"Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania.

BACKGROUND: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. METHODS: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. RESULTS: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.

Factors associated with major structural birth defects among newborns delivered at Muhimbili National Hospital and Municipal Hospitals in Dar Es Salaam, Tanzania 2011 - 2012.

INTRODUCTION: Ninety-four percent of all birth defects and 95% of deaths due to the birth defects occur in low and middle income countries, Tanzania among them. In Tanzania there are currently limited birth defects prevention strategies in place due to limited information on factors associated with the occurrence of birth defects. METHODS: We conducted a case control study that included newborns born from October, 2011 through February, 2012 at 4 participating hospitals. A case was defined as any newborn of a Dar es salaam resident with a neural tube defect, orofacial clefts, limb reduction defects or musculo-skeletal defects (SBD) born during the study period. A control was defined as the next three newborns (delivered after the case) without birth defects. Univariate, bivariate and multivariate analysis were done using Epi Info version 3.5.1. RESULTS: A total of 400 newborns participated in the study, 100 cases and 300 controls. Factors associated with higher odds of a SBD included maternal fever (adjusted odds ratio (AOR) = 1.99; 95% confidence interval (CI): 1.14-3.52), maternal hypertension (AOR = 3.99; 95% CI: 1.67-9.54), and low birth weight (AOR = 3.48; 95% CI: 1.77-6.85). Antimalarial use during pregnancy was protective (AOR = 0.48; 95% CI: 0.28-0.84). Folic acid supplementation was protective only in bivariate analysis (OR = 0.56; 95% CI: 0.32-0.96). CONCLUSION: Maternal fever, hypertension, and low birth weight are associated with higher odds of SBD. Antimalarial use during pregnancy was associated with lower odds of SBD. Early screening of pregnant mothers for hypertension and other causes of low birth weight may reduce SBD in Dar Es Salaam.

Supply-side dimensions and dynamics of integrating HIV testing and counselling into routine antenatal care: a facility assessment from Morogoro Region, Tanzania.

BACKGROUND: Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania. METHODS: This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti. RESULTS: Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. While assessment of infrastructure, including waiting areas, appeared adequate, long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women's care seeking at health centers. In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability. CONCLUSION: Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes.

Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking.

BACKGROUND: Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women's and providers' perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania. METHODS: From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents' demographic information were analyzed with Stata 12.0. RESULTS: Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women's responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system. CONCLUSION: While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women's care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women's care seeking in order to improve maternal and child health.

Effectiveness of community based Safe Motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania.

BACKGROUND: In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania. METHOD: This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues. RESULTS: Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (rho < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (rho < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues. CONCLUSION: The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.

Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets.

BACKGROUND: Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health. METHODS: Cross sectional study which employed quantitative research methods. RESULTS: We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72-6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75-3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25-2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65-5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors. CONCLUSION: Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.

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.