Against all odds: Giving delicate newborns a chance at life in Tanzania
Transplanting a tried and tested approach for improving neonatal survival to new regions
With infinite gentleness, the life-giving needle is slid into the microscopic vein, the oxygen mask placed over the gasping mouth and nose. The flutter in the tiny chest becomes stronger, the monitor now showing a regular heartbeat. Another baby saved at Mbeya Regional Referral Hospital – and the dedicated staff of the neonatal care unit (NCU) for at-risk newborns can now themselves take a deep breath and relax.
A Tanzanian-German commitment to improved newborn health
Worldwide, nearly half of child mortality (age 0-5 years) occurs in the first month of life – and one third of these deaths take place in the babies’ first 24 hours. In Tanzania 25 out of every 1000 new-borns die on their first day of life. Main threats to new-born lives are prematurity, breathing difficulties, infection and cold temperatures. Tanzanian-German cooperation has been tackling these challenges through the Improving Health Care Provision (IHCP) programme, a cooperation between Tanzania’s Ministry of Health, Community Development, Gender, Elderly and Children, the President’s Office Regional Administration and Local Government (PORALG) and the German Federal Ministry for Economic Cooperation and Development (BMZ). Since April 2019 the Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) has been implementing it in the Mbeya and Tanga regions. The programme is a continuation of Tanzanian-German collaboration with a focus on survival of newborns and their mothers that started several years earlier. In Tanzania, though neonatal and maternal mortality have decreased since independence in 1961, at respectively 25 deaths out of 1000 live births and 556/100,000 (2015-16 Demographic and Health Survey) they are still far from the Sustainable Development Goal (SDG) targets for 2030 of 12/1000 and 70/100,000.
‘I was afraid to work with fragile newborns….’
Asked about her work as In-Charge of the Mbeya Regional Referral Hospital NCU, Nurse Officer Maridhia Mvungi relates: ‘I used to work in the labour ward, but when I was assigned to the NCU in 2017 I was afraid. I didn’t know how to properly care for these tiny and very sick premature babies. Their skin is so thin and soft, they can so easily catch infections. We had no guidelines on newborn care and so many of them died of sepsis or asphyxia. Seeing babies die is so painful! We had some equipment, but didn’t know how to use it – in the end the hospital maintenance people had to show us how.’
Things changed in 2018 for Ms. Mvungi and her colleagues in the NCU, when German support started. Cutting-edge equipment was installed, including two continuous positive airway pressure (CPAP) machines for boosting babies’ oxygen intake and a special cannulation table that makes it easier and faster to place needles in newborns’ veins, and the staff were trained in their use and upkeep.
Particularly appreciated was the technical expertise provided by Dr Monika Frey, a German paediatrician and neonatologist assigned by the programme to Mbeya region. Ms. Mvungi explains: ‘In nursing school we only studied health of children under five in general, but Dr Monika gave us the specific knowledge on caring for newborns. She helped us tackle the problem of neonatal sepsis by advising us on infection prevention and control. The programme even installed special shelves above the babies’ cribs for the newborns’ files so people would no longer leave the files or other objects on the babies’ beds.’
Ms Mvungi and four of her colleagues from the NCU are now sharing their skills as trainers and mentors in the three district hospitals and four health centres that IHCP is supporting in Mbeya region. ‘The programme supported the Government in preparing new guidelines on neonatal care that are now used all over our country. Thanks to the programme I got confidence, I have knowledge and skills that can bring babies back to good health. I teach my colleagues confidently on topics they didn’t learn in pre-service training; when they mention challenges I share my experiences with them.’
Focus on newborn survival in low-income countries: Tanzania is blazing the trail
Emphasis on newborn survival is still rare in lower-income countries, where maternal survival tends to be seen as a higher priority. Yet neonatal mortality takes a shocking toll on a population: Nearly half of child mortality (age 0-5 years) takes place in the first month of life, and of these deaths, fully one-third occur in the first 24 hours after birth. The three big killers are prematurity, asphyxia and infection, and with premature babies a preventable factor such as low temperatures can be lethal. According to Dr Frey, the reality may be even grimmer than the official statistics: ‘The newborns tend to be seen as some kind of “attachments to the mother”. They are not given the attention they need in their own right. Sometimes, when newborns die, their birth and their death are not even recorded.’
In 2011, in Lindi and Mtwara regions, with support from IHCP’s predecessor, the Tanzanian-German Programme to Support Health (TGPSH), a ground-breaking initiative focussing specifically on newborn survival entitled ‘No Baby Left Out’ was introduced in a limited number of hospitals and health centres. When these facilities saw a strong decrease in newborn mortality, the health authorities requested German support to roll out the approach for more complete coverage of these two regions. In 2015 the new Improved Mother and Child Health programme (IMCH) was funded with a generous 4-million Euro budget out of Germany’s contribution to the G8’s Muskoka Initiative for Maternal, Newborn and Child Health. The IMCH supported a total of 209 health facilities and 1700 birth attendants in Lindi and Mtwara regions with capacity development and equipment, and though it extended its scope to include care of mothers during pregnancy and delivery, neonatal survival remained a central focus. 14 NCUs were established in the district and regional hospitals, and between 2015 and 2016 newborn deaths fell by 31% in these facilities: from 32 to 22 deaths per 1000 live births.
A set of standards for newborn care
These earlier projects in Lindi and Mtwara regions introduced measures that have become a hallmark of Tanzania’s standards for newborn care. These included organisation and equipment of fully-fledged NCUs in regional and district hospitals, and on lower levels, training staff to rapidly identify at-risk newborns needing to be evacuated to these referral facilities. A simple and user-friendly, colour-coded instrument for this was the Newborn Triage Checklist (NTC) to screen all newborns for potential danger signs at three crucial moments: shortly after birth, 4-8 hours later, and after 20-24 hours – or just before discharge from the facility. Widespread availability of basic neonatal resuscitation equipment including on health centre level saved many newborns’ lives. Young mothers were taught to keep fragile babies warm through skin-to-skin contact – an approach known as ‘kangaroo mother care’ (KMC).
This constellation of measures for screening and managing newborns and establishing and ensuring functioning of NCUs were formulated as standard operating procedures and shared with the Ministry of Health, Community Development, Gender, Elderly and Children. With support of the new IHCP programme, they would become the basis of Tanzania’s ‘National Guideline for Neonatal Care and Establishment of Neonatal Care Unit’.
A delicate transplantation: from Lindi and Mtwara to Mbeya and Tanga
In 2019 the IMCH came to an end, and it was agreed with the Ministry that with newborn healthcare so well advanced in Lindi and Mtwara, German support there should be phased out. The partners agreed that two new regions should now benefit from the highly successful support focused on neonatal care while at the same time making this approach more systemic by combining it with maternal care and family planning. Under the new IHCP programme lessons learned in Lindi and Mtwara would now be introduced in Mbeya and Tanga regions, which German development cooperation under TGPSH had already been supporting in hospital management and sustainable maintenance of equipment.
However, the new programme faced its own challenges. With the end of the Muskoka funding, the IHCP’s more limited budget meant it was not possible to provide blanket support to all districts across both new regions as had been the case in Lindi and Mtwara. Thus, it was initially agreed that IHCP would focus on a total of just eight hospitals in Mbeya and Tanga. However, before activities could start, Tanzania had a change in government, and the new health authorities, wishing to prioritise front-line activities, negotiated the addition of an equal number of larger health centres, four in each region.
Then, in March 2020 COVID-19 struck, delaying the launch of the new maternal-neonatal-family planning component. As a result, the consortium finally selected to support implementation could only begin work – particularly in Tanga region – in October 2020. This left them barely 18 months until the end of the phase in March 2022 to complete a programme originally planned to span 30 months.
The Neonatal Guideline is being rolled out nationwide by the Ministry
The first months of IHCP were focussed on supporting the Ministry in collaboration with other stakeholders on developing the new National Guideline for Neonatal Care. It was published in August 2019 and the Ministry is in the process of rolling it out countrywide. Dr Felix Bundala, Head of the Newborn and Child Health Unit in the Reproductive and Child Health Section of the Ministry, reports: ‘By now we have rolled out the neonatal guideline in 159 hospitals out of 350 nationally, of which 127 have already established NCUs with the support of different partners. By 2025 all health facilities are expected to apply these standards for neonatal health and survival.’
Comprehensive mentoring, from assessment to training and trouble shooting: A 100% package
‘We apply the guideline in our activities in Mbeya and Tanga regions,’ reports Dr Frey. ‘Preparatory to building up each NCU, we start with a participatory assessment – together with hospital staff – of all human resources, skills and equipment that will be needed. But it is a matter above all of building up staff’s self-confidence that they can indeed save the lives of these fragile infants and their mothers.’ Training and mentoring play complementary roles in the programme. Through group training workshops it is possible to reach large numbers of staff, to expose them to important concepts and practices that are often new to them. But it is equally important to ensure that after training individuals apply their new knowledge in their regular work environment. Experienced mentors such as Ms. Mvungi regularly visit the supported hospitals and health centres to advise staff in their daily work in order to consolidate these new skills as habits. ‘Proximity to our partners on the ground really supports capacity development as teachers and mentors,’ pursues Dr Frey. ‘The whole approach is comprehensive – from assessment to purchase of equipment, maintenance of equipment, training of staff, etc., it is a 100% package.’
The IHCP team is constantly updating and improving its training component on the basis of experience and new knowledge. Like with the guidelines, they hope to share their tried and tested in-service training courses with the Ministry to help fill health providers’ gap in knowledge on neonatology, a subject that is not covered in pre-service training for doctors and nurses. These materials could potentially also be adapted to the pre-service curriculum.
Doing the best with what one has
Dr Ralf Syring, Health Focus, Team Leader for implementation of the maternal-neonatal-family planning component, stresses the importance of attitude, particularly in communications between staff and units of the facilities, such as between maternal and neonatal care. Says Dr Syring: ‘I want people to adopt an attitude of “doing the best with what they have”. Guidelines are essential, but they are not enough. In the training you see that many staff members are not equipped to handle things that are unexpected. Experiential learning is not there and this is what they need to focus on: “Look at the baby and how it behaves. Why does it do this or that? What does this indicate?” ’
Dr Syring is encouraged that certain trainees do take this on board and show real interest in the baby or mother. ‘We try to find out those who care and have potential, and then support these people to become mentors towards their colleagues – these are the small successes we try to work with.’ His concern though, is the lack of time to bring these efforts to fruition: ‘Yes, we can show that it is possible to improve certain elements of care, but this is unlikely to have a lasting effect if time is too short – processes take time, require consolidation and follow-up.’
A simple checklist can make a big difference
Dr Ahmad Makuwani, Assistant Director for Reproductive, Maternal, Neonatal, Child and Adolescent Health in Tanzania’s Ministry of Health, Community Development, Gender, Elderly and Children, has been following GIZ’s support to newborn and maternal survival ever since 2012 in Lindi and Mtwara. ‘In Tanzania the newborn were falling through the cracks – we sat down and said, we can’t go on like this! It is no secret that German development cooperation has been showing the way on neonatal care: Most of our guideline has emanated from the experience in Lindi and Mtwara – and it has been seeding to all of Tanzania. In 2013, when I discovered the Newborn Triage Checklist, I collected lots of those charts and sent them to the Ministry. At the end of the day you need experts to improve service delivery. Don’t think high-tech technology: Think small interventions, even a small piece of paper like the checklist can make a huge difference in survival of the newborn!’
The proofed concept now needs scaling up
For the Ministry partners, German development cooperations in Lindi and Mtwara remains a reference. Says Dr Makuwani, ‘In this phase, in Mbeya and Tanga, particularly because of COVID, the GIZ team has barely been able to get activities under way. We need to scale up what we did in Mtwara and Lindi in neonatology.’
Dr Bundala, Head of the Newborn and Child Health Unit, echoes this sentiment: ‘In the next phase of IHCP we want to make sure to have full coverage of the intervention in capacity development and equipment, in all hospitals and health centres of the two regions.’
Dr Baltazar Ngoli, Head of the IHCP’s Reproductive Health component and long-term member of the Tanzanian-German programme team, observes: ‘In Germany’s technical cooperation each module builds on the preceding one.’ Indeed, the legacy of the landmark Muskoka support to neonatal health is still playing out in Tanzania via the national guideline and its countrywide roll-out as well as the ongoing adaptation of the approaches developed under IMCH in the new environment of Mbeya and Tanga. Another important contribution are the training courses developed in the current phase: Integrating them into the curricula of professional training institutions would reinforce long-term sustainability of the German contributions.
After first delays to get the new module’s plan approved, then the impediments due to COVID, the IHCP has been off to a slow start. Nonetheless, based on tried and tested successes in previous phases, and with a project team and counterparts who are highly motivated and convinced by the approach, a solid basis is being built up that promises positive impacts on neonatal and maternal health in Mbeya and Tanga regions.
Dr Mary White-Kaba, October 2021