A research agenda to improve incidence and outcomes of assisted vaginal birth.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

L'accès aux soins obstétriques d'urgence, y compris l'accouchement vaginal assisté et la césarienne, est essentiel pour améliorer les effets de la maternité et de l'accouchement. Toutefois, bien que la proportion de césariennes ait augmenté ces dernières décennies, le recours à l'accouchement vaginal assisté a diminué. C'est particulièrement le cas dans les pays à revenu faible ou intermédiaire, bien que l'accouchement vaginal assisté soit souvent moins risqué qu'une césarienne. Nous avons donc mené un processus en trois étapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours à l'accouchement vaginal assisté ou de le réintroduire. Après avoir réalisé une synthèse des données probantes, qui a servi de base à une consultation avec des experts techniques qui ont proposé un programme de recherche initial, nous avons sollicité et incorporé les avis des représentantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classés comme suit: (i) la nécessité de comprendre la perception qu'ont les femmes de l'accouchement vaginal assisté et de fournir des informations appropriées et fiables; (ii) l'importance de la formation des prestataires de soins de santé en matière de compétences cliniques, mais aussi de respect dans les soins de santé, de communication efficace, de prise de décision partagée et de consentement éclairé; ou (iii) les obstacles à la mise en œuvre et à la durabilité et les facteurs qui les facilitent. Les réactions de femmes nous ont appris qu'il était urgent de reconnaître que l'accouchement, la naissance et le post-partum sont des processus humains intrinsèquement physiologiques et dignes au cours desquels les interventions ne devraient être mises en œuvre qu'en cas de nécessité. La promotion et/ou la réintroduction de l'accouchement vaginal assisté dans les régions à faibles ressources nécessitent que les pouvoirs publics, les décideurs politiques et les administrations d'hôpitaux soutiennent les prestataires de soins de santé qualifiés, qui pourront à leur tour soutenir respectueusement les femmes pendant l'accouchement.

El acceso a la atención obstétrica de emergencia, incluido el parto vaginal asistido y el parto por cesárea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesárea ha aumentado en las últimas décadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los países de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesárea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigación necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una síntesis de la evidencia, que sirvió de base para una consulta con expertos técnicos que propusieron un programa de investigación inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigación exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar información adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clínicas, pero también en atención respetuosa, comunicación efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementación y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiológicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promoción o la reincoporación del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular políticas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa.

Individual, Community, and Health Facility Predictors of Postnatal Care Utilization in Rural Tanzania: A Multilevel Analysis.

INTRODUCTION: Postnatal care (PNC) is an underused service in the continuum of care for mothers and infants in sub-Saharan Africa. There is little evidence on health facility characteristics that influence PNC utilization. Understanding PNC use in the context of individual, community, and health facility characteristics may help in the development of programs for increased use. METHODS: We analyzed data from 4,353 women with recent births in Kigoma Region, Tanzania, and their use of PNC (defined as at least 1 checkup in a health facility in the region within 42 days of delivery). We used a mixed-effects multilevel logistic regression analysis to explain PNC use while accounting for household, individual, and community characteristics from a regionwide population-based reproductive health survey and for distance to and adequacy of proximal health facilities from a health facility assessment. RESULTS: PNC utilization rate was low (15.9%). Women had significantly greater odds of PNC if they had a high level of decision-making autonomy (adjusted odds ratio [aOR]: 1.56; 95% confidence interval [CI]=1.11, 2.17); had a companion at birth (aOR: 1.57; 95% CI=1.19, 2.07); had cesarean delivery (aOR: 2.27; 95% CI=1.47, 3.48); resided in Kasulu district (aOR: 3.28; 95% CI=1.94, 5.52); or resided in a community that had at least 1 adequate health facility within 5 km (aOR: 2.15; 95% CI=1.06, 3.88). CONCLUSION: Women's decision-making autonomy and presence of companionship at birth, as well as proximity to a health facility with adequate infrastructure, equipment, and workforce, were associated with increased PNC use. More efforts toward advocating for the health benefits of PNC using multiple channels and increasing quality of care in health facilities, including companionship at birth, can increase utilization rates.

A Comprehensive Approach to Improving Emergency Obstetric and Newborn Care in Kigoma, Tanzania.

INTRODUCTION: To address high levels of maternal mortality in Kigoma, Tanzania, stakeholders increased women's access to high-quality comprehensive emergency obstetric and newborn care (EmONC) by decentralizing services from hospitals to health centers where EmONC was delivered mostly by associate clinicians and nurses. To ensure that women used services, implementers worked to continuously improve and sustain quality of care while creating demand. METHODS: Program evaluation included periodic health facility assessments, pregnancy outcome monitoring, and enhanced maternal mortality detection region-wide in program- and nonprogram-supported health facilities. RESULTS: Between 2013 and 2018, the average number of lifesaving interventions performed per facility increased from 2.8 to 4.7. The increase was higher in program-supported than nonprogram-supported health centers and dispensaries. The institutional delivery rate increased from 49% to 85%; the greatest increase occurred through using health centers (15% to 25%) and dispensaries (21% to 46%). The number of cesarean deliveries almost doubled, and the population cesarean delivery rate increased from 2.6% to 4.5%. Met need for emergency obstetric care increased from 44% to 61% while the direct obstetric case fatality rate declined from 1.8% to 1.4%. The institutional maternal mortality ratio across all health facilities declined from 303 to 174 deaths per 100,000 live births. The total stillbirth rate declined from 26.7 to 12.8 per 1,000 births. The predischarge neonatal mortality rate declined from 10.7 to 7.6 per 1,000 live births. Changes in case fatality rate and maternal mortality were driven by project-supported facilities. Changes in neonatal mortality varied depending on facility type and program support status. CONCLUSION: Decentralizing high-quality comprehensive EmONC delivered mostly by associate clinicians and nurses led to significant improvements in the availability and utilization of lifesaving care at birth in Kigoma. Dedicated efforts to sustain high-quality EmONC along with supplemental programmatic components contributed to the reduction of maternal and perinatal mortality.

Improving Maternal and Reproductive Health in Kigoma, Tanzania: A 13-Year Initiative.

The Program to Reduce Maternal Deaths in Tanzania was a 13-year (2006-2019) effort in the Kigoma region that evolved over 3 phases to improve and sustain the availability of, access to, and demand for high-quality maternal and reproductive health care services. The Program intended to bring high-quality care closer to more communities. Cutting across the Program was the routine collection of monitoring and evaluation data. The Program achieved significant reductions in maternal and perinatal mortality, a significant increase in the modern contraceptive prevalence rate, and a significant decline in the unmet need for contraception. By 2017, it was apparent that the Program was on track to meet or surpass many of the targets established by the Government of Tanzania. Over the following 2-plus years, efforts to sustain Program interventions intensified. In April 2019, the Program fully transitioned to Government of Tanzania oversight. Four key lessons were learned during implementation that are relevant to governments, donors, and implementing organizations working to reduce maternal mortality: (1) multistakeholder partnerships are critical; (2) demand creation for services, while critical, must rest on a foundation of well-functioning and high-quality clinical services; (3) it is imperative to not only collect robust monitoring and evaluation data, but to be responsive in real time to what the data reveal; and, (4) it is necessary to develop a deliberate sustainability strategy from the start. The Program in Kigoma demonstrates that decentralizing high-quality maternal and reproductive health services in remote, low-resource settings is both feasible and effective and should be considered in places with similar contexts. By embedding the Program in the existing health system, and through efforts to build local capacity, the improvements seen in Kigoma are likely to be sustained. Follow-up evaluations are planned, providing an opportunity to more directly assess sustainability.

Factors related to the practice of vacuum-assisted birth: findings from provider interviews in Kigoma, Tanzania.

BACKGROUND: Vacuum-assisted birth is not widely practiced in Tanzania but efforts to re-introduce the procedure suggest some success. Few studies have targeted childbirth attendants to learn how their perceptions of and training experiences with the procedure affect practice. This study explores a largely rural cohort of health providers to determine associations between recent practice of the procedure and training, individual and contextual factors. METHODS: A cross-sectional knowledge, attitudes and practice survey of 297 providers was conducted in 2019 at 3 hospitals and 12 health centers that provided comprehensive emergency obstetric care. We used descriptive statistics and binary logistic regression to model the probability of having performed a vacuum extraction in the last 3 months. RESULTS: Providers were roughly split between working in maternity units in hospitals and health centers. They included: medical doctors, assistant medical officers (14%); clinical officers (10%); nurse officers, assistant nurse officers, registered nurses (32%); and enrolled nurses (44%). Eighty percent reported either pre-service, in-service vacuum extraction training or both, but only 31% reported conducting a vacuum-assisted birth in the last 3 months. Based on 11 training and enabling factors, a positive association with recent practice was observed; the single most promising factor was hands-on solo practice during in-service training (66% of providers with this experience had conducted vacuum extraction in the last 3 months). The logistic regression model showed that providers exposed to 7-9 training modalities were 7.8 times more likely to have performed vacuum extraction than those exposed to fewer training opportunities (AOR = 7.78, 95% CI: 4.169-14.524). Providers who worked in administrative councils other than Kigoma Municipality were 2.7 times more likely to have conducted vacuum extraction than their colleagues in Kigoma Municipality (AOR = 2.67, 95% CI: 1.023-6.976). Similarly, providers posted in a health center compared to those in a hospital were twice as likely to have conducted a recent vacuum extraction (AOR = 2.11, 95% CI: 1.153-3.850), and finally, male providers were twice as likely as their female colleagues to have performed this procedure recently (AOR = 1.95, 95% CI: 1.072-3.55). CONCLUSIONS: Training and location of posting were associated with recent practice of vacuum extraction. Multiple training modalities appear to predict recent practice but hands-on experience during training may be the most critical component. We recommend a low-dose high frequency strategy to skills building with simulation and e-learning. A gender integrated approach to training may help ensure female trainees are exposed to critical training components.

Birth companionship in a government health system: a pilot study in Kigoma, Tanzania.

BACKGROUND: Having a companion of choice throughout childbirth is an important component of good quality and respectful maternity care for women and has become standard in many countries. However, there are only a few examples of birth companionship being implemented in government health systems in low-income countries. To learn if birth companionship was feasible, acceptable and led to improved quality of care in these settings, we implemented a pilot project using 9 intervention and 6 comparison sites (all government health facilities) in a rural region of Tanzania. METHODS: The pilot was developed and implemented in Kigoma, Tanzania between July 2016 and December 2018. Women delivering at intervention sites were given the choice of having a birth companion with them during childbirth. We evaluated the pilot with: (a) project data; (b) focus group discussions; (c) structured and semi-structured interviews; and (d) service statistics. RESULTS: More than 80% of women delivering at intervention sites had a birth companion who provided support during childbirth, including comforting women and staying by their side. Most women interviewed at intervention sites were very satisfied with having a companion during childbirth (96-99%). Most women at the intervention sites also reported that the presence of a companion improved their labor, delivery and postpartum experience (82-97%). Health providers also found companions very helpful because they assisted with their workload, alerted the provider about changes in the woman's status, and provided emotional support to the woman. When comparing intervention and comparison sites, providers at intervention sites were significantly more likely to: respond to women who called for help (p = 0.003), interact in a friendly way (p < 0.001), greet women respectfully (p < 0.001), and try to make them more comfortable (p = 0.003). Higher proportions of women who gave birth at intervention sites reported being "very satisfied" with the care they received (p < 0.001), and that the staff were "very kind" (p < 0.001) and "very encouraging" (p < 0.001). CONCLUSION: Birth companionship was feasible and well accepted by health providers, government officials and most importantly, women who delivered at intervention facilities. The introduction of birth companionship improved women's experience of birth and the maternity ward environment overall.

Reintroducing vacuum extraction in primary health care facilities: a case study from Tanzania.

BACKGROUND: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned. METHODS: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries. RESULTS: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1. CONCLUSIONS: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries.

Introducing eHealth strategies to enhance maternal and perinatal health care in rural Tanzania.

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.

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

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.