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

Efforts to increase the availability and utilization of high-quality emergency obstetric and newborn care and routine delivery care services in Kigoma were successful and subsequently contributed to significant reductions in maternal and perinatal mortality in the region. Key Findings Decentralizing high-quality comprehensive emergency obstetric and newborn care (EmONC) to lower-level facilities delivered mostly by associate clinicians and nurses led to significant improvements in the availability and utilization of lifesaving care at birth in a remote, mostly rural region of Tanzania. Sustaining high-quality comprehensive EmONC services at health centers required continuous support including routine supportive supervision, clinical audits, mentorship, and multiple methods of providing continuing medical education. Increasing utilization of services required more than improving the quality of clinical services at supported health facilities; it included strengthening referral systems, improving women's experience of care, and increasing women's and communities' birth preparedness through multi-platform communications campaigns featuring hard-hitting radio spots and outreach by community health workers. Key Implications Policy makers and program implementers should include regular mentorship, clinical audits, and continuing medical education when supporting task sharing and decentralizing EmONC services to lower-level facilities to ensure high-quality services. For effective coverage, policy makers and program implementers should build demand generation activities on a foundation of high-quality EmONC services. ABSTRACT 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.