1
|
Kweyamba E, Nyamtema AS, LeBlanc JC, Shayo A, George RB, Scott H, Kilume O, Bulemela J, Abel Z, Mtey G. Scale up of anaesthesia services in underserved rural Tanzania. BMC Health Serv Res 2023; 23:1001. [PMID: 37723465 PMCID: PMC10506293 DOI: 10.1186/s12913-023-09963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 08/24/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania. METHODS In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia. RESULTS Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months. CONCLUSIONS This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.
Collapse
Affiliation(s)
- E Kweyamba
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - A S Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania.
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania.
| | - J C LeBlanc
- Pediatrics, Community Health and Epidemiology and Psychiatry, Dalhousie University, Dalhousie, Canada
| | - A Shayo
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - R B George
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - H Scott
- Department of Obstetrics and Gynaecology, Dalhousie University, Dalhousie, Canada
| | - O Kilume
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - J Bulemela
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Z Abel
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - G Mtey
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| |
Collapse
|
2
|
Tomblin Murphy G, Mtey G, Nyamtema A, LeBlanc J, Rigby J, Abel Z, Mselle LT. Building leadership and managerial capacity for maternal and newborn health services. BMC Health Serv Res 2022; 22:1129. [PMID: 36071415 PMCID: PMC9450380 DOI: 10.1186/s12913-022-08448-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania. Methods The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings. Results Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building. Conclusion Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.
Collapse
Affiliation(s)
- Gail Tomblin Murphy
- Nova Scotia Health and Dalhousie University WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, 90 Lovett Lake Ct., Suite 201, Halifax, NS, B3S 0H6, Canada.
| | - Godfrey Mtey
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Angelo Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania.,St Francis University College of Health and Allied Sciences, Ifakara, Tanzania
| | - John LeBlanc
- Faculty of Medicine, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
| | - Janet Rigby
- Nova Scotia Health and Dalhousie University WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, 90 Lovett Lake Ct., Suite 201, Halifax, NS, B3S 0H6, Canada
| | - Zabron Abel
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Lilian Teddy Mselle
- School of Nursing, Muhimbili University for Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| |
Collapse
|
3
|
Nyamtema AS, Scott H, LeBlanc JC, Kweyamba E, Bulemela J, Shayo A, Kilume O, Abel Z, Mtey G. Improving access to emergency obstetric care in underserved rural Tanzania: a prospective cohort study. BMC Pregnancy Childbirth 2022; 22:649. [PMID: 35978292 PMCID: PMC9386955 DOI: 10.1186/s12884-022-04951-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/28/2022] [Indexed: 12/02/2022] Open
Abstract
Background One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians. Methods A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge. Results The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 – June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 – June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49–58%) to 77% (95% CI 74–80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1%) to 1.1% (95% CI 0.7–1.6%) in the intervention group and from 3.3% (95% CI 1.2–7.0%) to 0.8% (95% CI 0.2–1.7%) in the control group. Conclusions When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.
Collapse
Affiliation(s)
- Angelo S Nyamtema
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania. .,Department of Obstetrics and Gynaecology, St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania.
| | - Heather Scott
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Canada
| | - John C LeBlanc
- Pediatrics, Community Health and Epidemiology and Psychiatry, Dalhousie University, Halifax, Canada
| | - Elias Kweyamba
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania.,Department of Obstetrics and Gynaecology, St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Janet Bulemela
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania.,Department of Paediatrics, St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Allan Shayo
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania
| | - Omary Kilume
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania.,Department of Obstetrics and Gynaecology, St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Zabron Abel
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania
| | - Godfrey Mtey
- Tanzanian Training Centre for International Health, P.O Box 39, Ifakara, Tanzania
| |
Collapse
|
4
|
Nyamtema AS, LeBlanc JC, Mtey G, Tomblin Murphy G, Kweyamba E, Bulemela J, Shayo A, Abel Z, Kilume O, Scott H, Rigby J. Scale up and strengthening of comprehensive emergency obstetric and newborn care in Tanzania. PLoS One 2022; 17:e0271282. [PMID: 35802730 PMCID: PMC9269945 DOI: 10.1371/journal.pone.0271282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/28/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction In Tanzania, inadequate access to comprehensive emergency obstetric and newborn care (CEmONC) services is the major bottleneck for perinatal care and results in high maternal and perinatal mortality. From 2015 to 2019, the Accessing Safe Deliveries in Tanzania project was implemented to study how to improve access to CEmONC services in underserved rural areas. Methods A five-year longitudinal cohort study was implemented in seven health centres (HCs) and 21 satellite dispensaries in Morogoro region. Five of the health centres received CEmONC interventions and two served as controls. Forty-two associate clinicians from the intervention HCs were trained in teams for three months in CEmONC and anaesthesia. Managers of 20 intervention facilities, members of the district and regional health management teams were trained in leadership and management. Regular supportive supervision was conducted. Results Interventions resulted in improved responsibility and accountability among managers. In intervention HCs, the mean monthly deliveries increased from 183 (95% CI 174–191) at baseline (July 2014 –June 2016) to 358 (95% CI 328–390) during the intervention period (July 2016 –June 2019). The referral rate to district hospitals in intervention HCs decreased from 6.0% (262/4,392) with 95% CI 5.3–6.7 at baseline to 4.0% (516/12,918) with 95% CI 3.7–4.3 during the intervention period while it increased in the control group from 0.8% (48/5,709) to 1.5% (168/11,233). The obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1) at baseline to 1.1% (95% CI 0.7–1.6) during the intervention period (not statistically significant). Active engagement strategies and training in leadership and management resulted in uptake and improvement of CEmONC and anaesthesia curricula, and contributed to scale up of CEmONC at health centre level in the country. Conclusions Integration of leadership and managerial capacity building, with CEmONC-specific interventions was associated with health systems strengthening and improved quality of services.
Collapse
Affiliation(s)
- Angelo S. Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
- * E-mail:
| | | | - Godfrey Mtey
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Gail Tomblin Murphy
- WHO/PAHO Collaborating Centre on Health Workforce Planning & Research, Dalhousie University and Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Elias Kweyamba
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Janet Bulemela
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | - Allan Shayo
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Zabron Abel
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Omary Kilume
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
- St. Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | | | - Janet Rigby
- WHO/PAHO Collaborating Centre on Health Workforce Planning & Research, Dalhousie University and Nova Scotia Health, Halifax, Nova Scotia, Canada
| |
Collapse
|
5
|
Dol J, Campbell-Yeo M, Bulemela J, McMillan D, Abel Z, Nyamtema A, LeBlanc JC. Knowledge acquisition after Helping Babies Survive training in rural Tanzania. Int Health 2019; 11:136-142. [PMID: 30252052 DOI: 10.1093/inthealth/ihy068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/02/2018] [Accepted: 09/13/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While the effectiveness of Helping Babies Breathe (HBB) training in Tanzania has been reported, no published studies of Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) in this setting have been found. This study compared knowledge before and after HBB, ECEB and ECSB training in Tanzania. METHODS Training was provided to future facilitators (n=16) and learners (n=24) in Tanzania. Using standardized multiple-choice questions, knowledge was assessed pre- and post-HBB and ECEB courses for both learners and facilitators, while ECSB assessment was conducted with facilitators only. A >80% score was considered to be a pass. Paired t-tests were used for hypothesis testing. RESULTS Knowledge significantly improved for both facilitators and learners on HBB and ECEB (p<0.001) and for facilitators on ECSB (p<0.001). After training, learners had difficulty identifying correct responses on one HBB item (21% incorrect) and three ECEB items (25-29% incorrect). After training, facilitators had difficulty identifying correct responses on five ECSB items (22-44% incorrect). CONCLUSIONS Training improved knowledge in Tanzania, but not sufficiently for feeding, especially for low birthweight babies. Targeted training on feeding is warranted both within the Helping Babies Survive program and in preclinical training to improve knowledge and skill to enhance essential newborn care.
Collapse
Affiliation(s)
- Justine Dol
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Janeth Bulemela
- Tanzanian Training Center for International Health & St Francis University College of Health and Allied Sciences, Ifakara, Tanzania
| | - Douglas McMillan
- Department of Pediatrics, Faculty of Medicine, Dalhousie University, & IWK Health Centre, Halifax, NS, Canada
| | - Zabron Abel
- Tanzanian Training Center for International Health, Ifakara
| | - Angelo Nyamtema
- Tanzanian Training Center for International Health & St Francis University College of Health and Allied Sciences, Ifakara, Tanzania
| | - John C LeBlanc
- Departments of Pediatrics, Community Health and Epidemiology and Psychiatry, Dalhousie University & IWK Health Centre, Halifax, NS, Canada
| |
Collapse
|
6
|
Nyamtema A, Mwakatundu N, Dominico S, Kasanga M, Jamadini F, Maokola K, Mawala D, Abel Z, Rumanyika R, Nzabuhakwa C, van Roosmalen J. Introducing eHealth strategies to enhance maternal and perinatal health care in rural Tanzania. Matern Health Neonatol Perinatol 2017; 3:3. [PMID: 28116114 PMCID: PMC5244514 DOI: 10.1186/s40748-017-0042-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, eHealth has attracted considerable attention as a means of supporting maternal and perinatal health care. This article describes best practices, gains and challenges of implementing eHealth for maternal and perinatal health care in extremely remote and rural Tanzania. METHODS Teleconsultation for obstetric emergency care, audio teleconferences and online eLearning systems were installed in ten upgraded rural health centres, four rural district hospitals and one regional hospital in Tanzania. Uptake of teleconsultation and teleconference platforms were evaluated retrospectively. A cross sectional descriptive study design was applied to assess performance and adoption of eLearning. RESULTS In 2015 a total of 38 teleconsultations were attended by consultant obstetricians and 33 teleconferences were conducted and attended by 40 health care providers from 14 facilities. A total of 240 clinical cases mainly caesarean sections (CS), maternal and perinatal morbidities and mortalities were discussed and recommendations for improvement were provided. Four modules were hosted and 43 care providers were registered on the eLearning system. For a period of 18-21 months total views on the site, weekly conference forum, chatroom and learning resources ranged between 106 and 1,438. Completion of learning modules, acknowledgment of having acquired and utilized new knowledge and skills in clinical practice were reported in 43-89% of 20 interviewed health care providers. Competencies in using the eLearning system were demonstrated in 62% of the targeted users. CONCLUSIONS E-Health presents an opportunity for improving maternal health care in underserved remote areas in low-resource settings by broadening knowledge and skills, and by connecting frontline care providers with consultants for emergency teleconsultations.
Collapse
Affiliation(s)
- Angelo Nyamtema
- Thamini Uhai Program, Dar es Salaam, Tanzania.,Tanzanian Training Centre for International Health, Ifakara, Tanzania.,Saint Francis University College for Health and Allied Sciences, Ifakara, Tanzania
| | | | | | | | | | | | | | - Zabron Abel
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Richard Rumanyika
- Thamini Uhai Program, Dar es Salaam, Tanzania.,Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Calist Nzabuhakwa
- Thamini Uhai Program, Dar es Salaam, Tanzania.,Maweni Regional Hospital, Kigoma, Tanzania
| | - Jos van Roosmalen
- Thamini Uhai Program, Dar es Salaam, Tanzania.,Leiden University Medical Centre, Leiden, The Netherlands.,Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|