Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Igunga District, Tanzania

Transcription

1 Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Igunga District, Tanzania Prepared by: Ubora wa Afya kwa Familia Duniani (Family Care International Tanzania) P.O. Box Dar es Salaam, Tanzania and Family Care International 588 Broadway, Suite 503 New York, NY USA October 2007

2 ACKNOWLEDGEMENTS Family Care International/Ubora wa Afya kwa Familia Duniani (FCI/UAFD) would like to acknowledge the Bill and Melinda Gates Foundation, which provided financial support for the implementation and evaluation of the Skilled Care Initiative. FCI/UAFD would like to extend sincere gratitude to the Government of Tanzania, particularly, the Ministry of Health and Social Welfare, for its support and guidance throughout the design, implementation and evaluation of the Skilled Care Initiative. In particular, FCI/UAFD would like to acknowledge the Director of Preventive Services; the Chief Medical Officer; and the Chief Nursing Officer in the Ministry of Health and Social Welfare for their support throughout the implementation of the Skilled Care Initiative project. Special thanks are also extended to the Assistant Director, Reproductive and Child Health Section (Dr. C. Sanga), Safe Motherhood Coordinator (Ms. L. Mfalila) and other staff in the Section for their readiness technical support and directives during the implementation of Skilled Care Initiative in Tabora Region. Extensive thanks are given to the office of Tabora Region Medical Officer (Dr. M. Damas) for allowing the Igunga and Urambo Districts Medical Officers to be involved in this initiative. In addition, we would like to thank the Western Zonal Reproductive and Child Health Section Coordinator (Ms. Z. Semanda) and the Tabora Region Reproductive and Child Health Section Coordinator (Ms. A. Maijo) and the Regional Nursing Officer (Mr. Kisambale) for their supportive participation and support. Much gratitude is also extended to the District Executive Directors of Igunga District and Urambo District for their extensive and whole-hearted support of the Skilled Care Initiative s activities in their district, and for permitting District Council staff, including health care providers, the District Medical Officers (Dr. N. Mwandu for Igunga District, and Dr. E. Mayalla of Urambo District), the District Reproductive and Child Health Section Coordinators (Ms. C. Mushi for Igunga District, and Ms. H. Chafwila for Urambo District), the District Nursing Officers (Ms. Matessi for Igunga District, and Ms. M. Nsalamba for Urambo District), and District Health Management Teams, as well as district officials, Councillors, Provisional Secretaries, Ward Executive Officers, Village Executive Officers, grassroots community leaders, and community at large to be part of this important project. FCI/UAFD would also like to express sincere appreciation for the support from University of Dar es Salaam, Department of Fine and Performing Arts, and particularly Mr. G. Mngereza who helped design the Behaviour Change Communication strategy in Igunga District to sensitize community members on the importance of using skilled care during pregnancy, childbirth, and postpartum period. His creativity in accommodating traditional values to communicate skilled care messages is highly appreciated. Special thanks are also due to the School of Public Health and Social Science (SPHSS) of the Muhimbili University of Health Sciences for their technical support in the baseline and endline evaluation research. In particular, FCI/UAFD would like to acknowledge Professor M.C. Leshabari for his tireless readiness to provide technical assistance during the two surveys. The survey work could not be completed without technical support from Dr. G. Kwesigabu, Dr. A.T. Kessy, Dr. C. Moshiro, Dr. C. Msoka, Ms. R. Mpembeni, Mr. F. Mayunga, and others in the team for their extensive contributions to the research components of this project. As it is not possible to mention every person individually, FCI/UAFD would like to thank all those who contributed in one way or another to the successful implementation and evaluation of the Skilled Care Initiative in Tabora Region. In particular, we would like to extend our deepest gratitude to community members in both Igunga and Urambo for their deep engagement in and support throughout the implementation of this project and related evaluation activities. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania

3 TABLE OF CONTENTS Executive Summary... i I. Background and Rationale... 1 A. Maternal Mortality... 1 B. Increasing Skilled Attendance at Delivery... 1 C. Maternal Health in Tanzania... 2 D. The Skilled Care Initiative... 3 E. The Project Context: Igunga District... 4 F. Skilled Care Initiative in Igunga District: Overview of Project Interventions... 5 II. Evaluation Design and Methods... 8 A. Health Facility Survey... 8 Sample Design and Estimation...9 Data Collection...9 B. Household Survey Sample Design and Estimation...11 Data Collection...12 C. Data Analysis III. Findings A. Antenatal Care Capacity to Provide Antenatal Care...16 Provision of ANC...17 Utilisation of ANC...19 B. Normal Delivery Care Capacity to Provide Normal Delivery Care...21 Facility Readiness Index for Normal Delivery Care...23 Provision of Normal Delivery Care...24 Utilisation of Normal Delivery Care...25 Association between facility readiness and utilisation by women for delivery care...27 C. Complicated Delivery Care Capacity to Provide Complicated Delivery Care...28 Facility Readiness Index for Complicated Delivery...31 Provision of Complicated Delivery Care...33 Utilisation of Complicated Delivery Care...34 D. Postpartum Care Capacity to Provide Postpartum Care...36 Provision of Postpartum Care...37 Utilisation of postpartum care...38 E. Interventions to Promote Skilled Care-Seeking During Childbirth Exposure to and Awareness of SCI Interventions...39 G. Factors Associated with Skilled Care-Seeking during Childbirth Demographic and Socio-Economic Factors Associated with Skilled Care-Seeking during Childbirth...41 IV. Discussion and Interpretation of Findings A. Antenatal Care B. Normal Delivery Care C. Care for Complicated Deliveries D. Postpartum Care V. Conclusion and Recommendations Annexes...52 Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania

4 Background and Rationale EXECUTIVE SUMMARY Each year, over 500,000 women die from complications of pregnancy and childbirth. The majority of these deaths occur either during or shortly after delivery, and most could be prevented. Experience has shown that the assistance of a skilled attendant during childbirth and immediately afterward is a critical intervention to save women s lives and avert maternal disabilities. Yet 60 million women in the developing world still give birth each year without skilled care attended by a traditional birth attendant, a family member, or no one at all. In Tanzania it is estimated that only 43% of all deliveries are attended by a skilled attendant. * The Skilled Care Initiative in Igunga District In 2001, Family Care International and the Ministry of Health and Social Welfare launched the Skilled Care Initiative in Igunga district, Tabora Region, Tanzania. Aimed at improving maternal health outcomes, the Skilled Care Initiative was specifically designed to: Improve the availability and quality of maternity care through health systems interventions. These interventions included upgrading the health infrastructure, including surgical facilities, where needed; addressing equipment and supply gaps; training providers in clinical and interpersonal skills in routine and emergency obstetric care; providing resources to strengthen referral systems and improve health management systems. Increase utilisation of maternity services through facility- and community-level behaviour change interventions. These interventions included strengthening antenatal counselling on birth preparedness and conducting behaviour change communication (BCC) campaigns on the benefits of skilled maternity care. The Skilled Care Initiative included a rigorous evaluation, using pre-test/post-test, quasiexperimental design with purposively selected comparison zones. Igunga district was selected as the intervention district, and Urambo district in south-central Tabora was selected as the comparison district. No external maternal health interventions were carried out in Urambo aside from the Ministry of Health and Social Welfare s ongoing efforts to improve maternal health. Two surveys were performed to measure the outcome of the intervention. A facility-based survey was conducted to measure the availability and quality of skilled care, facility infrastructure, equipment and supplies, provider readiness, and referral systems. A population-based household survey was administered to assess changes in service utilisation and related knowledge, attitudes, and care-seeking behaviours during pregnancy and childbirth in a randomly selected cohort of the women living in the two districts. * According to the World Health Organization, skilled attendants include trained midwives, nurse/midwives or doctors who have completed set course of study and are registered or legally licensed to practise. This definition does not include traditional birth attendants (TBAs). Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania i

5 Findings Capacity to provide maternal health care A series of functional and composite indexes were developed to assess changes in the capacity of health facilities to provide essential elements of maternal health care namely antenatal care, care for normal and complicated deliveries, and postpartum care. Evaluation results showed that there were improvements in the capacity to provide all elements of maternal health care. The largest improvements were in the capacity to provide normal and complicated delivery care, and the most noticeable changes were at dispensaries and health centres, which handle the largest proportion of deliveries in Igunga and were the primary focus of the intervention. A composite index of facility readiness for normal delivery care increased from 1.9 to 3.0 (p<.001) in Igunga, compared to 0.9 to 1.7 in Urambo district (p<.001). The majority of improvements in Igunga were at dispensaries and due to improvements in infrastructure and availability of equipment. There was also an increase in a composite index of facility readiness for complicated delivery care in Igunga (1.6 to 2.8 p<.01), and again, the largest improvements were among health centres and dispensaries. Changes in the capacity to provide care for complicated deliveries were mostly due to greater capacity for referral (emergency vehicles and radio or mobile phones) and obstetric equipment. Modest improvements were also observed in the provision of routine maternal health services, including antenatal, delivery, and postpartum care for both mothers and newborns. At the endline survey, these services were routinely provided by almost every facility in Igunga district. In contrast, little change was observed in the provision of basic essential obstetric care, despite measurable increases in the capacity to provide this care a result that could be due to caseloads rather than gaps in capacity. The management of health facilities was good at baseline as evidenced by the high percentage of providers who had frequent supervisory meetings, and there were no major changes in this regard. Record keeping of antenatal and maternity registers, and postpartum care record-keeping improved markedly through the introduction of a standard register at all facilities. Most providers reported that they had the necessary knowledge, equipment and supervision to perform their duties. Utilization of skilled care during childbirth Use of health facilities for delivery care was high at the baseline study, and above national averages. At baseline in Igunga, the intervention district, 64% of deliveries were at a facility and 48% of deliveries were assisted by cadres that are considered skilled birth attendants. At endline, a small increase in the proportion of births at facilities was observed (68%, p=.08), as well as the proportion of births assisted by skilled attendants (54%, p=.01). While these increases were small, they should be viewed in context, and it is noteworthy that the mean out-of-pocket costs of normal delivery care increased by almost 15% across the health system between the two studies, and by more than 45 % at mid- and lower-level health facilities where the majority of births take place. During the same period, delivery in a facility and assistance by a skilled attendant declined in Urambo, the comparison district. Other salient outcomes in terms of facility utilisation and care included earlier timing of the first antenatal care visit among pregnant women, from a mean of 7.0 months gestation to 6.1 months (p=.05). The percent of women who had a least one ANC visit also increased in Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania ii

6 Igunga from 88% to 95% (p<.001), and women received more services at the ANC visit at endline. In addition, women who experienced complications during pregnancy were more likely to go to a facility for treatment, and 82% of women with complications delivered at facility compared to 68% for all women. The percent of babies that had a postpartum checkup increased from 80% to 98% (p<.001) but the percent of mothers who had a postpartum check-up did not improve significantly. Exposure to Skilled Care Behaviour Change Interventions An index derived to reflect exposure to safe motherhood messages through counselling in the ANC setting did not exhibit a large increase, (1.1 to 1.3, p<.05). However, women who received more counselling during antenatal consultations were more likely to deliver at a facility than women who received less counselling (74% compared to 64%, p<.05). Household discussion and planning for delivery increased significantly in Igunga and was associated with use of health facilities for delivery, irrespective of wealth or educational status. Husband involvement in decision-making about delivery also was significantly associated with skilled care-seeking. A small reduction in the gap between wealth quintiles was also observed, and in the endline survey, there was almost no difference in use of facility delivery among the second, middle, fourth, and richest wealth quintiles. Conclusions and Recommendations The Skilled Care Initiative in Igunga District is one of the few maternal health interventions with a rigorous evaluation component. As such, it provides a wealth of information on the effectiveness of the intervention package and its impact on maternal health care-seeking, and it illuminates the challenges of improving and evaluating such strategies, given the multifaceted determinants of both the availability and quality of maternity care and the factors that influence women s care-seeking during childbirth. Drawing on this experience, key recommendations for subsequent efforts to increase skilled attendance during childbirth in Igunga and elsewhere in Tanzania include: Strengthening the content of antenatal consultations, including individualized birth preparedness counselling on place of delivery. Women who received counselling on place of delivery and danger signs during pregnancy were more likely to deliver at a health facility. Given the fact that the vast majority of women in Tanzania have at least one antenatal care visit during pregnancy, it is critical to ensure that birth preparedness counselling is given. This is a relatively low-cost intervention in comparison with community-level mobilisation and sensitisation campaigns. As such, it should be a key element of any skilled care strategy. Improving national logistics systems and the availability of essential drugs and supplies for obstetric care. While two systems were introduced to improve the availability of drugs and supplies for obstetric care in Igunga, stock-outs persisted because essential commodities were not available for purchase. Thus, it is crucial that forecasting and purchasing systems at the national level be reviewed and strengthened. A review of essential items needed for obstetric care should guide these efforts, and priority should be placed on ensuring that facilities at all levels of the health system receive uninterrupted stocks of these items. Strengthening mid- and lower-level health facilities. Peripheral health facilities are the most accessible, especially for the rural poor. In addition, the costs of care both to Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania iii

7 women and to the health system are lowest at these sites. Traditionally, however, these sites have received little investment and support, and many if not most are challenged by a crumbling physical infrastructure, shortages of skilled personnel, serious gaps in essential obstetric equipment, and limited referral capacity. In contexts where these sites are handling the majority of deliveries, there is an urgent need to address these gaps, and doing so can significantly improve the availability and provision of skilled maternity care before, during, and after childbirth. Improving financing of maternal health services. The vast majority of women incurred out-of-pocket expenditures for services that are officially provided free of charge, and these expenses increased dramatically over the period studied. These findings underscore the critical need to address the main costs to women, which were primarily related to the purchase of drugs and supplies for care. Increasing the training and deployment of skilled attendant cadres. Overall, there is a shortage of skilled attendants, which has negative consequences for the availability and quality of maternity care. The content of pre-service training programmes should be reviewed to ensure that essential competencies of a skilled attendant are acquired, and overall manpower shortages within the health system must be addressed to make quality care available to the women who need it. Ensuring that routine elements of quality maternal health services are provided, in addition to complications. While improvements were observed in the areas of antenatal care, normal delivery care, and postpartum care, there are still gaps in the content of routine services gaps that reduce the potential benefits of these health interventions in terms of preventing maternal mortality. Many women do not receive essential elements of focused antenatal care, and postpartum care visits are rarely used as an opportunity to assess the health status of new mothers and ensure that they are recovering well from childbirth. Given that a large proportion of maternal deaths take place in the early postpartum period, such missed opportunities can cost women their lives. Overall, the results of the project underscore the need for context-specific approaches that are based on the capacity of the health system and maternity care utilisation patterns of communities. Such approaches can lead to improvements in the availability of skilled maternity care and can increase the likelihood that women receive care to prevent complications and can access life-saving care when complications arise. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania iv

8 I. BACKGROUND AND RATIONALE A. MATERNAL MORTALITY Maternal mortality remains one of the health indicators with the greatest disparity between developed and developing countries. 1 While the lifetime risk of maternal death for women in the developed world is 1 in 2,800, for women in Africa the figure is one in 16. Extreme inequalities also exist within countries. It is well documented that certain groups the poor, the uneducated, adolescents, marginalized groups, and those living in rural and isolated areas face extreme disadvantages in accessing health services and bear a disproportionate burden of negative health outcomes. 2 Demographic and Health Survey data from more than 50 countries confirm these disparities: women in the richest quintile are five times more likely, on average, to deliver with assistance from a trained professional (doctor, nurse, or midwife) than those in the poorest quintile. 3 While inadequate access to maternal health care takes an obvious toll on women, it also has significant adverse effects on broader development goals. At least 30-40% of infant deaths can be attributed to inadequate care during pregnancy and delivery. 4 A woman s death has severe consequences for all her children, especially girls; her children may be pulled out of school to take care of household chores or to contribute to household income, and they are likely to receive less food and health care. 5 The economic cost of maternal death and disability the loss of income and productivity by women, their families, and their communities can also be enormous. 6 B. INCREASING SKILLED ATTENDANCE AT DELIVERY Almost 20 years after the Safe Motherhood Initiative was conceived, there is compelling historical, clinical, and epidemiological evidence suggesting that increases in skilled attendance rates are associated with reductions in maternal death rates. 7 Although most of the analyses showing this association are based on data from middle- or high-income countries, statistical analyses have shown an inverse relationship between maternal mortality and skilled attendance rates across countries with differing income levels. The experiences of several low-income countries, such as Sri Lanka and Malaysia, suggest that dramatic reductions in maternal mortality can be attained through increased rates of skilled attendance at delivery. 8,9 In fact, experience shows that even in the absence of hospitals, first-level maternal and newborn care can bring maternal mortality below 200 per 100,000; in optimal circumstances it may actually reduce maternal mortality to levels of 90 per 100, In light of this strong correlation, skilled attendance has been identified globally as a key indicator for measuring progress. The Millennium Development Goals (MDGs), adopted by the United Nations in 2000, are eight quantified goals for reducing global poverty. Among these is MDG 5, to improve maternal health, which aims to reduce maternal mortality by three-fourths by the year Skilled attendance at childbirth is being used as the proxy indicator to measure progress towards this target. While there is no silver bullet for reducing maternal mortality, the most promising approach for reducing maternal mortality is increasing use of skilled care during childbirth, with a strong emphasis on comprehensive, health systems-based approaches. While skilled care is now globally recognized as one of the most promising strategies for reducing maternal mortality, there is little evidence-based guidance for implementing this Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 1

9 approach in low-resource settings. As Miller et al. note in their article, Where is the E in MCH?, There is no clear evidence on the best way to ensure appropriate care of women in developing countries who require life-saving interventions in the delivery and postpartum period. 11 C. MATERNAL HEALTH IN TANZANIA According to the 2002 National Population and Housing Census, Tanzania s estimated population is 34.6 million. 12 Population growth is rapid at 2.9% per annum, and the total fertility rate is 5.7. Females account for just over half (51%) of the population. The crude birth rate is 39 live births per 1,000 persons, and the crude death rate is 17 per 1,000. The infant mortality rate is 103 per 1,000, and life expectancy at birth is 45 years. 13 The HIV/AIDS epidemic is expected to reduce the life expectancy further in the near future. Tanzania has an extensive network of approximately 5,000 health facilities. However, most health facilities are heavily concentrated in urban areas, leaving rural communities with little access to the formal health system. In addition, gaps in skilled personnel, essential equipment and supplies and other resources constrain the provision of obstetric care. About 65% of hospitals provide comprehensive emergency obstetric care (CEOC), and only about 6% of health centres are providing basic emergency obstetric care (BEOC). 14 Maternal mortality is a serious problem in the United Republic of Tanzania; the maternal mortality ratio (MMR) is estimated at 578 maternal deaths per 100,000 live births, however, this estimate may be low given that the majority of women (53%) deliver in the community, where maternal deaths are not accurately or reliably recorded. 15 Although antenatal care coverage is extensive (94% of women make at least one visit), nationally, only about 47% of deliveries occur in health facilities. 16 Moreover, not all facility births are attended by cadres recognised globally as skilled attendants (e.g. doctors, nurses, and midwives); only about 43% of all births are attended by skilled attendant cadres, and about 4% are attended by lower-level cadres, such as MCH Aides. Overall, the majority of births (56%) occur at home; 19% are assisted by trained and untrained traditional birth attendants, 30% are assisted by relatives, neighbours, or friends, and the remaining 3% of births without assistance. 17 Tanzania was one of the first sub-saharan African countries to adopt a safe motherhood strategy in 1989, and priority has been given to the reduction of maternal mortality in the Ministry of Health and Social Welfare s reproductive health and child survival strategies. The Strategy for Reproductive Health and Child Survival aimed to reduce maternal mortality by 50% by the year 2001 through the following strategies: Improving the nutritional and socioeconomic status of women; Strengthening post-abortion and antenatal care; Reviving postnatal care; Increase human resource capacity for managing maternal care; Strengthening management of obstetrical problems in health facilities; and Enhancing efficiency of the referral system. The most recent strategy document, Reproductive and Child Health Strategy , was developed based on lessons learned from previous policies. The vision of this Strategy is to foster a healthy and well-informed Tanzanian population with access to quality reproductive Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 2

10 and child health services that are accessible, affordable, sustainable, and which are provided through an efficient and effective support system. Maternal health is identified as a key priority, and includes the following areas of action: focused antenatal care, skilled care during childbirth, care for obstetric emergencies, postpartum care, post-abortion care, family planning, and prevention of harmful practices. 18 In addition, the Ministry of Health and Social Welfare recently finalized the National Road Map Strategic Plan to Accelerate Reduction of Maternal and Newborn Deaths as a response to the persistently high maternal mortality rates. This strategic plan provides a framework for the integration of maternal and newborn care and a focus on evidence-based strategies for saving newborn lives, including increasing the coverage of births by skilled attendants from 46% to 80% by Although the Health Sector Reform instituted by the Government in 1996 extended costsharing to all health facilities, health services for pregnant women and children under five years are officially provided free of charge. In practice, however, evidence suggests that outof-pocket expenditures are incurred for these services, and there was a decline from 47 to 40 percent in the proportion of deliveries attended by a skilled attendant in six districts of Tanga Region from 1994 to 1997 concurrent with the implementation of the cost-sharing system. 19 D. THE SKILLED CARE INITIATIVE In 2001, Family Care International (FCI) and the Ministry of Health and Social Welfare (MOHSW), with support from the Bill and Melinda Gates Foundation, launched the Skilled Care Initiative a five-year, multi-faceted project aimed at improving maternal health outcomes in Igunga District, Tabora Region. The specific objective of the Skilled Care Initiative was to increase rates of skilled attendance in the intervention district. As illustrated in Figure 1, project activities focused on two main areas: improving the availability and quality of maternity care, and promoting increased utilisation of maternity services. The project was part of a larger-three country initiative aimed at testing strategies for increasing rates of skilled attendance at childbirth; similar interventions were implemented and evaluated in one district in Burkina Faso and two districts in Kenya. The project focused on improving maternity care where the need is greatest in the health centres and dispensaries closest to women and to motivate women and their families to use these services. It also aimed to strengthen care at Igunga District Hospital and Nkinga Mission Hospital where women are referred with more serious complications. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 3

11 Figure 1: SCI Conceptual Framework E. THE PROJECT CONTEXT: IGUNGA DISTRICT Igunga is one of six districts in Tabora Region of Tanzania. With a population of 382,029, the district is comprised of four divisions, 26 wards, and 96 villages. The population is primarily engaged in mixed agriculture and livestock and consists of four major ethnic groups: the Sukuma (50%), the Nyiramba (30%), and the Nyamwezi and Taturu (the remaining 20%). Women of reproductive age make up 23% of the district population, and the ratio of women to men is 100: Igunga district was selected as the intervention area by the Ministry of Health in collaboration with Family Care International. Tabora Region is one of the most underserved regions in Tanzania. Although its official maternal mortality rate of 240 per 100,000 live births is lower than the national average, this is most likely due to serious underreporting. In 1999, it was reported that 38 %of deliveries in Tabora were facility-based, while 69% of pregnant women received antenatal care. Few women receive postnatal care, largely because people do not appreciate the need for such care and are deterred by the long distances to facilities. Igunga district was chosen as the intervention district for the Skilled Care Initiative in Tanzania for several reasons. The district was relatively small, and it had an active and committed District Health Management Team (DHMT) which had successfully piloted the Community Health Fund, a World Bank-funded community health insurance scheme. In addition, the district had an adequate health infrastructure at the outset of the project, which was an essential foundation for planned interventions. Igunga had a total of 34 health facilities (two hospitals, five health centres, and 27 dispensaries), most of which were in good physical condition at the outset of the project and offered labour and delivery services for uncomplicated births. The district s two hospitals include the District Hospital and Nkinga Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 4

12 Mission Hospital, which are located at opposite sides of the district, and had the capacity to provide comprehensive essential obstetric care (i.e. Caesarean section and blood transfusion). Urambo District, also in Tabora Region, was selected as a comparison district, based on its comparability in terms of key health, and socio-demographic indicators available at the outset of the project. It had a total of 40 health facilities including the District Hospital, 3 health centres, and 36 dispensaries, the majority of which were government owned. F. SKILLED CARE INITIATIVE IN IGUNGA DISTRICT: OVERVIEW OF PROJECT INTERVENTIONS The Skilled Care Initiative was implemented in Igunga district from late 2001 to late Baseline evaluation studies were conducted from late 2001 to early 2003, and the majority of project interventions were implemented from 2003 to late As described above, project interventions included both health facility- and community-level interventions to increase the availability, quality, and utilisation of skilled maternity care throughout pregnancy, childbirth, and the postpartum period. Health systems interventions introduced at all public and private health facilities providing maternity care (two hospitals, five health centres, and 22 dispensaries) were specifically designed to: Strengthen the physical infrastructure for maternity care: Solar equipment was installed at selected rural health facilities to improve the availability of lighting. Address equipment and supply gaps: Based on gaps identified through baseline research, a package of essential obstetric equipment was provided to each health facility equipment such as blood pressure gauges, weighing scales, delivery kits, examination beds, autoclaves/sterilisers, examination lamps, reagents, autoclave drums, speculum, trays, baby towels, etc. FCI also worked with district health managers and facility incharges to strengthen logistics systems and improve the availability of essential obstetric drugs and supplies. These efforts included modification of the Community Health Fund (CHF) drug ordering form to include drugs specific to maternal and child health, as well as training staff at all health centres and dispensaries in a new logistics system (the Indent System) to support the district s shift from a kit system to a pull system in which each facility determines and orders its needs based on its caseload. Improve provider skills: A total of 115 maternity care providers from the district were trained in routine obstetric care skills, such as focused antenatal care, active management of the third stage of labour, use of the partograph, infection prevention, and interpersonal communication skills, including compassionate care, as well as the management of obstetric complications (e.g. pregnancy-induced hypertension, haemorrhage, shock, prolonged and obstructed labour, and sepsis). A total of 76 providers (doctors, nursing officers, nurse/midwives, and clinical officers) were trained in advanced life-saving skills (ALSS), and 39 providers (Public Health Nurse Bs, trained nurses, and MCH Aides) were trained in basic life-saving skills (BLSS). In addition, 20 providers from health centres and the district hospital were trained in post-abortion care, including Manual Vacuum Aspiration (MVA) to treat incomplete abortions. To reinforce the trainings and to address the lack of standards and protocols, FCI worked with the Ministry of Health and Social Baseline evaluation studies highlighted some crucial differences between the two districts in terms of maternal health care-seeking that had not been apparent from previous indicators and research. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 5

13 Welfare to develop an Emergency Obstetric Job Aid. This tool was field tested in Igunga and other districts, and was distributed to all health facilities in the district. Strengthen referral systems: An ambulance was provided to the district, along with a radio call system linking health centres and remote dispensaries to the district hospital to enable them to call the district hospital to request emergency transport or receive advice on managing or stabilising complicated cases. Detailed guidelines on the ambulance use and the fees to be charged for fuel and maintenance were developed in close consultation with community leaders throughout the district and were distributed to all health facilities. In addition, a prototype standardised referral form was developed and introduced to improve referrals. Strengthen supervision and health service management: FCI worked with district health managers to improve maternal health record-keeping particularly related to the provision of postpartum care, referrals, and the use of the partograph. In addition, district health managers received training and on-the-job support in areas such as annual planning and budgeting, and computer skills. A computer was also donated to the office of the District Medical Officer to support management functions. To complement health systems interventions, FCI also launched intensive behaviour change communication and mobilisation efforts to encourage health-seeking behaviours and build community support for the use of skilled care. These behaviour change communication interventions were specifically designed to: Heighten awareness of the risks associated with pregnancy and childbirth, Promote birth preparedness and planning for delivery, Strengthen recognition of and responses to obstetric complications at household and community levels, and Promote the use of skilled care throughout pregnancy, childbirth, and the postpartum period. Based on in-depth qualitative research conducted among women, men, community leaders and maternal health providers in Igunga, the behaviour change communications efforts included both facility-level counselling on birth preparedness, as well as a community-level campaign targeting key participant groups, including women, husbands, female elders, and community leaders. Campaign activities included: Participatory meetings at the village level: Approximately 215 meetings were held at the village level with women and men. The meetings were used as a forum to discuss danger signs during pregnancy, the benefits of preparing for delivery, and the importance of delivering at a facility with a skilled attendant. Conducted by trained village health workers, each meeting generated considerable discussion and dialogue about household and community-level factors that affect the use of skilled care, and how families and communities can overcome some of the barriers to reaching care. Approximately 6,500 men and women were directly reached through such meetings. Theatre and performing arts: Drama, song, and dance were used to convey key messages. As part of the launch of the behaviour change campaign, a traditional singing and dancing performance called mamanju was held. The performance constituted a threeday festival on the theme of skilled care, and it drew approximately 10,000 people from the district. In addition to the mamanju performance, local dramatists from each of the predominant ethnic groups were trained in participatory theatre. FCI worked with these groups to help them develop skits and songs to communicate messages about the Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 6

14 importance of delivering at a facility, preparing for delivery, and discussing plans with immediate family members. A total of 23 performances were held throughout Igunga, drawing approximately 5,600 community members. To support the village meetings and folk media activities, a small booklet was developed to communicate key skilled care messages to women, their families, and other community members. The 20-page booklet was designed for low- or non-literate readers, and was tailored for the Igunga context. Approximately 12,000 copies of the booklets were distributed at village meetings, drama performances, and traditional song and dance performances, and additional copies were distributed during women s antenatal care visits at the health facilities. In addition to these materials, two posters were created one to encourage women to seek early postpartum care within a week of delivery, and another to inform community members in Igunga of their rights to quality care. The posters were posted in facilities and other public places. Finally, special khangas were produced for women who deliver at any facility in Igunga. The khangas, which came in three colours and included an image of a pregnant woman approaching a facility, served as an incentive for women to deliver at the facilities and promote skilled care to other community members. An estimated 10,000 pairs of khangas were distributed in Igunga in Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 7

15 II. EVALUATION DESIGN AND METHODS SCI used a rigorous methodology to evaluate the availability and quality of skilled care in the intervention districts, its financial and cultural accessibility, and changes in use of skilled care over time. The pre-test, post-test, quasi-experimental design included the following components: Facility assessments in the intervention and comparison districts to collect information on the quality, availability, and utilisation of maternal health services. Household surveys covering a random sample of households in each district to collect information on the use of skilled care at delivery, and knowledge, attitudes, and careseeking behaviours during pregnancy and childbirth. A. HEALTH FACILITY SURVEY Facility surveys were conducted in Igunga and Urambo districts at baseline and endline in The specific objectives of the health facility surveys were to: Assess the availability, use and quality of maternal health services provided to women and newborn babies at all levels of the health care system and to identify gaps in these services Guide the design of project interventions by identifying possible strategies for improving the coverage and quality of maternal health services and to assist in prioritising interventions in training, logistics, community education and outreach, as well as other areas as appropriate Evaluate the impact of SCI project interventions on the availability, use, and quality of maternal health services at health care facilities by comparing baseline and endline data. The World Health Organization s (WHO s) Safe Motherhood Needs Assessment methodology was selected from among a number of internationally developed methodologies for evaluating the quality of maternal health services in the two districts. The WHO Safe Motherhood Needs Assessment methodology is a collection of tools designed to describe the availability, use and quality of each of the four pillars of safe motherhood family planning, antenatal care, clean/safe delivery, and essential obstetric care at each level of the health system. This needs assessment methodology was selected for two reasons. First, it covers the entire spectrum of maternal health care and safe motherhood, as opposed to solely obstetric care or primary health care, more generally. Secondly, this assessment methodology prioritises the collection and analysis of data by district, primarily because the district health system is recognised by the WHO as a mechanism for linking families and communities with health centres and hospitals in a functional and cost-effective manner. This ensures that maternal health services are available as close as possible to people s homes. Drawing on instruments developed by Unicef, the Prevention of Maternal Mortality Program, the Population Council and MotherCare, additional questions were added to the set of WHO instruments to better explore key issues related to staff training, supervision, and record-keeping, as well as to explore providers knowledge and skills related to the management of obstetric complications. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 8

16 The survey instruments included: Structured interviews with district health management teams to collect information about the management of maternal health services, as well as the number, categories and training of available health personnel. Structured interviews with facility department managers to gather detailed information on available maternal health services, as well as the physical infrastructure and management structure of each facility, and capacity to provide essential obstetric care or to refer complicated cases. Structured observation of equipment, consumable supplies and medicines Reviews of facility records to collect information on: antenatal, delivery, and postpartum care; the type, number and management of obstetric complications; the number of Caesarean section deliveries performed; and stillbirths, maternal and neonatal deaths. Structured interviews with midwifery personnel to record data on the number, qualifications, training, supervision and practices of delivery care providers at each health facility. All cadres involved in the day-to-day provision of maternal health services who were present during the day of data collection, including nurse auxiliaries, were interviewed. Structured exit interviews with antenatal and postpartum clients to assess the content and quality of available services. Sample Design and Estimation During the baseline survey, all health facilities in Igunga district were covered. As certain private and mission clinics were found to not be providing maternity care, they were not included in the analysis, and they were excluded from the endline survey. In Urambo district, a sample of facilities providing maternity care was selected in consultation with the District Health Management Team, and the same facilities were visited during the endline survey. Data Collection Health personnel and administrators were recruited and trained as interviewers for both surveys. They were recruited from the regional level (Tabora town), as well as from the two districts surveyed. However, no health staff were involved in surveying their own worksites. Baseline data collection was completed over a two-week period in each district in late Endline data collection was completed in August-September Both surveys were supervised by an external consultant research coordinator from the School of Public Health and Social Sciences, Dar es Salaam, Tanzania. Table 1. Facility sample, by survey form Survey form Baseline Endline Facility management Facility register review Interview with midwife or maternity nurse Antenatal client exit interview Postpartum client exit interview Normal delivery record review Complicated delivery (eclampsia) record review 8 14 Complicated delivery (obstructed labour) record review Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 9

17 B. HOUSEHOLD SURVEY Population-based household surveys were conducted in Igunga and Urambo districts at baseline and endline. The specific objectives of the surveys were to: Gather basic data on demographic, socioeconomic, and other variables that may influence the use of skilled care Assess the knowledge, attitudes, and behaviours related to birth preparedness and careseeking during pregnancy, delivery, and the early postpartum period; Measure the use of skilled care during normal and complicated deliveries and the early postpartum period by the district population; Evaluate the impact of SCI project interventions regarding these indicators One of the most difficult issues in designing a survey questionnaire for measuring behaviour surrounding pregnancies and births is that, depending on the level of fertility in a population, a large number of women must be interviewed in order to obtain information on a sufficient number of births for analysis. 21 While it is possible to ask women about births that occurred in the past, little is known about how much women may forget about the details of their pregnancies and care-seeking as the interval since the birth increases. Some studies have asked women of reproductive age about their most recent birth only. Such a sample would be representative of women who have births, but not all births, because births to women with more than one birth would be underrepresented. In addition, this type of sample would be prone to recall bias for those women who had the last birth several years before the survey. Restricting the sample to most recent births in a specified period prior to the survey (e.g., the last year or two) reduces recall bias, but adds a bias due to women with high fertility being more likely than other women to be represented. These two representation biases not all births of high fertility women being included and higher fertility women being included in the sample more often would counterbalance, but not necessarily in a way that would create an unbiased sample of births. An alternative is to include all births in a specified period, which creates an unbiased sample representative of births during that period. In this type of sample, women and their births would appear in the sample in proportion to the number of births the women has had. Moreover, all births in the specified period would have an equal chance of appearing in the sample. In addition to being unbiased, this type of sample would require a smaller sample of women than a sample based on the most recent birth, because all births in the specified period would be included, not just the most recent birth. Therefore, FCI asked women about all of their births and stillbirths in the two years prior to the survey. This procedure, while more cumbersome than asking about the most recent birth only, yields an unbiased sample of all births and stillbirths occurring in a recent period. Since there is evidence that early pregnancy losses are underreported in surveys these were excluded. Testing Approaches for Increasing Skilled Care during Childbirth: Key Findings from Igunga District, Tanzania 10