Bixby Project 2004

Kigoma, TanzaniaAndy Anglemyer, Nadia Diamond-

Smith, Jessica Jeffrey

Study Overviews

Maternal Mortality in Kigoma

TACARE’s Community Based Distribution (CBD) Program

Maternal Mortality in Kigoma

Kigoma is located on the eastern shores of Lake Tanganyika

Annual per capita income is $140, $80 in very rural areas

One of the four highest maternal mortality rates in the country

300/100,000 490,816 residents

25% are women between 15 and 45

Regional Health Facilities

Maweni is the only public hospital in the region• 75 registered villages, spread over

11,600 km² 4 health clinics 54 village dispensaries

Previous Interventions

Between 1984-1991 at Maweni Hospital

Health worker involvement and effective utilization of local resources

MM rate fell from 933 to 186/100,000 residents

Replication of InterventionMethods

Pre-intervention survey in 1999Considered lessons learned from previous interventionHealth centers and dispensaries focal points for data collectionInformation collected on:• Community perceptions of antenatal

care, emergency OB care, FP, TBA, equipment availability for emergency OB care in peripheral health units

Methods (cont) Sisterhood method used to determine

maternal mortality in rural A post-intervention survey conducted in

2003 using same methods and health units

2 health units from each division selected (12 total selected)• Records reviewed

Individuals interviewed• 40 health workers, 20 TBA’s from 2 randomly

selected villages, 480 community members

Suggested Risk Factors Lack of community education

regarding maternal mortality Gender imbalances Knowledge of obstetric health issues

--low quality of care Transportation difficulties

• 50% of villages only accessible by boat• Qualified personnel unwilling to work in

remotest areas

Risk Factors (cont)

Health facilities lack proper equipment• Partial supply of OB care equipment and

drugs Lack of a blood transfusion program

• Results in anemia and hemorrhaging Facilities in disrepair with lack of

funding Deficit of qualified staff

Interventions

Subsidized mosquito nets Village leaders’ meetings Community referral funds Transportation options

• 3 ambulance cars• Subsidized boat costs

Additional health care workers in rural areas

Interventions (cont)

Benefits for health care workers• Education and leave

Locals trained in maternal health• 20 TBA’s, 102 VHW’s• OB complications and specialized training

DHO flights to rural communities New hospital equipment Blood transfusion centers Health facilities renovated

Results

MM rate decrease using “sisterhood method” 166 to 137/100,000

Increased referral compliance among community leaders

Increase in trained personnel Number of health units with

appropriate personnel (29%-60%) Prenatal care sought more often

• 25 in 1999, 201 in 2003

Results (cont)

Deliveries by trained personnel increased• 5,823 in 1999; 7,225 in 2003

Partographs used routinely Increase of referrals from health units

to hospital• 160 in 1999; 1,583 in 2003

Referrals

Most common reasons:• Primi gravidae, multiparous

Self referrals increased• Average of 8/month in 2002; 12/month

in 2003

Discussion

Leading causes of maternal death• Anemia, malaria-induced and malnutrition

Long term impact expected Self referrals

• More faith in the health care system Drawbacks

• Lack of comparison group• Inconsistent data• Maternal deaths occur in villages

Rates are rough estimates

Conclusion

Low-cost interventions Potential for replication Much can be done with little Increased awareness and education

the most significant aspect to lowering maternal mortality

TACARE’s CBD Program

Participating Regional Health Facilities

4 Health Centers--IUD’s and injectables

54 Village Dispensaries--oral contraceptives,

injectables, condoms

Health Centers

Usually staffed by a nurse or clinical officer

Provides basic inpatient health care

Village Dispensaries

54 total in Kigoma Region The majority of population relies on

these for FP services and health care Patient referrals Provide basic medications and

contraceptives

Family Planning Access

Contraceptives provided by funds from USAID (1970’s) and the Ministry of Health (1995)

Contraceptives available at no cost in health facilities

Contraceptive Prevalence estimated at 4%, Birth Rate 2.8%

Acceptance Rate for FP ~ 14%

Accessibility Obstacles

What must a CBD program overcome?

• Great traveling distances• Accessible only by boat or 4WD• Work Priorities• Local religious opposition• Patriarchal society

TACARE’s CBD Program

Lake Tanganyika Catchment Reforestation and Education Project

--original purpose of promoting sustainable land-use practices and preserving indigenous

forests In 1999 CBD project initiated

--currently 14 villages, 40 agents

The Agent

Village selected Kiswahili literate and 7 years of

education Must have a willingness to openly

discuss FP topics among community Attend 3 week training session CBD Supervisor

Services Offered

Counseling and education in family planning and sexual health

--info about oral contraceptives, condoms, IUD’s, injectables,

Norplant, tubal ligation, vasectomies

--alternatives discussed: withdrawal, “standard days” method

Services Offered (cont)

Client referrals to dispensaries Oral contraceptives’ side effects

management STI/HIV information Info on breastfeeding, ORT,

vaccinations, and nutrition

The Approach

Individual Counseling--2183 sessions in 2003

Household Counseling--673 sessions in 2003

Group Counseling--134 sessions in 2003

Client Preferences

Spacing births Condoms and pills preferred

injectables seen as a plausible alternative

IUD’s considered uncomfortable Possible stigma attached if referred

“Standard Days” method difficult

Access and Restrictions

CBDA’s responsibility to motivate couples seeking services

Women given contraceptives regardless of partner’s approval• The well, market, or kids’ vaccinations• Single women have access• 15 years or older

Supply Chain

Central Medical Store in Kigoma(2400 km from Kigoma)

Zone Medical Store in Tabora (600 km from Kigoma)

District Medical Office in Kigoma

Village Dispensaries in Kigoma Rural

Community Based Distribution Agents in Villages

Funding

Funds dried-out in 2002• Training ceased in 2003

FY 2004 funded by Packard Foundation and USAID

$63,486 total for FP and HIV programs

CBDA Concerns

Transportation• Addressed in FY 2004 Budget

Safety• Umbrellas, flashlights, boots

Refresher courses• Restarted in FY 2004

Other• Safe Motherhood Training, more information

about malaria for children > 5

CBDA Concerns (cont)

Salary • Experimental incentive program failed in

2002• Could include compensation such as

sugar or rice