Promotion of Clinical Outcomes by Institutionalization of Maternal Care Quality Improvement Measures in Tanzania

Purpose:

According to the World Health Organization, Tanzania is one of the eight ‘high burden countries’ in terms of maternal deaths, where were 454 in 2010 (TDHS) and reduced to 410 in 2013 (UN estimate).  The maternal death rate remains more than twice as high as the target of 193 per 100,000 live births by 2015. Unlike antenatal care (ANC) coverage of 96% of at least one visit, facility delivery is at 51 % with the other half delivering at home which exposes mothers to direct causes of deaths such as postpartum haemorrhage, eclampsia, infections and obstructed labor as well as asphyxia, prematurity and infections in newborns. Reduction in neonatal mortality is equally slow from 32 to 26 by 2010 (TDHS) while the target is at 19 per 1000 live births by 2015. Low facility utilization for delivery, post-partum and repeated ANC visits is attributed to low quality services.

The USAID-funded MAISHA program supported the Ministry of Health and Social Welfare (MOHSW) in improving the quality of ANC and Basic Emergency Obstetric and Newborn (BEmONC) health services in Tanzania.  The program institutionalized quality improvement process known as standards-based management and recognition or SBMR.  The SBMR process consists of the systematic, consistent and effective utilization of operational updated national performance standards as the basis for the organization of services of focus, in this case MNH including ANC.  It engages stakeholders through advocacy, training and repeated assessments with rewarding compliance through facility recognition.

Methods:

ANC and BEmONC performance standards were developed according to scientific evidence translated into national policies and strategies.  Stakeholders were engaged for consensus building and selection of sites.  Health managers and service providers were trained on the implementation of SBMR.

The first observational quality of care assessment was conducted in 2010 to describe the quality of ANC and BEmONC services in 52 health facilities in 12 regions of Tanzania where about 360 ANC consultations and 490 deliveries were observed.  Health records, medication inventories and health worker knowledge were all assessed.

After first assessment, the new performance standards were rolled out to targeted facilities, along with the means of measuring progress.  Persistent gaps and successes were noted and provided momentum for change.  

Results:

A follow QOC assessment was conducted in 2012, with several positive results.   Preventative treatment in antenatal care improved at the 12 regional hospitals.  Malaria prevention (IPTp) increased from 41% in 2010 to 73% in 2012. Counseling for patients on both IPTp intake and fesolate for prevention of anaemia during ANC consultations improved in terms of providers effectively communicating the reason for the medications and the directions for use.

During labor, mean scores increased by 27% in asking about danger signs at initial assessment, by 10% in providing women friendly care and by 13% for use of partograph. There was increased use of oxytocin and an increase in the provision of active management of the third stage of labor (AMTSL) from 33% in 2010 to 44% in 2012.      

Overall performance of essential newborn care practices in 2012 showed significant improvements, including: drying the baby at 95%, assisting breastfeeding within 1 hour after childbirth at 86% and skin to skin at 54%. In total, 44 facilities scored over 70% in focused antenatal care (FANC) and received MOHSW certificates of recognition after external verification.  Most notably, maternal deaths decreased from 16 deaths in all facilities in 2010 to 10 deaths in 2012.  The decline was negatively associated with the improvement in service delivery.

Overall, the program reached 60 national BEmONC trainers, 921 providers, 251 sites equipped with essential BEmONC commodities, 619 district supervisors trained on supportive supervision skills, and 49 sites which were recognized by the MOHSW for provision of quality BEmONC.  All target facilities were reached, and 100% of district councils displayed ownership of the SBMR process by including it in subsequent annual budgets.  These improvements have led to improved clinical outcomes. 

Conclusion:

In Tanzania, SBMR has produced important changes in the quality of ANC and BEmONC services in facilities, which fit in with national strategies to reduce maternal and newborn mortality. Sustaining and institutionalizing these changes is part of the ongoing work to improve quality of care for mothers and newborns.