Background: Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania.

IntroductionThe COVID-19 pandemic has substantially impacted maternity care provision worldwide. Studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. The objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers.MethodsWe conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in 12 languages. Information was collected between 24 March and 10 April 2020 on respondents’ background, preparedness for and response to COVID-19 and their experience during the pandemic. An optional module sought information on adaptations to 17 care processes. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (LMICs) and high-income countries (HICs).ResultsWe analysed responses from 714 maternal and newborn health professionals. Only one-third received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, 47% of participants in LMICs and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices.ConclusionsSubstantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information-sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses.

ObjectiveTo prospectively document experiences of frontline maternal and newborn healthcare providers during the COVID-19 pandemic. DesignCross-sectional study via an online survey disseminated through professional networks and social media in 12 languages. We analysed responses using descriptive statistics and qualitative thematic analysis disaggregating by low-and middle-income countries (LMICs) and high-income countries (HICs).Setting 81 countries, between March 24 and April 10, 2020.Participants 714 maternal and newborn healthcare providers. Main outcome measuresPreparedness for and response to COVID-19, experiences of health workers providing care to women and newborns, and adaptations to 17 outpatient and inpatient care processes during the pandemic. ResultsOnly one third of respondents received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, only 47% of participants in LMICs, and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing, and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based. ConclusionsSubstantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations, and support rapid development of effective responses. We would like to thank the study participants who took time to respond to this survey despite the difficult circumstances and increased workload. We acknowledge the Institutional

Avoidable mortality and morbidity remains a formidable challenge in many developing countries like Tanzania. Birth preparedness and complication readiness by mothers are critical in reducing morbidities and mortalities due to these complications. The aim of this study was to assess knowledge and practices with respect to birth preparedness and complication readiness among women in Mpwapwa district in Tanzania. A total of 600 women who became pregnant and or gave birth two years preceding the survey were interviewed. Among them 587 (97.8%) attended antenatal clinic (ANC) at least once during their last pregnancy. Two thirds of those who attended ANC made four or more visits. The median gestation age at booking for antenatal care was 16 weeks. However, 73.9% the women booked after 16 weeks of gestation. Two thirds of the women were 20-34years old and had at least primary education level. Three hundred and forty six (57.7%) had parity between two and four. Only 14.8% of the women knew three or more obstetric danger signs. The obstetric danger signs most commonly known included vaginal bleeding during pregnancy (19%), foul smelling vaginal discharge (15%) and baby stops moving (14.3%). The majority (86.2%) of the women had decisions made on place of delivery, a person to make final decision, a person to assist during delivery, someone to take care of the family and a person to escort her to health facility. Majority (68.1%) of the women planned to be delivered by skilled attendant. One third of the women planned to deliver at home in the absence of a skilled birth attendant. In the bivariate analysis, age of the woman, education, marital status, number of ANC visits and knowing ≥3 obstetric danger signs were associated with birth preparedness and complication readiness. In multivariate logistic regression analysis, women with primary education and above were twice more likely to be prepared and ready for birth and complications. Women who knew ≥3 obstetric danger signs were 3 times more likely to be prepared for birth and complications. In conclusion, women with higher level of education and those who knew obstetric complications were more prepared for birth and complications. Further studies are recommended to find out why women do not prepare for birth or complications especially that need blood transfusion. __________________________________________________________________________________ _______

BackgroundThe functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.MethodsA follow-up study was conducted in Rufiji rural district in Tanzania. A total of 1538 women referred from 18 primary level of care facilities during a 13 months period were registered and then identified at hospitals. Those not reaching the hospitals were traced and interviewed.ResultsOut of 1538 women referred 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age <20 years were the most common referral indications. The compliance rate was 37% for women referred due to demographic risks and more than 50% among women referred in the other groups. Among women who did not comply with referral advice, almost half of them mentioned financial constraints as the major factor. Lack of compliance with the referral did not significantly increase the risk for a perinatal death.ConclusionMajority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review the referral indications and strengthen counseling on birth preparedness and complication readiness.

BackgroundThe high rate of antenatal care attendance in sub-Saharan Africa, should facilitate provision of information on signs of potential pregnancy complications. The aim of this study was to assess quality of antenatal care with respect to providers' counselling of pregnancy danger signs in Rufiji district, Tanzania.MethodsA cross-sectional study was conducted in 18 primary health facilities. Thirty two providers were observed providing antenatal care to 438 pregnant women. Information on counselling on pregnancy danger signs was collected by an observer. Exit interviews were conducted to 435 women.ResultsOne hundred and eighty five (42%) clients were not informed of any pregnancy danger signs. The most common pregnancy danger sign informed on was vaginal bleeding 50% followed by severe headache/blurred vision 45%. Nurse auxiliaries were three times more likely to inform a client of a danger sign than registered/enrolled nurses (OR = 3.7; 95% CI: 2.1-6.5) and Maternal Child Health Aides (OR = 2.3: 95% CI: 1.3-4.3) and public health nurses (OR = 2.5; CI: 1.4-4.2) were two times more likely to provide information on danger signs than registered/enrolled nurses. The clients recalled less than half of the pregnancy danger signs they had been informed during the interaction.ConclusionTwo out of five clients were not counselled on pregnancy danger signs. The higher trained cadre, registered/enrolled nurses were not informing majority of clients pregnancy danger signs compared to the lower cadres. Supportive supervision should be made to enhance counselling of pregnancy danger signs. Nurse auxiliaries should be encouraged and given chance for further training and upgrading to improve their performance and increase human resource for health.

BackgroundImproving maternal health is one of the eight millennium development goals adopted at the millennium summit in the year 2000. Within this frame work, the international community is committed to reduce the maternal mortality ratio by 75% between 1990 and 2015. The objective of this study was to determine the maternal mortality ratio, classify causes of maternal deaths and assess substandard care factors at Muhimbili National Hospital (MNH), Dar-es-Salaam in Tanzania.MethodsA retrospective review of all maternal death records of cases that occurred from 1st January to 31st December 2011 was done.ResultsThere were 10,057 live births, 155 maternal deaths and hence MMR of 1,541 per 100,000 live births. Direct causes of maternal deaths were classified in 69.5% of the maternal deaths. Of the direct causes, preeclampsia/eclampsia was the major cause (19.9% of all deaths), followed by post partum haemorrhage (14.9%), abortion complications (9.9%) and sepsis (9.2%). Among the indirect causes anaemia was the leading cause (11.3%) of all deaths, followed by HIV/AIDS (9.9%). Substandard care factors contributing to deaths were identified in 116 (82.3%) of all cases. Among these 28 had patient factors only, 71 medical service factors while 17 had both patient and medical service substandard care factors. The common factors from the woman’s side included delay in seeking care (73.3%) and complete lack of antenatal care (11.1%). Of the medical service factors, inadequate (26.1%) or no blood for transfusion (19.3%), delay in receiving treatment (18.3%) and mismanagement (17%) were the common factors.ConclusionThere is a high maternal mortality ratio at MNH. Hypertensive disorders of pregnancy, post partum haemorrhage and anaemia are the leading causes of maternal deaths in this institution. Multiple substandard care factors identified both at individual and health care service levels that contributed to maternal deaths. There is a need for increasing efforts in the fight to reduce maternal deaths at the institution. A more pro-active role from the referring facilities in the region is needed.

BackgroundEffective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved.MethodsA cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed.ResultsOverall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed.ConclusionsMaternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.