Health system support for childbirth care in Southern Tanzania: results from a health facility census

Abstract

BackgroundProgress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth.ResultsHealth centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2–3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months.ConclusionsEssential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive “skilled attendance” and adequate care for common obstetric complications such as post-partum haemorrhage.

Trends in and socio-demographic factors associated with caesarean section at a Tanzanian referral hospital, 2000 to 2013

“…Health facilities range from dispensaries to tertiary hospitals such as KCMC [ 30 ] and the high percentage of CS at KCMC might reflect the fact that few CSs are being performed at other health facilities in the region, implying that many women are referred to KCMC from lower level facilities due to medical complications. Several studies from Tanzania show that the quality of care in lower level facilities is insufficient [ 38 - 42 ] and that symptoms are often not acted upon properly at the stage of labour [ 43 , 44 ]. This might lead to preventable CSs [ 43 ] because it might be the only option left when the women arrive late at the referral facility.…”

Where Do the Rural Poor Deliver When High Coverage of Health Facility Delivery Is Achieved? Findings from a Community and Hospital Survey in Tanzania

“…The consequence of the expansion of primary health care on childbirth care is that deliveries are dispersed over a large number of facilities. There is not much available evidence on the optimal number of deliveries to be assisted per year to ensure quality, though a caseload greater than 150 per year has been suggested [24] .…”

“…Skilled birth attendants (SBA) are accredited health professionals with the necessary skills to manage childbirth and to identify, manage and refer complications in women and newborn [22] , [23] . In Tanzania, clinicians (medical officers, assistant medical officers, clinical officers), and enrolled and registered nurses are classified as skilled birth attendants; lower cadres such as nursing assistants are not [24] .…”

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys

“…3 Although researchers have identifi ed serious quality defi cits at some hospitals, quality of care at lower level facilities (eg, health centres and dispensaries) typically staff ed with nurses or nursing aides has come under particular scrutiny. [7][8][9][10] By contrast with the extensive research on quality of obstetric care in high-income countries, systematic research on quality is scarce in LMICs. 7,11,12 This diff erence could be a result of the overarching focus on use and the scarcity of health system and outcome data on quality.…”

“…[7][8][9][10] By contrast with the extensive research on quality of obstetric care in high-income countries, systematic research on quality is scarce in LMICs. 7,11,12 This diff erence could be a result of the overarching focus on use and the scarcity of health system and outcome data on quality. 13 One important question in resource-constrained contexts concerns the safety and quality of low-volume, primary care delivery facilities where pregnant women deemed at low risk of complications are directed to deliver.…”