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1.  Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania: a cross-sectional study 
Background
Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning.
Methods
This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described.
Results
The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency.
Conclusions
Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives.
doi:10.1186/1472-6963-14-96
PMCID: PMC3944798  PMID: 24581003
Antenatal care; Childbirth; Cost; Unit cost; Quality; Efficiency; Rural area; Tanzania; Health care provider
2.  Grand multiparity: is it still a risk in pregnancy? 
Background
The association of grand multiparity and poor pregnancy outcome has not been consistent for decades. Classifying grand multiparous women as a high-risk group without clear evidence of a consistent association with adverse outcomes can lead to socioeconomic burdens to the mother, family and health systems. We compared the maternal and perinatal complications among grand multiparous and other multiparous women in Dar es Salaam in Tanzania.
Methods
A cross-sectional study was undertaken at Muhimbili National Hospital (MNH). A standard questionnaire enquired the following variables: demographic characteristics, antenatal profile and detected obstetric risk factors as well as maternal and neonatal risk factors. Predictors of adverse outcomes in relation to grand multiparous women were assessed at p = 0.05.
Results
Grand multiparas had twice the likelihood of malpresentation and a threefold higher prevalence of meconium-stained liquor and placenta previa compared with lower-parity women even when adjusted for age. Neonates delivered by grand multiparous women (12.1%) were at three-time greater risk of a low Apgar score compared with lower-parity women (5.4%) (odds ratio (OR), 2.9; 95% confidence interval (CI), 1.5–5.0). Grand multiparity and low birth weight were independently associated with a low Apgar score (OR, 2.4; 95%, CI 1.4–4.2 for GM; OR, 4.2; 95% CI, 2.3–7.8) for low birth weight.
Conclusion
Grand multiparity remains a risk in pregnancy and is associated with an increased prevalence of maternal and neonatal complications (malpresentation, meconium-stained liquor, placenta previa and a low Apgar score) compared with other multiparous women who delivered at Muhimbili National Hospital.
doi:10.1186/1471-2393-13-241
PMCID: PMC3878019  PMID: 24365087
Grand multiparity; Pregnancy outcome; Diabetes mellitus; Hypertension; Malpresentation; Abruptio placentae; Placenta previa
3.  'How to know what you need to do': a cross-country comparison of maternal health guidelines in Burkina Faso, Ghana and Tanzania 
Background
Initiatives to raise the quality of care provided to mothers need to be given priority in Sub Saharan Africa (SSA). The promotion of clinical practice guidelines (CPGs) is a common strategy, but their implementation is often challenging, limiting their potential impact. Through a cross-country perspective, this study explored CPGs for maternal health in Burkina Faso, Ghana, and Tanzania. The objectives were to compare factors related to CPG use including their content compared with World Health Organization (WHO) guidelines, their format, and their development processes. Perceptions of their availability and use in practice were also explored. The overall purpose was to further the understanding of how to increase CPGs' potential to improve quality of care for mothers in SSA.
Methods
The study was a multiple case study design consisting of cross-country comparisons using document review and key informant interviews. A conceptual framework to aid analysis and discussion of results was developed, including selected domains related to guidelines' implementability and use by health workers in practice in terms of usability, applicability, and adaptability.
Results
The study revealed few significant differences in content between the national guidelines for maternal health and WHO recommendations. There were, however, marked variations in the format of CPGs between the three countries. Apart from the Ghanaian and one of the Tanzanian CPGs, the levels of both usability and applicability were assessed as low or medium. In all three countries, the use of CPGs by health workers in practice was perceived to be limited.
Conclusion
Our cross-country study suggests that it is not poor quality of content or lack of evidence base that constitute the major barrier for CPGs to positively impact on quality improvement in maternal care in SSA. It rather emphasises the need to prioritise the format of guidelines to increase their usability and applicability and to consider these attributes together with implementation strategies as integral to their development processes.
doi:10.1186/1748-5908-7-31
PMCID: PMC3372446  PMID: 22500744
CPGs; Health service delivery; Implementation; Information and communication technology (ICT); Maternal health; Quality improvement; Sub Saharan Africa; WHO
4.  Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania 
Background
Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).
Methods
From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.
Results
The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.
Conclusion
There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.
doi:10.1186/1471-2393-9-45
PMCID: PMC2754979  PMID: 19765312
5.  Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania 
Background
Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care.
Methods
We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care.
Results
Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time.
Conclusion
Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.
doi:10.1186/1471-2393-9-13
PMCID: PMC2670267  PMID: 19323846
6.  Medium and long-term adherence to postabortion contraception among women having experienced unsafe abortion in Dar es Salaam, Tanzania 
Background
Postabortion contraceptive service is considered an effective means in addressing the problem of unsafe abortion; in spite this fact this component remains one of the weakest parts of postabortion care. In this context, the paper aims to describe the impact of a postabortion contraceptive service intervention among women admitted with complications from unsafe abortions and to explore the women's long-term contraceptive adherence.
Methods
392 women having experienced unsafe abortion were identified by an empathetic approach and offered postabortion contraceptive service, which included counselling on HIV and condom use. Questionnaire interviews about contraceptive use were conducted at the time of inclusion and 12 months after the abortion. Additionally, in-depth interviews were performed 6–12 months after the abortion.
Results
Eighty-nine percent of the women accepted postabortion contraception. Follow-up information was obtained 12 months after the abortion among 59 percent of the women. Among these, 79 percent of the married women and 84 percent of the single women stated they were using contraception at 12 months. Condom use among the single women increased significantly during the 12 months follow up.
Conclusion
Postabortion contraceptive services appear to be well accepted by women who are admitted with complications after an unsafe abortion and should thus be recognized as an important means in addressing the problem of unsafe abortion. In addition, counselling about HIV and condom use should be considered an essential aspect of postabortion care.
doi:10.1186/1471-2393-8-32
PMCID: PMC2529258  PMID: 18667094
7.  Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets 
Background
Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health.
Methods
Cross sectional study which employed quantitative research methods.
Results
We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72–6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75–3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25–2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65–5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors.
Conclusion
Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.
doi:10.1186/1471-2393-7-29
PMCID: PMC2222241  PMID: 18053268
8.  The unmet need for Emergency Obstetric Care in Tanga Region, Tanzania 
Background
Improving maternal health by reducing maternal mortality constitutes the fifth Millennium Development Goal and represents a key public health challenge in the United Republic of Tanzania. In response to the need to evaluate and monitor safe motherhood interventions, this study aims at assessing the coverage of obstetric care according to the Unmet Obstetric Need (UON) concept by obtaining information on indications for, and outcomes of, major obstetric interventions. Furthermore, we explore whether this concept can be operationalised at district level.
Methods
A two year study using the Unmet Obstetric Need concept was carried out in three districts in Tanga Region, Tanzania. Data was collected prospectively at all four hospitals in the region for every woman undergoing a major obstetric intervention, including indication and outcome. The concept was adapted to address differentials in access to emergency obstetric care between districts and between rural and urban areas. Based upon literature and expert consensus, a threshold of 2% of all deliveries was used to define the expected minimum requirement of major obstetric interventions performed for absolute maternal indications.
Results
Protocols covering 1,260 complicated deliveries were analysed. The percentage of major obstetric interventions carried out in response to an absolute maternal indication was only 71%; most major obstetric interventions (97%) were caesarean sections. The most frequent indication was cephalo-pelvic-disproportion (51%). The proportion of major obstetric interventions for absolute maternal indications performed amongst women living in urban areas was 1.8% of all deliveries, while in rural areas it was only 0.7%. The high proportion (8.3%) of negative maternal outcomes in terms of morbidity and mortality, as well as the high perinatal mortality of 9.1% (still birth 6.9%, dying within 24 hours 1.7%, dying after 24 hours 0.5%) raise concern about the quality of care being provided.
Conclusion
Based on the 2% threshold, Tanga Region – with an overall level of major obstetric interventions for absolute maternal indications of 1% and a caesarean section rate of 1.4% – has significant unmet obstetric need with a considerable rural-urban disparity. The UON concept was found to be a suitable tool for evaluating and monitoring the coverage of obstetric care at district level.
doi:10.1186/1471-2393-7-16
PMCID: PMC1988833  PMID: 17683590

Results 1-8 (8)