of IPTi on drug resistance. METHODS: Twenty-four areas were randomly assigned to receive or not receive IPTi. Blood collected during representative household surveys at baseline and 15 and 27 months after implementation was tested for SP and resistance markers. RESULTS: The frequency of SP in blood was similar in the IPTi and comparison areas at baseline and at 15 months. dhfr and dhps mutations were also similar at baseline and then increased similarly in both arms after 15 months of SP-IPTi. First-line treatment was switched from SP to artemether-lumefantrine before the final survey, when SP positivity fell among infants in comparison areas but increased in IPTi areas. This was accompanied by an increase in dhfr but not dhps mutations in IPTi areas (P = .004 and P = .18, respectively). CONCLUSIONS: IPTi did not increase drug pressure or the selection on dhfr and dhps mutants, when SP was the first-line malaria treatment. Introduction of artemether-lumefantrine was followed by an increase in dhfr mutations, consistent with weak selection attributable to SP-IPTi, but not by an increase in dhps mutations, suggesting a fitness cost of this mutation.

Staff experiences of providing maternity services in rural southern Tanzania - a focus on equipment, drug and supply issues.

BACKGROUND: 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 patient outcomes through delaying care provision. We aim to describe staff experiences of providing maternal and neonatal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies. METHODS: 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. RESULTS: 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 with potential health risks to themselves as a result. CONCLUSIONS: 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.

The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system.

BACKGROUND: Tanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga). DESCRIPTION OF INTERVENTION: Connect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre - Community Health Agents (CHA) - who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect's district-wide emergency referral strengthening intervention includes clinical and operational improvements. EVALUATION DESIGN: Designed as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system. DISCUSSION: Global commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania's need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities. TRIAL REGISTRATION: ISRCTN96819844.

Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania.

BACKGROUND: To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. METHODS: We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. RESULTS: Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. CONCLUSION: System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.

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 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 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 the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting 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.