tanzania maternal health program - thamini uhai uhai... · 2018. 7. 19. · i. improving clinical...

Tanzania Maternal Health Program

ANNUAL REPORT 2016

TA B L E O F C O N T E N T S

Acknowledgments 4

Credits 4

Letter from the Executive Director 5

Introduction 7

What We Do 10

Accomplishments 12

I. Improving Clinical Skills 12

II. Communication 19

III. Infrastructure 20

IV. Partnerships 21

Quality of Care Indicators and Trends 22

Challenges 25

Priority Areas in 2017 29

Thamini Uhai Staff and Consultants 30

2016 Photos 31

4

Thamini Uhai acknowledges all Tanzania and New York staff,

consultants and health care providers who were devoted to

the project’s success in achieving substantial results in 2016.

Thamini Uhai also thanks the Tanzania Ministry of Health,

Community Development, Gender, Elderly and Children

(MoHCDGEC) and the regional health secretariats of Kigoma,

Morogoro and Pwani for their support and collaboration.

We extend deep appreciation to Bloomberg Philanthropies,

Fondation H&B Agerup, Blue Lantern and Svenska

PostkodStiftelsen for the generous financial support that

made our activities and achievements possible in 2016.

Acknowledgments

This annual report was written by Thamini Uhai staff including Dr. Nguke Mwakatundu, Dr. Sunday Dominico, Dr. Mkambu Kassanga, Victoria Marijani, Adolf Kaindoa, Fadhili Jamadini, Ignus Kalongola and Magdalena Metta, with assistance from Vital Strategies global staff including Karen Schmidt, Samantha Lobis and Sandra Mullin.

Photos by Thamini Uhai staff and by Fadhili Abdalah (Photographer for Habari Leo Newspaper Kigoma) for Thamini Uhai. Design by Johnny Hsu and Sarah Tan.

Credits

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Letter from the Executive Director

Dear Colleagues,

For nearly a decade, our team has been supporting the government of Tanzania in its efforts to reduce maternal and newborn death and disability, and 2016 marked a major milestone: Thamini Uhai, formerly known as World Lung Foundation, became a locally registered Tanzanian organization. Thamini Uhai, which means “Value Life,” is carrying on World Lung Foundation’s lifesaving work, with the same staff, leadership, strategies and supporters. Becoming a Tanzanian organization is central to our project’s ongoing mission and sustainability. It enables full Tanzanian ownership of our work and objectives under a new brand that more closely reflects our core mission of improving maternal and newborn health.

We made significant progress in 2016 in our ongoing efforts to improve the quality of emergency obstetric and newborn care (EmONC); continued our work on demand generation and the community-based referral system; and moved forward with plans to hand over supported facilities in the Morogoro and Pwani regions to the government. In December 2015, Thamini Uhai had begun supporting four additional health centers in the Kigoma region that had been recently upgraded for comprehensive EmONC (CEmONC) by our partner EngenderHealth, and that intensive supportive supervision and mentoring continued in 2016.

Thamini Uhai’s work in 2016 contributed to significant improvements in clinical performance in supported facilities: The number of deliveries rose from 27,431 in 2015 (in 15 facilities) to 30,738 in 2016 (in 19 facilities). The four newly supported facilities, which registered 1,242 deliveries in 2015, saw deliveries triple in 2016, to 3,769. The rate of assisted vaginal deliveries using vacuum extraction increased from 1.2% in 2015 to 1.9% in 2016. A total of 67 maternal deaths were reported in project-supported facilities in 2016, indicating a 3.5% decrease in the facility-based maternal mortality ratio from 226 to 218 maternal deaths per 100,000 live births.

While independent, Thamini Uhai remains a close affiliate of Vital Strategies (the organization formed in January 2016 from the merger of World Lung Foundation and the Union North America). Vital Strategies will continue to be a strong supporter of Thamini Uhai and its essential work in Tanzania. Generous financial support from Bloomberg Philanthropies, Blue Lantern, Fondation H&B Agerup and Svenska PostkodStiftelsen continues to make this work possible.

I would like to congratulate and sincerely thank Thamini Uhai staff in Tanzania and Vital Strategies staff in New York for their efforts leading to these achievements, as well as the Tanzanian government for

its collaboration and support and EngenderHealth for its strong partnership.

In 2017, we plan to: hand over activities we have been supporting in Morogoro and Pwani; support efforts to ensure quality EmONC services are available in supported facilities in Kigoma with an emphasis on improving perinatal care and its outcomes; expand the access and referral improvements to more catchment areas; increase demand generation activities; and support the initiation of birth companionship programs. We will also be working closely with our partners, including EngenderHealth, to make sure that other interventions to reduce maternal and newborn deaths, such as family planning and comprehensive post-abortion care, are improved in Kigoma. Our collaboration with the government and other stakeholders will also increase in order to help build the sustainability of supported activities in Kigoma. These efforts will take us closer to our goal of improving met need in Tanzania for emergency obstetric care and skilled birth attendance and saving the lives of more and more mothers and babies.

I hope you enjoy reading the report!

Dr. Nguke MwakatunduExecutive Director

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Thamini Uhai (formerly known as World Lung Foundation), an

affiliate of Vital Strategies, is a nonprofit organization supporting

the Tanzanian government’s efforts to reduce maternal and

newborn deaths in rural areas of Tanzania. Since 2008, Thamini

Uhai has established comprehensive emergency obstetric and

neonatal care (CEmONC) in 15 health centers and five hospitals

in Kigoma, Morogoro and Pwani regions. Recently, Thamini Uhai

expanded its support in Kigoma to 18 dispensaries offering

basic emergency obstetric and neonatal care (BEmONC),

and to four health centers recently upgraded by our partner

EngenderHealth to offer CEmONC. Working closely with the

government at national, regional and local levels, Thamini Uhai

has established a model for saving the lives of mothers and

newborns by expanding access to CEmONC. The maternal health

program operates on two basic principles: that decentralizing

CEmONC services to the health-center level significantly

expands access to lifesaving services, and that CEmONC can

be offered safely by well-trained non-physician providers.

Introduction

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T H A M I N I U H A I A N N UA L R E P O R T 2016

Sustainable maternal and neonatal care is

available in all vulnerable communities in

Tanzania, thereby eliminating maternal and

neonatal mortality and morbidity.

To develop and promote accessible and

sustainable comprehensive emergency

obstetric and neonatal care (CEmONC)

services in targeted vulnerable communities

in Tanzania for the reduction of maternal and

neonatal mortality.

O U R V I S I O N

O U R M I S S I O N

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TRAINING HEALTH PROFESSIONALS

Thamini Uhai trains non-physician clinicians so that health centers can provide CEmONC close to the community. Assistant medical officers (AMOs), nurse-midwives and clinical officers work as a team to manage emergency obstetric cases, including blood transfusion, anesthesia, cesarean section and neonatal resuscitation as needed.

MENTORING AND SUPPORTIVE SUPERVISION

The program’s senior specialists have created an environment of close interaction through regular in-person visits, with team-based learning that includes clinical practice scenarios in the facilities.

INCREASING ACCESS TO CEMONC SERVICES

Thamini Uhai has launched a pilot referral project in Nguruka Health Center’s catchment area in Uvinza district that is aimed at reducing the time it takes for a woman experiencing an obstetric emergency to reach appropriate care. Communities and health facilities work together to design local solutions, leading to quicker referrals, better access to transportation and improved communication.

INFORMATION AND COMMUNICATION TECHNOLOGY (ICT) INNOVATIONS

Thamini Uhai uses information and communication technology to improve the quality of care in supported facilities. These include: weekly teleconferences to review challenging cases; 24-hour emergency call support from senior obstetricians using toll-free mobile phones; and an online e-learning platform through which healthcare providers can access clinical instruction videos and interactive online training.

Thamini Uhai supports the government of Tanzania’s efforts to reduce maternal and newborn mortality through a wide array of interventions that aim to improve the quality of routine and emergency obstetric and newborn care in supported facilities. We also work to increase access to maternal and newborn care through community-based demand creation interventions and by strengthening referral systems. Our interventions are highlighted below.

What We Do

MATERIAL SUPPORT

Thamini Uhai has built and renovated operating theaters and delivery and postpartum wards, built staff housing and provided key equipment for CEmONC. The program also procures supplies and commodities for partner sites, particularly in cases of severe stockouts.

COMMUNICATION

Thamini Uhai’s communication initiative, designed to help women and families make life-saving choices about childbirth, child spacing and limiting family size, was launched in 2014. Media campaigns have focused on facility delivery as well as birth planning, pregnancy danger signs and family planning. Thamini Uhai uses mass media, mid-media and trained community health workers to reach the target audience. Thamini Uhai has also trained journalists and advocated in the media for improved human resources, supplies and budgets for maternal health services.

MONITORING AND EVALUATION

Regular data collection and clinical auditing is conducted to monitor services and identify clinical issues requiring attention. We also analyze data quarterly to review “near-misses,” cesarean sections, CEmONC signal functions and maternal and neonatal deaths.

PARTNERSHIPS

Strategic partnerships have been key for Thamini Uhai’s work improving maternal health in Tanzania. The team works closely with all levels of the Ministry of Health, Community Development, Gender, Elderly and Children, as well as with district councils and regional authorities. Our other two main partners are EngenderHealth, which focuses on family planning services, and the U.S. Centers for Disease Control and Prevention, which monitors and evaluates the Thamini Uhai program.

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Thamini Uhai Executive Director Dr. Nguke Mwakatundu (second from right) describes to former Kakonko District Commissioner Mr. Peter Toyima (third from left) the upgrades that Thamini Uhai made to Kakonko Health Center, during the formal handover of the renovated operating theater in April 2016. In addition to renovations, Thamini Uhai donated an operating table. Others shown are staff from Kakonko Health Center, the office of the district medical officer, and Thamini Uhai.

Former Kigoma Regional Administrative Secretary Eng. John Ndunguru (second from right) hands over a vacuum extraction device to Dr. Fadhili Kibaya, the Medical Officer in charge of Maweni Hospital (second left), witnessed by Thamini Uhai Executive Director Dr. Nguke Mwakatundu (right) and former Regional Nursing Officer Annatolia Yabba (left) in January 2016. Thamini Uhai donated 10 sets of vacuum extraction devices to Kigoma region to support safe delivery in health facilities. This method is a safe non-surgical alternative to cesarean section in some cases of prolonged labor.

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Accomplishments

I. Improving Clinical Skills

In an effort to sharpen emergency obstetric and newborn care skills and continue building the competency of healthcare providers in supported facilities, Thamini Uhai provides continuous training and targeted onsite mentorship. In 2016, Thamini Uhai coordinated, supported, supervised and facilitated five major trainings as well as numerous apprenticeships and continuing medical education (CME) workshops.

Three nurse midwives, one each from Mahenge Hospital, Mlimba Health Center in Morogoro and Nguruka Health Center in Kigoma, completed a three-month competency-based training on obstetric anesthesia at the Tanzania Training Center for International Health.

Two newly graduated AMOs from Kibiti and Mwaya health centers in Pwani and Morogoro completed six-week CEmONC clinical apprenticeships at high volume hospitals (Maweni, Kibondo and St. Francis).

Thamini Uhai conducted three CME workshops in 2016 with more than 120 healthcare providers from supported facilities in Kigoma, Morogoro and Pwani. In March, 16 AMOs and nurse-midwives from six Thamini Uhai supported facilities in Morogoro and Pwani attended a three-day workshop at Mahenge Hospital on management of obstetric hemorrhage.

In partnership with EngenderHealth, Thamini Uhai also conducted a second series of three-day CME workshops in May and June on principles of infection prevention and control (IPC), including management of maternal sepsis. The primary objective was to improve adherence to standard IPC protocols, ensure processing

and sterilization of medical equipment and supplies, and update healthcare providers on the management of sepsis. A total of 50 healthcare workers from 18 CEmONC facilities in Kigoma, Morogoro and Pwani attended the training, which was intended to reverse maternal mortality trends in supported facilities where maternal sepsis was the leading cause of maternal deaths in 2015. In addition, job aids on IPC were successfully disseminated to all supported facilities.

A third series of CME workshops trained 54 healthcare providers from Kigoma, Morogoro and Pwani on the use of vacuum extraction for assisted vaginal delivery. This method is a safe non-surgical alternative to cesarean section in some cases of prolonged labor.

Thamini Uhai conducted four rounds of targeted onsite mentorship in 2016, with a focus on maternal and newborn complications. About 250 healthcare providers benefited from the mentorship, which involved the use of mannequins and supervised clinical practice. Three of the four rounds of onsite mentorship were carried out in collaboration with experts from EngenderHealth and local government councils in Kigoma. The aim was to build the capacity of both providers and facilities to offer quality CEmONC, post-abortion care and family planning services. A separate five-day facility-based mentorship involved 20 healthcare providers working in the maternity ward at Mahenge District Hospital in Morogoro, who learned about managing obstetric hemorrhage.

Rose H. Sengo, Morogoro regional referral hospital theater in-charge and national infection prevention and control (IPC) trainer, demonstrates a point to participants during a practical IPC theater session in June 2016.

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1. Supportive Supervision: Maintaining and Enhancing Clinical Expertise

Using the innovative, hands-on approach that Thamini Uhai has developed for building the capacity of healthcare providers, routine supportive supervision and clinical audits were conducted throughout 2016. Thamini Uhai clinical specialists teamed with members of regional and council health management teams (RHMTs and CHMTs) during supervision, and a district pharmacist was added to help build providers’ ability to order and manage medicine and supplies.

During four rounds of routine quarterly supportive supervision and clinical auditing, the supervision team focused on quality of care and helping providers adhere to standard protocols and guidelines. The action-oriented feedback included the CHMTs, RHMTs and healthcare providers with an eye toward improving work performance among all stakeholders. Furthermore, the gaps identified in audited reports will inform the efforts of Thamini Uhai’s clinical team to plan appropriate interventions. Supportive supervision and onsite mentorship help providers refresh and maintain their skills, and it’s clear this was an important factor in the impressive 2016 results: the successful treatment of 1,022 women with life-threatening complications and 1,275 newborns with severe birth asphyxia.

The newly upgraded CEmONC health centers in Kigoma (Bitale, Kiganamo, Nyanzige and Kifura) received monthly supportive supervision and clinical audits to ensure that they perform at least to the levels of previously supported facilities.

The 18 dispensaries that the Thamini Uhai team began supporting in 2015 were supervised monthly by the CEmONC facility in-charges, and quarterly by members of CHMT, facility in-charges and Thamini Uhai clinical team members. The focus of the supervision was to reinforce delivery-of-care skills and preparedness so they can offer skilled birth attendance and some BEmONC signal functions. Thamini Uhai also procured and distributed nine motorcycles to CEmONC facility in-charges tasked with supervising the dispensaries.

Clinical Director Dr. Sunday Dominico helps a nurse-midwife practice vacuum extraction on a mannequin during the assisted vaginal delivery CME workshop at Mahenge Hospital in July 2016.

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SPECIAL FEATURE

Technical Support to Four Newly Upgraded CEmONC Facilities in Kigoma

Cesarean sections and assisted vaginal deliveries in newly supported CEmONC facilities in Kigoma, 2016

Cesarean Sections Assisted Vaginal Deliveries

250

Bitale Kiganamo Kifura Nyanzige All (n=4)

200

100

5036

52 52

227

87

3

64

30

110

13

0

150

Deliveries in newly supported CEmONC facilities, Kigoma, 2015-2016

2015 2016

4000

Bitale Kiganamo Kifura Nyanzige All (n=4)

3500

2500

2000

1500

1000

383 353 394

1242

112

641836

617

3776

1682

500

0

3000

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In December 2015, Thamini Uhai started supporting four newly upgraded facilities in Kigoma to provide CEmONC. The services began after the facilities were renovated by EngenderHealth, another partner in the Bloomberg Philanthropies-supported maternal health initiative.

The Thamini Uhai clinical team collaborated with EngenderHealth and regional and council management teams to provide technical support including supportive supervision, targeted onsite mentorship, CME workshops and provision of routine and emergency obstetric care job aids.

In February 2016, the regional medical officer led a team of government and partner experts from Thamini Uhai and EngenderHealth to conduct high-level supportive supervision for the newly upgraded CEmONC facilities. The objective of the visit was to evaluate the CEmONC implementation status of the facilities and identify successes, challenges and recommendations for further improvement.

In March and September 2016, Thamini Uhai led a team of experts to conduct two five-day rounds of onsite mentorship for healthcare providers in the newly upgraded CEmONC facilities. These activities came in response to competency gaps identified during the

high-level and routine supportive supervision visits in February and July 2016. The team of mentors included Thamini Uhai’s clinical director and deputy clinical director, family planning experts, theater management experts and district reproductive and child health coordinators. The topics in focus were EmONC preparedness for facilities and providers, partography, management of obstetric hemorrhage, pre-eclampsia, and documentation and record-keeping.

Thamini Uhai organized two series of CME workshops for healthcare providers from all supported facilities in Kigoma in May and June 2016. Two providers from each of the four new facilities attended the workshops, one focused on infection prevention and control, and the other on assisted vaginal delivery.

All year, Thamini Uhai experts, together with members of regional and council health management teams, continued to conduct routine monthly supportive supervision and clinical audits at the facilities to ensure CEmONC service delivery is sustained at acceptable quality standards.

After a year of technical support, significant results have been noted. The number of deliveries occurring in the four facilities has tripled in just a year from 1,242 in 2015 to 3,766

in 2016. The increase was most remarkable at Kiganamo Health Center, which logged 1,682 deliveries in 2016, nearly 14 times the 2015 figure of 122. A total of 227 cesarean sections have been performed at the four facilities, giving an overall facility cesarean section rate of 6%. The CME workshop on assisted vaginal deliveries offered in June 2016 was followed by an exceptional performance rate of vacuum extraction. A total of 110 vacuum extractions were performed, for a vacuum extraction rate of 3% (compared to 1.7% in previously supported facilities). Two maternal deaths and 21 very early neonatal deaths were reported during this period, giving facility-based maternal mortality and very early neonatal mortality ratios of 54 per 100,000 live births and 5.7 per 1,000 live births, respectively.

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2. Dissemination of the Program Model

Under the leadership of Dr. Angelo Nyamtema, Thamini Uhai professional staff developed and successfully published two articles in international peer-reviewed journals:

• “Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model” was published in PLoS ONE in March 2016. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151419

• “Increasing the availability and quality of cesarean section in Tanzania” was featured in the September 2016 issue of the British Journal of Obstetrics and Gynaecology (BJOG). http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14223/abstract

3. New Interventions

Helping Babies Breathe: Building Capacity on Basic Newborn Resuscitation

Perinatal mortality—defined as the death of a fetus in utero (before or during labor) or neonatal death within seven days of birth—has remained persistently high in the project-supported facilities. Improving providers’ knowledge, skills and competencies on proper monitoring of labor with partographs and newborn resuscitation at birth has been shown to reduce neonatal deaths resulting from birth asphyxia (shortage of oxygen to the brain). In 2016, Thamini Uhai partnered with the CDC in Kigoma to introduce a pilot intervention on newborn resuscitation in five health facilities in Kigoma. Known as “high-frequency, low-intensity helping babies breathe,” the intervention uses skill-based training and supportive supervision to improve healthcare providers’ ability to provide newborn resuscitation. Thamini Uhai supports logistics and procurement of supplies, while the CDC leads on training providers and evaluating the project’s impact, a process that will take place in 2017. The project will be scaled up if appropriate.

4. Information and Communication Technology

Two eLearning sessions, on vacuum extraction and pre-eclampsia, were finalized and uploaded to the eLearning platform in January 2016. These increased the total number of eLearning sessions to six.

5. Teleconferences and Emergency Calls

Thamini Uhai’s specialists also support trained staff with weekly teleconferences and a 24-hour emergency line. The team conducted 38 teleconferences in 2016, five more than in 2015. On average, four facilities joined each call, with Ujiji Health Center leading in frequency of participation, followed by Kibiti Health Center. These teleconferences allow providers to share experiences and update knowledge on EmONC through case-based learning: more than 500 severe obstetric complications were discussed.

One teleconference conducted on June 17, 2016, and chaired by Dr. Donald Mawalla, a Thamini Uhai consultant obstetrician, included providers from five supported facilities. Twenty cases were presented, including cesarean sections, vacuum extractions, eclampsia and postpartum hemorrhage. For each cesarean section performed, the providers described the justification, indication and care provided before, during and after the operation. These interactive sessions help to update providers on case management approaches and follow-up, with a goal of improving and standardizing their practice. Facilities also reported challenges such as water supply, human resources deficiencies and communication difficulties; those challenges were resolved promptly, and government authorities were informed to address other challenges.

Emergency calls continue to be attended by an obstetrician/gynecologist on call every day, and support has been extended to the newly upgraded facilities. Among the beneficiaries was a 35-year-old woman who came to Ujiji Health Center in March 2016 from a village 20 kilometers away. The mother of three had been in labor for four hours at home but was experiencing abnormal bleeding and could no longer feel the baby moving after using local herbs.

Health providers found her to be exhausted, restless, sweating and pale, with undetectable blood pressure. They could not hear a fetal heartbeat. The woman was taken into surgery with a diagnosis of a ruptured uterus and received several liters of resuscitation fluids and blood. But once the operation began, the surgeon, an assistant medical officer, found the case to be more complicated than expected. He immediately called the Thamini Uhai consultant based at the nearby regional hospital, who rushed to the health center and helped complete a hysterectomy. The baby did not survive, but the mother recovered and was discharged 10 days later. Without the surgical intervention—and the availability of the senior consultant—the woman probably would not have survived.

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6. Increasing Access through Referral

In the catchment area of Nguruka Health Center in Uvinza district, Thamini Uhai continued an initiative to strengthen the referral system in the area in an effort to increase the number of women who access EmONC without delay when they experience obstetric complications. By increasing access and reducing delays, the project seeks to avert maternal and perinatal deaths and injuries. The project covers the five dispensaries—Mganza, Malagarasi, Mtegowanoti, Ilalangulu and Chagu—that serve the 11 villages in Nguruka’s catchment zone.

The system is based on three pillars: preparedness, communication and transport. To support preparedness, 14 community health workers were trained to mobilize the community; they met with more than 14,000 community members through group meetings and home visits and during antenatal care. Seven health providers at dispensaries were trained in basic emergency obstetric care in order to better identify and manage complications, and the Thamini Uhai expert clinical team followed up with support visits.

The project provided mobile phones to community leaders, transporters and the dispensaries themselves. Wireless phones installed in the labor wards at Nguruka Health Center and at Maweni Regional Hospital in Kigoma town completed a prepaid closed user group, which allowed all members to call one another toll-free. By October 2016, nearly 400 calls had been made on the system — 250 from community health workers to health facilities, alerting them about obstetric emergencies.

The second pillar of the referral project—transport—addresses issues that are frequently cited as major barriers to timely obstetric care: the long distance to health facilities and costs of transportation. In 2016, Thamini Uhai staff worked with the district social welfare officer and community leaders in each of the 11 villages to establish and manage emergency fund schemes, with small contributions solicited from all community members. By October, emergency fund accounts had between 45,000 and 118,500 TZS. A total of 222 women in need have used the emergency funds to travel from their villages to dispensaries and from dispensaries to Nguruka Health Center.

To further support transportation, the health center’s ambulance was repaired and the district council agreed to provide funds for fuel and maintenance. Since the ambulance serves a large area and is not always available, and the district supply of petrol can quickly be exhausted, community leaders also met with local drivers and negotiated standard prices for transport to facilities. Now each village has a list of at least five private drivers who can provide transportation at an agreed-upon price. The initiative seems to be helping women get to care: achievements include an 11% increase in deliveries at Nguruka Health Center and the five dispensaries, and an 81% increase in documented referrals of obstetric complications to Nguruka Health Center and Maweni Regional Hospital, suggesting a reduction in home deliveries in the area.

Thamini Uhai, formerly World Lung Foundation, launched its new brand in November 2016 at the Hyatt Regency Hotel in Dar es Salaam. The rebranding followed the organization’s registration as an independent Tanzanian entity with the same staff, program and commitment to saving mothers’ and babies’ lives. Thamini Uhai remains a close affiliate of Vital Strategies (the organization formed in January 2016 from the merger of World Lung Foundation and the Union North America). Seated from left: Ms. Rose Mlay, national coordinator for White Ribbon Alliance in Tanzania; Dr. Nguke Mwakatundu, executive director for Thamini Uhai; Dr. Koheleth Winan, assistant director for the reproductive and child health section at MoHCDGEC; Dr. Anna Nswila, representative from PO-RALG; Prof. Andrea Barnabas Pembe, Muhimbili University of Health and Allied Sciences. The others pictured are representatives of various organizations in Tanzania.

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SUCCESS STORY FROM THE FIELD: Referral System Helps Women Access Emergency Obstetric Care in Tanzania

When Suzana Saimoni, 24, went into labor with her third child in November 2016, she went to the nearby village dispensary. As the lowest level of care in the Tanzanian health system, dispensaries are mostly equipped to manage normal births, but in Saimoni’s case, complications set in after 10 hours of labor.

In situations like this, timely treatment is critical, and delays can be deadly for mothers and babies. Thamini Uhai’s referral project was designed to get women with obstetric complications to care quickly. Without the community preparedness led by the project, “I honestly would have lost my life,” Saimoni says. “The situation was dire. We had to get to the health center immediately and we had no money at all.”

The provider recognized the signs of a complicated labor and called for the district ambulance, using one of the mobile phones the project had provided, But the ambulance was out of fuel, so the provider and the community health worker quickly arranged for another vehicle to take Saimoni and her husband, Isaka Matheo, 32, to Nguruka Health Center, about 30 minutes away. Thamini Uhai successfully advocated for a routine supply of petrol for the ambulance, but in months when the need is great, the supply is insufficient. The driver was one of the back-ups already identified by community leaders, so the price of transport had been negotiated in advance.

Though still in its early stages, the referral system is already making a tremendous impact, working to ensure women can access the emergency obstetric care Thamini Uhai is supporting. “I had a cesarean section,” Saimoni reported later, “and my baby was born safely and healthy and alive.”

Deputy Clinical Director Dr. Mkambu Kasanga demonstrates the use of magnesium sulfate for prevention and treatment of seizures in severe eclampsia. The demonstration was part of a joint quarterly supportive supervision visit at Kagunga Dispensary in Kigoma District Council, August 2016.

Thamini Uhai experts listen to a case presentation on eclampsia during a bedside mentorship session at Ilagala Health Center in Kigoma.

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II. Communication

In an ongoing effort to increase the number of women who choose to deliver at health facilities, in 2016 Thamini Uhai rebroadcast its successful maternal health mass media campaign. The radio spots ran from June through August on Radio Kwizera and Clouds FM radio, supported by posters, brochures and interpersonal communication from community health workers. Thamini Uhai has collaborated with EngenderHealth to recruit 126 community health workers and to supervise and monitor them after training using the ministry’s comprehensive safe motherhood curriculum.

Since 2015, more than 3,000 pregnant women have registered for the mHealth system, a nationwide mobile phone-based system for maternal health. Thamini Uhai has also amplified activities via social media through Jamii Forums, Twitter and Facebook (@ThaminiUhai). News conferences, interviews and journalist tours led to significant media coverage. Thamini Uhai participated in the Media Council of Tanzania’s annual Excellence in Journalism Awards in Tanzania for the second time, sponsoring awards for maternal health electronic news.

In 2016, the project focused on interpersonal and community-based communication. Thamini Uhai conducted 32 events to promote maternal health, using local drama groups and choirs. These events, which included 100 to 200 participants, helped link health facilities with the communities they serve, with at least one staff member attending each event to ensure that the issues raised by the communities would be heard. The meetings included discussions among women and men on myths and misconceptions about family planning methods, pregnancy danger signs and the importance of facility delivery, birth preparedness and family planning.

In yet another effort to build stronger relationships between health facilities and communities, 15 provider engagement

meetings were held in five districts so that community members and facility staff could discuss quality of care and client concerns. Issues commonly raised by community members included shortages of medicine and other supplies; complaints from women that they were not given respectful care during delivery; and contraceptive stock-outs. Providers cited concerns including women starting antenatal care too late in their pregnancies; waiting too long to come to a health facility when they have obstetric complications; and following practices such as the use of traditional medicines. The objective of the dialogue was to help providers feel better supported by communities and to encourage community members to be more comfortable using health facilities.

Among the solutions proposed were these: empowering community health committees by educating them about maternal health; ensuring that all antenatal care visits include information on danger signs, the importance of delivering at a facility and what to include in a birth plan; developing wall posters for use during antenatal care; and helping health facilities develop a plan for achieving zero maternal deaths in two years.

The Women’s Promotion Center, a Kigoma-based community organization, partnered with Thamini Uhai in 2016 to provide maternal health education in Sunuka ward. Six community leaders and 12 community activists were trained to discuss reproductive and maternal health with communities. The activists conducted 32 sessions, reaching 913 women and 785 men. The project staff learned during this process about the importance of helping community-based organizations build their capacity on maternal and reproductive health when it is not their usual focus.

Thamini Uhai Communication Manager Victoria Marijani (center) observes Herman Joseph (left), a community health worker from Songambele Dispensary at Buhigwe District, during a supportive supervision visit as he provides maternal health information to a pregnant mother at her home.

Anamaria Thomas, a CHW from Mabamba Health Center, Kibondo discusses maternal health during an event at Mabamba area in KIbondo, Kigoma.

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III. Infrastructure

Major infrastructure improvements completed in 2016 included the renovation and handover of operating theater buildings at Kakonko, Nguruka, Mtimbira, Mlimba and Mwaya health centers in Kigoma and Morogoro regions.

Other improvements were the upgrade of solar power at Nguruka and Kibiti health centers and installation and repairs of CEmONC equipment in Mabamba and Kibiti health centers. Also in 2016, Thamini Uhai purchased and installed medical equipment for various health facilities in Morogoro and Pwani, including:

2BABY WARMERS(Mwaya and Mlimba

health centers)

2DELIVERY BEDS

(Mlimba)

3OPERATING TABLES

(Kakongo, Buhingu and Utete health centers)

1AUTOCLAVE

(Nyenge Health Center)

15VACUUM

EXTRACTORS(all Thamini Uhai

supported facilities)

2SUCTION

MACHINES(Maweni Regional Hospital)

1BLOOD BANK

REFRIGERATOR(Nguruka Health Center)

Nguruka Health Center’s renovated operating theater, which was formally handed over to the Kigoma regional commissioner, Retired Brigadier General Emmanuel Maganga, in November 2016.

Thamini Uhai Clinical Director Dr. Sunday Dominico (far left) describes the organization’s work to former Brigadier General Emmanuel Maganga, the regional commissioner for Kigoma (at right in dark suit) during the official handover of the operating theater renovated and equipped by Thamini Uhai at Nguruka Health Center. Also shown are Mwamvua Mrindoko, the honorable district commissioner for Uvinza (second from left); Dr. Nguke Mwakatundu, Thamini Uhai executive director (third from left); and other government leaders and staff from the Uvinza district office.

Nine electrical technicians (three from Morogoro, one from Pwani and five from Kigoma) were trained at Arusha Technical Collage to perform service repairs on and otherwise troubleshoot biomedical equipment. These improved technical skills will help the electricians support their districts by keeping medical equipment in good condition.

21


IV. Partnerships

Building strong partnerships at the national and regional level is important for ensuring sustainability of the program. Thamini Uhai’s primary partner is the Ministry of Health, Community Development, Gender, Elderly and Children, and in October 2016 the project welcomed the ministry’s reproductive and child health assistant director to Kakonko Health Center to see the operating theater that Thamini Uhai had renovated in 2015. The ministry team praised the theater’s structural design and details and asked for the design documents to be used in building other proposed theaters around the country.

Coordination with other national partners has also been essential. In September 2016, Dr. Nguke Mwakatundu, Thamini Uhai’s executive director, attended a high-level legislative meeting in Dodoma, Tanzania’s capital, that was organized by the White Ribbon Alliance for Safe Motherhood, Tanzania. The meeting with the minister of health and members of Parliament’s safe motherhood committee focused on increasing the budget for CEmONC in Tanzania. The committee members promised to press the government to prioritize maternal health in its annual budget and increase resource allocation in the coming years. The committee also recommended that the alliance meet personally with members of Parliament to discuss the issue, and promised to help to organize a meeting.

At the regional level, Thamini Uhai supported and attended a Kigoma regional partners meeting that was hosted by the regional health management team and secretariat. The focus of the events was laying a foundation for better coordination of health services in the area. Thamini Uhai took the occasion to ask the district medical officers to address supply shortages. We also shared the regional action plan for human resources for health, which was written in collaboration with CHMT

representatives and is to be incorporated in the Regional Health Strategic Plan covering the next five years. It was agreed that the RHMT will form a strategic plan committee that includes implementing partners, who were in turn encouraged to increase collaboration among themselves and to include the district executive directors in their ongoing activities.

V. Birth Companionship

Thamini Uhai began work in 2016 on a pilot project to introduce birth companionship in nine facilities in the Kigoma region over 18 months. Continuous emotional and social support during childbirth has been shown to improve maternal and newborn health outcomes and increase women’s satisfaction with care, and the WHO is promoting birth companionship as part of its “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities,” published in 2016. Through this pilot, women will be encouraged and supported to choose a female companion to stay with them during labor and delivery, a practice that is not common in health facilities in Tanzania.

In 2016, the team began meeting with stakeholders and presenting the project to the ministry. Upcoming activities will include a workshop to develop a code of good practice for birth companionship. Thamini Uhai will examine whether birth companionship is feasible, acceptable and effective in increasing institutional deliveries and improving the quality of care in targeted facilities. The intention of this pilot project is also to learn whether birth companionship as an intervention should be replicated and scaled up in other parts of Tanzania. This project will be designed to respond to the needs of women, as well as to the concerns of health providers.

Thamini Uhai received donor representatives from Fondation H&B Agerup in April 2016 and Svenska PostkodStiftelsen in November 2016. Helen Agerup, chief executive officer of the Fondation H&B Agerup and a member of the Vital Strategies Board of Directors, visited Mabamba Health Center to meet some of project’s beneficiaries. From left, standing in front: Dr. Nguke Mwakatundu, Thamini Uhai executive director; Dr. Laurian Kanaganwa, acting district medical officer, Kibondo district, Kigoma; Helen Agerup; and Dr. Primus Ijuma, facility in-charge of Mabamba Health Center, visiting a mother who had recently experienced a maternal complication and delivered safely by cesarean section.

Thamini Uhai consultants and staff at the birth companionship project orientation meeting at Kasulu District in October 2016.

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Quality of Care Indicators and Trends

1. Deliveries

A total of 30,738 deliveries were attended in the 19 project-supported facilities in 2016, including the four newly upgraded health centers in Kigoma that Thamini Uhai began supporting in 2016. Deliveries in those four facilities—Bitale, Kiganamo, Nyanzige and Kifura health centers—more than tripled between 2015 and 2016, from 1,242 to 3,769. Kibiti Health Center in Pwani and Mahenge District Hospital in Morogoro both reported 25% surges in deliveries (from 1,218 to 1,527 at Kibiti and from 1,313 to 1,639 at Mahenge). Buhingu and Kakonko health centers and Kasulu Hospital recorded declines in the number of deliveries. The declines at Kakonko and Kasulu can be explained by improved performance at the two newly upgraded CEmONC facilities nearby (Nyanzige and Kiganamo health centers), while the declining performance of Buhingu Health Center can be attributed to a staff shortage.

2. Cesarean Sections

Cesarean sections were performed on 3,218 pregnant women with various maternal and fetal indications, indicating an institutional cesarean section rate of 11% in 2016, up from 9.8% in 2015. The overall number of cesarean sections performed in 2016 increased over previous years, in part because of the start of CEmONC services in the new health centers but also due to improved performance in 12 of the 15 previously supported facilities. The leading indications for cesarean section were obstructed labor, poor progress of labor, antepartum hemorrhage, malpresentation, fetal distress and a failed trial of scar, when a woman who has previously given birth by cesarean is unable to deliver vaginally.

Cesarean Sections in Supported CEmONC Facilities 2011–2016

4000

2011 2012 2013 2014 2015 2016

TotalHospitals (N=5)

Health centers upgraded since 2015/16 (N=4)

Health centers

2500

2000

1500

1000

229

852

709670580692624

n/an/an/an/an/a

3244

1822 1858

1609

1901 1857

25662571

2189

25502446

2163

500

0

3000

Deliveries in Supported CEmONC Facilities 2011–2016

5,000

10,000

15,000

20,000

25,000

30,000

35,000

-

2011 2012 2013 2014 2015 2016

TotalHospitals (N=5)

Health centers upgraded since 2015/16 (N=4)

Health centers

1,2423,769

30,731

13,810

13,15212,27912,29910,86111,43610,788

10,950 12,056 12,376 13,729 13,910

26,18926,028

23,23723,49221,738

n/an/an/an/an/a

23


3. Assisted Vaginal Deliveries

Delivery assisted by vacuum extraction is a safe, nonsurgical alternative to cesarean section in some cases of prolonged labor. A total of 576 deliveries were assisted by vacuum extractions in supported facilities in 2016, including 466 in the original 15 facilities and 110 in the newly supported facilities. This represents a remarkable 41% surge from the previous year’s figure in the original 15 facilities and an increase in the overall vacuum extraction rate from 1.2% to 1.9%. The change was more marked in the third quarter of the year; this followed continuing medical education workshops on assisted vaginal delivery for 56 healthcare providers from all the supported facilities in June and July 2016.

4. Referrals

A total of 273 cases were referred from supported facilities to higher-level facilities in 2016, an increase from 2015. There was an especially large increase in obstetric referrals to Morogoro facilities during the first quarter of 2016 due to the temporary suspension of cesarean sections services at Mwaya and Mtimbira health centers because of renovations of their operating theaters. As for the Kigoma facilities, increases at the Nguruka, Mabamba, Nyenge and Buhingu health centers can be explained by the greater availability of reliable ambulance services in these facilities and unstable CEmONC capabilities due to human resource shortages.

5. Newborn Lives Directly Saved

A total of 1,275 newborns with severe birth asphyxia underwent resuscitation with bag and mask, 1,122 from the previously supported facilities (representing a 9.8% increase since 2015) and 153 from newly supported health centers.

Assisted Vaginal Deliveries in Supported CEmONC Facilities 2011–2016

500

400

300

200

492

331

576

247

219

110

n/an/an/an/an/a

198

133

115

285307

34

400

207

100

0

600

2011 2012 2013 2014 2015 2016

136

71

185

34

Health Centers (N=10)

Hospitals (N=5)

Health Centers upgraded 2015/16 (N=4)

Total

24

6. Very Early Neonatal Mortality

The number of very early neonatal deaths (within 24 hours) has not declined over the past five years. The overall number increased from 125 in 2015 to 173 in the previous facilities; the new facilities reported 21 very early neonatal deaths in 2016. As a result, the facility-based very early neonatal mortality rate increased from 4.9 early neonatal deaths per 1,000 live births in 2015 to 6.3 per 1,000 live births in 2016. Birth asphyxia resulting from prolonged/obstructed labor was responsible for 80% of these deaths; prematurity and congenital malformations contributed to 10% and 6.3%. The increase in the number of early neonatal deaths can be attributed in part to critical shortages in the number of skilled providers and to delays in decision-making when complications arise. Thamini Uhai began a series of interventions late in 2016 to address this trend, including newborn resuscitation, building providers’ capacity on labor management using partography and strengthening kangaroo mother care, a technique of newborn care emphasizing skin-to-skin contact between mother and newborn, especially for pre-term infants.

7. Maternal Life-threatening Complications

A total of 1,022 life-threatening obstetric complications were successfully managed in the 19 supported facilities in 2016 (944 in the original facilities and 78 in the newly supported facilities). The number of complications attended in the 15 original facilities in 2016 is 41% more than those attended in the same facilities in 2015. This suggests increased access to life-saving emergency obstetric care for women with serious complications of pregnancy, labor and delivery. Complications managed included: postpartum hemorrhage (38%), pre-eclampsia/eclampsia (22%), antepartum hemorrhage (18%), puerperal sepsis (9%), uterine rupture (7%) and ectopic pregnancy (3%).

Very early neonatal mortality rate (per 1,000 live births) in supported facilities (n=19) 2011–2016

7

2011 2012 2013 2014 2015 2016

6

4

3

2

0

1

5

3.9

5.5 5.64.7 4.9

6.3

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8. Maternal Mortality

A total of 67 maternal deaths were reported in project-supported facilities in 2016, three-quarters of them (50 maternal deaths) in supported hospitals. Of the maternal deaths, 65 were reported from previously supported facilities (n=15) and two from the four new supported health centers. Overall, five supported health centers (Kifura, Bitale, Nyenge, Mtimbira and Mwaya) registered no facility-based maternal deaths at all in 2016. The overall facility-based maternal mortality ratio was 218 maternal deaths per 100,000 live births. Causes of maternal death in 2016 included: post-partum hemorrhage (37%), puerperal sepsis (20%), antepartum hemorrhage (12%) and ruptured uterus (9%), as well as severe malaria, severe anemia, ectopic pregnancy, anesthetic complications and pre-eclampsia/eclampsia.

Causes of Maternal Death in Supported Facilities (n=67)

Post-partum Hemmorhage

37%

Others

21%

Ruptured Uterus

21%Sepsis

20%

Ante-partum Hemmorhage

12%

Pre-eclampsia/ Eclampsia

1%

Facility-based maternal mortality ratio (per 100,000 live births) in supported facilities (n=19) 2011–2016

260

2011 2012 2013 2014 2015 2016

250

230

220

210

200

240

244

253

249243

226

218

Challenges

Major challenges in 2016 included a chronic shortage of supplies and medicines in all supported facilities, primarily due to inadequate and delayed deliveries from the medical stores department and local councils. Another major challenge was the limited quantity and quality of healthcare providers in supported facilities. Some facilities had only one AMO and one anesthetist, instead of two of each as required, and some health centers and dispensaries had an inadequate number of nurse-midwives.

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SPECIAL FEATURE: Performance of Pwani and Morogoro Facilities

Thamini Uhai’s efforts to build and sustain capacity for delivering routine and emergency obstetric care in those facilities have resulted in massive improvements, as measured by a range of quality-of-care indicators.

PWANI

• Three AMOs were trained in CEmONC practice and six nurse-midwives and clinical officers were trained in anesthesia in short competency-based training courses between 2008 and 2016.

• In the same timeframe, 54 providers attended three- to five-day CME workshops on topics including obstetric anesthesia, neonatal resuscitation, obstetric hemorrhage, vacuum extractions and infection prevention and control.

• Kibiti Health Center registered a nearly four-fold increase in deliveries between 2009 and 2016, jumping from 331 to 1,527.

• A total of 574 cesarean sections and 262 vacuum extractions were performed at Kibiti between 2009 and 2016.

• The number of obstetric referrals at Kibiti decreased from 128 in 2011 to 29 in 2016, reflecting increased CEmONC capabilities.

• The number of maternal and perinatal deaths has remained relatively low despite the increased caseload at Kibiti. The overall facility-based maternal mortality ratio is 70 per 100,000 live births during the support period, 2009 to 2016, which is among the lowest in project-supported facilities. The fresh stillbirth rate and the early neonatal death ratio declined by 64% and 84%, respectively, from 2009 to 2016.

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Total deliveries at Kibiti HC, 2009–2016Operative deliveries at Kibiti HC, 2009–2016

Obstetric referrals at Kibiti HC, 2009–2016Very early neonatal mortality rate (per 1,000 live births) and

fresh stillbirth rate (per 1,000 live births) at Kibiti HC, 2009–2016

140

2011

2011

20112009

2009

2009

201120102009

2012

2012

20122010

2010

2010

2012

2013

2013

2013

2013

2014

2014

2014

2014

2015

2015

2015

2015

2016

2016

2016

2016

120

200

80

2000

150

60

1500

100

40

0

5000

0

1000

50

20

250

100

0

8

12.1128

8.5

87

75 75

4.8

102

4.2

1527

1218

1483

118211981035

938

331

73

4833

1333

6757

93

136

192

011

46

0

34

29

2.5

4.0

1.6 2.0

3.33.3

5.4

3.4

5.8

7.77.59.1

Assisted Vaginal DeliveriesCesarean Sections

Fresh stillbirth rateVery early neonatal mortality rate

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MOROGORO

• Nine AMOs were trained in CEmONC practice and 14 nurse-midwives and clinical officers were trained in anesthesia in short competency-based training courses between 2008 and 2016.

• In the same period, 84 providers attended three- to five-day CME workshops on topics including obstetric anesthesia, neonatal resuscitation, obstetric hemorrhage, vacuum extractions and infection prevention and control.

• The number of deliveries attended at supported health centers in Morogoro has increased by a staggering 442% since Thamini Uhai began its support in 2009, from 819 in 2009 to 4,435 deliveries in 2016.

• A total of 2,326 cesarean sections have been performed in the three supported health centers since 2009, an average of 332 per year.

• Assisted delivery by vacuum extraction was introduced in the supported health centers in 2009 and since then, 495 babies have been delivered successfully by vacuum extractions between 2009 and 2016, an average of almost 71 vacuum extractions per year during implementation.

• The number of obstetric referrals in the three supported centers decreased from 117 in 2009 to an average of 66 in subsequent years.

Deliveries in supported Morogoro HCs 2009-2016

20112009 20122010 2013 2014 2015 2016

4000

3000

2000

0

1000

5000

Mtimbira Mwaya TotalMlimba

Total Deliveries

819

1,984

2,940 3,428 3,4713,824 3,940

4,435

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Priority Areas in 2017

1. Improve and sustain the quality of skilled birth attendance and BEmONC services in supported dispensaries.

• Train additional skilled providers on BEmONC.• Distribute job aids and orient providers to their use.• Conduct routine monthly and quarterly supportive supervision.

2. Improve provision of quality routine labor and delivery care.

• Onsite training of healthcare providers from CEmONC facilities on labor monitoring (using partographs) and management.

• Revive routine partogram audit at CEmONC facilities.

3. Improve perinatal care and outcomes.

• Ensure success of the pilot “Helping Babies Breathe” neonatal resuscitation intervention in five facilities.• Support neonatal resuscitation mentorship in nine other health centers.• Support provider orientation and initiation of services for kangaroo mother care, a technique of newborn care

emphasizing skin-to-skin contact between mother and newborn, especially for pre-term infants.

4. Improve and sustain quality of services in new and previously supported CEmONC sites in Kigoma.

• Provide technical support for smooth continuation of CEmONC services in Ilagala and Muyama health centers.• Increase healthcare providers’ EmONC skills through onsite EmONC skills workshops at hospitals.• Conduct five-day onsite supportive supervision and mentorship visits.• Support anesthesia training and CEmONC apprenticeship in supported facilities.

5. Continue to promote institutional delivery.

• Conduct comprehensive maternal health mass media campaign

6. Hand over community activities to district officials.

• Work with CHMTs to supervise community health workers.

7. Engage traditional birth attendants. • Orient traditional birth attendants and pair them with community health workers. Ensure they understand their role of escorting mothers to health facilities for delivery.

8. Improving birth experience of women in supported facilities through birth companionship.

• Promote birth companionship through a multi-media campaign and community outreach and ensure health facilities are prepared to accommodate the birth companionship intervention.

30

Thamini Uhai Staff and Consultants

FRONT ROW, SEATED FROM LEFT: Fadhili Jamadini, Facilities Manager; Dr. Sunday Dominico, Clinical Director; Dr. Nguke Mwakatundu, Executive Director;

Adolf Kaindoa, Kigoma Program Manager; Victoria Marijani, Communication Manager.

STANDING, FROM RIGHT: Dr. Mkambu Kassanga, Deputy Clinical Director; Ignus Kalongola, Referral Project Manager; Magdalena Metta, Birth Companionship

Project Coordinator; Juma Kibingira, Project Driver; Agnes Mbanza, Birth Companionship Project Coordinator; Afumba Mulanda, Monitoring and Evaluation

Officer; Violet Mushi, Administration Officer; Dr. Benedict Nyiro, Birth Companionship Project Manager; Banzi Msumi, Finance and Administration Manager.

STANDING SECOND ROW AT THE BACK, FROM LEFT: Alphonce Simfukwe, Project Driver; Melckizedech Yange, Project Driver; Lutengano Mwakalonge,

Administrative Assistant.

Thamini Uhai consultants have played a major role in the success of the program in 2016. We thank them for their valuable contributions to date and look

forward to working with them in 2017: Prof. Jos Van Roosmalen, Dr. Donald Mawalla, Dr. Angelo Nyamtema, Dr. Richard Rumanyika, Dr. Irene Kasiga, Dr.

Calist Nzabuhakwa, Dr. Bigilimana Mapigano, Dr. Jonas Chagi, Dr. Allan Shayo, Dr. Majura Magafu, Dr. Elias Kweyamba, Dr. Ally Bendera, Dr. Omary Issa,

Geofrey Mwanyingili and Maria Sarungi-Tsehai.

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2016 Photos

CLOCKWISE (L-R): Dr. Nguke Mwakatundu, the executive director of Thamini Uhai (left), presents a prize to one of the winners during the Excellence in Journalism Awards in Tanzania. Thamini Uhai sponsored awards for electronic news about maternal health.

Kakonko Health Center, which Thamini Uhai renovated in April 2016.

Referral project supporters Moa Stenholm (project manager, right) and Emilia Hellqvisit (project coordinator) from Svenska PostkodStiftelsen visit with a woman and child helped through the referral system designed to address delays in handling maternal health emergencies.

Birth Companionship project community health workers with Kigoma Regional Medical Officer, Dr. Paul Chaote (second seated from left), during their training in Kigoma.

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DAR ES SALAAM OFFICE

Plot # 5, Block No. MKC/MCA/1201, Kilimanjaro Street, Mikocheni AP.O. Box 110228, Dar es Salaam, Tanzania

KIGOMA OFFICE

NSSF Building, 1st floor, Mnarani RoadP.O. Box [email protected]

tanzania maternal health program - thamini uhai uhai... · 2018. 7. 19. · i. improving clinical...

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