Improving health care facility birth rates in Rorya District, Tanzania: a multiple baseline trial

Gail Webber,Nyamusi Magatti,Monica Taljaard,Bwire Chirangi,Ranjeeta Mallick

doi:10.1186/s12884-022-04408-5

Gail Webber, Nyamusi Magatti + Show 3 more

Open Access

https://doi.org/10.1186/s12884-022-04408-5

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Abstract

BackgroundRates of maternal mortality and morbidity in Africa remain unacceptably high, as many women deliver at home, without access to skilled birth attendants and life-saving medications. In rural Tanzania, women face significant barriers accessing health care facilities for their deliveries.MethodsFrom January 2017 to February 2019 we conducted a multiple baseline (interrupted time series) trial within the four divisions of Rorya District, Tanzania. We collected baseline data, then sequentially introduced a complex intervention in each of the divisions, in randomized order, over 3 month intervals. We allowed for a 6 month transition period to avoid contamination between the pre- and post-intervention periods. The intervention included using community health workers to educate about safe delivery, distribution of birth kits with misoprostol, and a transport subsidy for women living a distance from the health care facility. The primary outcome was the health facility birth rate, while the secondary outcomes were the rates of antenatal and postpartum care and postpartum hemorrhage. Outcomes were analyzed using fixed effects segmented logistic regression, adjusting for age, marital status, education, and parity. Maternal and baby morbidity/mortality were analyzed descriptively.ResultsWe analyzed data from 9565 pregnant women (2634 before and 6913 after the intervention was implemented). Facility births increased from 1892 (71.8%) before to 5895 (85.1%) after implementation of the intervention. After accounting for the secular trend, the intervention was associated with an immediate increase in the odds of facility births (OR = 1.51, 95% CI 1.14 to 2.01, p = 0.0045) as well as a small gradual effect (OR = 1.03 per month, 95% CI 1.00 to 1.07, p = 0.0633). For the secondary outcomes, there were no statistically significant immediate changes associated with the intervention. Rates of maternal and baby morbidity/mortality were low and similar between the pre- and post-implementation periods.ConclusionsAccess to health care facilities can be improved through implementation of education of the population by community health workers about the importance of a health care facility birth, provision of birth kits with misoprostol to women in late pregnancy, and access to a transport subsidy for delivery for women living at a distance from the health facility.Clinical trials registrationNCT03024905 19/01/2017.

Highlights

Rates of maternal mortality and morbidity in Africa remain unacceptably high, as many women deliver at home, without access to skilled birth attendants and life-saving medications
After accounting for the secular trend, the intervention was associated with an immediate increase in the odds of facility births (OR = 1.51, 95% confidence intervals (CIs) 1.14 to 2.01, p = 0.0045) as well as a small gradual effect (OR = 1.03 per month, 95% CI 1.00 to 1.07, p = 0.0633)
This study demonstrated that facility birth rates can be improved by a complex intervention including CHWprovided education about the importance of health facility births, late third trimester provision of free supplies in birth kits, and transportation subsidies for women living at a distance from the health facility

Summary

Introduction

Rates of maternal mortality and morbidity in Africa remain unacceptably high, as many women deliver at home, without access to skilled birth attendants and life-saving medications. In rural Tanzania, women face significant barriers accessing health care facilities for their deliveries. Two thirds of global maternal deaths in 2017 were in Sub-Saharan Africa - an estimated 196 thousand women died in this region [1]. Most maternal deaths can be averted by high quality maternal health care by skilled providers in well-equipped settings, there are many barriers to care. Thaddeus and Main [2], have described the three delays women experience in accessing health care services at the time of their deliveries: the delay in making the decision to go, the delay in finding transport, and the delay in receiving care once at the health facility. Physical equipment and supplies within the facility, the availability of staff to deliver services, and appropriate and timely referrals are key components [5]

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