Mothers attend clinic at a health centre
Although evidence based interventions to substantially reduce maternal , neonatal and child mortality are available, maternal, newborn and child mortality rates remains unacceptably high, particularly in remote, rural areas of sub-Saharan Africa.
The continuing high mortality in part reflects the challenges associated with appropriate packaging and implementation of evidence based interventions with high coverage and quality at scale.
According to the Morogoro Evaluation Project (MEP) report that was disseminated this week in Dar es Salaam, done in collaboration with the Ministry of Health and Social Welfare, Muhimbili University of Health and Allied Sciences, Jhpiego and the Johns Hopkins Bloomberg School of Public Health, coverage in large maternal newborn and child health (MNCH) programme is often undermined by difficulties in integrating intervention components and ensuring comprehensiveness, quality and continuity of care.
Although significant achievement has been made towards reduction of child mortality showing a trend towards achieving the Millennium Development Goals (MDGs) number 4 by 2015; however, a lot remains to be done in reducing neonatal mortality which constitutes 47 per cent of the 112 deaths per 1,000 live births among children aged below five years.
Despite multiple efforts and resources put in place, maternal mortality remains unacceptably high at 454 deaths per 100,000 live births. This calls for concerted efforts to rethink our methods and assess what works, what does not work and what needs to be changed.”
Complications of childbirth and pregnancy are leading causes of death among women of reproductive age. Developing countries account for 99 per cent of maternal deaths. The collaboration was commissioned to evaluate the integrated facility-community maternal, newborn and child health programme of the ministry of health and social welfare in collaboration with Jhpiego under the USAID funded project on mothers and infants, safe, healthy and Alive (MAISHA), which was designed to improve access to and quality of maternal, newborn and reproductive health services with a focus on postnatal care including post-partum family planning (PPFP) and prevention of mother-to child transmission of HIV (PMTCT).
Other findings show that maternal mortality ratio in Tanzania had been on a downward trend from 453 to 200 per 100,000 live births. However, from 1990’s there been an increasing trend to 578 per 100,000 live births.
Current statistics indicate that maternal mortality ratio has dropped slightly in 2010 to 454 per 100,000 live births. Despite a high coverage (96 per cent) in pregnant women who attend at least one antenatal clinic, only half of the women (51 per cent) have access to skilled delivery.
Coverage of emergence obstetric services is 64.5 per cent and utilization of modern family planning method is 27 per cent. Only about 13 per cent of home deliveries access post natal check-up. Despite a number of efforts maternal mortality is still unacceptably high. Some of the efforts done to reduce maternal mortality in Tanzania included the following initiatives: reproductive and child survival; increased skilled delivery; maternal death audit; coordination and integration of different programs including maternal and child health services, family planning, malaria interventions, expanded program on immunization and adolescent health and nutrition programmes.
These initiatives are however challenged by inadequate access to maternal health care services. In order to considerably reduce maternal deaths some of recommended strategies include: strengthening the health system to provide skilled attendance during child birth; upgrading rural health centres to provide emergency obstetric services; providing adolescent and male friendly family planning services; and strengthening public–private partnership to ensure continuum of care.
Others are supporting operational research to answer the immediate concerns of the health system; and strengthening community participation and women empowerment to take role of their own health and the family at large.
Maternal mortality ratio in Tanzania is unacceptably high and still very far from reaching the millennium development goals. Maternal health care services should focus on ensuring there is continuum of care through strengthening the health system; provision of good quality of health care in a well organized referral health system and operation research to support programme implementation.
Challenges in reduction of maternal death in Tanzania
Despite various efforts done in the country by the government and development partners, maternal mortality ratio in Tanzania has remained very high in the past 10 years and is beyond halfway to reach the MDG target of 133. A number of challenges still prevail as follows.
Accessibility to maternal health care services is still inadequate particularly in rural and underserved areas. Available reports show that only 51 per cent of pregnant women are attended by skilled providers during delivery.
Furthermore, emergency obstetric care (EMOC) service is available in 64.5 per cent of health facilities. Poor utilization of Post-natal check-up of less than 30 per cent increases the risk of maternal death since most of these deaths are happening during the first 24 hours to seven days.
Inadequate infrastructure, poor communication and transport between health facilities and district hospital, inadequate number of skilled personnel and irregular supplies of essential drugs and equipment make the accessibility of this important intervention not possible to a greater number of women.
Despite a high knowledge of family planning among women of reproductive age, only 27 per cent of them use family planning method (TDHS, 2010). Use of family planning has shown to significantly reduce maternal mortality (UNFPA & PATH 2008), since it minimizes the chances of getting unplanned pregnancy which increases risk of unsafe abortion.
More than 94 per cent of women attend antenatal care (ANC) in health facilities at least once but only 47 per cent deliver in these facilities. Even those delivering in health facilities not all receive skilled attendance at birth.
Of the 53 per cent of births that occur outside the health facilities 31 per cent are attended by relatives, 19 per cent by traditional births attendants (TBA) while 3 per cent have no assistance at all (TDHS, 2005).
This indicates that there are factors that impede these women delivering in the health facilities. It is now agreed that skilled attendance at delivery and timely access to quality EmOC when a complication occurs, are the best ways to avoid deaths and morbidities in women.
Some authors support to continue using trained TBAs in areas where home births are common, maternal and neonatal mortality remains high and the shift to skilled attendance at delivery is a distant reality.
Low awareness of danger signs of obstetric complication may be one of the contributing factors for delay or not seeking care when a complication occur thus contributing to the high maternal mortality. Studies in Tanzania show that most women are not aware of danger signs of obstetric complications
Inadequate quality of health services provided by the health care system in Tanzania has been cited as among the reasons for maternal deaths in a study carried out in Dar es Salaam city. Surprisingly, the majority of the deaths occurred among women who had contacted modern health care system and spent reasonable time receiving treatment.
What should be done to mitigate the problem?
Maternal health care services should focus on ensuring there is continuum of care through strengthening the health system and provision of good quality of health care in a well organized referral health system from community level to high facility levels.
Addressing the rural–urban differences should be a priority in order to ensure EmOC services are available up to the peripheral health facility levels. It is important to ensure that health facilities are well equipped with required mix of skilled personnel, essential drugs and simple standard equipment with availability of reliable transport to attend emergency services in case there is a need for referral to high level facilities.
Specific strategies should be in place to empower women, men and community members at large which are complemented with adequate health information for them to make informed decision of issues affecting health and family.
The government budget allocation cannot meet the need of the health system; therefore there is a need for resource mobilization within the country, to fill in the gaps rather than depending largely on donor funding support which are not sustainable.
Government support and leadership commitment, strong public-private partnership in health service delivery, sharing of best practices experiences, and an organized monitoring and evaluation system backed up with a well functioning health information system can help to facilitate improvement of delivery of quality maternal health care services.
In addition, linkages, from the communities, local dispensaries and health centres to first referral hospitals that are adequately equipped, need to be developed and sustained.
In early 20th century, developed countries decreased their maternal mortality through increasing professional midwifery care at delivery and access to effective hospital treatments. When quality care in first line and referral facilities are combined then the maternal mortality can be reduced very fast as occurred in developed countries.
In conclusion, the direct causes and problems associated with maternal death have already been identified and solutions have been proposed. However, the main issue is how to apply the solutions taking into account the socio-cultural, political and economic realities and inherent constraints. The majority of women in Tanzania still deliver at home with no skilled attendant, but even with those who deliver in the health care facilities, the quality of care is questionable.
Scaling up of effective initiatives aimed at reducing maternal death is the key to achieving Millennium Development Goals. However, insufficient resources, and other associated socio-economic and cultural factors preventing an effective scale-up of the interventions are major causes for concern.
Upgrading health workers skills especially staff of lower cadre who are the most common service providers at lower level facilities in the rural areas.
This will involve supporting more training to assistant medical officers and clinical officers to provide EmOC services in rural areas were medical doctors are unavailable. There is need to ensure skilled delivery especially in lower level facilities in rural areas by providing adequate supplies. Evenly distribution of skilled health workers among districts and provision of motivation packages to attract and retain health worker to stay and continue working in rural areas is equally important.
Women empowerment and community participation
There is need for the government to support socio-economic women empowerment programmes so that women can take decision affecting their health and the family at large including decision to access to quality health care. This can be done by proving women with education, entrepreneur skills and facilitate access to financial capital and assistance for self-reliance activities.
Community participation and involvement in health care services should be encouraged and strengthened. This can be done by capacitating village health committees to play their role to monitoring health indicators in their communities and demand for government and other health actor’s support towards health issues facing the particular community. Advocacy should focus to male partner involvement in reproductive health services.
SOURCE:
THE GUARDIAN
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