Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019

Abstract

IntroductionRapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city’s facility births.MethodsMultiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed.ResultsSignificant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%).ConclusionsThis collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.

A growing disadvantage of being born in an urban area? Analysing urban–rural disparities in neonatal mortality in 21 African countries with a focus on Tanzania

“…It is also possible that the higher NMR in urban areas in Tanzania can be partly explained by the under-reporting of neonatal death in rural areas; these deaths might have been misclassified as stillbirths or not reported at all. 42 However, the Tanzania DHS 2015-2016 results showed that also the perinatal mortality rate (stillbirths and early neonatal deaths per 1000 pregnancies of seven or more months' duration) was higher in urban (47) compared to rural areas (37). If this bias plays a role in the findings in our paper, it is therefore more likely to operate through under-reporting of perinatal deaths in rural areas rather than through differential misclassification of neonatal deaths as stillbirths.…”

“…Given the pressure exerted by population increase in urban areas on existing resources, particularly public health facilities providing care to the poor, it is possible that crowding, staff shortages, and lack of routine provision of essential care elements converge in such urban health facilities and contribute to increased risk of neonatal mortality. [37][38][39] Additionally, the risk of acquiring nosocomial infections within health facilities is particularly relevant to premature and lowbirth newborns who are highly vulnerable to acquiring and dying from such infections.…”

WHO next‐generation partograph: revolutionary steps towards individualised labour care?

“…Second, one may question the claim that the LCG sets off ‘revolutionary steps towards individualized labour care’, as it is not context‐stratified to the available resources 1 . Maternity units in low‐ and low‐ to middle‐income countries are increasingly congested and the human resources crisis is tremendous 8,9 . It is impossible to follow the LCG surveillance regime if caring for more than two women simultaneously 4 .…”

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

“…The hospitals are typical examples of overburdened urban maternity units in a lower-middle-income country, where the quality of care is impacted by lack of physical infrastructure, human resources and supplies. In 2019, the selected hospitals jointly cared for 40% of all hospital-based births in Dar es Salaam [ 19 ]. Each birth attendant typically takes care of multiple women simultaneously.…”