Scale up of anaesthesia services in underserved rural Tanzania.

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.

Staffing needs for quality perinatal care in Tanzania.

In Tanzania maternal and perinatal mortalities and morbidities are problems of public health importance, and have been linked to the shortage of skilled staff. We quantified the available workforce and the required nursing staff for perinatal care in 16 health institutions in Dar es Salaam. WHO safe motherhood needs assessment instruments were used to assess the availability of human resources, WHO designed Workload Indicators for Staffing Need (WISN) and Tanzanian standard activities and components of the workload for labour ward nursing were used to calculate nurse staffing requirements and WISN ratios. There was a severe shortage of essential categories of health staff for perinatal care in all institutions. The ranges of WISN ratios for nursing staff working in the municipal hospitals' labour wards were; nurse officers 0.5 - 1, trained nurses/midwives 0.2 - 0.4 and nurse assistants 0.1. These findings reflect extremely huge perinatal care workload pressure and suggest the urgent need for more staff in order to achieve the global millennium development goals set for maternal and infant survival.

Partogram use in the Dar es Salaam perinatal care study.

OBJECTIVE: To assess the quality of partograms used to monitor labor in Dar es Salaam hospitals, Tanzania. METHODS: The study team reviewed the records of the parameters of labor, and maternal and fetal conditions in 367 partograms, and interviewed 20 midwives. RESULTS: All midwives interviewed had been previously trained to use the partogram. Of all partograms reviewed, 50% had no records of duration of labor. Although cervical dilation and fetal heart rates were recorded in 97% and 94% of the partograms respectively, 63% and 91% of these were judged to be substandard. Substandard monitoring of fetal heart rates was strongly associated with poor fetal outcome (P<0.001). Blood pressure, temperature, and pulse rates were not recorded in 47%-76% of partograms. CONCLUSION: These findings reflect poor management of labor and indicate urgent in-service training to address the importance of documentation and regular partogram audit in order to reduce maternal and perinatal deaths.