"Are all referrals necessary?" Experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania.

BACKGROUND: Intrapartum continuity of care to reduce maternal morbidity and mortality relies heavily on a functional and effective referral system between tiers of care. Capacity building of providers in managing intrapartum referrals is expected to improve the efficiency of the referral system, but this does not always work in practice. This study explored the experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania. METHODS: An exploratory qualitative study was conducted at Amana Regional Referral Hospital and Muhimbili National Hospital in Dar es Salaam. Maternity healthcare providers were purposively recruited based on cadre, working experience of more than three years in the maternity wards. An in-depth interview guide which involved questions and probes was used to conduct eleven interviews. Data was thematically analyzed. RESULTS: Three major themes emerged, namely: 1) causes of referrals are beyond medical indications; 2) limited maternity healthcare provider capability at referring facilities; and 3) limited communication between referring and receiving facilities. According to maternity healthcare professionals, referrals were seen as a way to minimize blame and a clinical management tool to prevent difficulties. They advocated for more understanding of the skill set among maternity healthcare providers, but some had negative perceptions towards performing their responsibilities. CONCLUSIONS: Skills gaps among maternity healthcare providers at referring hospitals influenced referral decision-making and service provision. There was hostility between referring and receiving hospitals. Capacity-strengthening strategies such as ongoing skills training and changes in attitudes toward referrals require improvements. The referring hospital should only consider referrals as a last resort after other case management has been completed.

Vaccination willingness, vaccine hesitancy, and estimated coverage of SARS-CoV-2 vaccine among healthcare workers in Tanzania: A call for action.

BACKGROUND: The global COVID-19 pandemic presented an immense obstacle to public health, with vaccination emerging as a crucial measure to curb transmission. This study aimed to evaluate the willingness, hesitancy, and coverage of SARS-CoV-2 vaccines among healthcare workers (HCWs) in Tanzania and reveal their concerns about SARS-CoV-2 vaccines and the reasons that might prevent them from getting vaccinated. METHODS: We conducted a cross-sectional study using an anonymous online survey from October to November 2022. The multivariate logistic regression model explored the factors associated with SARS-CoV-2 vaccine willingness, hesitancy, and coverage. RESULTS: The study included 560 HCWs, with the largest group being doctors (47.9%), followed by nurses (26.9%) and other HCWs (25.2%). A total of 70.5% of HCWs reported being vaccinated against SARS-CoV-2. The primary driver for SARS-CoV-2 vaccination was collective responsibility. A total of 81.4% of HCWs reported being willing to accept SARS-CoV-2 vaccines, while 62.5% of HCWs reported vaccine hesitancy. HCWs with higher educational qualifications were likelier to take the vaccine, while the respondents aged 18-30 years had the highest SARS-CoV-2 vaccination refusal (71.9%). We also investigated the role of HCWs as a source of information to promote COVID-19 vaccine uptake. 79.4% of HCWs provided information and advice on SARS-CoV-2 vaccines. CONCLUSION: To increase vaccine acceptance among HCWs and the general population, targeted messaging is needed to deliver transparent information on vaccine safety, efficacy, and development.

COVID-19 vaccine hesitancy among pregnant women attending public antenatal clinics in Dar es Salaam, Tanzania.

The COVID-19 pandemic has claimed over six million lives and caused significant morbidities globally. The development and use of COVID-19 vaccines is a key strategy in ending this. There is a general public hesitancy on vaccine uptake, including pregnant women who are at high risk of severe forms of the disease and death when infected with the virus. To determine the magnitude of hesitancy toward COVID-19 vaccines and the associated factors among pregnant women attending public antenatal clinics in Dar es Salaam‬. This was a cross-sectional analytical study conducted among 896 pregnant women attending antenatal clinics at public health facilities in Dar es Salaam. A structured interviewer-based questionnaire, in an electronic form, was used. The analysis was done by a multivariable linear regression model using STATA 16 to obtain factors associated with vaccine hesitancy, and P < .05 was considered significant. The proportion of pregnant women with vaccine hesitancy was 45%. Hesitancy was higher among unemployed pregnant women (AOR 2.16 (95% CI 1.36-3.42) and the self-employed group (AOR 1.62 (95% CI 1.07-2.44). It was also higher among pregnant women with poor attitudes to COVID-19 vaccines (AOR 2.44 (95% CI 1.75-3.39) and women who had low perceived benefits of the vaccines (AOR 2.57 (95% CI 1.83-3.60). COVID-19 vaccine-targeted interventions should aim at the provision of knowledge on COVID-19 and the COVID-19 vaccine and address poor attitudes and perceptions that pregnant women have on these vaccines.

Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania.

BACKGROUND: Shared decision-making between clinicians and pregnant women with prior cesarean on the subsequent mode of delivery improves trial of labor rates, and reduces the number of repeat cesarean sections and their related complications. However, this practice is insufficient worldwide and the factors influencing it are still unknown. The study aimed at determining the proportion of pregnant women involved in shared decision-making and its associated factors in Dar es Salaam. METHODS: A cross-sectional analytical study among 350 pregnant women with one prior cesarean section. Data was collected using a structured questionnaire and SPSS 23 was used for analysis. A score of 80 or higher on the nine-item Shared Decision-Making Questionnaire (SDM-Q9) was used to calculate the proportion of women, and the associated factors were obtained using a logistic regression model. P value of < 0.05 was considered significant. RESULTS: The proportion of pregnant women involved in shared decision making was 38%. Factors that were significantly associated with sharing decision making were; having low level of education (AOR 0.55 95% CI 0.33-0.91), being married/having partner (AOR 2.58 95% CI 1.43-4.63), having a companion who had active participation (AOR 3.31 95% CI 1.03-10.6) and being familiar with the clinician (AOR 5.01 95% CI 1.30-19.2). CONCLUSION: To promote practice of shared decision making in our setting, encouragement of socially vulnerable pregnant women's participation in decision-making by health care professionals, encouragement of companion participation during antenatal care and promotion of personal continuity of care to improve familiarity to clinicians are needed.

Antenatal depression and adverse birth outcomes among pregnant women living with HIV in Dar es Salaam, Tanzania.

BACKGROUND: Women who experience antenatal depression may be at increased risk of adverse birth outcomes. Few studies have examined this association among women living with HIV (WHIV). METHODS: We conducted a prospective cohort study of 2298 pregnant WHIV on antiretroviral therapy (ART) in Dar es Salaam, Tanzania, who were participants in a randomized trial of vitamin D3 supplementation. Depressive symptoms were assessed at 12-27 weeks gestation using the Hopkins Symptoms Checklist (HSCL-25). Generalized estimating equations to account for twins were used to assess the relative risks of adverse birth outcomes. RESULTS: Approximately 67 % of the women in our study population reported symptoms consistent with depression. We observed a 4.0 % prevalence of stillbirth and a 25.1 % prevalence of preterm birth. We found that low social support, higher education, and more recent initiation of ART were associated with a greater risk of antenatal depression. There was no association of antenatal depression with risk of fetal loss, stillbirth, low birth weight, birth weight, preterm birth, gestational age at delivery, or small-for-gestational age. LIMITATIONS: Depression was self-reported and only collected at one timepoint in pregnancy. Our findings may not be generalizable to all WHIV. CONCLUSIONS: Our findings illustrate the high risk of both depression and adverse birth outcomes among WHIV and underscore the need for interventions to improve their mental health and the health of their infants; however, the relationship between depression and birth outcomes remains unclear. Further research on this topic is merited, particularly examining the chronicity and timing of depression in pregnancy.

Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage.

BACKGROUND: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. METHODS: We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle. RESULTS: A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28). CONCLUSIONS: Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.).

Understanding maternity care providers' use of data in Southern Tanzania.

INTRODUCTION: Health information management system data is collected for national planning and evaluation but is rarely used for healthcare improvements at subnational or facility-level in low-and-middle-income countries. Research suggests that perceived data quality and lack of feedback are contributing factors. We aimed to understand maternity care providers' perceptions of data and how they use it, with a view to co-design interventions to improve data quality and use. METHODS: We based our research on constructivist grounded theory. We conducted 14 in-depth interviews, two focus group discussions with maternity care providers and 48 hours of observations in maternity wards to understand maternity providers' interaction with data in two rural hospitals in Southern Tanzania. Constant comparative data analysis was applied to develop initial and focused codes, subcategories and categories were continuously validated through peer and member checks. RESULTS: Maternity care providers found routine health information data of little use to reconcile demands from managers, the community and their challenging working environment within their daily work. They thus added informal narrative documentation sources. They created alternative narratives through data of a maternity care where mothers and babies were safeguarded. The resulting documentation system, however, led to duplication and increased systemic complexity. CONCLUSIONS: Current health information systems may not meet all data demands of maternity care providers, or other healthcare workers. Policy makers and health information system specialists need to acknowledge different ways of data use beyond health service planning, with an emphasis on healthcare providers' data needs for clinical documentation.

Health workers' experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework.

BACKGROUND: In-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers' experiences of the HMS BAB training. METHODS: Our qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation. RESULTS: Overall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational. CONCLUSION: The HMS BAB training has great potential to improve health workers' competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures.

Timing of Antiretroviral Therapy: Initiation and Birth Outcomes Among Pregnant Women With Human Immunodeficiency Virus in Tanzania

BACKGROUND: Combination antiretroviral therapy (cART) initiation during pregnancy reduces the risk of perinatal human immunodeficiency virus (HIV) transmission; however, studies have suggested that there may be unintended adverse consequences on birth outcomes for selected cART regimens. METHODS: We analyzed adverse birth outcomes among a prospective cohort of 1307 pregnant women with HIV in Dar es Salaam who initiated cART during the first or second trimester of a singleton pregnancy. Our primary analysis compared birth outcomes by gestational age at cART initiation among these women initiating cART in pregnancy. RESULTS: Among women who initiated cART in pregnancy, there was no relationship of gestational age at cART initiation with the risk of fetal death or stillbirth. However, women who initiated cART before 20 weeks of gestation compared with after 20 weeks had increased risk of preterm birth (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.03-1.67) but decreased risk of small-for-gestational age birth (RR, 0.71; 95% CI, .55-.93). CONCLUSIONS: With increasing use of cART preconception and early in pregnancy, clinicians should be aware of the benefits and potential risks of cART regimens to optimize birth outcomes.

Quality of oxytocin and tranexamic acid for the prevention and treatment of postpartum hemorrhage in Kenya, Nigeria, South Africa, and Tanzania.

OBJECTIVE: To check the quality of oxytocin and tranexamic acid-two recommended products for prevention and treatment of postpartum hemorrhage (PPH)-used in facilities taking part in an implementation research project to improve PPH diagnosis and management. METHODS: Between September 2020 and August 2021, oxytocin and tranexamic acid products used in the study facilities in Kenya, Nigeria, South Africa, and Tanzania were collected and transported in cold storage for analysis. Samples were analyzed according to the International (oxytocin) and British Pharmacopeia (tranexamic acid) standards. RESULTS: Of the 17 unique oxytocin products, 33 individual measurements were made. Only six unique products had adequate content and no related substances exceeding the recommended limits. Of 14 tranexamic acid samples, 10 showed adequate content. One product in Kenya and two products in Nigeria from different manufacturers had a high content of related substances, which classified them as substandard. CONCLUSION: While we were unable to investigate the origin regarding poor manufacturing or poor storage or both, the high number of substandard oxytocin samples is of great concern. Most of the tranexamic acid samples had adequate content but the presence of impurities in multiple products is worrying and requires further study.

Vitamin D3 supplementation during pregnancy and lactation for women living with HIV in Tanzania: A randomized controlled trial.

BACKGROUND: Observational studies suggest that vitamin D deficiency among people living with HIV is associated with a greater risk of disease progression and death. Low levels of vitamin D in pregnancy are also associated with poor fetal and infant growth. Therefore, vitamin D supplementation may improve clinical outcomes for pregnant women living with HIV and improve fetal and postnatal growth for their infants. METHODS AND FINDINGS: We conducted a randomized, triple-blind, placebo-controlled trial of vitamin D3 supplementation among pregnant and lactating women living with HIV in Dar es Salaam, Tanzania (ClinicalTrials.gov NCT02305927). Participants were randomized with 1:1 allocation stratified by study clinic to receive either daily 3,000 IU vitamin D3 supplements or matching placebo supplements from the second trimester of pregnancy (12-27 weeks) until 1 year postpartum. The primary outcomes were (i) maternal HIV progression or death, (ii) small-for-gestational-age (SGA) live births (<10th percentile), and (iii) infant stunting at 1 year of age (length-for-age z-score < -2). We also examined the effect of vitamin D3 supplementation on secondary maternal and infant health outcomes, maternal and infant serum 25-hydroxyvitamin D (25[OH]D) concentrations, and maternal hypercalcemia. An intent-to-treat analysis was used as the primary analytic approach. We enrolled 2,300 pregnant women between June 15, 2015, and April 17, 2018, and follow-up of mothers and infants was completed on October 20, 2019. There were 1,148 pregnant women randomly assigned to the vitamin D3 group, and 1,152 to the placebo group. The proportion of mothers lost to follow-up at 1 year postpartum was 6.6% in the vitamin D3 group (83 of 1,148) and 6.6% in the placebo group (76 of 1,152). The proportion of children lost to follow-up at 1 year of age was 5.5% in the vitamin D3 group (59 of 1,074 live births) and 5.2% in the placebo group (57 of 1,093 live births). There was no difference in the risk of maternal HIV progression or death, with 166 events during 1,461 person-years of follow-up in the vitamin D3 group and 141 events during 1,469 person-years of follow-up in the placebo group (hazard ratio 1.21, 95% CI 0.97 to 1.52, p = 0.09). There was no difference in the risk of SGA birth between the vitamin D3 (229 SGA births among 1,070 live births) and placebo groups (236 SGA births among 1,091 live births) (relative risk 1.03, 95% CI 0.87 to 1.22, p = 0.70). There was also no difference in the risk of infant stunting at 1 year of age between the vitamin D3 (407 events among 867 infants) and placebo groups (413 events among 873 infants) (relative risk 1.00, 95% CI 0.92 to 1.10, p = 0.95). In terms of adverse events, no cases of maternal hypercalcemia were identified. One hypersensitivity reaction to the trial supplements occurred for a pregnant woman in the placebo group. A limitation of our study is that our findings may not be generalizable to HIV-negative pregnant women or contexts where severe vitamin D deficiency is prevalent. CONCLUSIONS: The trial findings do not support routine vitamin D supplementation for pregnant and lactating women living with HIV in Tanzania. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02305927.

Predictors of change of health workers' knowledge and skills after the Helping Mothers Survive Bleeding after Birth (HMS BAB) in-facility training in Tanzania.

BACKGROUND: Our study aimed to assess the effect of Helping Mothers Survive Bleeding after Birth on knowledge and skills of health workers and whether such effect varies by health workers characteristics. METHODS: Nested in a cluster-randomised trial to assess the effect of the training on health outcomes, we assessed changes in knowledge and simulated skills in 61 facilities. The assessments were done i) before, ii) immediately-after training session and iii) at 10-month follow-up for subset of health-workers of implementation facilities as defined by the trial. We used a self-administered questionnaire and Objective Structures Clinical Examinations to assess three skill sets: Active Management of Third Stage of Labour, removal of retained placenta and management of severe postpartum haemorrhage. We computed summary statistics and used the paired t-test to assess change of knowledge and skills immediately post-training and at 10-month follow-up. Linear regression was done to assess association of scores and health worker characteristics. RESULTS: Of the 636 health workers included, 606 (96.7%) and 591 (91.4%) completed the knowledge and skills assessments, respectively. Majority of the participants (68%) were nurse-midwives. Knowledge scores increased by 15 percentage-points from 77.5% to 93% (95% CI 14.3, 16.3, p-value <0.000), and skills scores by 47 percentage-points (95% CI 46.5, 49.2, p-value <0.000) from 37.5% to 83%. There was a 4.0% decline of skills at 10-month follow-up. The decline was higher in auxiliary staff (-11.8%) and least in nurse-midwives (-2.1%) p-value <0.001. Health workers who assisted less than 5 deliveries in the last month, those who never attended postpartum haemorrhage in-service training and profession experience >8 years were associated with lower mean skill change immediately post-training. CONCLUSION: Our study supports the potential of the Helping Mothers Survive Bleeding after Birth training to increase knowledge and skills of postpartum haemorrhage among all professional groups. Auxiliary staff benefited most from the training but also showed higher skill decline at 10-month. Our study highlights the importance to disaggregate knowledge and skills by health workers characteristics.

"We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage.

Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH).Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers' perceptions of their health facilities' readiness to provide PPH care.Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software.Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care.Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed.

Rethinking the definition of maternal near-miss in low-income countries using data from 104 health facilities in Tanzania and Uganda.

OBJECTIVE: To assess the consistency of maternal near-miss incidence and mortality index between two definitions across 104 facilities in Tanzania and Uganda. METHODS: Based on WHO guidance, cross-sectional near-miss data were collected in Tanzania (July 2015 to October 2016) and Uganda (June 2016 to September 2017). Prepartum hemorrhage and abortion were included as additional screening events and the number of blood units transfused was recorded. Near-miss incidence and mortality index were determined by using two near-miss definitions: the WHO standard definition, and a modified definition including women receiving at least 1 unit of blood. A sensitivity analysis excluded the additional screening events. RESULTS: Near-miss incidence differed between Tanzania and Uganda (1.79 and 4.00, respectively, per 100 deliveries) when estimated by the standard definition, but was similar (5.24 and 4.94, respectively) by the modified definition. The mortality index was higher in Tanzania than in Uganda when estimated by the standard definition (8.56% vs 3.54%), but was similar by the modified definition (3.10% vs 2.89%). CONCLUSION: The modified definition provided a more consistent estimate of near-miss incidence and mortality index. Lowering the threshold for units of blood transfusion might improve comparability between settings, but more research is needed.

Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training on maternal morbidity: a cluster-randomised trial in 20 districts in Tanzania.

BACKGROUND: Training health providers is an important strategy to improve health. We conducted a cluster-randomised two-arm trial in Tanzania to assess the effect of a 1-day competency-based training 'Helping Mothers Survive Bleeding after Birth (HMS BAB)' followed by eight weekly drills on postpartum haemorrhage (PPH)-related morbidity and mortality. METHODS: Twenty districts in four purposefully selected regions in Tanzania included 61 facilities. The districts were randomly allocated using matched pairs to ensure similarity in terms of district health services in intervention and comparison districts. In the 10 intervention districts 331 health providers received the HMS BAB training. The other half continued with standard practices. We used the WHO's near miss tool to collect information on severe morbidity (near misses) of all women admitted to study facilities. We performed interrupted time series analysis to estimate differences in the change of near miss per delivery rate and case fatality rates. We also assessed implementation of evidence-based preventive and basic management practices for PPH as secondary outcomes. RESULTS: We included 120 533 facility deliveries, 6503 near misses and 202 maternal deaths in study districts during study period (November 2014 to January 2017). A significant reduction of PPH near misses was found among women who suffered PPH in the intervention district compared with comparison districts (difference-in-differences of slopes -5.3, 95% CI -7.8 to -2.7, p<0.001) from a baseline PPH-related near miss rate of 71% (95% CI 60% to 80%). There was a significant decrease in the long-term PPH near miss case fatality (difference-in-differences of slopes -4 to 0) (95% CI -6.5 to -1.5, p<0.01) in intervention compared with the comparison districts. The intervention had a positive effect on the proportion of PPH cases treated with intravenous oxytocin (difference-in-differences of slopes 5.2, 95% CI 1.4 to 8.9) (p <0.01). CONCLUSION: The positive effect of the training intervention on PPH morbidity and case fatality suggests that the training addresses important deficits in knowledge and skills. TRIAL REGISTRATION NUMBER: PACTR201604001582128.