A package of in-house training and mentoring at dispensaries, health centres and hospitals helped save lives
Over the last two years a German-supported initiative in the neighbouring regions of Lindi and Mtwara in south-eastern Tanzania has dramatically improved the survival rates and health of mothers and their newborn babies. How was this done? Intensive training and mentoring of healthcare professionals, as part of a health systems approach, seem to have done the trick.
Point of departure: Unacceptably high levels of maternal and newborn mortality
In 2014 Lindi and Mtwara regions in south-eastern Tanzania both recorded unacceptably high rates of maternal and newborn mortality: The 2012 census showed that for every 100,000 live births, 456 mothers in Lindi and 579 in Mtwara died during childbirth. The 2016 Demographic and Health Survey also showed that between 2010 and 2015 47 babies died for every 1,000 live births in each region.
At that time fewer than half of Lindi’s health facilities and only 7% of health facilities in Mtwara had at least one healthcare professional trained to manage emergencies during pregnancy and childbirth. In addition, many health facilities were short of staff, had insufficient stocks of medicines and technical equipment for even basic maternal and newborn care.
Building on long-standing and successful Tanzanian-German cooperation
For several years now, the German Federal Ministry for Economic Cooperation and Development (BMZ) through Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH has supported efforts by Sokoine Regional Referral Hospital in Lindi region to improve the quality of newborn care. In 2011, a dedicated neonatal unit was established at the hospital and furnished with special equipment. Healthcare professionals received regular training and mentoring from a German paediatrician. The results were very positive: Newborn mortality dropped significantly from 32 (in 2011) to 9 (in 2012) for every 1,000 live births.
As a result, in 2014, the Lindi and Mtwara regional health authorities decided that this approach should be rolled out throughout their regions. Tanzania’s Ministry of Health agreed, and approached the BMZ for support. After BMZ’s approval, the regional health teams worked with GIZ staff to conduct a thorough analysis of the situation in both regions before jointly designing a holistic package of interventions under the new Improved Mother and Child Health Programme (IMCH). This programme would work with 209 health facilities over a two-year period and also extend its focus from newborn care to obstetric care for pregnant women.
BMZ contributed four million Euros and the Ministry of Health, together with the President’s Office for Regional Administration and Local Government, ensured the availability and cooperation of regional health management teams and healthcare workers from the 209 facilities and contributed through the improved supply of essential medicines and commodities.
The IMCH Programme: Aim and Approach
The aim of the two-year IMCH programme was to reduce the unacceptably high levels of maternal and newborn mortality in the two regions’ dispensaries, health centres and hospitals. The four million Euro budget was used to invest in some essential equipment, but mostly to fund a comprehensive package of training and mentoring for the existing workforce.
Through this package of continuous on-the-job training and mentoring, tailor-made to the specific capacities needed at the different levels of healthcare provision and delivered by a team of Tanzanian and German experts, the IMCH programme enabled staff to confidently manage emergencies in mothers and newborn babies , and to refer onwards or get help where necessary.
The package included regular practice on medical dolls, the introduction of standard protocols for examining mothers and babies, training in maintenance and repairs of essential equipment and regular, constructive reviews of cases where things had gone wrong.
In addition, at hospital level, the IMCH programme helped to establish dedicated neonatal care units with specially trained staff to care for seriously ill babies.
As a result, care at dispensaries and health centres has improved
Prior to 2014 the only option for most women going into labour in Mtwara or Lindi region would usually be to walk to the closest dispensary to give birth. If a pregnant woman faced life-threatening complications such as haemorrhaging, medical staff could do little to help and she would probably die before she could reach a health centre. And even if she was able to get to the local health centre in time, conditions there were not necessarily any better, since many facilities also lacked both trained staff and basic equipment.
After the IMCH intervention, women experiencing complications during labour will now experience a very different situation at most dispensaries and health centres: Eighty five percent of dispensary healthcare workers and 98% of health centre staff have now received training in the management of maternal and newborn emergencies and proper use of essential equipment. Overall, 1,120 mentoring visits to 160 dispensaries were carried out by teams of GIZ experts and senior medical staff of regional and district hospitals who were specially trained as mentors. Today, the mentoring teams from the hospitals continue their regular visits to dispensaries and health centres every three months without further support from GIZ experts. They discuss critical cases and practice emergency case scenarios using medical dolls in order to maintain skills and confidence.
At the same time, dispensary and health centre staff have received training on how to undertake minor repairs to essential equipment, followed up by regular visits and telephone support from a technician from the regional hospital.
As a result, they are now both capable of and confident in dealing with complications or starting treatment before referring women on to a hospital, which entails a costly and sometimes life-threatening journey for them. As a healthcare professional from Mtwara put it: “With the right support and equipment in place, healthcare workers can manage normal deliveries and minor complications confidently and competently.”
In addition, the hospitals now offer specialist services
Prior to the IMCH interventions, even if a mother or baby experiencing complications made it safely to a hospital in Lindi or Mtwara regions, it did not necessarily mean they would receive any better quality care than at a dispensary or health centre. Only three hospitals in the two regions had a dedicated unit providing specialist paediatric care for seriously ill babies, and many hospitals were also short of trained staff that could conduct caesareans.
By 2017 all 14 hospitals in the two regions had established dedicated neonatal units with specially trained staff to care for seriously ill babies.
Delivery and operating rooms at the hospitals are now much better equipped and maintained and medical standards and procedures are clearly displayed on delivery room walls for easy reference. Each month a mentoring team from the regional hospital visits the district hospital to review complicated cases, discuss challenges and practice emergency procedures on medical dolls. Initially, these were also supported by specialists from Dar es Salaam, who are now available by phone to provide continued backup support to hospital staff. Last but not least, the introduction of quarterly maternal and perinatal surveillance review meetings has led to big changes: “Now we are discussing each death – how it happened, where it happened and why”, says Dr Wedson Sichalwe, Regional Medical Officer, Mtwara. “We analyse each case and then learn from them so that mistakes are not repeated.”
Achieving impact through a health systems approach
There is clear evidence that this combination of interventions makes a difference: Between 2015 and 2017, neonatal mortality in Mtwara and Lindi regions went down from 32 to 20/1,000 and the maternal case fatality rate (mothers who develop complications during delivery) has been reduced from 2,4% to 1,1%, says Dr Sichalwe. And this has happened without an increase in the number of staff or in the health facilities’ overall budget.
“Achieving such results can only be done using a health systems approach,” says Dr Susanne Grimm, GIZ Programme Manager of the Tanzanian-German Programme to Support Health. “Capacity development not only needs to address a critical number of healthcare providers but it also needs to follow the logic of a healthcare delivery system. All facilities, from the lowest up to the highest level, need to be included, providing tailor-made training and mentoring to each of them. In addition, the training and mentoring concept should not just aim at boosting healthcare professionals’ knowledge but also their confidence in handling complicated cases. This programme’s remarkable results were not just achieved by hospitals or by the 14 GIZ employees. They are the achievement of 1,500 healthcare professionals who were trained and mentored and now confidently deliver services in all the 209 health facilities.”
As services continue to improve, the evidence suggests that more mothers will use them, helping to reduce maternal and newborn mortality, even though the IMCH programme has now come to an end. According to Dr Grimm, “this programme has shown that with the right approach it is possible to significantly improve mothers’ and babies’ health.”
Moving towards better care for mothers and babies nationwide
The intervention package of this Tanzanian-German development cooperation has been made available to the Ministry of Health for roll out to other regions improve care for mothers and babies country-wide. As a first step, standard operating procedures which have been developed in Lindi and Mtwara regions and proven to be successful are now being reviewed by the Ministry and will soon be made available as national standard guidelines for new born care in Tanzania.
Ruth Evans, February 2018
- Maternal and Child Health Programme (GIZ Tanzania, 2017) | PDF | 1.4 MB