Improvements in Obstetric and Newborn Health Information Documentation following the Implementation of the Safer Births Bundle of Care at 30 Facilities in Tanzania.

This paper examines changes in the completeness of documentation in clinical practice before and during the implementation of the Safer Births Bundle of Care (SBBC) project. This observational study enrolled parturient women with a gestation age of at least 28 weeks at the onset of labour. Data collectors extracted information from facility registers and then a central data manager summarised and reported weekly statistics. Variables of clinical significance for CQI were selected, and the proportion of non-documentation was analysed over time. A Pearson chi-square test was used to test for significant differences in non-documentation between the periods. Between 1 March 2021 and 31 July 2022, a total of 138,442 deliveries were recorded. Overall, 75% of all patient cases had at least one missing variable among the selected variables across both periods. A lack of variable documentation occurred more frequently at the district hospital level (81% of patient cases) and health centres (74%) than at regional referral hospitals (56%) (p < 0.001). Non-documentation decreased significantly from 79% to 70% after the introduction of the SBBC (p < 0.001). A tendency towards negative correlations was noted for most variables. We noted an increased attention to data quality and use which may have a positive impact on the completeness of documentation. However, halfway through the project's implementation, the completeness of documentation was still low. Our findings support the recommendation to establish short-spaced feedback loops of locally collected data using one data platform.

Investment case for small and sick newborn care in Tanzania: systematic analyses.

BACKGROUND: Small and sick newborn care (SSNC) is critical for national neonatal mortality reduction targets by 2030. Investment cases could inform implementation planning and enable coordinated resource mobilisation. We outline development of an investment case for Tanzania to estimate additional financing for scaling up SSNC to 80% of districts as part of health sector strategies to meet the country's targets. METHODS: We followed five steps: (1) reviewed national targets, policies and guidelines; (2) modelled potential health benefits by increased coverage of SSNC using the Lives Saved Tool; (3) estimated setup and running costs using the Neonatal Device Planning and Costing Tool, applying two scenarios: (A) all new neonatal units and devices with optimal staffing, and (B) half new and half modifying, upgrading, or adding resources to existing neonatal units; (4) calculated budget impact and return on investment (ROI) and (5) identified potential financing opportunities. RESULTS: Neonatal mortality rate was forecast to fall from 20 to 13 per 1000 live births with scale-up of SSNC, superseding the government 2025 target of 15, and close to the 2030 Sustainable Development Goal 3.2 target of <12. At 85% endline coverage, estimated cumulative lives saved were 36,600 by 2025 and 80,000 by 2030. Total incremental costs were estimated at US$166 million for scenario A (US$112 million set up and US$54 million for running costs) and US$90 million for scenario B (US$65 million setup and US$25 million for running costs). Setup costs were driven by infrastructure (83%) and running costs by human resources (60%). Cost per capita was US$0.93 and the ROI is estimated to be between US$8-12 for every dollar invested. CONCLUSIONS: ROI for SSNC is higher compared to other health investments, noting many deaths averted followed by full lifespan. This is conservative since disability averted is not included. Budget impact analysis estimated a required 2.3% increase in total government health expenditure per capita from US$40.62 in 2020, which is considered affordable, and the government has already allocated additional funding. Our proposed five-step SSNC investment case has potential for other countries wanting to accelerate progress.

"Safer Births Bundle of Care" Implementation and Perinatal Impact at 30 Hospitals in Tanzania-Halfway Evaluation.

Safer Births Bundle of Care (SBBC) consists of innovative clinical and training tools for improved labour care and newborn resuscitation, integrated with new strategies for continuous quality improvement. After implementation, we hypothesised a reduction in 24-h newborn deaths, fresh stillbirths, and maternal deaths by 50%, 20%, and 10%, respectively. This is a 3-year stepped-wedged cluster randomised implementation study, including 30 facilities within five regions in Tanzania. Data collectors at each facility enter labour and newborn care indicators, patient characteristics and outcomes. This halfway evaluation reports data from March 2021 through July 2022. In total, 138,357 deliveries were recorded; 67,690 pre- and 70,667 post-implementations of SBBC. There were steady trends of increased 24-h newborn and maternal survival in four regions after SBBC initiation. In the first region, with 13 months of implementation (n = 15,658 deliveries), an estimated additional 100 newborns and 20 women were saved. Reported fresh stillbirths seemed to fluctuate across time, and increased in three regions after the start of SBBC. Uptake of the bundle varied between regions. This SBBC halfway evaluation indicates steady reductions in 24-h newborn and maternal mortality, in line with our hypotheses, in four of five regions. Enhanced focus on uptake of the bundle and the quality improvement component is necessary to fully reach the SBBC impact potential as we move forward.

Implementation of distance learning IMCI training in rural districts of Tanzania.

BACKGROUND: The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants' accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania. METHODS: A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators. RESULTS: About 60 key informant interviews were conducted, of which 53% of participants were healthcare workers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhancing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilitators. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materials. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport. CONCLUSION: DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI.

SaferBirths bundle of care protocol: a stepped-wedge cluster implementation project in 30 public health-facilities in five regions, Tanzania.

BACKGROUND: The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival. METHODS: The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live. Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99. DISCUSSION: Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope. TRIAL REGISTRATION: Name of Trial Registry: ISRCTN Registry. TRIAL REGISTRATION NUMBER: ISRCTN30541755 . Date of Registration: 12/10/2020. Type of registration: Prospectively Registered.

Correct diagnosis of childhood pneumonia in public facilities in Tanzania: a randomised comparison of diagnostic methods.

OBJECTIVE: This study compares two methods for clinical diagnosis of childhood pneumonia that aim to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by examining the sensitivity of Integrated Management of Childhood Diseases implementation in routine care against lung ultrasound (LUS) diagnosis. SETTING: We conducted observations in 83 public health facilities (dispensaries, health centres and district hospitals) in Pwani, Dodoma and Tabora, Tanzania between October and December 2017. METHODS: We used a novel method to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by comparing directly observed public provider diagnoses to the results of diagnoses made by trained clinicians using Mindray DP-10 ultrasound machines. We perform multivariate analysis to identify confounding effects and robustness checks to bound the result. We also explore a number of observable characteristics correlated with higher rates of agreement between provider diagnoses and ultrasound diagnoses. RESULTS: We observed 93 providers conducting exams on patients aged 2 months-5 years who presented respiratory symptoms or were given a respiratory diagnosis by the provider. Of these 957 patients, 110 were excluded from analysis resulting in a final sample of 847.17.6% of cases identified as pneumonia via LUS examinations in our sample were diagnosed as pneumonia by providers, suggesting that a significant number of pneumonia cases for which care is sought in the public sector go undiagnosed. Provider knowledge of breath counting and years of experience are positively correlated with higher agreement. While clinical examination rates are not statistically correlated with agreement, it is notable that providers conducted a clinical examination on only about one-third of patients in the sample. CONCLUSION: Our results suggest that provider training and knowledge of clinical examination protocols for pneumonia diagnosis are predictive of correct diagnosis of pneumonia and should be further explored in future research as a tool for improving quality of care.

Scale-Up of Doppler to Improve Intrapartum Fetal Heart Rate Monitoring in Tanzania: A Qualitative Assessment of National and Regional/District Level Implementation Factors.

High-quality intrapartum care, including intermittent monitoring of fetal heart rates (FHR) to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and creates potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscope and are more sensitive to detecting accelerations and decelerations of the fetal heart as compared to Pinard. This study assessed perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up use of the hand-held Doppler for assessing FHR during labor and delivery. From November 2018-August 2019, nine high-level policymakers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor's implementation outcomes framework. Interviewees largely saw use of Doppler to improve intrapartum FHR monitoring as aligning with national priorities, though they noted competing demands for resources. They felt that GoT should fund Doppler, but prioritization and budgeting should be driven from district level. Recommended ways forward included learning from scale up of Helping Babies Breathe rollout, making training approaches effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, introduction of Doppler must be concurrent with improving case management practices for abnormal intrapartum FHR. WHO's guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.