Trends in caesarean section rates between 2007 and 2013 in obstetric risk groups inspired by the Robson classification: results from population-based surveys in a low-resource setting.

OBJECTIVE: To describe caesarean section rates and neonatal mortality to assess change in access to life-saving interventions in a rural low-resource setting between 2007 and 2013. DESIGN: Population-based cross-sectional study. SETTING: Southern Tanzania. POPULATION: A total of 34 063 women from 384 549 households who gave birth in the previous year. METHODS: Using data collected in two geo-referenced household surveys conducted in 2007 and 2013 in the context of two cluster-randomized controlled trials, we describe trends in caesarean section and neonatal mortality in obstetric risk groups inspired by the 10-group Robson classification. MAIN OUTCOME MEASURES: Rates of self-reported birth by caesarean section and neonatal mortality. RESULTS: Population-based caesarean section rates increased from 4.0% in 2007 to 6.4% in 2013. In 2013, the lowest caesarean section rate was found in multipara whose labour was not induced or augmented [4.4%, 95% confidence interval (CI) 3.9-4.9], a group that showed a rate increase of over 50% from 2007 [adjusted prevalence ratio 1.57 (95% CI 1.34-1.82)]. Nullipara whose labour was not induced or augmented had rates of 6.2% in 2007 and 8.5% in 2013. Caesarean rates in multiple pregnancies were low at 8.1% (95% CI 5.6-10.5) in 2007, and 14.6% (95% CI 9.4-19.8) in 2013. Overall neonatal mortality was high: 3.5% in 2007 and 3.2% in 2013, with rates being lowest in multiparous women whose labour was not induced or augmented: 2.4% (95% CI 2.2-2.7) and 1.7% (95% CI 1.4-2.0) in 2007 and 2013, respectively. CONCLUSION: Although use of caesarean section remains insufficient, and higher rates do not necessarily imply better quality of care, our analysis highlights improvements in reaching women with caesarean section. Rates in multiple birth remained low compared with high-income settings. TWEETABLE ABSTRACT: In Southern Tanzania caesarean section rates increased over time, but the rate in high-risk births remained alarmingly low.

Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda.

BACKGROUND: Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services. METHODS: Collaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors. RESULTS: The intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25-28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6-9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2-60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0-28%). CONCLUSIONS: The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201311000681314.

A COMPARATIVE ANALYSIS OF FIRST DAY NEONATAL MORTALITY BETWEEN ADOLESCENTS AND ADULT FEMALES GIVING BIRTH AT LIGULA HOSPITAL IN MTWARA, SOUTH EASTERN TANZANIA 2008-2009.

OBJECTIVE: Compare first day neonatal mortality between adolescents and adults delivering at the main referral hospital in Mtwara, Tanzania DESIGN: Cross-sectional chart review SETTING: The study was conducted at the main referral hospital in Mtwara, Tanzania. Rates of adolescent pregnancy at the hospital were 15.5% in 2009 and 14.3% in 2010 SUBJECTS: A total of 450 adolescent and adult females delivering at Ligula Hospital between 2008 and 2009 were included in the study. OUTCOME MEASURES: First day neonatal mortality between adolescents and adults was the primary outcome. Secondary outcomes included neonatal birth weight, parity, gravidity, prematurity, HIV and neonates delivered. RESULTS: First day neonatal mortality was 5.56%. Birth weight was the only risk factor significantly associated with neonatal mortality CONCLUSION: Younger women have predisposal to neonatal mortality due to underlying causal mechanisms. In order to validate the results of this study, further research on risk and causes of first day neonatal mortality at facilities is warranted.

Household decision-making about delivery in health facilities: evidence from Tanzania.

This study investigated how partners' perceptions of the healthcare system influence decisions about delivery-location in low-resource settings. A multistage population-representative sample was used in Kasulu district, Tanzania, to identify women who had given birth in the last five years and their partners. Of 826 couples in analysis, 506 (61.3%) of the women delivered in the home. In multivariate analysis, factors associated with delivery in a health facility were agreement of partners on the importance of delivering in a health facility and agreement that skills of doctors are better than those of traditional birth attendants. When partners disagreed, the opinion of the woman was more influential in determining delivery-location. Agreement of partners regarding perceptions about the healthcare system appeared to be an important driver of decisions about delivery-location. These findings suggest that both partners should be included in the decision-making process regarding delivery to raise rates of delivery at facility.

Controlling postpartum hemorrhage after home births in Tanzania.

OBJECTIVES: Determine safety of household management of postpartum hemorrhage (PPH) with 1000 microg of rectal misoprostol, and assess possible reduction in referrals and the need for additional interventions. METHODS: Traditional birth attendants (TBAs) in Kigoma, Tanzania were trained to recognize PPH (500 ml of blood loss). Blood loss measurement was standardized by using a local garment, the "kanga". TBAs in the intervention area gave 1000 microg of misoprostol rectally when PPH occurred. Those in the non-intervention area referred the women to the nearest facility. RESULTS: 454 women in the intervention and 395 in the non-intervention areas were eligible. 111 in the intervention area and 73 in the non-intervention had PPH. Fewer than 2% of the PPH women in the intervention area were referred, compared with 19% in the non-intervention. CONCLUSION: Misoprostol is a low cost, easy to use technology that can control PPH even without a medically trained attendant.

Randomized intervention study comparing several regimens for the treatment of moderate anemia among refugee children in Kigoma Region, Tanzania.

Anemia-specific mortality was markedly elevated among refugee children < 5 years of age in Tanzania. In a randomized, double-blind study, 215 anemic children were initially treated for malaria and helminth infection and then received 12 weeks of thrice-weekly oral iron and folic acid. Group I received placebo and chloroquine treatment for symptomatic malaria infection (i.e., no presumptive anti-malarial treatment given). Group II received placebo and monthly presumptive treatment with sulfamethoxazole-pyrimethamine (SP). Group III also received monthly SP and thrice-weekly vitamins A and C (VAC). Mean hemoglobin concentration increased from 6.6 to 10.2 g/dL, with no significant differences among groups. Group II had lower mean serum transferrin receptor levels (TfR) than group I [P = 0.023]. A greater proportion of participants in group III had normal iron stores (TfR < 8.5 microg/ mL) than in group II [P = 0.012]. Initial helminth and malaria treatment, followed by thrice-weekly iron and folic acid supplements resulted in increased hemoglobin levels. Monthly SP and thrice-weekly VAC contributed to improve iron stores. Monthly SP may have a role in situations where asymptomatic disease is prevalent or where access to care is limited. Because administration of VAC also hastened recovery of iron stores over administration of monthly SP alone, health care personnel could add VAC to the treatment for moderate anemia if maximum recovery of iron stores is desired.

In vivo efficacy study of amodiaquine and sulfadoxine/ pyrimethamine in Kibwezi, Kenya and Kigoma, Tanzania.

We conducted two randomized clinical trials to determine the in vivo efficacy of amodiaquine and sulfadoxine/pyrimethamine in treating Plasmodium falciparum malaria. Seventy-five patients under the age of 10 years in Kibwezi, Kenya, and 171 patients in Kigoma, Tanzania, were enrolled for treatment. Due to loss of eight patients in Kibwezi and 37 in Kigoma to follow-up, we used best and worst case scenarios for the parasitological response. The in vivo sensitivity of Plasmodium falciparum to amodiaquine was 75% (no loss to follow-up) in Kibwezi and ranged from 85% in the best to 65% in the worst case scenario in Kigoma. The sensitivity to sulfadoxine/pyrimethamine was 70% to 88% in Kibwezi and 65% to 89% in Kigoma. R1 resistance to amodiaquine was 22% in Kibwezi and varied from 6% in the best to 26% for the worst case scenario in Kigoma. The R1 resistance to sulfadoxine/pyrimethamine was 5% to 23% in Kibwezi and 2% to 26% in Kigoma. R2 resistance was 3% for amodiaquine and 7% for sulfadoxine/pyrimethamine in Kibwezi and 9% in Kigoma for each treatment group. There was no statistically significant difference between treatment groups at either study site, except for a slight difference in R1 resistance in the best case scenario, Kibwezi, in favour of S/P. Although both amodiaquine and sulfadoxine/pyrimethamine resistance seems to be increasing, these antimalarials are still effective in parasite clearance.

Randomised trial of alternative malaria chemoprophylaxis strategies among pregnant women in Kigoma, Tanzania: II. Results from baseline studies.

OBJECTIVE: To determine baseline data among pregnant women consenting to participate in a randomised trial of alternative strategies of malaria chemoprophylaxis in Kigoma urban district, western Tanzania. DESIGN: Cross-sectional study. SETTING: The study was conducted in an urban MCH clinic in Kigoma town in western Tanzania. SUBJECTS: All consenting pregnant women who fulfilled entry criteria were recruited into the study. BASELINE STUDIES: Baseline data were collected prior to randomisation of women to antimalarial prophylactic regimens. Baseline measurements included examination for blood depleting parasitic infections (stool and urine examinations), haemoglobin levels, haematocrit, sickling test, and blood slide for malaria parasites. RESULTS: A total of 728 pregnant women consented to participate in the interview and of these 705 participated in baseline studies constituting a participation rate of 96.8%. The age of participating women ranged from 14 to 45 years with a mean age of 23.7 years (standard deviation [SD] = 5.4) while the mean number of pregnancies ranged from 1 to 13 with a mean of 3.2 (SD = 2.2). The prevalence of malaria parasitaemia among the pregnant women examined was 9.4% (N = 705) while the prevalence of anaemia (defined as Hb < 8.5 gdl-1) was 12.4% (N = 579). No significant difference was observed in prevalence proportions of malaria parasitaemia in relation to age, parity, marital status and use of mosquito bednets. However the prevalence of anaemia among women in the age group 31-45 years was significantly lower than that observed among women in the age group 14-20 years (2.9% versus 18.9%; crude odds ratio [OR] = 0.13; 95% confidence interval [CI], 0.02-0.55). Sickle cell disease (HbAS) was found in 2.3% (N = 564) of the pregnant women examined. CONCLUSION: It is concluded that the prevalence of malaria parasitaemia and anaemia was very high in this population suggesting the need for interventions directed at controlling these major causes of maternal morbidity and mortality in Tanzania.

PIP: This cross-sectional study conducted in Kigoma urban district, western Tanzania, determined the baseline data among pregnant women consenting to participate in a randomized trial of alternative malaria chemoprophylaxis strategies. Baseline data were obtained prior to randomization of women to antimalarial prophylactic regimens (intermittent or continuous chloroquine and proguanil). Baseline measurements included examination for blood depleting parasitic infections (stool and urine examinations), hemoglobin levels, hematocrit, sickling test, and blood slide for malaria parasites. A total of 728 pregnant women consented to participate, and of these, 705 participated in baseline studies constituting a participation rate of 96.8%. The age range was 14-45 years, while the number of pregnancies ranged from 1 to 13. The prevalence of malaria parasitemia among the subjects was 9.4% (N = 705), while the prevalence of anemia was 12.4% (N = 579). There was no significant difference in prevalence proportions of malaria parasitemia in relation to age, parity, marital status and use of mosquito bednets. However, the prevalence of anemia among women aged 31-14 years was significantly lower than among women in the age group 14-20 years (2.9% vs. 18.9%; crude odds ratio = 0.13; 95% confidence interval, 0.02-0.55). Sickle cell disease (HbAS) was found in 2.3% (N = 564) of the pregnant women examined. The prevalence of malaria parasitemia and anemia was very high in this population, suggesting the need for effective disease control interventions.

Reducing maternal mortality in Kigoma, Tanzania.

An intervention programme aiming at a reduction of maternal deaths in the Regional Hospital, Kigoma, Tanzania, is analyzed. A retrospective study was carried out from 1984-86 to constitute a background for an intervention programme in 1987-91. The retrospective study revealed gross under-registration of data and clarified a number of potentially useful issues regarding avoidable maternal mortality. An intervention programme comprising 22 items was launched and the maternal mortality ratio was carefully followed in 1987-91. The intervention programme paid attention to professional responsibilities with regular audit-oriented meeting, utilization of local material resources, schedules for regular maintenance of equipment, maintenance of working skills by regular on-the-job training of staff, norms for patient management, provision of blood, norms for referral of severely ill patients, use of antibiotics, regular staff evaluation, public complaints about patient management, travel distance of all essential staff to the hospital, supply of essential drugs, the need of a small infusion production unit, the creation of culture facilities for improved quality of microbiology findings, and to efforts to stimulate local fund-raising. The results indicate that the maternal mortality ratio fell from 933 to 186 per 100,000 live births over the period 1984-91. Thus it is underscored that the problem of maternal mortality can be successfully approached by a low-cost intervention programme aiming at identifying issues of avoidability and focusing upon locally available problem solutions.

PIP: A review of all 1984-1986 hospital records at the Regional Hospital in Kigoma, Tanzania, aimed to determine the maternal mortality rate and contributory/medical causes of death. Underregistration of data was evident. Contributory causes of maternal death were: a lack of most of the basic equipment, outdated existing basic equipment, no reserve water tank, poor staff attitude, absent hospital staff during office hours, prescriptions without physically seeing the patients, low supply of drugs, acute shortage of blood, and no trained anesthetist. A low-cost intervention program implemented 22 items which focused on professional responsibilities with regular audit-oriented meetings, utilization of local material resources, schedules for regular maintenance of equipment, maintenance of working skills by regular on-the-job training of staff, norms for patient management, provision of blood, norms for referral of severely ill patients, use of antibiotics, regular staff evaluation, public complaints about patient management, travel distance of all essential staff to the hospital, supply of essential drugs, the need for a small infusion production unit, the creation of culture facilities for improved quality of microbiology findings, and efforts to encourage local fund-raising. A 1991 prospective study revealed that the average maternal mortality ratio fell significantly between 1984-1986 and 1987-1991 (849-275/100,000 live births; p 0.001). Specifically, it fell from 933 to 186/100,000 between 1984 and 1991. Causes of maternal death were difficult to determine because relatives refused to allow autopsies in most cases. Based on the unreliable data available, the most common causes of death during the retrospective study were uterine rupture, sepsis, and anemia. The prevalence of uterine rupture, sepsis, and postpartum/ antepartum hemorrhage, as main causes of admission fell somewhat between 1984 and 1991, while anemia, septic abortion, and pelvic infection increased.