Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model

Abstract

Background: In Tanzania, maternal mortality ratio (MMR), unmet need for emergency obstetric care and health inequities across the country are in a critical state, particularly in rural areas. This study was established to determine the feasibility and impact of decentralizing comprehensive emergency obstetric and neonatal care (CEmONC) services in underserved rural areas using associate clinicians.

Methods: Ten health centres (HCs) were upgraded by constructing and equipping maternity blocks, operating rooms, laboratories, staff houses and installing solar panels, standby generators and water supply systems. Twenty-three assistant medical officers (advanced level associate clinicians), and forty-four nurse-midwives and clinical officers (associate clinicians) were trained in CEmONC and anaesthesia respectively. CEmONC services were launched between 2009 and 2012. Monthly supportive supervision and clinical audits of adverse pregnancy outcomes were introduced in 2011 in these HCs and their respective district hospitals.

Findings: After launching CEmONC services from 2009 to 2014 institutional deliveries increased in all upgraded rural HCs. Mean numbers of monthly deliveries increased by 151% and obstetric referrals decreased from 9% to 3% (p = 0.03) in HCs. A total of 43,846 deliveries and 2,890 caesarean sections (CS) were performed in these HCs making the mean proportion of all births in EmONC facilities of 128% and mean population-based CS rate of 9%. There were 190 maternal deaths and 1,198 intrapartum and very early neonatal deaths (IVEND) in all health facilities. Generally, health centres had statistically significantly lower maternal mortality ratios and IVEND rates than district hospitals (p < 0.00 and < 0.02 respectively). Of all deaths (maternal and IVEND) 84% to 96% were considered avoidable.

Conclusions: These findings strongly indicate that remotely located health centres in resource limited settings hold a great potential to increase accessibility to CEmONC services and to improve maternal and perinatal health.

Fig 1. Timeline for facility construction and introduction of CEmONC services in WLF Supported Health Facilities.

Fig 2. Mean monthly deliveries before and after introduction of CEmONC services in WLF supported health centres.

Fig 3. Overtime trends of referral rates before and after introduction of CEmONC services in WLF supported health centres based on regions.

Fig 4. Overtime trend of institutional maternal mortality ratio and intrapartum and very early neonatal mortality rate in WLF supported health facilities before and after introduction of CEmONC services.