Availability, distribution and use of emergency obstetric care in northern Tanzania

+ Author Affiliations 1. Centre for International Health, University of Bergen, Norway, 2Centre for Educational Development and Health, Arusha (CEDHA), Tanzania and 3Section for Medical Ethics and Philosophy of Science, Department of Public Health and Primary Care, University of Bergen, Norway
1

1. Correspondence: ystein Evjen Olsen, P.B. 105297, Dar Es Salaam, Tanzania. Email: oystein.olsen@cih.uib.no

Abstract
The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n=129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500 000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500 000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500 000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility. http://heapol.oxfordjournals.org/content/20/3/167.abstract

Basic Emergency Obstetric Care

According to the Department of Health (DOH), almost four thousand six hundred (4,600) women die giving birth each year translating into ten (10) mothers dying and leaving more than thirty children motherless every day. In the Philippines today, 6 out of 10 births take place at home making it difficult to follow a woman from prenatal to postnatal stage thus contributing to a high maternal fatality rate. Hemorrhage, hypertensive disorders during pregnancy and obstructed labor constitute the majority of complications relating to maternal fatalities. All of these problems can be prevented through proper medical care. The DOH also mentioned three (3) factors that contribute to the growing maternal fatality rate: (1) the decision when to seek care, (2) reaching the health facility and, (3) receiving appropriate care in the facility.

Essential Health Service Packages

A. Antenatal Registration
a. Prenatal Visits: 1st visit2nd visit3 visit
rd

As early in pregnancy as possible before four months or during the first trimester During the 2nd trimester During the 3rd trimester

Every 2 wks. After 8th month of pregnancy till delivery

B. Tetanus Toxoid Immunization

When given to women of childbearing age, vaccines that contain tetanus toxoid not only protect women against tetanus, but also prevent neonatal tetanus in their newborn infants

Vaccine TT1

Minimum Percent Age/Interval Protected As early as possible -during pregnancy

Duration of Protection --

y
TT2 At least 4 weeks later 80%

y y

infants born to the mother will be protected from neonatal tetanus gives 3 years protection for the mother infants born to the mother will be protected from neonatal tetanus gives 5 years protection for the mother infants born to the mother will be protected from neonatal tetanus gives 10 years protection for the mother gives lifetime protection for the mother

TT3

At least 6 months later

95%

y y

TT4

At least 1 year later

99%

y y

TT5

At least 1 year later

99%

all infants born to that mother will be protected

In June 2000, the 57 countries that have not yet achieved elimination of neonatal tetanus were ranked and the Philippines was listed together with 22 other countries in Class A, a classification for countries close to maternal and neonatal tetanus elimination

C. Micronutrient Supplementation
Vitamin A- 10,000 IU 2x a week starting on the 4th month of pregnancy Do not give Vitamin A before 4th month of pregnancy. It might cause congenital problems in the baby Iron- 60mg/400 ug tablet Daily

D. Treatment of Diseases and Other Conditions

Types: 1. Difficulty of breathing/ obstruction of airway 2. Unconsciousness 3. Post partum bleeding 4. Intestinal parasite infection 5. Malaria 6.

E. Clean and Safe delivery

Presence of skilled birth attendant Purpose: A. to ensure hygiene during labor and delivery. B. Provide non-traumatic delivery C. recognize complications D. Referred those complicated deliveries to high level of care

F. Recommended Schedule for Post Partum Care Visits

1st visit-1st week post partum preferably 3-5 days 2nd visit-6 weeks post partum

G. Importance of Breast Feeding

Breast milk is best for babies up to 2 years old. Exclusive breastfeeding is recommended for the first six months of life. At about six months, give carefully selected nutritious foods as supplements. Breastfeeding provides physical and psychological benefits for children and mothers as well as economic benefits for families and societies.

BENEFITS : For infants a. b. c. d. Provides a nutritional complete food for the young infant. Strengthens the infants immune system, preventing many infections. Safely rehydrates and provides essential nutrients to a sick child, especially to those suffering from diarrheal diseases. Reduces the infants exposure to infection.

BREASTFEEDING/ LACTATION MANAGEMENT EDUCATION TRAINING Breastfeeding practices has been proved to be very beneficial to both mother and baby thus the creation of the following laws support the full implementation of this program: A. Executive Order 51 B. Republic Act 7600 C. The Rooming-In and Breastfeeding Act of 1992

A. EO 51 THE MILK CODE Protection and promotion of breastfeeding to ensure the safe and adequate nutrition of infants through regulation of marketing of infant foods and related products. (e.g. breast milk substitutes, infant formulas, feeding bottles, teats etc. ) B. RA 7600 THE ROOMING IN and BREASTFEEDING ACT of 1992 =An act providing incentives to government and private health institutions promoting and practicing rooming-in and breast-feeding. =Provision for human milk bank. =Information, education and re-education drive =Sanction and Regulation For The Baby -Provides Antibodies -Contains Lactoferin (binds with Iron) -Leukocytes -Contains Bifidus factor-promotes growth of the Lactobacillus-inhibits the growth of pathogenic bacilli For the Mother

-Reduces a woman s risk of excessive blood loss after birth -Provides a natural method of delaying pregnancies. -Reduces the risk of ovarian and breast cancers and osteoporosis. For the Family and Community -Conserves funds that otherwise would be spent on breast milk substitute, supplies and fuel to prepare them. -Saves medical costs to families and governments by preventing illnesses and by providing immediate postpartum contraception.

POSITIONS IN BF THE BABY: 1. 2. 3. Cradle Hold = head and neck are supported Football Hold Side Lying Position Bonding Resistance Economical Allergy Free Safe Time Saving Family Planning (LAM) Energy Giviing Error Free Formula Digestible Inexhaustible Supply No Vitamins Needed Guaranteed