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Challenges and Successes of Distributing Birth Kits with Misoprostol to Reduce Maternal Mortality in Rural Tanzania

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Challenges and Successes of Distributing Birth Kits with Misoprostol to Reduce Maternal Mortality in Rural Tanzania Sango-Coker and Bein xxxxxxxxxxxxxxxxxxxxx ORIGINAL RESEARCH ARTICLE Challenges and Successes of Distributing Birth Kits with Misoprostol to Reduce Maternal Mortality in Rural Tanzania DOI: 10.29063/ajrh2019/v23i3.7 Gail C. Webber1*, Bwire M. Chirangi2 and Nyamusi J. Magatti2 Bruyere Research Institute, University of Ottawa, Canada1; Shirati KMT District Hospital, Shirati, Rorya, Mara, Tanzania *For Correspondence: Email: [email protected]; Phone: +1 (613) 738-9119 Abstract The Saving Mothers Project was conducted from September 2015 to March 2017 in Bunda and Tarime Districts, Mara Region, Tanzania. The purpose of this project was to train community health workers (CHWs) to use mobile phones applications to register and educate pregnant women about safe deliveries and encourage them to access skilled health care providers for antenatal care and delivery, and to provide nurses and CHWs with clean birth kits with misoprostol to distribute to women. The birth kits were for use in case women could not access the health facility, or if the health facility was lacking supplies at the time of delivery. The overall goal of the study was to reduce the maternal mortality rate by increasing women‘s access to health services where possible, and to clean supplies when a non-facility birth was unavoidable. This paper reports on a mixed methods evaluation of the project including a survey of over two thousand four hundred women, and focus groups with women, community health workers, and nurses participating in the project. The results of the survey and focus groups demonstrate a high degree of satisfaction with the birth kits and misoprostol and an increase in facility birth rates where the project was implemented. Differences between the two districts illustrate that policy maker support is key to successful implementation. (Afr J Reprod Health 2019; 23[3]: 68-78). Keywords: Birth kits, misoprostol, maternal mortality, access to health services, Community health workers, Tanzania Résumé Le projet Saving Mothers a été mené de septembre 2015 jusqu‘au mois du mars 2017 dans les districts de Bunda et Tarime, dans la région de Mara, en Tanzanie. Ce projet visait à former des agents de santé communautaires (ASC) à utiliser des applications du téléphone mobile pour enregistrer et éduquer les femmes enceintes sur la sécurité des accouchements et les encourager à faire appel à des prestataires de soins de santé qualifiés pour les soins prénatals et l'accouchement, et pour fournir aux infirmières et aux ASC des bagages d'accouchement propres contenant misoprostol à distribuer aux femmes. Les bagages d'accouchement devaient être utilisés au cas où les femmes ne pourraient pas accéder au centre de santé, ou si le centre de santé manquait de fournitures au moment de l'accouchement. L‘objectif général de l‘étude était de réduire le taux de mortalité maternelle en améliorant, dans la mesure du possible, l‘accès des femmes aux services de santé, ainsi qu‘à nettoyer les fournitures lorsqu‘un accouchement dans un autre lieu était inévitable. Cet article présente une évaluation du projet comportant plusieurs méthodes, notamment une enquête auprès de plus de deux mille quatre cent femmes et des groupes de discussion avec des femmes, des agents de santé communautaires et des infirmières participant au projet. Les résultats de l'enquête et des groupes de discussion montrent un degré élevé de satisfaction à l'égard des bagages d'accouchement et misoprostol et une augmentation du taux de natalité dans les établissements où le projet a été mis en œuvre. Les différences entre les deux districts montrent que l‘appui des décideurs est la clé d‘une mise en œuvre réussie. (Afr J Reprod Health 2019; 23[3]: 68-78). Mots-clés: Trousses de naissance, Misoprostol, mortalité maternelle, Tanzanie Introduction and childbirth continue to be very high-risk periods in women‘s lives, particularly if they Primary health care for women is not complete reside in a region where obstetric health care without access to quality antenatal care and safe services are difficult to access or poor in quality. childbirth. In many areas of the world, pregnancy Unfortunately, this remains the case for women African Journal of Reproductive Health September 2019; 23 (3):68 Webber et al. Birth Kits with Misoprostol living in rural Tanzania. Despite the efforts of the significant factor, contributing about 15 percent of government and other stakeholders, many deaths15. Tanzanian women still die in childbirth; the Sepsis is a risk for those women who maternal mortality ratio remains very high at 556 cannot access the clean supplies provided at the per 100,000 women1. Women who deliver outside health facilities. To address the risks of postpartum of a health care facility are most at risk, as they hemorrhage and sepsis, we conducted the Saving lack access to life-saving medications and skilled Mothers Project in Tarime and Bunda Districts of birth attendants. There is evidence that for years to Mara Region, Tanzania, near the eastern shores of come, millions of women will not have access to Lake Victoria and Tanzania‘s northern border with skilled birth attendance in Sub-Saharan Africa, Kenya. The overall objective of the project was to thus interventions to reduce deaths in non-attended reduce maternal mortality through increasing births are required2. In the Mara region of women‘s access to safe delivery at health care Tanzania, about 40 percent of women deliver in facilities and providing supplies for women to their villages with no skilled attendants1. Barriers make their deliveries safer. to accessing health facilities in this rural region are Methods numerous and include long distances to the health facilities, accessibility and affordability of Ethical approval for this research was sought and transportation, costs of informal health facility obtained from the Ottawa Health Science Network fees, dissatisfaction with care at the health facility, Research Ethics Board and Bruyere Continuing and cultural beliefs about home births being Care Research Ethics Board in Canada, and the superior3. These barriers are not unique to National Institute of Medical Research in Tanzania but are also common to low and middle- Tanzania. To address the gaps in primary care income countries around the globe4. services in this region, we trained CHWs to The most common cause of maternal support the health system by using mobile phone mortality is postpartum hemorrhage, accounting applications to register pregnant women from their for about one third of maternal deaths in Africa5. villages. Once registered the CHWs then educated For the women who deliver in the villages or on the women about healthy pregnancies and safe the way to a health facility without skilled birth birthing practices, warned them about danger attendants, oral misoprostol is an effective signs, encouraged them to attend health facilities alternative to injectable medications to prevent for antenatal care and delivery, and provided them postpartum hemorrhage5-7. The World Health with a clean delivery kit with misoprostol for Organization and International Federation of prevention of postpartum hemorrhage and sepsis if Obstetricians and Gynecologists have the woman had not already received the kit from a recommended the use of oral misoprostol in nurse at the health facility. The birth kit contained situations where injectable medications cannot be soap for the woman to wash, a clean mat for provided8,9. Misoprostol does not require delivery, two pairs of gloves, two cord clamps and refrigeration and can be self-administered; thus, it a blade to cut the cord, a pad for postpartum use is particularly suitable for use in rural and 600 mcg of misoprostol (to be taken orally communities. The Tanzania Food and Drug immediately after delivery). Women were Authority have approved misoprostol for use in the recruited if they were pregnant, lived in the study prevention of postpartum hemorrhage (PPH)10. In districts and were willing to receive a birth kit. the literature, traditional birth attendants (TBAs)11, There were no exclusion criteria. The CHWs and dispensary nurses12, and both community health nurses were encouraged to distribute as many kits workers (CHWs) and dispensary nurses13,14 have as possible during the study. The project also been successfully used to distribute misoprostol to included regular meetings with policy makers at women for PPH prevention in Tanzania. While the district and regional levels, as there is good postpartum hemorrhage is the highest cause of evidence for the need for policy maker maternal deaths globally, puerperal sepsis is also a engagement to improve program sustainability of African Journal of Reproductive Health September 2019; 23 (3):69 Webber et al. Birth Kits with Misoprostol misoprostol distribution16,17. As per the direction of the local government partners, the study was District (36 percent). (The population of Bunda conducted in Tarime Rural District and the whole District was 335,061 and the population of Tarime of Bunda District (which as later split into Bunda District was 339.693 according the 2012 Rural and Bunda Town Districts). Tanzanian census data, however, we did not To evaluate this project, we conducted a include Tarime town in this study as the focus was survey with a proportion of the women who had on rural populations.). The results from the survey been registered by the CHWs. Information letters data are shown below in Tables 1 to 3. Table 1 were provided to all survey participants in Swahili provides the demographic information about the and the letters were read to them if they were women who were surveyed. The average age of unable to read the letter themselves. Each the women was 25.6 years, and the average participant was asked to provide signed consent. number of children they had was 3.4. Over 80 Women under the age of eighteen were requested percent of the women reported living within 10 km to have a family member also sign the consent of the nearest dispensary or health centre, while form.
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