Improving uptake of delivery care services in rural Tanzania through demand creation, ambulance transport and quality of care: a feasibility study
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Epidemiology and Population Health
Abstract
This is a proposal for a trial development and feasibility study for a complex intervention to improve pregnancy- and birth-related maternal and neonatal health outcomes in rural Tanzania.
The intervention aims to prevent emergencies in pregnancy and childbirth by increasing uptake of antenatal and delivery care services in rural Tanzania. Progress has been much too slow towards reducing the high rates of avoidable pregnancy- and birth-related deaths that persist in the region despite 2015 marking the end of the MDG era, which helped place maternal and newborn health on the global agenda. More research is urgently needed to address this important public health issue.
The high rates of adverse birth outcomes can largely be attributed to a handful of common complications during pregnancy and labour which are in principle trivially avoided or resolved given adequate antenatal and delivery care. The central barriers to increased uptake of facility-based delivery care are, (1) a lack of awareness of the importance of delivering with assistance from skilled birth attendants, (2) limited access to transport for women in labour, and (3) inadequate quality of delivery care in rural facilities with outdated midwifery skills among many health workers and a lack of essential equipment and consumables, poor supervision structures and inadequate procedures for timely referral to larger facilities.
Our intervention consists of the following main components: (1) Campaigning in the community to raise awareness among women and their families of the importance of delivering with skilled birth attendants (which in rural Africa is only available in health facilities). (2) A free-of-charge telephone hotline to the nearest Health Centre (HC) to arrange transport at onset of labour or in case of emergency. (3) Free-of-charge transport for women in labour to the nearest HC using locally produced low-cost motorcycle-drawn ambulance trailers. (4) Strengthening of essential midwifery skills in local HCs thus improving the reputation of the care they provide.
To date no feasible, cost-effective intervention has been demonstrated to simultaneously address each of the major barriers to care and improve 'hard' pregnancy outcomes. Robust evidence is needed of a scalable, affordable intervention with a sustained effect. The definitive evaluation in a main trial will estimate effectiveness and cost-effectiveness of the intervention in improving maternal and neonatal health outcomes in a cluster randomised trial with clusters comprising rural HCs and the communities (wards) they serve.
The proposed early-phase study is required to strengthen the intervention, generate evidence on its feasibility, and allow us to perfect the design of the evaluation in the main trial. The objectives of this early phase study are:
(-) to conduct formative research to feed into the design of the intervention, and to improve participation from potential study participants in the development of the intervention.
(-)incorporating observations from the formative research phase, to finalise all aspects of the intervention components and produce a set of standard operating procedures and intervention manuals.
(-) to pilot the intervention in its entirety which will help identify and resolve unforeseen challenges, facilitate operational research to evaluate process measures and feasibility of all individual aspects of the intervention.
(-)to obtain preliminary indicators as to how successful the intervention is likely to be in creating increased demand for facility-based delivery care.
(-)to establish and test the feasibility of survey techniques planned for the main study.
The intervention aims to prevent emergencies in pregnancy and childbirth by increasing uptake of antenatal and delivery care services in rural Tanzania. Progress has been much too slow towards reducing the high rates of avoidable pregnancy- and birth-related deaths that persist in the region despite 2015 marking the end of the MDG era, which helped place maternal and newborn health on the global agenda. More research is urgently needed to address this important public health issue.
The high rates of adverse birth outcomes can largely be attributed to a handful of common complications during pregnancy and labour which are in principle trivially avoided or resolved given adequate antenatal and delivery care. The central barriers to increased uptake of facility-based delivery care are, (1) a lack of awareness of the importance of delivering with assistance from skilled birth attendants, (2) limited access to transport for women in labour, and (3) inadequate quality of delivery care in rural facilities with outdated midwifery skills among many health workers and a lack of essential equipment and consumables, poor supervision structures and inadequate procedures for timely referral to larger facilities.
Our intervention consists of the following main components: (1) Campaigning in the community to raise awareness among women and their families of the importance of delivering with skilled birth attendants (which in rural Africa is only available in health facilities). (2) A free-of-charge telephone hotline to the nearest Health Centre (HC) to arrange transport at onset of labour or in case of emergency. (3) Free-of-charge transport for women in labour to the nearest HC using locally produced low-cost motorcycle-drawn ambulance trailers. (4) Strengthening of essential midwifery skills in local HCs thus improving the reputation of the care they provide.
To date no feasible, cost-effective intervention has been demonstrated to simultaneously address each of the major barriers to care and improve 'hard' pregnancy outcomes. Robust evidence is needed of a scalable, affordable intervention with a sustained effect. The definitive evaluation in a main trial will estimate effectiveness and cost-effectiveness of the intervention in improving maternal and neonatal health outcomes in a cluster randomised trial with clusters comprising rural HCs and the communities (wards) they serve.
The proposed early-phase study is required to strengthen the intervention, generate evidence on its feasibility, and allow us to perfect the design of the evaluation in the main trial. The objectives of this early phase study are:
(-) to conduct formative research to feed into the design of the intervention, and to improve participation from potential study participants in the development of the intervention.
(-)incorporating observations from the formative research phase, to finalise all aspects of the intervention components and produce a set of standard operating procedures and intervention manuals.
(-) to pilot the intervention in its entirety which will help identify and resolve unforeseen challenges, facilitate operational research to evaluate process measures and feasibility of all individual aspects of the intervention.
(-)to obtain preliminary indicators as to how successful the intervention is likely to be in creating increased demand for facility-based delivery care.
(-)to establish and test the feasibility of survey techniques planned for the main study.
Technical Summary
The intervention aims to prevent emergencies in pregnancy and childbirth by increasing uptake of antenatal and delivery care services in rural Tanzania. The target population will be women of childbearing age in rural communities who are at high risk of suffering adverse pregnancy outcomes due to low perceived priority on the need to deliver with skilled birth attendants and poor transport to health facilities.
The intervention will be designed to reduce the three delays in accessing delivery care, (i) decision to seek care, (ii) reaching a medical facility and (iii) receiving adequate treatment, and will comprise the following main components: (1) Raising awareness in the community of the importance of delivering with skilled birth attendants. (2) A free-of-charge telephone hotline to the nearest Health Centre (HC) to arrange transport at onset of labour (3) Free-of-charge transport for women in labour to the nearest HC using locally produced low-cost motorcycle-drawn ambulance trailers. (4) Strengthening of essential midwifery skills in local HCs thus improving the reputation of the care they provide.
Within a Theory of Change (ToC) framework, we will use the proposed early-phase study to work the project through the development and feasibility phases of the MRC's model for complex interventions while improving the theoretical basis for the intervention and later-stage evaluation.
The specific objectives are to: 1) Use a participatory ToC approach to further develop the theoretical basis for the intervention and identify a set of suitable indicators for process evaluation. 2) Finalise content and delivery method for the awareness raising and care strengthening components 3) Implement all intervention components, assess feasibility and test the ToC, and make adaptations to the intervention where necessary. 4) Develop and test methods for evaluation in the main trial.
The intervention will be designed to reduce the three delays in accessing delivery care, (i) decision to seek care, (ii) reaching a medical facility and (iii) receiving adequate treatment, and will comprise the following main components: (1) Raising awareness in the community of the importance of delivering with skilled birth attendants. (2) A free-of-charge telephone hotline to the nearest Health Centre (HC) to arrange transport at onset of labour (3) Free-of-charge transport for women in labour to the nearest HC using locally produced low-cost motorcycle-drawn ambulance trailers. (4) Strengthening of essential midwifery skills in local HCs thus improving the reputation of the care they provide.
Within a Theory of Change (ToC) framework, we will use the proposed early-phase study to work the project through the development and feasibility phases of the MRC's model for complex interventions while improving the theoretical basis for the intervention and later-stage evaluation.
The specific objectives are to: 1) Use a participatory ToC approach to further develop the theoretical basis for the intervention and identify a set of suitable indicators for process evaluation. 2) Finalise content and delivery method for the awareness raising and care strengthening components 3) Implement all intervention components, assess feasibility and test the ToC, and make adaptations to the intervention where necessary. 4) Develop and test methods for evaluation in the main trial.
| Description | Below is a summary of the key findings from this study which aimed to develop and assess feasibility of an intervention to address the three delays in reaching delivery care in rural Tanzania. • Awareness raising campaigns were well attended with active engagement and support from local leaders, particularly for the ambulance transport. The average rate of deliveries across the two facilities increased from 25/month before implementation to 39/month during the observation period. • Two low-cost ambulances* were locally manufactured using locally sourced materials and were operational for the entire 5-month observation period. Ambulances were used with 33% of deliveries in both facilities. Being reliably accessible and free to use were reported as the most important features of the ambulance system. Operational costs comprising fuel, driver salaries and minor vehicle maintenance amounted to £4.50/day per health centre. Challenges included occasional resistance from stakeholders arguing that motorcycle ambulance transport is primitive and non-sustainable. • Healthcare strengthening* Improved availability of drugs, tests, consumables, and working equipment was observed in both facilities. Knowledge, skills and practices among healthcare staff improved following the clinical training efforts and supervision. Better quality routine management of labour was observed and examples of correct identification and management of emergencies as a result of the clinical training. Improved water and sanitation infrastructure and hygiene practices were implemented. Reports from patients and staff of better-quality care. Challenges to clinical care improvements included poor basic infrastructure at the facilities (e.g. poor sanitation and toilet facilities, lighting, waste disposal systems, water and electricity supplies). National policy focuses on the need for facilities to meet the seven signal functions for BEmONC, however we found it necessary to focus efforts on strengthening implementation of routine delivery care practices such as monitoring of labour using partographs. Staff shortages reduced incentives among some staff to increase patient uptake. Existing structures within the health system for ordering and processing supply orders of drugs, tests and other consumables are strained and facilities struggle to prevent stockouts of supplies. Our research team continued to provide essential supplies to the health centres throughout the study. • Conclusions: The objectives of developing an intervention to address the three delays in reaching delivery care were met: It was feasible and affordable to implement a 24-hour transport system that operates from rural HCs and is free-of-charge to women in labour. Good community engagement and support around such a system was observed. Local ambulance transport systems embedded within local facilities that meet national standards for maternity care could be instrumental in increasing facility-based deliveries and reducing maternal mortality. A future large-scale cost-effectiveness evaluation study is needed. Our research team is now planning for this. Research paths closed off: Although possible with sustained effort from the study team to affect changes in the care provided at local health centres, we found that strains on the broader health systems such as staff shortages and stretched supply chains presented challenges to the project. Intervention efforts to strengthen the quality of local delivery care services will also need to target strains in the health system more broadly. |
| Exploitation Route | • A key lesson from this work was the need for intervention components to be self-reliant, in the sense that their success should rely as little as possible on improvements to infrastructure or systems at the health facility. • We found that the ambulance transport component worked well, and was feasible to implement at the local level, with good community support. We are developing this intervention further and planning for a future study to demonstrate effectiveness and cost-effectiveness of a low-cost, reliable, free-of-charge motorcycle-based ambulance service at rural health centres. • Effecting sustained improvements in the delivery care at health facilities was shown to be complex and fraught with challenging. It seems unfeasible for a scope-limited intervention operating at the local health centre level to sustainably bring about significant improvements in the delivery care. Such initiatives are probably better addressed through high-level health systems interventions that operate on systemic and structural improvements. • Our work highlighted that systems interventions are needed to address deficiencies in the medical supplies chain, local-level access to health budgets and understaffing at rural facilities, however we do not think such intervention targets are within the scope of the type of intervention piloted in the current study. |
| Sectors | Communities and Social Services/Policy,Healthcare,Transport |
| Description | This is early-phase research to develop and test the feasibility of an intervention in two rural health centres in North-western Tanzania and overall economic or societal impact resulting directly from the findings is not expected. However, several non-academic benefits resulted from the project for staff and patients working and receiving care at the participating health centres. There was an increase in the number of mothers delivering at the participating health facilities during the follow-up period following intervention implementation as many pregnant women benefitted from the free ambulance service which enabled them to travel to their local health facility at the onset of labour. The health centres (and by extension the patients) benefited considerably from the upgrade of equipment, drugs and other supplies, as well as the clinical training given to its staff. We recorded several accounts of women in labour benefitting directly from the intervention under life-threatening circumstances. These include the correct identification and management of emergencies as a result of the clinical training, e.g. successful treatment by a medical attendant of post-partum haemorrhage (PPH) using a pre-prepared PPH tray, and fast referral to the district hospital made possible upon identification of complications using the motorcycle ambulance trailer. |
| First Year Of Impact | 2017 |
| Sector | Healthcare |
| Impact Types | Societal |
| Description | Improved practice at the participating health centres |
| Geographic Reach | Local/Municipal/Regional |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Impact | This was a small-scale feasibility study of an intervention to improve delivery care. The intervention was implemented in two rural health centres in Mwanza Region, Tanzania. There has been an impact on practice at these health centres and access to care in the communities served by the facilities through the ambulance transport and making services freely available. Within those two facilities it is evident that the level of care improved significantly and we have know that lives have been saved as a result of the intervention within those health facilities. The clearest example was a woman who immediately after delivering her baby suffered severe postpartum hemorrhage and lost consciousness, but whose life was saved by a medical assistant, the only staff on duty, who identified the PPH tray, correctly administered oxytocin to stop the bleeding and saline bags to replenish fluids. The medical assistant reported that the woman would have died had he not had the training or supplies from our Safer Deliveries intervention. |
| Description | Funds from MSc student |
| Amount | £700 (GBP) |
| Organisation | London School of Hygiene and Tropical Medicine (LSHTM) |
| Sector | Academic/University |
| Country | United Kingdom |
| Start | 06/2017 |
| End | 08/2017 |
| Title | Innovative data collection using satellite images and motorcycles |
| Description | We developed a method for representatively surveying women who completed or terminated a pregnancy in the past 12 months. Research assistants traveled using motorcycle taxis to inaccessible rural households in order to systematically visit every household in a geographically defined area determined using satellite images of the study communities. |
| Type Of Material | Improvements to research infrastructure |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | Improved validity and sample size in household community surveys. |
| Title | Data from formative research phase |
| Description | We have collected qualitative research data through observations, interviews and formal and infomal discussions with women and other community members in our study area and in the participating health facilities. |
| Type Of Material | Database/Collection of data |
| Provided To Others? | No |
| Impact | This is a feasibility study still in its preparatory phase. |
| Description | Good collaborative links with Developing Technologies London |
| Organisation | Developing Technologies |
| Country | United Kingdom |
| Sector | Charity/Non Profit |
| PI Contribution | As planned, our research centre, Mwanza Intervention Trials Unit (MITU) hosted an engineer visit from Developing Technologies London from mid-September to mid-December 2016. Developing Technologies is a charity based at City University London with a track record in the development of sustainable transport solutions to alleviate effects of poverty and reduce mortality in low income countries. During 2017 we have continued this collaboration and in September 2017 MITU hosted a supervising engineer, Mr Miles Franklin, from Developing Technologies. Miles is our main collaborating partner at DevTech. During Miles' visit to Mwanza we discussed findings from the transport system, plans for sustaining the ambulance transport system and for future work and spent much of the time in the field observing the ambulance transport in operation. |
| Collaborator Contribution | The engineer from Developing Technologies successfully supervised the manufacturing of two motorcycle ambulance trailers according to DevTech's design specifications. We continue to collaborate with and consult Developing Technologies on matters to do with the transport component of the intervention, and hope to collaborate in future in the definitive large-scale controlled trial of our intervention. During 2017 we relied on expert technical advice from DevTech on a number of occasions to address operational issues with the ambulance vehicles. We also had a visit from our main collaborating partner at DevTech, Mr Miles Franklin, who visited Mwanza in September 2017. |
| Impact | We have two motorcycle ambulance trailers as a result of this collaboration. This grant is also a results of the collaboration. |
| Start Year | 2016 |
| Description | Mama na Mtoto Project, Agriteam Canada |
| Organisation | Agriteam Canada Consulting Ltd |
| Country | Canada |
| Sector | Private |
| PI Contribution | We are now working the Mama na Mtoto project which aims to strengthen maternal, newborn and child health in Tanzania and which is now operating in Kwimba district where our feasibility study took place. Further to discussions in Septeber-October 2017 between the District Commissioner for Kwimba, the Mama na Mtoto project and our Safer Deliveries project, the Mama na Mtoto project has taken on the responsibility of sustaining the motorcycle ambulance transport system and has committed to providing the necessary funds to this end. The District Commissioner, and under him the District Medical Officer, are now responsible for overseeing the operational side of the transport system. |
| Collaborator Contribution | As explained above, the Mama na Mtoto project which is run by Agriteam Canada, is now funding the operation of the motorcycle ambulance system in Kwimba. |
| Impact | The motorcycle ambulance system, the operation of which is now funded by AgriTeam Canada, has a direct impact on the health of women in labour and their babies by providing better access to care and improved referral mechanisms to higher health facilities where needed. |
| Start Year | 2017 |
| Description | Touch foundation |
| Organisation | Touch Foundation, Inc |
| Country | United States |
| Sector | Charity/Non Profit |
| PI Contribution | The Touch Foundation is a US NGO which operates in Mwanza with a focus on strengthening the healthcare system. Delivery care is one of the main focus areas of their work. We involved the Touch Foundation in an advisory capacity early on through workshops at MITU in Mwanza due to their extensive experience in the field. Lately I have had discussions with Dr Renae Stafford (who is responsible for the development, management, and implementation of programs and partnerships within the foundation) about future collaborative work on a study proposal to develop and evaluate an intervention to improve maternal health outcomes in the region. This collaborative work would build on the current feasibility work and would be a partnership between the Touch Foundation in Mwanza, the London School of Hygiene and Tropical Medicine and the Tanzanian National Institute for Medical Research. |
| Collaborator Contribution | Please see above. The Touch Foundation has extensive, local experience in health systems strengthening initiatives and has offered advice and opportunities for future collaborative work. |
| Impact | Ideas for future collaborative work on a study proposal to develop and evaluate an intervention to improve maternal health outcomes in the region. This collaborative work would build on the current feasibility work and would be a partnership between the Touch Foundation in Mwanza, the London School of Hygiene and Tropical Medicine and the Tanzanian National Institute for Medical Research. |
| Start Year | 2016 |
| Description | Dissemination community meetings in Kwimba |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Public/other audiences |
| Results and Impact | We have had very high engagement and interest in our Safer Deliveries project at the community level since the start of this project. In September 2017 we conducted a number of dissemination meetings in the communities that we have worked in. During these meetings, which were well attended by local officials and influential community members, we discussed the progress and findings from our study and plans for sustaining the improved level of services, both at the health centres and the transport service. |
| Year(s) Of Engagement Activity | 2017 |