Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study.

INTRODUCTION: Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes. METHODS: We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO's Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for 'comparison'. We interviewed 43 facility managers and 818 providers, observed 1516 client-provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality. RESULTS: EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems. CONCLUSION: Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Distribution of Pantoea agglomerans isolates and molecular detection of blaPER-1 ESßL gene: A statistical study.

THE PURPOSE: to study the distribution of Pantoea agglomerans (P. agglomerans) statistically and the presence of blaPER-1 type ESßL in the clinical and environmental isolates. METHODS: During a period of 2014-2015, 895 blood specimens and 438 hospital environmental samples were collected from one children's hospital in Baghdad city. The results of statistical analysis showed there was no relationship between the infection with P. agglomerans and the sex, while there was a relationship between the infection with the P. agglomerans and the place of residence and also the age of patients. RESULT: A total of 23 P. agglomerans were isolated during the study, out of 23 isolates, 13 (56.52%) and 10 (43.48%) were isolated from blood specimens and from hospital environment. All 23 isolates had 100% sensitivity rate to Imipenem and the highest resistant rate was (95.65%) to Ampicillin. Out of 23 P. agglomerans, 14 (60.87%) isolates were positive ESßL producing by the screening test. CONCLUSION: The result of molecular screening of the gene blaPER-1 showed the presence of this gene only in phenotypically ESBL producing isolates, while all negative ESßL producing isolates don't harboring blaPER-1 gene. Out of 14 positive ESßL producing P. agglomerans isolates, 5 (35.71%) were harboring blaPER-1 gene and 9 (64.29%) of positive ESßL producing isolates were don't harboring blaPER-1 gene (significant difference at ≤0.05).

Evaluation of distance learning IMCI training program: the case of Tanzania.

BACKGROUND: The standard 11-days IMCI (Integrated Management of Childhood Illness) training course (standard IMCI) has faced barriers such as high cost to scale up. Distance learning IMCI training program was developed as an alternative to the standard IMCI course. This article presents the evaluation results of the implementation of distance learning IMCI training program in Tanzania. METHODS: From December 2012 to end of June 2015, a total of 4806 health care providers (HCP) were trained on distance learning IMCI from 1427 health facilities {HF) in 68 districts in Tanzania. Clinical assessments were done at the end of each course and on follow up visits of health facilities 4 to 6 weeks after training. The results of those assessments are used to compare performance of health care providers trained in distance learning IMCI with those trained in the standard IMCI course. Statistical analysis is done by comparing proportions of those with appropriate performances using four WHO priority performance indicators as well as cost of conducting the courses. In addition, the perspectives of health care providers, IMCI course facilitators, policy makers and partners were gathered using either focussed group discussions or structured questionnaires. RESULTS: Distance learning IMCI allowed clusters of training courses to take place in parallel, allowing rapid expansion of IMCI coverage. Health care providers trained in distance learning IMCI performed equally well as those trained in the standard IMCI course in assessing Main Symptoms, treating sick children and counselling caretakers appropriately. They performed better in assessing Danger Signs. Distance learning IMCI gave a 70% reduction in cost of conducting the training courses. CONCLUSION: Distance learning IMCI is an alternative to scaling up IMCI as it provides an effective option with significant cost reduction in conducting training courses.

Tanzania's countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015.

BACKGROUND: Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study. METHODS: We analysed progress made in Tanzania between 1990 and 2014 in maternal, newborn, and child mortality, and unmet need for family planning, in which we used a health systems evaluation framework to assess coverage and equity of interventions along the continuum of care, health systems, policies and investments, while also considering contextual change (eg, economic and educational). We had five objectives, which assessed each level of the health systems evaluation framework. We used the Lives Saved Tool (LiST) and did multiple linear regression analyses to explain the reduction in child mortality in Tanzania. We analysed the reasons for the slower changes in maternal and newborn survival and family planning, to inform priorities to end preventable maternal, newborn, and child deaths by 2030. FINDINGS: In the past two decades, Tanzania's population has doubled in size, necessitating a doubling of health and social services to maintain coverage. Total health-care financing also doubled, with donor funding for child health and HIV/AIDS more than tripling. Trends along the continuum of care varied, with preventive child health services reaching high coverage (≥85%) and equity (socioeconomic status difference 13-14%), but lower coverage and wider inequities for child curative services (71% coverage, socioeconomic status difference 36%), facility delivery (52% coverage, socioeconomic status difference 56%), and family planning (46% coverage, socioeconomic status difference 22%). The LiST analysis suggested that around 39% of child mortality reduction was linked to increases in coverage of interventions, especially of immunisation and insecticide-treated bednets. Economic growth was also associated with reductions in child mortality. Child health programmes focused on selected high-impact interventions at lower levels of the health system (eg, the community and dispensary levels). Despite its high priority, implementation of maternal health care has been intermittent. Newborn survival has gained attention only since 2005, but high-impact interventions are already being implemented. Family planning had consistent policies but only recent reinvestment in implementation. INTERPRETATION: Mixed progress in reproductive, maternal, newborn, and child health in Tanzania indicates a complex interplay of political prioritisation, health financing, and consistent implementation. Post-2015 priorities for Tanzania should focus on the unmet need for family planning, especially in the Western and Lake regions; addressing gaps for coverage and quality of care at birth, especially in rural areas; and continuation of progress for child health. FUNDING: Government of Canada, Foreign Affairs, Trade, and Development; US Fund for UNICEF; and the Bill & Melinda Gates Foundation.

Recognition of high risk pregnancies and referral practices among traditional birth attendants in Mkuranga District, Coast Region, Tanzania.

A cross-sectional study was carried out in Mkuranga District of Tanzania with the aim of comparing the ability of trained and untrained traditional birth attendants (TBAs) in identifying women with danger signs for developing complications during pregnancy and childbirth as well as their referral practices. Study findings revealed that majority of the TBAs (86.5%) had not received any training. Trained TBAs were more knowledgeable on danger signs during pregnancy and childbirth and were more likely to refer women with complications to a health facility, compared to untrained TBAs. The authors recommend that in resource constrained countries like Tanzania and especially in remote rural areas, TBAs should be trained on early identification of mothers with obstetrical complications and on their prompt referral to health facilities that can provide emergency obstetric care.