Maternal health services in Tanzania: strengths and weaknesses of different levels of health facility

Dunstan Bishanga
Chief of Party MAISHA Program

Background
Close to half of deliveries in Tanzania occur at home, but SBA in facilities gradually increasing 41% of all deliveries in 1999, 51% in 2010 Quality of care critical to increase attendance of deliveries of women in health facilities Interpersonal skills particularly important

Background

Quality of BEmONC services assessed in joint MOHSW / MAISHA assessments in 2010 and 2012 52 health facilities in Tanzania assessed, including 12 regional hospitals and 40 health centres/ dispensaries In 2010, n=489 deliveries observed; in 2012, n=555

Background
2012 results showed dramatic improvements. Many indicators showed noted differences between regional hospitals and lower level health facilities Persistent gaps included: use of oxytocin (rather than other uterotonic) for AMTSL; receiving uterotonic within 1 minute of delivery; allowing a support person, and monitoring of vital signs after delivery

AMTSL with (Oxytocin within 1 min+CCT+Uterine Massage)

Notable increase occurred between 2010 and 2012 on use of oxytocin for AMTSL in lower level HF from 55% of observed deliveries in 2010 to 83% in 2012. Gap between levels still statistically significant
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

47% 33%

39% 8%

44% 26%

HOSPITALS

HC/DISP 2010 2012

ALL

Uterotonic within 1 minute of delivery

Dramatic increase occurred between 2010 and 2012 on administration of uterotonic within 1 minute of delivery, but gap still statistically significant
Received uterotonic within one minute of delivery % correctly % correctly Statistical performed performed (health significance (regional hospitals) centers/ (Fishers dispensaries) Exact Test)

2010 2012

35 56

11 45

P=0.001 P=0.0205

Relaxed definition: regional hospitals: 70%, HC/disp: 56%

Oxytocin for AMTSL

Dramatic increase occurred between 2010 and 2012 on use of oxytocin for AMTSL. Gap between levels still statistically significant. AMTSL was done with oxytocin % deliveries observed (regional hospitals) % deliveries observed (health centers/ dispensaries) Statistical significance (Fishers Exact Test)

2010 2012

31% 48%

8% 37%

P=0.001 P=0.02

Ask about support person

In both 2010 and 2012, lower level health facilities were more likely to ask the woman if she had a support person. The proportion for Regional hospitals increased dramatically in 2012, but the difference is still statistically significant. Provider asks about support person at initial assessment % deliveries observed (regional hospitals) % deliveries observed (health centers/ dispensaries)

2010 2012

27 40

48 50

Screening for PE/E in initial assessment

Dramatic increases were seen at both levels for screening for PE/E *composite indicator, includes asking about symptoms and checking for other signs Provider asks about support person at initial assessment % deliveries observed (regional hospitals) % deliveries observed (health centers/ dispensaries)

2010 2012

29 59

27 50

Interpersonal communication indicators in 2012

On several IPC indicators, lower level health facilities were significantly more likely to have better IPC. Ex. More women got counseled on Fe/Fo and malaria in ANC

Indicator
Counseling for iron/ folic acid in ANC Counseling on malaria in ANC HW asks about complications during initial assessment (L&D)

% deliveries observed (regional hospitals)

% deliveries observed Statistical significance (health centers/ (Fishers Exact Test) dispensaries)

16% 62% 42%

54% 77% 77%

0.000 0.03 0.03

Conclusion/Recommendations
Prevention of PPH, screening for PE/E dramatically increased; differences in provision of AMTSL remain persistent across levels of HF Lower level health care facilities are less crowded and could potentially provide more friendly services Higher level health care facilities demonstrate better clinical practices Work to address factors that make one level do better than the other

Conclusion/Recommendations
Quality maternal health care is every womans right, at every level of the health system. Adherence to national clinical standards must be observed by all providers no matter which level Supportive supervision and other quality improvement measures should be utilized in order to achieve high quality maternal health services at all levels of the health system

Acknowledgements
Authors: Dunstan Bishanga; Gaudiosa Tibaijuka; Christina Makene; Marya Plotkin; Sheena Currie;; Maryjane Lacoste
Institutions: Reproductive and Child Health Section, Ministry of Health and Social Welfare, Tanzania; Jhpiego Tanzania; Jhpiego Washington DC
This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Cooperative Agreement No. 621-A-00-08-00023-00. The contents are the responsibility of the Mothers and Infants, Safe Healthy Alive (MAISHA) program and do not necessarily reflect the views of USAID or the United States Government.