The United Republic of Tanzania Ministry of Health and Social Welfare
Needs Assessment of Reproductive Maternal Newborn and Child Health in Lake and Western Zones of Tanzania
Technical Report
July 2015
Disclaimer
This need assessment was conducted by a team of contributors from National Institute for Medical Research (NIMR). Funding of the survey was organized by the MOHSW and implemented by the United Nations through UNFPA. The opinions given herein are those of the authors and are not necessarily reflective of the funding agents or the government of Tanzania.
List of contributors
SN Name Affiliation 1. Dr Julius J.Massaga NIMR
2. Dr Edward S.Maswanya NIMR 3. Dr. Gasto Frumence MUHAS 4. Dr.Ahmadi Makuwani MoH&SW/EAC 5. Ms. Stella Kilima NIMR 6. Ms. Grades Stanley NIMR 7. Prof. Projectine S.Muganyizi MUHAS
MsRegional Grades supervisors Stanley 1. Dr. Judith Msovela Shinyanga
2. Dr. Magreth Kagashe Geita
3. Dr. Ali Said Mwanza 4. Ms. Diana Kasembe Tabora 5. Ms, Alfreda Kabakama Kagera 6. Ms, Winfrida C.Newa Simiyu 7. Ms Vicky Magoti Mara 8. Ms. Eugenia Kidyalla Kigoma 9. All data collectors Appendix
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TABLE OF CONTENT
LIST OF ABBREVIATIONS ...... VIII EXECUTIVE SUMMARY ...... X 1. BACKGROUND ...... 1 1.1 EMERGENCY OBSTETRIC AND NEWBORN CARE (EMONC) IN TANZANIA ...... 2 2 METHODOLOGY AND LIMITATIONS ...... 5 2.1 SAMPLE SIZE AND DESIGN ...... 5 2.1 QUESTIONNAIRE ...... 8 2.2 TRAINING OF FIELD STAFF ...... 8 2.3 DATA COLLECTION AND QUALITY CONTROL ...... 9 2.4 DATA ANALYSIS AND PRESENTATION ...... 9 2.5 LIMITATIONS OF THE SURVEY ...... 11 1. FINDINGS ...... 13 3.1 AVAILABILITY OF EMONC SERVICES ...... 13 3.2 EMONC SERVICE UTILIZATION ...... 21 3.3 QUALITY OF LABOUR MONITORING USING PARTOGRAPHY ...... 28 3.4 REFERRAL SYSTEM AND INFRASTRUCTURE ...... 31 Distance to refferal Health facility ...... 33 3.5 NEWBORN CARE ...... 35 4 CONCLUSION AND RECOMMENDATIONS ...... 45
LIST OF TABLES
Table 1: Calculation of sample weights for Kagera region ...... 10
Table 2: Distribution of potential EmONC health facilities by type and region in Lake and Western Zones ...... 13
Table 3: Percentage of fully functional health facilities in the Lake and Western Zones ...... 15
Table 4: Distribution of fully functional EmONC facilities per population in the Lake and Western zones ...... 16
Table 5: Percentage of all potentially EmONC health facilities that provided specific EmONC signal functions in last three months ...... 18
Table 6: Percentage of EmONC health facilities that provided specific EmONC signal functions adjusted for absence of indicated cases and limiting policy issues...... 18
Table 7: Percentage of Health Facilities giving reasons for failure to provide BEmONC functions ...... 21 iii | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Table 8: Crude Birth Rates and proportion of births in EmONC health facilities in the Lake and Western zones ...... 22
Table 9: Annual Caesarean Section Rate for deliveries that occurred in the Lake and Western zones of Tanzania, 2014 ...... 23
Table 10: Direct causes of Mortality- All cases, deaths and Case Fatality Rate in Lake and Western Zone, 2014 ...... 26
Table 11: Percentage of Health Facilities using specific types of partograph ...... 31
Table 20: The distribution of Average Time Distance to nearest referral point for EmONC health facility in Lake and Western Zones ...... 34
Table 21: Proportion (%) of Health Facilities with sanitation and sterilization services ...... 35
Table 23: Percentage of Health Facilities with utilities for newborn and adult resuscitation in ...... 36
Table 22: Percentage of HFs with elements of essential newborn care and baby friendliness services .. 37
Table 24: Percentage of Health Facilities with utilities for newborn care in Neonatal room ...... 38
Table 25: Percentage of Health Facilities with case management protocols in place ...... 39
Table 26: Percentage of Health Facilities that consistently provided Antenatal tests and services in last three months ...... 40
Table 27: Percentage of all Health Facilities that provided Family planning Methods in last three months ...... 42
LIST OF FIGURES
Figure 1: Total number of health facilities that provide delivery services in Lake and Western zones ...... xi
Figure 2: Percentage of all deliveries that took place in health facilities (weighted data)...... xii
Figure 3: Percentage of health facilities that provided full sets of EmONC functions in last three months ...... xiii
Figure 4: Proportion of deliveries in full and non-fully functional health facilities ...... xiv
Figure 5: Percentage of direct obstetric complications treated in health facilities (weighted data) ...... xiv
Figure 6: Annual Cesarean section rates (%) in Lake and Western Zone during 2014...... xv
Figure 7: Percentage of health facilities that provided EmONC functions in last three months ...... xvi
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Figure 8: Percentage met need for fully functional EmONC facilities by region ...... xvii
Figure 9: Overall Case Fatality Rate (%) for the major direct obstetric complications in 2014 ...... xviii
Figure 10: Causes of maternal deaths in the Lake and Western zones ...... xix
Figure 11: Percent distribution of maternal deaths by health facility level and region ...... xix
Figure 12: Percent distribution of maternal deaths by health facility level and obstetric complication .... xx
Figure 13: Percentage of health facilities that had not used partographs in last three months ...... xxi
Figure 14: Percentage of health facilities that ranked good to excellent on partograph filling ...... xxi
Figure 15: Percentage of heath facilities providing intergrated RMCH services by region ...... xxiii
Figure 16: Percentage of heath facilities in access of ambulance service ...... xxiv
Figure 17: Average time in hours needed to transfer a patient to the nearest referral points by region. xxv
Figure 18: Assessment organisation and Management ...... 5
Figure 19: The distribution of the surveyed potential EmONC Health Facilities in Western and Lake zones...... 7
Figure 20: Field workers attending a training session in May 2015...... 9
Figure 21: Percentage of all the potential EmONC facilities with capacity to perform Caesarean section14
Figure 22: Distribution of EmONC services in Lake and Western Zones ...... 17
Figure 23: Percentage of Health Facilities that performed EmONC Signal function in the last 3-month. 20
Figure 24: Percent of all Institutional deliveries taking place in fully functional and non-fully functional EmONC facilities ...... 22
Figure 25: Institutional delivery in the Lake and Western Zones ...... 23
Figure 26 : Distribution of causes of maternal mortality in the study Zones ...... 27
Figure 27: Percentage of maternal deaths occurring in HF type by region ...... 27
Figure 28: Percent distribution of cause-specific maternal deaths by type of health facilities ...... 28
Figure 29: Percentage of all HFs that did not have partographs to monitor labour in last three months 29
Figure 30: Percentage of all Health Facilities scoring good to excellent on Partograph (P1-P4) filling .... 29
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Figure 31: Percentage of all Health Facilities scoring good to excellent on Partograph (P1-P4) filling by zone, ownership and type ...... 30
Figure 32: Availability of means of referral system in lake and western zone Regions ...... 32
Figure 34: Percentage of HF with access to ambulance services in the Lake and Western Zones ...... 32
Figure 34:Average time in hours taken to the referral point in the Lake and Western Zones...... 34
Figure 35: Coverage (%) of Routine ANC services provided by HFs by region...... 41
Figure 36: Proportion of EmONC health facilities with electric power supply ...... 43
Figure 37: Proportion of Health facilities with water supply ...... 44
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Acknowledgements
The smooth completion of the need assessment of reproductive maternal newborn and child health in lake and western zones of Tanzania was made possible by the joint efforts of a number of organizations and individuals, whose participation we would like to acknowledge with gratitude. First, we would like to thank the Ministry of Health and Social Welfare (MOHSW) for mobilizing resources and for the support throughout implementation of this exercise. We thank the Technical Working Group for Reproductive and Child Health Service (RCHS) under the Ministry of Health and Social Welfare (MOHSW) for the inputs to this study. Furthermore, we acknowledge all Regional Administrative Secretaries, Regional Medical Officers, Regional Reproductive Health Coordinators, District Medical Officers, District Reproductive Health Coordinators, health facility managers and MNCH service providers for accepting to participate in the assessment.
In addition, we express our gratitude to the task team for their commitment to review this work at different stages of development. The team consisted of Dr. Georgina Msemo (MOHSW), Dr. Koheleth Winani (MOHSW), Dr. Victor Bakengesa (MOHSW), Dr. Mary Azayo (MOHSW), Mr. Clement Kihinga (MOHSW), Dr. Dadi Rutasha (UNFPA), Dr. Jarrie Kabba-Kebbay (UNFPA), Dr. Theopista John (WHO) and Dr. Asia Hussein (UNICEF).
A considerable number of other stakeholders contributed to the proposal development. The survey would not have taken off the ground without the support of National Institute for Medical Research (NIMR). Similarly; we would like to convey our gratitude to all regional supervisors for training data collectors and supervising data collection process. We are ever more grateful to all the survey respondents who generously contributed part of their time and efforts to enable us gather crucial data for this important exercise. The Ministry of Health and Social Welfare through the United Nations Population Fund (UNFPA), Tanzania country office for making the assessment possible through a financial support and technical, WHO and UNICEF for providing highly needed technical input.
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List of abbreviations
1. AMDD Averting Maternal Death and Disability 2. AMREF African Medical and Research Foundation 3. EmONC Emergency Obstetric Newborn Care 4. BEmONC Basic Emergency Obstetric and Newborn Care 5. BRN Big Results Now 6. CEmONC Comprehensive Emergency Obstetric and Newborn Care 7. CBO Community Based Organization 8. CHMT Council Health Management Team 9. CBR Crude Birth Rate 10. DRCHCo District Reproductive and Child Health Coordinator 11. FBO Faith Based Organization 12. FGD Focus Group Discussion 13. GIS Geographic Information System 14. GPS Global Positioning System
15. HF Health Facility 16. HSSP Health Sector Strategic Plan
17. HMIS Health Management Information System 18. IDI In depth Interview 19. MoHSW Ministry of Health and Social Welfare 20. MRH Maternal and Reproductive Health 21. MDG Millennium Development Goal 22. MMR Maternal Mortality Rate 23. MNCH Maternal Neonatal Child Health 24. MVA Manual and Vacuum Aspiration 25. MTUHA “Mfumo wa Taarifa za Huduma za Afya” in English “Health Management Information System”
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26. NBS National Bureau of Statistics 27. NIMR National Institute for Medical Research 28. RCH Reproductive Child Health 29. RMNCH Reproductive Maternal Newborn and Child Health 30. RMO Regional Medical officer 31. RCHCo Regional Reproductive and Child Health Coordinator 32. SRH Sexual Reproductive Health 33. UNFPA United Nations Population Fund 34. UNICEF United Nations Children's Fund 35. WHO World Health Organization
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EXECUTIVE SUMMARY The 2015 Emergency Obstetric and Newborn Care (EmONC) needs assessment in the Lake and Western Zones of Tanzania was conducted in early June and data analysis started early July. The main objective of this assessment was to establish the availability, utilisation and quality of the provided EmONC services. Data collection was done using a tool adapted from AMDD and modified to include extra questions that were relevant from the local context perspective. Data collection involved physical visits to the selected health facilities and to different units within the facility. The sourses of information were multiple including interviews with facility managers and unit in-charges, review of routinely stored data including MTUHA and HIMS, review of documents and direct observation of the services. The data were entered into an electronic questionnaire and promptly submitted through online system. At the same time the GPS location of the health facility was captured and automatically sent along with the data. The entire process of tool development, data collection, data analysis and report writing were done by the team of researchers from NIMR and MUHAS in close supervision by the RCH Technical Committee of the MoHSW. During data analysis, where nationally generated demographic data were needed we relied on the 2012 National Population and Housing Census data as obtained from the National Bureau of statistics (NBS). The main results in this document are interpreted against the United Nations standard indicators for EmONC needs assesment.
Availability of EmONC Health Facilities In total 1609 HFs were identified as providers of delivery services in the two zones with the Lake zone contributing 1197 (74.4%). Overall 1348 (83.7%) of the HFs that conducted deliveries were dispensaries (Figure 1). Four regions, Tabora, Mwanza, Mara and Kagera had the number of HFs above 200. Geita region had the lowest number (n=113) of all the regions.
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Figure 1: Total number of health facilities that provide delivery services in Lake and Western zones
Service access and utilization Institutional delivery is usually compared with a reliable and recent National rate. In all the regions institutional delivery was above the National average of 51% except Simiyu which had the lowest institutional delivery rate of 46% (Figure 2). Institutional delivery rate for Mara exceeded 100% probably indicating service provision to people from outside the regional population.
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Figure 2: Percentage of all deliveries that took place in health facilities (weighted data).
Health facilities that provide delivery services should be able to provide a full set of EmONC functions in order to be able to effectively manage the complications of pregnancy and childbirth. According to UN indicators a health facility should have provided a full set of EmONC functions in the last three months in order to become Fully Functional EmONC health facilities. Such health facilities were generally few across the regions ranging from 12% (Simiyu) to 38% (Mara) for BEmONC functions and 12% (Shinyanga) to 60 %(Kagera) for health facilities that were capable of providing CEmONC (Figure 3).
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Figure 3: Percentage of health facilities that provided full sets of EmONC functions in last three months
In most regions institutional deliveries were mostly taking place in non-fully functioning EmONC facilities that were unable to provide all emergency services (Figure 4).
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Figure 4: Proportion of deliveries in full and non-fully functional health facilities
Although institutional delivery was generally encouraging, met need for EmONC services was low. Met need estimates the proportion of all women with major direct obstetric complications that seek treatment in EmONC health facilities. Met need for EmONC services varied across the regions from 7% in Geita to 46% in Mara (Figure 5), all far below the recommended 100%.
Figure 5: Percentage of direct obstetric complications treated in health facilities (weighted data)
Cesarean section is a common intervention to avert maternal and newborn morbidity and mortality. Overall, 90% of hospital and 32% of health centres in the study zones were capable of performing Cesarean section with Kigoma reporting the highest percentage of health centres (54%).
It is recommended that a population Cesarean section rate should range between 5-15%. In this survey the Population Cesarean section rate across regions revealed poor access in the range of 0.3-3% as compared to what is recommended. This indicates that there are many women who need Cesarean section in Lake and Western Zones but who have no access to this service (Figure 6).
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Figure 6: Annual Cesarean section rates (%) in Lake and Western Zone during 2014
A health facility does not necessarily need to provide a full set of EmONC functions in order to save mothers’ and Newborns lives. A focus on the provision of individual EmONC functions also indicates that most facilities were not well prepared to effectively manage the major obstetric causes of maternal and perinatal morbidity and mortality. Overall 426 (54.8%) of the surveyed facilities did not provide all the 7 BEmONC functions in the last three months including 162 (62.1%) hospitals. Accross the regions BEmONC functions that were provided by the least proportions of facilities in the last three months were assisted vaginal delivery using Vacuum (16- 43%) and evacuation of products of conception (37-64%). Injectable uterotonics were universally available (90-100%) across the regions followed by injectable antibiotics (81-99%) and newborn resuscitation (72-96%), Figure 7.
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Figure 7: Percentage of health facilities that provided EmONC functions in last three months
Provision of CEmONC functions among hospitals and health centres was also very sporadic. Cesarean section in the last 3 months was provided by just 1%-10% of all the hospitals and health centres and Blood was provided by 8-19% of all the health hospitals and health centres across regions. When these figures were adjusted to exclude facilities that did not attend an indicated case for Cesarean section or Blood transfusion and those hospital and health centres that had some policy issues limiting their performances, across the regions 25-90% of the health facilities provided Cesarean Section and Blood transfusions. Among facilities that did not perform CEmONC functions the main reasons for non-performance were the lack of training (mentioned by 45-80% of HFs across the regions) and supply issues (51-88%).
Access to EmONC services is also dependent on the geographical distribution of service providing HFs. A UN indicator requires that a minimum of 5 fully functional
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EmONC facilities should be available per 500,000 populations and at least one of them should be a fully functioning CEmONC. Using this criterion, fully functional EmONC health facilities exceeded the minimum UN standards in Mwanza (126%) and Kagera (122%) regions. Most regions were above 50% of the UN indicator except Simiyu (31.6%) and Shinyanga (32.6%) regions that operate at only one-third of the minimum recommended level (Figure 8). Nevertheless all the regions had a huge potential of health facilities that can be upgraded to the desired level.
Figure 8: Percentage met need for fully functional EmONC facilities by region
Quality of EmONC services
One of the measures of quality EmONC services is case fatality rate which shows the percentage of women who are treated for a severe direct obstetric complication that dies of the complication. This percentage should not be more than 1% in circumstances of standard care. In this study across the regions the range was 1-8% for all the major direct obstetric complications with sepsis leading by 8% Case fatality Rate (Figure 9). This indicates that there is still a room to save mothers and their newborns from dying of severe direct obstetric complications in EmONC health facilities by maximizing the quality of care.
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Figure 9: Overall Case Fatality Rate (%) for the major direct obstetric complications in 2014
Hemorrhage was the cause of maternal deaths being responsible for almost a third of all maternal deaths, followed by abortion complications (19%) and obstructed labor (13%), (Figure 10). Overall 41% of all maternal deaths in the Lake and Western Zones are related to hemorrhage and anemia indicating a huge demand for blood.
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Figure 10: Causes of maternal deaths in the Lake and Western zones
Further, the results of this survey show that except for Mwanza region, most deaths were occurring in lower level health facilities, mostly in dispensaries. In six (75%) regions, Simiyu, Shinyanga, Geita, Tabora, Kagera and Kigoma most maternal deaths occurred in dispensaries facilities (Figure11).
Figure 11: Percent distribution of maternal deaths by health facility level and region
Deaths in the lowest level facility (the dispensary) included conditions that are better managed at higher-level facilities (Figure 12).
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Figure 12: Percent distribution of maternal deaths by health facility level and obstetric complication
Deaths that mostly occurred in dispensaries include Sepsis (57%), Hypertensive disorders (54%), Anemia (51%) and Hemorrhage (40%) with the last two requiring blood transfusion service that is typically unavailable at this facility level. Moreover, 64% of deaths due to abortion and 59% of all deaths due to malaria occurred in health centres. These results indicate that poor adherence to referral is deep rooted in the community and lower facility levels.
The Partograph as a labor progress monitoring tool was not consistently used by the majority of health facilities. Overal 60% of all the facilities had not used a partograph in last three months. The problem was particularly big in Kigoma, Mara and Simiyu where partograhs were not used by more than half of their health facilities (Figure 13).
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Figure 13: Percentage of health facilities that had not used partographs in last three months
For each of the health facility that had used a partograph, the use of partograhs was ranked according to how correctly the 4 reviewed partographs were filled. Kigoma and Mwanza had the lowest proportions of health facilities in the rank of good to excellent. Kagera had good to excellent scores in around 80% of all its health facilities that were using Partographs (Figure 14). Overall hospitals scored the best of the other types of facilities.
Figure 14: Percentage of health facilities that ranked good to excellent on partograph filling
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Regarding sanitation and infection prevention and control, across the regions, only 8-29% of HFs had toilets and a shower connected to labor room and the majority of these toilets were clean. The availability of three buckets decontamination system was almost universal (77- 100%) across regions, and 58-83% of them had the disinfectant changed in 24 hours as recommended.
Many labor rooms did not have important protocols to guide EmONC service delivery. A protocol for Help Babies Breath (HBB) was the commonest protocol that was observed in the labor room being possessed by 15% of HFs in Shinyanga to 83% in Mara. Protocol for Kangaroo Mother Care (KMC) was only available in 4-22%.
Newborn care, Antenatal and FP services
Functional suction machines (69-95%), Ambu bag (49-91%) and Penguine sucker (23-93%) were the most commonly available newborn resuscitation apparatus across regions. Heating source for newborns was available only in 5-30%, yet KMC was practiced in just 6-26% of HF across regions.
The integration of Immunisation (TT), PMTCT services, ARV provision, IPTp, with antenatal services was almost universal; however the routine antenatal screening tests including syphilis test, urine test, Hb test were the least practiced by less than 50% of health facilities. This pattern of preference of intergrated services over the primary routine antenatal care services was similar in all the study regions (Figure 15).
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Figure 15: Percentage of heath facilities providing intergrated RMCH services by region
FP methods were largely available except the permanent methods (Vasectomy and BTL), EC and PPIUD that were least practiced.
Referral system
The availability of ambulance services was the lowest in Mara, Kigoma, and Kagera where only about half of HFs had access to own or hired ambulances. By far most HFs relied on hired ambulances from a neighboring HF or the district hospital (Figure 16).
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Figure 16: Percentage of heath facilities in access of ambulance service
Hired ambulances were not an efficient means for case transfer in emergency situations as indicated by the multiple complaints of inefficiency from almost all of HFs using this kind of ambulance. Transfer of referred patient to referral points was through the longest average distance of more than 3 hours in Shinyanga, Kigoma, Simiyu and Mwanza (Figure 17).
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Figure 17: Average time in hours needed to transfer a patient to the nearest referral points by region.
Conclusion and Recommendations
In conclusion, although the number of EmONC health facilities and delivery in EmONC HFs had improved, access to EmONC services and quality services were suboptimal in all the regions indicating that maternal care system is not working well. It is therefore recommended that:
All EmONC indicators should be part of routine health information system.
Improve fully functional EmONC facilities through upgrading of the existing HFs
Put in place a functioning system at the health facility, district and regional levels that analyses EmONC indicators regularly and give feedback for improvement. Recognition of HFs with consistently good performance may improve EmONC services.
To channel most resources on improving service quality rather than quantity
To reinforce community awareness campaign with emphasis on early identification of severe obstetric complications and reporting to appropriate HFs. This campaign should aim at increasing the met need for EmONC.
To conduct a community based study to understand why women with severe complications are not treated in EmONC health facilities. The study should also focus on training needs of healthcare workers.
To improve communication infrastructure and strengther ambulance systems in order to promptly refer patients to points where they can be adequately managed.
To train and carry a sustainable system for continual education of health care workers especially in lower level health facility.
Blood is key in managing many causes of maternal deaths. There was need to promote availability of blood for Hemorrhage and anemia that has contributed 41% of all deaths.
To identify HFs and areas with special needs such as non-use of partograph, poor indicators such as Simiyu region and focus on their special needs.
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1. BACKGROUND The United Republic of Tanzania (URT) has identified many economic and social development challenges as national priorities. Consistent with the health Millennium Development Goals (MDGs), Tanzania’s national development priorities address public health and healthcare challenges including those related to maternal, newborn, and child health (MNCH). For instance maternal mortality ratio (MMR) currently standing at 410 per 100000 live births and under five mortality rate of 54 per 1,000 live births1 are still are among the major challenges facing the health sector in Tanzania.
Although Tanzania has witnessed a decline of maternal mortality ratio from 870 per 100,000 live birth (UN 1990) to 454 per 100,000 live births2, the annual reduction rate of MMR of 3.2% reported at this period has was insufficient against the UN recommended rate of at least 5% (Tanzania One Plan MTR). Furthermore, despite the fact that Tanzania is among the sub Saharan countries reported to attain its MDG 4 goal of reducing underfive mortality by 2/3, the country is as yet to attain its MDG 4 goals of reducing newborn mortality rate to 19 per 1000 live births by December, 20153.
The causes of maternal mortality are known. Each year in Tanzania, Hemorrhage, Hypertensive disorders of pregnancy, obstructed labour, infection (sepsis) and abortion- related complications are the leading causes of maternal deaths. For each maternal death a significant number of women suffer pregnancy- and delivery-related morbidities and disabling conditions. Report from the MoHSW show that in Tanzania, haemorrhage is the most frequent cause of maternal deaths accounting for 28% of maternal deaths, followed by unsafe abortion (19%), hypertensive disorders in pregnancy (pre-eclampsia/eclampsia [PE/E]) (17%), infections/sepsis (11%) and obstructed labour4. The Tanzania countdown case study report 2015 shows that the haemorrhage and severe preeclampsia/eclampsia
1 WHO (2014). Countdown to 2015. Fulfilling the health agenda for women and children—the 2014 Report. Geneva: World Health Organization.
2 National Bureau of Statistics of Tanzania (2011). ICF Macro. Tanzania Demographic and Health Survey 2010. Calverton, MD: ICF Macro.
3 UNICEF, WHO, The World Bank and United Nations (2013). Levels and Trends in Child Mortality – Report 2013. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf (Accessed June 25, 2015).
4 United Republic of Tanzania Ministry of Health and Social Welfare (2008). The National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania (2008–2015) — One Plan. Dar es Salaam: Ministry of Health and Social Welfare.
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The Government of Tanzania has been continuing to invest a number of interventions towards improving maternal and child health and achieve the Millennium Development Goals number 4 and number 5. The 2008-2015 National Roadmap Strategic Plan to accelerate reduction of Maternal, Newborn and Child death will reach to an end shortly. Other long-term development programmes such as Vision 2025, the National Strategy for Growth and Reduction of Poverty (NSGRP), and the Primary Health Services Development Program (PHSDP-MMAM) have been ongoing concurrently with the expected positive impact on health and development. MNCH services are key components of the National Package of Essential Reproductive and Child Health Interventions focusing on improving the quality of life of women, adolescents and children. The major elements of the package include ANC, care during delivery, EmONC and Child Health Services. Periodic reviews of these programs have been conducted to measure the progress in key indicators of these plans.
1.1 Emergency Obstetric and Newborn Care (EmONC) in Tanzania In Tanzania Basic Emergency Obstetric and Neonatal Care (BEmONC) is provided at primary health care facilities, whilst Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) is provided in hospitals and upgraded health centres (MoHSW, 2013). Emergency Obstetric Care (EmONC) is required to handle potentially life-threatening complications during pregnancy that affect both the mother and newborn.
Emergency Obstetric and Newborn signal functions for the effective obstetric and newborn care are shown in the table below.
EmONC Signal function Basic Comprehensive EmONC EmONC 1. Administer parenteral antibiotics X X 2. Administer parenteral oxytocic’s X X 3. Administer parenteral anticonvulsants X X 4. Perform manual removal of placenta X X 5. Perform removal of retained products X X 6. Perform assisted (instrumental) vaginal births X X 7. Newborn resuscitation using ambubag&mask X 8. Perform safe blood transfusions X 9. Perform surgery (birth by caesarean section) X *Among those facilities offering delivery services; Source: Manji 2009
5 Afnan-Holmes, et al., (2015). Tanzania’s Countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015. Lancet Glob Health, Vol 3 July 2015
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According to the 2006 EmONC survey of mainland Tanzania, comprehensive EmONC services were available in 65 percent of hospitals surveyed, and basic services were available in just 6 percent of surveyed health centres. None of the regions met basic EmOC requirement (four BEmONC facilities per 500,000 people) and just nine out of 21 regions met the comprehensive EmONC requirement (one comprehensive EmONC facility per 500,000 people). Both essential drugs and supplies were lacking in several of the surveyed districts6.
In 2008, the Tanzania Maternal, Newborn, and Child Health Partnership launched a set of strategies for reducing mortality through the adoption of the ―One Plan and set key targets for improved maternal, newborn, and child health4. Two operational targets stated in the plan and reinforced in the Sharpened Plan were focusing in ensuring that 100% of hospitals provide comprehensive EmONC and 70% of health centres and dispensaries provide basic EmONC by 20157. Currently, SARA report, 2013, has showed that only 20% and 39% of dispensaries and health centres respectively were providing BEmONC services and 7% and 73% of health centres and hospitals respectively were CEmONC compatible8.
Internationally recognizes access to family planning services, available skilled birth attendant and EmONC services to be important strategies in reducing maternal and newborn mortality. However, a mid-term review of the Health Sector Strategic Plan III 2009 – 2015, showed that despite of the increase in additional resource allocation to maternal and newborn health, shown by some increase in skilled birth attendance (from 43% to 52%) and an increased in BEmONC, overall RMNCH service deliveries are still underperforming. This is demonstrated by shortages of staff, medicines and supplies at service delivery point8. The situation painted above tally with a 2009 Health Sector Performance Profile Report which showed a critical shortage in medical doctors, nurses, clinical officers and pharmacists/technicians9. The picture drawn above inevitably affects the quality of health services provided including EmONC. Further evidence reveals that skilled birth attendant is shown to be approximately
6 Manji, K (2009). Situation analysis of newborn health in Tanzania: Current situation, existing plans and strategic next steps for newborn health. Dar es Salaam: Ministry of Health and Social Welfare, Save the Children; 2009.
7 United Republic of Tanzania Ministry of Health and Social Welfare (2014). The Sharpened One Plan—The National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008–2015. http://www.mamaye.or.tz/sites/default/files/evidence/RMNCH%20Plan%202014%20to%202015.p df (Accessed June19, 2015).
8 Ministry of Health and Social Welfare United Republic of Tanzania (2013), Tanzania Service Availability And Readiness Assessment (Sara). Dar es Salaam, Tanzania.
9 Ministry of Health and Social Welfare United Republic of Tanzania (2009). Health sector performance profile report 2009. Dar es Salaam, Tanzania.
3 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 two midwives per every 1,000 births in the country; 42% of rural births where more than 80% of the Tanzania’s population live are attended by skilled health personnel; and the majority of rural births are done at home10, 11.
HSSP III and One plan (2008- 2015) reviews have shown that the Lake and Western zones of Tanzania comprise of regions which are under performing on various RMNCH indicators compared to other regions in the country. For instance, only one-third of all women in Mara region deliver in a health facility (HF) compared to the Lake Zone average of 45% and national average of 50%11. Addressing this as a gap, Tanzania launched RMNCH Sharpened One Plan 2014-2015and health sector “Big Result Now (BRN)” approach which, prioritised a set of interventions based on evidences from midterm review of the HSSP III and One Plan 2008-2015. The priorities include; geographical focus (Lake and Western zones), address issues of high burden population, target and expand coverage on selected high impact interventions, provide supportive environment for education empowerment and equity and mutual accountability and transparent. Moreover, using Life Saved Tool (LisT) analysis showed that if the country needs to accelerate in reduction of maternal and newborn mortality, more resources were required to increase provision of high impact interventions, notably Family Planning services, care at birth, postpartum and postnatal care and commodity security5.
This EmONC assessment aimed at understanding distribution of services in a specified geographical location of the country by assessing all enablers of EmONC service delivery. This was a rapid assessment of EmONC and other related services in all eight (8) regions of Lake and Western Zones in order to understand the current situation on the availability and quality of EmONC services provided and provide recommendations based on the findings.
Rationale of the Study This study wanted to establish the availability and accessibility of emergency obstetric and newborn care services including (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) in the eight regions that constitute the Lake and Western zones of Tanzania. The results obtained from the assessment provide better understanding of the quality of EmONC services including geographical distribution of EmoONC services, existing gap in provision and utilization of EmONC services, community and facility referral capacity, healthcare provider training coverage and needs.
10 UNFPA (2009) Maternal health: Pregnancy by choice not chance, no woman should dies while giving life.
11 National Bureau of Statistics (NBS) [Tanzania] and ICF Macro (2011). Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro.
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Main Objective: To carry out a rapid assessment of EmONC services in selected facilities in eight (8) regions of Lake and Western zones.
Specific objectives: 1. To assess the availability of EmONC services by geographical distribution, physical structure, service delivery including available skilled personnel.
2. To assess the quality of EmONC services provided in the study area
3. To conduct gap analysis in the provision and utilization of EmONC services.
4. Provide recommendation based on the findings of the assessment.
Survey Organisation and Management The hierarchy on how the assessment was managed is as shown in figure 1 below.
Figure 18: Assessment organisation and Management
2 METHODOLOGY AND LIMITATIONS
2.1 Sample size and design The sampling frame for the survey included all HFs (public, FBO, parastatal and Private) in Lake and Western zones that conduct deliveries in the eight regions of Kagera, Geita, Mwanza, Mara, Shinyanga, Simiyu, Tabora and Kigoma. A nearly exhaustive list of all
5 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 potentially EmONC HFs was derived from the MoHSW list of all HFs and improved with data from recent research sources in the two study zones. This list was reviewed and a final list that formed our sampling frame was generated by involving and verifying by RHMTs and CHMTs specific through a collaboration of Regional Reproductive and Child Health Coordinator (RRCHco), all District Reproductive and Child Health coordinators (DRCHco), two data collectors per district and a researcher. Eight regional teams produced regional potential EmONC HFs that together resulted in a list of 1609 HFs for the two zones. Based on this sampling frame, all hospitals and health centres were included in the study sample. According to the TOR, only 10 dispensaries were to be selected for the study from each district unless the total number did not exceed 10. In order to select the dispensaries a district was arbitrarily divided into quadrants from which a proportionate number of dispensaries were determined and the selection achieved using a simple random technique. In total 780 HFs were selected for the study of which data were obtained for 777 HFs with 99% response rate. Figure 18 shows a uniform distribution of the surveyed HFs.
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Figure 19: The distribution of the surveyed potential EmONC Health Facilities in Western and Lake zones.
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2.1Questionnaire
The questionnaire that was used for the survey is based on the UN tool for standard EmONC indicators which is published in a handbook for Monitoring of Emergency Obstetric [WHO, UNFPA, UNICEF, and Averting Maternal Death and Disability (AMDD) 2009, http://www.amddprogram.org]. The primary aim of this study was to capture the availability, utilization and quality of EmONC services in the study areas which makes the adoption of this tool ideal. Our questionnaire added extra questions deemed relevant for the MoHSW policies and strategies. Thus some of the important RMNCH indicators in the National Roadmap strategic Plan to Accelerate Reduction of Maternal, Newborn and Child deaths in Tanzania, 2008-20015 were added7. This 5-moduled questionnaire permits for the data collectors to obtain needed information from one unit at a time or concurrently. The modules include General information, RCH, Maternity, Obstetric Theatre and Blood transfusion. Before fieldwork was initiated, this questionnaire was tested in 7 HFs in Dar es Salaam and Pwani and amended accordingly without altering of the key EmONC indicator questions. This questionnaire was available in hard and electronic forms to permit for online filling, uploading and prompt submission.
2.2 Training of field staff Training of field staff took place in two phases. Phase 1 training was conducted in Dar es Salaam over a period of 5 days in May 2015. A total of 56 data collectors were trained on EmONC functions, objectives of the study, field approach and the tool. This training also included 8 regional supervisors and it involved class presentations, mock interviews, tests, and field practice on 7 HFs in Dar es Salaam and Pwani regions. The trainees had hands on practice on filling both the hard copy and electronic forms of the tool. ICT programmers and GPS experts instructed the field staff on how to fill the electronic questionnaire, trouble shooting, GPS locations, uploading and submitting the questionnaire. All data collectors were nurses or doctors who had worked as RCH coordinators or have been involved in similar surveys before.
After a 5-day training and practice, the field staff and the team of researchers went through the questionnaire identifying and clarifying the encountered problems during fieldwork. A final questionnaire was then made available for use in the field. In their assigned regions, each regional team (number equal to total number of district councils in the region + one supervisor + One researcher) conducted a two-day phase 2 training of the local field teams in their allocated regions. Each district council had prepared one data collection assistant. This local data collection assistant and the DRCHco formed a local team. Thus, phase 2 training involved these local teams of one data collection assistant from each district, all DRCHco, a RRCHco and a zonal RCHco (where applicable). The training was conducted by the regional supervisors, assisted by other members of the regional teams who were trained during phase 1. After phase 2 trainings district teams of 3 data collectors and a driver went straight to their respective districts under the guidance of a local DRCHco. The data collector who was trained in Dar es Salaam was responsible for filling the electronic questionnaire, GPS, and submission. The assistant data collector assisted in interviewing, reading record books and
8 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 carrying observations. The DRCHco apart from guiding the team was also responsible to assist in data collection, organizing logistics and ensuring that there is a prior notice has been given to the target HF before the visit. In total, 176 data collectors were directly involved in data collection in all the 56 district councils. Fieldwork took place for 21 days from 1st June 2015.
Figure 20: Field workers attending a training session in May 2015
2.3 Data Collection and quality control Data collection in all the 56 district councils was concurrent. Data were immediately entered into tablets that also served to locate the HFs using GPS. The location of HFs using GPS and online submission of the data provided assurance that data collectors actually visited the HFs. Once submitted data were received and saved in a central database at NIMR headquarters in Dar es Salaam they were accessed and processed by a team of 8 people including two statisticians, two ICT programmers and 4 researchers who had access password. There was communication between the central database supervisor, regional supervisors and data collectors for prompt feedback on the quality issues for the uploaded data. This system of prompt submission and feedback served as a quality control measures which was further reinforced by independent quality check visits to the field made by the technical committee on EmONC Assessment established by the MoHSW. The role of this committee was to work in collaboration with Consultant(s) to ensure smooth running of the assessment from review of pertinent project documents, existing data, research design, data collection process, data management, drafting of the report, dissemination of results to stakeholders and submission of the final report.
2.4 Data analysis and presentation Analysis of the survey data was done using STATA, SPSS and EXCEL computer programs after downloading of the data from the online system. Since the performance of EmONC signal functions should be guided by standard indicators both international and local, in order to
9 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 effectively address the study objectives, some extra demographic data were needed from recent (not older than 5 years) and reliable sources (WHO, UNFPA, UNICEF, and AMDD, 2009). For the purpose of this survey, additional information based on the National population and Housing Census of 2012 was officially sought from the National Bureau of Statistics (NBS). This information included local population figures and crude birth rates (CBR).
To estimate the availability of EmONC services, ratios of EmONC HFs were calculated against the area population. Our sample included all the health centres and hospitals that provide at least delivery services (potential EmONC HFs) and a proportion of such dispensaries. Because only a proportion of dispensaries were surveyed the sample was not self-weighting hence weighting factors were calculated and used to estimate counts of the entire study areas. The calculation of weights took into consideration of the total universe (i.e. all the potential EmONC HFs), the initial sample and the corrections made on these two items as a result of the various field challenges. An example of weight calculations for Kagera region is shown in Table 1. The ultimate weights were calculated by dividing the corrected Total of the potential EmONC facilities in universe by the corrected sample for each facility type. Table 1: Calculation of sample weights for Kagera region
Non- Health Reg.Hos Reg.Hos Centre Dispensarie Kagera p p s s Total Universe 1 14 28 218 261 % Initial sample 100 100.0 100 36.7 47.1 Number of initial sample 1 14 28 80 123 Duplicate cases (Found in field) 0 0 0 0 0 Never exist/Never delivered/Demolished before 2014(Found in field) 0 0 0 0 0 Upon interview did not deliver (Q.1.7-Analysis) 0 0 0 0 0 HF Could not be reached (security/logistics etc) 0 0 0 0 0 Total health facilities out of sample 0 0 0 0 0 Total health facility out of sample and universe 0 0 0 0 0 CORRECTED SAMPLE 1 14 28 80 123 CORRECTED UNIVERSE 1 14 28 218 261 Non-responding facilities (Analysis) Total # responding facilities (with complete forms) 1 14 28 80 123 Response Rate 100 100 100 100 100 Weight 1.00 1.00 1.00 2.7 2.1
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In calculating the total number of fully functional EmONC HFs (that provided all the 7 BEmONC functions in past three months) in Kagera region the weighted number of all EmONC HFs was divided by the area population assuming an international standard of at least 5 such facilities per 500,000 population as ideal. Likewise it was assumed that there should be at least 1 fully functional CEmONC HFs in the same 500,000 populations.
The percentage of population childbirths that took place in potential EmONC HFs in the year 2014 was estimated in each study area by dividing the weighted EmONC HF births by the expected number of childbirth for the study area. A total expected number of delivery was calculated based on area crude birth rates. The rate of childbirth in EmONC facilities should be interpreted against the National facility delivery rate of 51% (TDHS, 2010).
The met need for EmONC was calculated by dividing the number of women with direct obstetric complications who delivered in EmONC HFs by the total expected number of such cases in the given population. In order to arrive to the desired proportion it was assumed that 15% of all live births in a population experience severe direct obstetric emergencies. Since the study was conducted at all HF levels cases referred in and out of HFs with obstetric complications must have inflated the recorded number of cases due to double counting. In order to adjust for double counting of such cases the combined number of the reported referrals (in and out) was obtained and half of this total was subtracted from the weighted counts of direct obstetric complications that were delivered in the past one-year in all the EmONC HFs (i.e. 2014). The cases considered as direct obstetric complications are: 1. Antepartum Haemorrhage 2. Postpartum Haemorrhage 3. Pre-eclampsia/Eclampsia 4. Obstructed labour 5. Ruptured uterus 6. Abortion related complications 7. Ectopic pregnancy and 8. Postpartum sepsis
Number 1, 2, 5 and 7 causes of maternal deaths were further grouped together as obstetric haemorrhage since the underlying cause of deaths in all is acute haemorrhage and its consequences.
2.5 Limitations of the survey This study relied mostly on recorded data hence subjected to lack of information or the necessary details as a result of poor data recording and keeping. In order to mitigate this limitation the sought information was of relatively short duration (only past three months or one year) in order to minimize missing information. Moreover, we relied on established routine records such as MTUHA and HIMS, interviewed key staff and conduct direct observations of the real practice on the ground in order to obtain a more complete picture. A few HFs were hard to reach due to poor road infrastructure during the rainy season and presence of quarantine for security purposes in Kigoma. In one such case in Kagera region
11 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 some information was to be obtained through mobile telephone communication due to the lack of reliable transport to reach a far placed Island. In some areas particularly in Kigoma it was difficult to capture HF location using GPS due to poor internet services though these were very few. Fortunately, it was possible to obtain the GPS location from the regional authorities. The design of this study totally relied on facility based information due to the short duration that we had to conduct the study. Some qualitative information involving healthcare workers, the clients and the community would have given a more complete explanation of our results. These additional studies are therefore recommended.
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3.0 FINDINGS
3.1 Availability of EmONC services Availability of EmONC services in any specified geographical area is partly dependent on the total number of facilities available and how the facilities are distributed among the population. The UN accepts a minimum of 5 fully functional EmONC health facilities per 500,000 populations with at least one of them providing comprehensive EmONC services. Table 2 provides the available number of health facilities capable of conducting deliveries (the potential EmONC health facilities) in both the study zones.
Table 2: Distribution of potential EmONC health facilities by type and region in Lake and Western Zones
Characteristics Types of Health facilities
No. of No. of Health No. of Total Hospitals Centres Dispensaries
Zone 53 149 995 1197 Lake 16 43 353 412 Western Region Geita 4 17 92 113
Kagera 15 28 218 261
Kigoma 6 24 127 157
Mara 12 37 220 269
Mwanza 13 35 196 244
Shinyanga 4 18 137 159
Simiyu 5 14 132 151
Tabora 10 19 226 255
All regions 69 192 1348 1609
A total of 1609 Health facilities were capable of conducting deliveries in the Lake and Western zones with 1348 (83.7%) of them being dispensaries. A great majority 1197 (74.4%) of EmONC health facilities were in the Lake zone. In total 777 HFs were surveyed and data analysed.
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Most obstetric complications are unpredictable hence all facilities that conduct deliveries should be prepared with minimum enabled environment to manage obstetric and newborn emergencies and refer accordingly when there is a need. However, there is a substantial difference between the capacities of a HF to provide EmONC functions from becoming a fully functional EmONC HF. In a recent survey report (SARA, 2012) 79% of hospitals and 13% of health centres in Tanzania were reported to be capable of conducting caesarean section.
Figure 21: Percentage of all the potential EmONC facilities with capacity to perform Caesarean section
Figure 4 shows that overall 90% of all the hospitals and 32% of health centres were able to perform caesarean section in the study zones which is a substantial improvement compared to SARA study in 2012. With exception of Mara, Simiyu and Tabora, all hospitals in other regions were capable of performing caesarean section. Of all the 8 regions, Kigoma had the highest percentage of health centres (54.2%) capable of performing caesarean section. However, only HFs that provided all EmONC signal functions in the last three months were categorized as fully functional EmONC facilities and considered better positioned to manage a variety of obstetric complications than facilities that provide the services sporadically. Overall 426 (54.8%) of the surveyed HFs did not provide all the 7 BEmONC functions in the last three months. Among Health centres and hospitals (n=261), 162 (62.1%) did not provide a full set of CEmONC services in the last three months (Table 3).
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Table 3: Percentage of fully functional health facilities in the Lake and Western Zones
Characteristics % EmONC HFs % EmONC HFs % Health % Health centres providing full set providing full set centres and and Hospitals BEmONC BEmONC Hospitals providing full set functions functions providing full CEmONC functions adjusted for lack set CEmONC adjusted for lack of of indicated functions indicated cases and cases* policy issues
HF ownership
Public 09.2 20.0 08.7 25.8
Private 15.0 38.0 14.1 29.7
Type of HF
Hospitals 18.8 37.1 17.4 33.3
Health Centers 12.5 27.3 7.80 23.8
Dispensaries 8.14 18.4 - -
Zone
Lake 10.73 26.6 09.9 28.2
Western 8.54 14.4 11.9 25.0
Region
Geita 13.7 25.0 9.5 33.3
Kagera 13.0 37.2 14.0 60.0
Kigoma 8.9 13.0 13.3 25.0
Mara 11.1 38.2 06.1 13.6
Mwanza 10.5 23.9 14.6 31.8
Shinyanga 11.0 19.6 04.5 12.5
Simiyu 03.8 12.5 05.3 33.3
Tabora 08.2 16.3 10.3 25.0
The availability of EmONC health facilities that are able to provide a full set of seven BEmONC functions or 9 signal functions (CEmONC) in the last three months (i.e. fully functioning
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EmONC) was generally better in the Lake than the Western zone, in Private than public and in hospitals than lower level facilities. The percentage of fully functional EmONC facilities was improved after adjusting for non-performance due to lack of indicated cases and limiting policy issues during the evaluation period of last three months. Adjusting for these limitations was important in order to give a full picture of EmONC functions although this is often missing in other studies. A HF even when equipped with appropriately trained health cadre, equipment and supplies may not perform MVA for evacuation of the remaining products of conception, for example, if there has not been a case for incomplete abortion in the last three months. Likewise a health centre capable of operating will not perform caesarean section if it has not received the approval due to delays in holding an approval meeting by the relevant authorities. Such limitations can lead to underestimation of fully functional HFs. Even more important as a measure of service availability is the distribution of the fully functional EmONC HFs per area population because this shows how close are these HFs to the people which are intended to be served (Table 4).
Table 4: Distribution of fully functional EmONC facilities per population in the Lake and Western zones
Zone Area Ideal Minimal Number Available Number of Health Facilities per % Met need Population Health Facilities per population for Fully population Functional CEmONC Fully Fully Fully Fully Fully Health Functional functional Functional functional functional Facilities per EmONC CEmONC and Non- EmONC CEmONC population Health Health Fully health health Facilities Facilities Functional E Facilities* Facilities mONC Lake 11,832,857 118 24 1215 114 20 84 Western 4,419,553 44 09 353 26 7 79 Region Geita 1,739,530 17.4 04 92 15 2 58 Kagera 2,458,023 25 05 218 28 6 122 Kigoma 2,127,930 21 04 127 13 4 94 Mara 1,743,830 17 04 220 28 3 86 Mwanza 2,772,509 27 06 196 20 7 126 Shinyanga 1,534,808 15 03 137 18 1 33 Simiyu 1,584,157 16 03 132 05 1 32 Tabora 2,291,623 22.9 04.6 226 13.2 3 65.5
The overall distribution of fully functional EmONC HFs services exceeds the minimum UN standards in Mwanza and Kagera regions. Most regions were above 50% of the recommended level per population except Simiyu and Shinyanga regions that operate at only one- third of the minimum recommended level. However, the presence of a high number of non-fully functioning health facilities in these regions provides an ample opportunity for upgrading some of these HFs to at least reach a minimum recommended level. This
16 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 distribution can be better appreciated in the maps (Figure 16) that indicate a better distribution of BEmONC and CEmONC services in the Lake than the Western zone.
Figure 22: Distribution of EmONC services in Lake and Western Zones
Although the availability of a full set of EmoNC functions is an important indicator of the ability to manage a variety of obstetric and newborn emergency conditions, the availability of individual functions is also important in understanding the kind of complications the HF was able or unable to manage efficiently. Tables 5 and 6 show that the provision of uterotonics is universal in the Lake and Western zones in contrast to assisted vaginal delivery that seem to be rarely practiced across the regions. Among hospitals and Health centres blood transfusion and caesarean sections were provided by around a half of these facilities after adjusting for policy issues and absence of indicated cases. The results in Tables 5, 6 and Figure 23 indicate that most health facilities were not well prepared to effectively manage the major obstetric causes of maternal and perinatal morbidity and mortality. Apart from haemorrhage and anaemia that need blood transfusion services, most HFs were neither prepared to manage eclampsia using a gold standard treatment of injection Magnesium Sulphate nor managing abortion complications by providing MVA services and unlikely to perform assisted vacuum delivery (Fig 23). The burden of abortion complications can be expected to be high in the two 17 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 zones due to the very low contraceptive prevalence rate. Despite this fact only a third of facilities would perform MVA. The low intervention with assisted vacuum to assist vaginal delivery when interpreted with a low caesarean section rate implies that poor perinatal outcomes, maternal morbidity and deaths could be high in both zones.
Table 5: Percentage of all potentially EmONC health facilities that provided specific EmONC signal functions in last three months
Injectable Injectable Anti- Assisted Manual Evacuation Newborn Blood Cesarean Antibiotics Uterotonics convulsants Vaginal Removal of Section ŧ delivery of products resuscitation placenta
Zone Lake 62.3 93.4 42.9 19.3 47.6 34.1 67.5 11.4 6.4 Western 72.4 95.9 56.3 14.6 55.3 35.2 75.34 14.6 6.5 Region Geita 54.8 97.3 54.8 22.2 63.0 27.4 61.6 8.2 5.5 Kagera 59.4 93.5 36.6 27.6 31.7 29.3 85.4 13.8 7.3 Kigoma 76.2 98.0 52.5 15.8 48.5 32.7 92.1 18.8 7.9 Mara 57.3 88.9 38.5 17.9 43.6 34.2 73.5 13.7 10.3 Mwanza 69.5 94.3 43.8 15.2 50.5 43.8 74.3 12.4 8.6 Shinyanga 79.3 98.8 63.4 16.3 63.4 48.8 62.2 10.9 2.4 Simiyu 53.9 89.7 25.6 14.1 43.6 19.2 32.0 6.4 1.3 Tabora 68.4 93.9 60.2 13.3 62.2 37.8 58.2 10.2 5.1 Type of HF ownership Private 66.9 95.3 47.2 26.0 48.8 37.8 73.2 21.3 16.5 Public 64.5 93.8 46.1 16.5 49.7 33.7 68.8 10.5 4.5 Type of HF Types Hospital 69.6 95.6 55.1 29.0 47.8 47.8 78.3 33.3 33.3 Health Centre 70.3 94.3 47.9 21.9 55.2 40.6 71.3 15.6 14.1 Dispensary 62.2 93.8 44.6 15.2 47.7 30.2 67.6 - -
Table 6: Percentage of EmONC health facilities that provided specific EmONC signal functions adjusted for absence of indicated cases and limiting policy issues.
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Injectable Injectable anti- Assisted Manual Evacuation Newborn Blood Cesarean Antibiotics Uterotonics convulsants Vaginal Removal of products resuscitation Section delivery of placenta Zone Lake 88.4 95.4 74.5 30.8 74.5 52.2 81.6 50.7 52.1 Western 85.7 96.0 78.5 17.8 70.5 45.4 85.2 60.7 46.4 Region Geita 81.6 98.6 80.0 27.1 79.3 35.7 73.8 66.7 66.7 Kagera 90.1 97.5 68.2 43.0 60.9 49.3 94.6 90.0 90.0 Kigoma 81.1 98.0 66.3 19.8 54.4 38.4 93.0 81.3 50.0 Mara 85.9 89.7 86.5 36.2 86.4 66.7 95.6 54.5 54.5 Mwanza 86.9 95.2 66.7 24.2 72.6 57.5 83.9 36.4 40.9 Shinyanga 98.5 100.0 91.2 22.8 82.5 62.5 71.8 25.0 25.0 Simiyu 85.7 93.3 51.3 26.8 65.4 34.1 48.1 33.3 33.3 Tabora 91.8 93.9 93.7 15.9 92.4 54.4 75.0 33.3 41.7 Type of HF Ownership Private 92.0 98.0 74.0 56.0 74.0 56.0 86.0 59.5 56.8 Public 88.7 96.0 74.4 29.5 69.8 49.8 83.7 50.0 46.8 Type of HF Types Hospital 85.7 97.1 71.4 48.6 71.4 60.0 82.9 63.9 63.9 Health 47.6 Centre 88.6 94.3 75.0 38.6 75.0 60.2 87.5 42.9 Dispensary 89.9 96.9 74.6 28.9 68.4 45.6 82.9 - -
Tables 7 - shows reasons for not providing EmONC functions in past three months. Some irregularities in provision of EmONC services can be expected where the caseload is small or staff turnover is high which could be partly responsible for the observations in the Lake and Western Zone. However, a high percentage of HFs that did not provide EmONC services should alert HF managers and Council Authorities of a high number of women with complications that are affected with the shortages. In this survey, the lack of supplies and training were most outstanding. HF managers and council authorities are advised to regularly monitor, document, give feedback and intervene on the performance of the HFs and reclassify them as fully or non-fully functional EmONC facilities. A list of Health centres and hospitals that did not provide CEmONC services in the last three months is given as Appendix 4.
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Figure 23: Percentage of Health Facilities that performed EmONC Signal function in the last 3- month.
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Table 7: Percentage of Health Facilities giving reasons for failure to provide BEmONC functions
Training Supplies Management Policy No issues issues issues issues indication Zone Lake 61.8 67.5 31.1 59.2 77.9 Western 62.8 69.3 35.2 61.8 68.3 Region Geita 78.1 65.7 38.4 78.1 86.3 Kagera 48.8 60.2 17.9 77.2 85.4 Kigoma 80.2 71.3 38.6 46.5 59.4 Mara 53.8 67.52 21.4 65.8 81.2 Mwanza 53.3 51.4 35.2 33.3 67.6 Shinyanga 71.9 80.5 40.2 48.8 67.1 Simiyu 79.5 88.5 44.9 48.7 78.2 Tabora 44.9 67.3 31.6 77.5 77.5 Types of HF Hospital 49.28 50.7 23.2 44.9 66.7 Health Centre 60.94 66.7 30.7 58.3 76 Dispensary 64.15 70.7 33.9 62.4 76.4 Ownerships of HF Private 55.91 67.7 29.9 53.54 76.4 Public 63.23 68 32.6 61.08 75.2
3.2 EmONC Service utilization EmONC services are meant for women who develop emergency obstetric complications. Since obstetric emergencies are largely unpredictable women are encouraged to deliver in health facilities so that they can promptly receive EmONC services if the need arise. Table 8 provides institutional births in the study areas.
As seen from Table 8 and figure 18, institutional delivery in all the regions was above the National average of 51% except Simiyu which had 46% institutional delivery rate in 2014. However, a smaller proportion of these women delivered in fully functional health facilities as shown in Figure 18 &19. Institutional delivery in Mara exceeds 100% indicating that more deliveries could have originated from populations outside the region. Generally, institutional delivery was better in the Lake zone than the Western zone. Figure 18 provides proportions of all deliveries in fully and non-fully functioning EmONC health facilities. The proportion of deliveries conducted in fully functional EmONC facilities, was highest in Mara (54.8%) and Kagera (45.2%). It should be noted that institutional delivery alone, is not a guarantee to reduce maternal and newborn mortality as it has been recently observed in Bangladesh which is on track with MDG 5 target despite of 25% institutional delivery (The Lancet, 2013).
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Table 8: Crude Birth Rates and proportion of births in EmONC health facilities in the Lake and Western zones
Region Population Crude Birth Total Total Total Total % % Delivery in (2012 Rate (per Annual Delivery in Deliveries Deliveries in Deliver fully Census) 1000 popn) births HFs in HF Fully y in HF functional based on 2012 (unweight (Weighted) functional EMONC HF census ed) EmONC HF (Weighted) Geita 1,739,530 56.9 98,979 33,694 50,080 11,440 50.6 11.6 Kagera 2458023 44.2 108,645 41,843 68,086 30,803 62.7 28.4 Kigoma 2127930 48.4 102,992 41,032 62,741 10,985 60.9 10.7 Mara 1743830 49 85,448 52,712 91,659 50,253 107 58.8 Mwanza 2772509 48.2 133,635 60,389 95,662 36,818 71.6 27.6 Shnyanga 1534808 44.1 67,685 30,312 55,459 15,303 81.9 22.6 Simiyu 1584157 52.2 82,693 20,218 38,378 11,568 46.4 14.0 Tabora 2,291,623 49.6 113,66 40,106 97,687 28,676 85.9 25.2 4
Figure 24: Percent of all Institutional deliveries taking place in fully functional and non-fully functional EmONC facilities
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Figure 25: Institutional delivery in the Lake and Western Zones
Table 9: Annual Caesarean Section Rate for deliveries that occurred in the Lake and Western zones of Tanzania, 2014
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Zone Total deliveries Total Cesarean Annual in the study section in EmONC Cesarean area (Based Health Facilities Section rate in on CBR, 2012) 2014 Lake 577,084 9,720 1.7 Western 216,656 2,742 1.3 Region Geita 98,979 78 0.1 Kagera 108,645 3,301 3.0 Kigoma 102,992 931 0.9 Mara 85,448 1,194 1.4 Mwanza 133,635 3,969 3.0 Shinyanga 67,685 940 1.4 Simiyu 82,693 238 0.3 Tabora 113,664 1,811 1.6 Types of HF Hospital 82,949 9,781 11.8 Health Centre 92,545 2,681 2.9 All 175,494 12,462 7.1 Ownership of HF Private 78,472 7,147 9.1 2.1 Public 251,130 5,315
As shown in Table 9 institutional Caesarean section rates were generally higher than population rates. Most regions had population Caesarean Section in the range of 1-2% which according to UN standards indicates poor access to surgical intervention. No region had attained Caesarean section rate that is within the recommended range of 5-15%.
Table 10: Met need of EMONC in Lake and Western Zone Regions
Region Expected Weighted No. of No. of women %Direct number of women with with major direct obstetric severe major severe major obstetric complication direct obstetric direct obstetric complications managed in complications complications treated in EmONC EmONC (15% of total treated in EmONC Facilities in 2014 Facilities (Met annual Facilities (Adjusted for need for deliveries) (Unadjusted for double counting) EmONC) double counting) Geita 14846.9 1495 995 6.7 Kagera 16296.7 4280 3424 21.0 Kigoma 15448.8 3703.2 3018.2 19.5 Mara 12817.2 6980 5906 46.1 Mwanza 20045.2 5176 4322 21.7 Shinyanga 10152.8 3859 3492 34.4 Simiyu 12404.0 2039 948 7.6 17049.7 5785 1620 Tabora 9.5
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Met need for women with major direct obstetric complications was lower than the ideal 100%. However, in Sub-Saharan Africa and some Asian countries the met need was generally less than 15% in 2004.
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3.3 Quality of Care in the facilities
Table 11: Direct causes of Mortality- All cases, deaths and Case Fatality Rate in Lake and Western Zone, 2014
Hypertensive disorders of Obstructed Ruptured Abortion Ectopic Hemorrhage pregnancy Sepsis Labour uterus complications pregnancy
No. of cases Geita 350 211 19 350 23 133 35 Kagera 477 555 169 872 68 133 202 Kigoma 885 408 70 751 43 346 19 Mara 700 655 189 909 407 1512 862 Mwanza 846 792 127 687 37 1601 216 Shinyanga 452 635 95 570 77 383 73 Simiyu 220 270 46 302 51 305 14 Tabora 822 692 168 1205 96 754 207 Total 4752 4218 883 5646 802 5167 1628 No. of deaths
Geita 28 1 1 19 5 0 0 Kagera 55 9 3 3 5 15 14 Kigoma 35 32 7 4 0 1 0 Mara 46 5 8 44 22 75 2 Mwanza 24 8 12 8 8 4 2 Shinyanga 12 14 18 3 8 1 0 Simiyu 7 13 5 12 2 3 0 Tabora 21 20 16 35 0 23 0 Total 228 120 70 128 60 189 18 Case Fatality Rate/ CFR (%) Geita 8 0.5 5.3 5.4 21.7 0.0 0.0 Kagera 11.5 1.6 1.8 0.3 7.4 11.3 6.9 Kigoma 4.0 7.8 10.0 0.5 0.0 0.3 0.0 Mara 6.6 0.8 4.2 4.8 5.4 5.0 0.2 Mwanza 2.8 1.0 9.4 1.2 21.6 0.2 0.9 Shinyanga 2.7 2.2 18.9 0.5 10.4 0.3 0.0 Simiyu 3.2 4.8 10.9 4.0 3.9 1.0 0.0 Tabora 2.6 12.9 9.5 2.9 0.0 3.1 0.0 Overall CFR (%) 4.8 2.8 7.9 2.3 7.5 1.5 1.1
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Case fatality rates were highly variable across the regions. In Kagera region, the highest CFR were due to haemorrhage, abortion complications and ruptured uterus while in Mwanza and Geita ruptured uterus had the highest CFR. Overall sepsis and ruptured uterus were associated with the highest case fatality rates of more than 7% across the regions. Ectopic pregnancy was associated with the lowest CFR.
Figure 26 : Distribution of causes of maternal mortality in the study Zones
Figure 27: Percentage of maternal deaths occurring in HF type by region
27 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 28: Percent distribution of cause-specific maternal deaths by type of health facilities
Overall most deaths occurred in dispensaries and health centres indicating that referral of severely ill patients to hospitals was not taking place appropriately either due to barriers in decision-making at a community level or delay in referral at facility level. As can be seen from Figure 23, by far deaths due to malaria and abortion complications occurred in health centres than in hospitals.
3.3 Quality of labour monitoring using partography Sepsis, obstructed labour and ruptured uterus can be largely prevented by close monitoring of labour using a partograph and prompt interventions. A total of 462 (59.5%) of the surveyed heath facilities had partographs for use in labour monitoring and 315 were not using a partograph in their labour rooms in past 3 months (Figure 30). Of the 462 facilities 62 were not analysed due to missing data. In each facility observation was made on four random partographs to assess adherence to the standard guidelines on filling the partographs on 8 specified items. The filling of each partograph was scored as 0 (not done), 1 (partially done) and 2 (completely done). A total score of 0-5 was interpreted as poor, 6-8 as satisfactory, 9- 14 as good and 15-16 as excellent.
28 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 29: Percentage of all HFs that did not have partographs to monitor labour in last three months
Figure 30: Percentage of all Health Facilities scoring good to excellent on Partograph (P1-P4) filling
The assessment results of the 4 partograhs in each facility are displayed in Figure 31 which indicates that Health Facilities in Kagera region performed the best while Mwanza region performed the worst. The lack of Partographs in the labour wards of 40.5% of health facilities indicate that labour is commonly not closely monitored.
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Figure 31: Percentage of all Health Facilities scoring good to excellent on Partograph (P1-P4) filling by zone, ownership and type
The percentage of all health facilities whose performances in Partograph filling were scored good to excellent ranged 60% to 70% in both zones and for public and private owned facilities. Hospitals were doing better than health centres and dispensaries with 80% of them scoring good to excellent (Figure 32).
30 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Table 12: Percentage of Health Facilities using specific types of partograph
Percentage of HFs Percentages Percentages using of HFs using of HFs using Modified partography other types WHO with a latent of partography phase partography
Zone Lake 21.35 74.32 7.57 Western 13.24 85.29 5.15 Region Geita 34.55 60 5.45 Kagera 28.26 68.48 4.35 Kigoma 20 71.11 15.56 Mara 12.77 70.21 19.15 Mwanza 20.97 75.81 4.84 Shinyanga 18.57 81.43 12.86 Simiyu 4.55 95.45 0 Tabora 9.89 92.31 0 HF_TYPES Hospital 14.89 74.47 10.64 Health_Centre 26.87 67.91 8.21 Dispensary 16.62 81.54 5.85 HF OWNERSHIP Private 24.68 68.83 6.49 Public 18.18 78.79 6.99
3.4 Availability of means of referral services The survey assessed the availability of means of referral system. These included the functional landline and mobile phone, shortwave radio; available car, motorcycle and bicycle ambulances. In additional, the assessed looked into feedback mechanism for the referral. It was observed that mobile phones were more prevalent means of communication than landline phones though the expectation was every facility would one line for communication. The range for HFs by region acquiring this mode of communication was 9-60% of health facilities in regions, with Mwanza region leading, 60% and Kigoma the least, 8.9% (Figure 33). The survey further demonstrates that car ambulance than motor cycle was the most available mode of transport of patient from one point to another with Mwanza regional having more proportional of ambulance per HFs, 23% and Simiyu having the least, 10.3% (Figure 34). Feedback of patient’s management is the best practice to ensure improved car. However, in this survey it is shown that less than 10% of patient’s referred feedback was given as a routine practice.
31 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 32: Availability of means of referral system in lake and western zone Regions
Figure 33: Percentage of HF with access to ambulance services in the Lake and Western Zones
32 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Distance to refferal Health facility In this survey distance of referral was assessed by walking, referral in dry and rainy season. The longest transport distances of transportation by hours was observed in Shinyanga, Kigoma and Simiyu regions (Figure 35).
33 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Table 13: The distribution of Average Time Distance to nearest referral point for EmONC health facility in Lake and Western Zones
% HF Average Average Average Public/Privat accepting Walking Transport in Transport in e Health any Health distance dry season rain season facility Ratio Insurance (Minutes) (Minutes) (Minutes) scheme Zone Lake 282.0 129.5 169.4 4.6 95.0 Western 359.6 183.0 223.7 7.7 98.0 Region Geita 372.3 109.3 139.6 9.4 95.9 Kagera 256.5 87.8 127.4 3.2 95.1 Kigoma 373.1 220.0 261.6 9.1 98.0 Mara 130.8 83.2 117.1 3.0 91.5 Mwanza 297.6 150.5 192.1 6.0 99.1
Shinyanga 377.6 264.2 301.3 6.5 95.1 Simiyu 377.7 171.2 227.5 5.0 93.6 Tabora 349.0 153.8 193.8 6.5 98.0
Figure 34:Average time in hours taken to the referral point in the Lake and Western Zones.
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Effective sanitation and sterilization In all regions toilets I the HFs maternity and labour wards was only available in less than 30% of the surveyed HFs and this was the same in all zones. However, presence of toilet was more prevalent in hospital in maternity and labour room by almost 86% and 68% respectively. Furthermore, it shown that private health facilities has proportionately had toilets in the maternity and labour room close to 50% of their HFs (Table 21).
The survey further shows that by far boiling was the commonest method of sterilization used by most HFs compared to other methods. Assessing by region this method had a mean of 67.9% compared to a mean 21.0% for autoclaving and 12.2% for steam autoclaving. Furthermore, the autoclaves were more found in the hospital setting than dispensaries and health centres and more found in private health facilities (Table 21).
The survey demonstrates that there is no much variation of use incinerators, placenta pit and rubbish pit in disposing biological materials. However, the three methods were more prevalent in the hospitals and private health facilities (Table 21).
Table 14: Proportion (%) of Health Facilities with sanitation and sterilization services
HFs HFs with HFs with HFs with HFs with HFs using with toilet in a a toilet HFs with steam boiling HFs with placenta rubbish maternity in labour autoclave autoclave sterilization incinerator pit pit Zone Lake 27.0 20.1 20.0 10.4 77.3 51.4 57.9 77.7 Western 20.6 20.6 24.8 19.2 60.1 51.3 51.8 68.8 Region Geita 21.9 16.4 15.1 4.1 84.9 63.0 71.2 69.9 Kagera 18.7 12.2 18.9 13.9 80.3 66.4 50.4 76.4 Kigoma 15.8 12.9 18.0 14.0 67.0 44.6 48.5 62.4 Mara 31.6 28.5 23.1 10.3 80.3 44.0 59.0 82.9 Mwanza 37.1 25.7 18.1 12.4 77.1 46.7 52.4 71.4 Shinyanga 24.4 20.7 30.5 13.4 70.7 40.2 79.0 84.2 Simiyu 26.9 15.4 13.0 5.2 67.5 46.2 41.0 80.8 Tabora 25.5 28.6 31.6 24.5 53.1 58.2 55.1 75.5 Health facilities Hospital 85.5 68.1 87.0 33.3 17.4 91.2 88.4 87.0 Health Centre 34.4 27.1 36.5 17.2 63.0 67.7 74.0 77.6 Dispensary 14.0 11.3 6.6 8.2 84.0 40.0 45.4 73.1 Ownership of HFs Private 56.7 46.5 51.2 22.8 48.8 82.5 81.9 78.7 Public 19.2 15.1 15.3 10.7 77.6 45.3 51.3 74.8
3.4 Newborn care In the survey facilities were assessed of the readiness to perform resuscitation of newborn and adult. The survey observed that majority of the health facilities had newborn ambubag and mask for resuscitation but not adult ambubag and mask (Table 23). The gap for newborn
35 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015 resuscitation was observed in the lack of suction machine, newborn suction catheters and source of oxygen (Table 23).
Table 15: Percentage of Health Facilities with utilities for newborn and adult resuscitation in labour room
HFs wih HFs HFs size with a HFs with 250 cc newbor with HF HFs newbor HFs ambub HFs with n function with HFs with n HFs with with ag and adult resuscit ing pengui with function suction adult source mask ambuba ation Heating n suction ing cathete suction of size g & table source sucker avail suction r catheter oxygen 0&1) mask
Zone Lake 76.0 27.7 35.1 13.5 62.7 37.5 89.4 19.6 13.0 15.3 Western 76.4 41.2 43.7 11.6 67.3 49.3 89.7 26.1 18.6 13.6 Region Geita 56.2 31.5 13.7 8.2 34.3 42.5 90.3 19.4 9.6 9.6 Kagera 91.0 28.5 49.6 14.8 89.4 30.9 86.8 22.8 12.2 13.8 Kigoma 81.2 32.7 47.5 11.0 93.1 33.7 84.9 24.8 16.8 13.9 Mara 96.6 25.6 44.0 9.4 93.2 32.5 86.8 15.4 15.4 18.8 Mwanza 81.9 21.0 46.2 29.8 65.7 42.9 95.6 21.2 16.2 19.1
Shinyanga 59.8 35.4 22.0 4.9 23.2 53.7 93.2 23.2 15.9 18.3 Simiyu 49.4 26.9 18.0 10.3 39.0 26.9 76.2 15.4 6.4 9.1 Tabora 71.4 50.0 39.8 12.2 40.8 65.3 92.2 27.6 20.4 13.3 HF types Hospital 83.8 44.9 50.7 30.4 75.4 43.5 93.3 33.3 29.0 29.0 Health_Centre 75.5 33.3 40.8 15.2 66.5 46.9 87.8 23.6 19.3 18.8 Dispensary 75.3 28.5 34.2 9.9 61.4 37.8 89.7 18.8 10.7 11.5 HF ownership Private 77.6 38.6 50.4 18.1 74.0 40.9 88.5 29.1 24.4 22.8 Public 75.9 29.7 34.7 12.1 61.9 40.5 89.7 19.8 12.5 13.3
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Table 16: Percentage of HFs with elements of essential newborn care and baby friendliness services
HFs establishing newborn on HFs with newborn not HFs practicing mother HFs practicing baby breast bathed before 24-hrs after care skin to skin wiped dry & wrapped immediately after delivey birth
Zone Lake 89.8 98.8 98.4 87.0 Western 92.0 97.5 100.0 90.0 Region Geita 84.9 100.0 100.0 83.3 Kagera 92.6 97.5 97.5 88.5 Kigoma 94.1 99.0 100.0 88.1 Mara 88.0 99.2 98.3 89.7 Mwanza 89.5 98.1 99.1 83.8 Shinyang 92.7 100.0 98.8 92.7 a Simiyu 89.7 98.7 97.4 82.1 Tabora 89.8 95.9 100.0 91.8 HF_TYPES Hospital 94.1 100.0 97.1 85.3 Health_Centre 91.7 99.0 99.0 90.6 Dispensary 89.3 98.1 99.0 87.0 HF OWNERSHIP Private 91.3 100.0 96.0 89.7 Public 90.2 98.2 99.4 87.4
Generally there was weak supportive infrastructure to provided neonatal care in neonatal rooms whereby less than 20% of the HFs had phototherapy machines, suction machine, Kangaroo Mother Care services, and source of oxygen, room thermometers and pulsoxymeters. The situation was the same for availability of weighing scale and neonatal ambu bag and mask with overall less than 50% HFs in the regions having these equipment (Tables 24).
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Table 17: Percentage of Health Facilities with utilities for newborn care in Neonatal room
HFs HFs HFs HFs with Hfs with Hfs with with HFs with with with HFs with Phototherapy KMC room eonate newborn suction Oxygen pulsoxymeter machine services thermometer weighing ambubag machine source
scale
Zone
Lake 4.7 17.4 14.9 6.9 4.2 3.3 37.5 38.7
Western 2.8 27.6 14.4 9.3 2.8 2.8 43.1 41.2
Region
Geita 2.9 11.4 5.7 2.8 1.4 0.0 25.7 12.7
Kagera 0.0 12.3 10.7 5.7 5.7 4.1 31.4 50.8
Kigoma 1.0 13.3 12.2 8.2 3.1 1.0 30.9 35.7
Mara 8.6 20.5 19.7 10.3 5.1 4.3 47.0 58.1
Mwanza 10.6 22.1 14.6 8.7 3.9 3.9 31.1 26.9
Shinyanga 3.3 29.5 26.2 9.8 4.9 3.2 53.2 46.8
Simiyu 1.3 10.4 14.3 2.6 2.6 2.6 39.0 23.4
Tabora 4.8 44.6 16.9 10.7 2.4 4.8 57.1 47.6
HF_TYPES
Hospital 12.5 34.4 32.8 23.4 12.5 10.9 53.2 53.1
Health_Centre 5.5 19.2 17.1 9.3 5.0 5.0 37.4 37.4
Dispensary 2.7 18.3 11.5 4.7 2.3 1.4 37.6 38.2
HF OWNERSHIP
Private 4.3 19.7 22.2 10.3 2.6 6.0 42.7 45.3
Public 4.2 20.0 13.4 7.0 4.1 2.6 38.1 38.2
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Table 18: Percentage of Health Facilities with case management protocols in place
HFs HFs with HFs with supervise HFs HFs with HFs with HFs with Obstructe Puerperal HFs with HFs with HFs d by AMTSL PPH APH eclampsia d labour sepsis HBB KMC conductin CHMTs in protocol protocol protocol protocol mgt mgt protocol protocols g MDR the last 3- protocols protocol Mo Zone Lake 53.8 38.0 24.4 46.5 15.1 14.0 47.0 10.9 76.8 15.9 Western 56.3 47.7 30.2 52.8 17.6 18.2 56.8 14.6 80.4 23.6 Region Geita 52.1 34.3 15.1 28.8 13.7 4.1 26.0 4.1 79.5 8.2 Kagera 45.1 32.8 24.6 42.6 18.9 15.6 75.4 10.7 78.7 20.5 Kigoma 52.5 41.6 33.7 38.6 20.8 28.0 80.2 21.8 77.2 19.8 Mara 40.2 23.9 17.1 30.2 15.4 13.7 82.9 12.0 69.2 15.4 Mwanza 62.5 56.2 33.3 59.1 19.1 20.0 33.3 19.1 71.4 10.6 Shinyang 85.4 58.5 39.0 82.9 8.5 9.8 14.6 9.8 95.1 35.2 a Simiyu 44.9 24.4 16.7 38.5 11.5 18.0 20.5 6.4 70.5 6.4 Tabora 60.2 54.1 26.5 67.4 14.3 8.2 32.7 7.1 83.7 27.6 HF_TYPES Hospital 58.2 47.1 36.8 48.5 27.9 29.4 58.8 14.7 75.0 28.8 Health_Centre 57.3 42.7 33.3 53.7 21.9 18.8 55.2 17.7 77.6 21.6 Dispensary 52.9 38.8 21.7 46.0 11.8 11.8 46.1 9.3 78.1 15.2 HF OWNERSHIP Private 49.2 33.3 26.2 38.1 16.7 16.7 52.4 15.9 74.6 16.3 Public 55.5 41.9 25.9 50.1 15.5 14.8 48.9 11.1 78.3 18.3
39 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Proportion of Health facility providing routine antenatal services In this survey shows that almost all (>85%) HFs by zone, region, type and ownership were providing Antenatal services on weekly 3-5 days a week. In the ANC it is expected that every client will be checked of BP, urine for protein, syphilis screening, haemoglobin, HIV counseling and testing and mRDT (malaria rapid test). These were performed as routine in only 47.0% for syphilis, 43.5% for haemoglobin and 35.4% for urine check. However, good coverage for ANC services was observed in checking BP, HIV counseling&testing and mRDT. Routine availability of Fefol, SP tablets and ANC card no. 4 was universal to almost all HFs by zone, region, type of HFs and ownership.
Table 19: Percentage of Health Facilities that consistently provided Antenatal tests and services in last three months
40 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 35: Coverage (%) of Routine ANC services provided by HFs by region.
41 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Family Planning services
Table 20: Percentage of all Health Facilities that provided Family planning Methods in last three months
Condoms Tubal Natural Postpartu Oral ligation family Emergency m contrac Injection Implan Vasect plannin contraceptio intrauterin eptive contraceptive ts omy g n e device Zone Lake 79.4 87.3 79.6 70.3 21.5 8.6 45.1 54.0 33.0 Western 76.9 85.9 80.4 68.3 18.7 6.0 43.7 42.2 32.7 Region Geita 73.6 83.3 81.9 66.7 25.0 11.1 43.1 48.6 27.8 Kagera 71.9 89.3 71.9 74.4 20.7 7.4 40.0 46.7 35.8 Kigoma 78.2 85.2 75.3 68.3 18.8 5.0 36.6 42.6 30.7 Mara 82.1 90.6 78.6 69.2 23.9 10.3 49.6 59.0 35.0 Mwanza 87.4 88.5 85.6 69.9 18.3 8.7 48.1 58.7 27.9
Shinyanga 80.5 84.2 81.7 63.4 26.8 8.5 45.1 51.2 30.5 Simiyu 80.5 84.4 80.5 76.6 14.3 5.2 44.2 59.7 40.3 Tabora 75.5 86.7 85.7 68.4 18.6 7.1 51.0 41.8 34.7 HF_TYPES Hospital 76.5 86.8 80.9 76.5 20.6 10.3 48.5 45.6 41.2 Health_Centr e 79.9 87.4 76.8 69.0 22.1 5.8 42.1 54.2 30.5 Dispensary 78.6 86.8 80.7 69.2 20.3 8.4 45.2 50.5 32.8 HF OWNERSHIP Private 76.8 85.6 74.4 72.8 24.8 10.4 46.4 52.8 33.6 Public 79.1 87.2 80.8 69.2 20.0 7.4 44.4 50.6 32.8
Electric power supply in health facilities The survey looked into the extent of availability of electric power for lighting and running of critical services in the health facilities. By facility it was observed that majority of the hospitals had some form electric power supplied in EmONC service delivery points such labour room, nursery and theatre rooms. Similar trend is observed in private than public health facilities where labour rooms are always supplied with electricity. Generally, solar power in this survey is observed to be more prevalent as source of electric energy in most health facilities when viewed by region. It should be remembered this may be as a result of rural HFs solar electrification program under a collaborative effort of the Ministry of Health and Social Welfare and Clinton Health Access which commenced as early as 2008.
42 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 36: Proportion of EmONC health facilities with electric power supply
Availability of water supply in the Health Facility Health facilities in the 8-regions were assessed on the presence of water supply as a critical need for the service delivery and maintenance of sanitation. Kagera and Mara regions were leading in having water to most of its HFs, 85 and 80% respectively while Geita demonstrated the least proportional of HFs with water supply, 41%. Further analysis shows that more water supply was available in the private HFs and hospitals. The later may indicate the correlation of water supply with urban than urban setting. There was no demonstrated variation of water supply by zone.
Analysis shows that hospitals were leading in having of pipe water supply 81.2% complemented with rainy water harvest, the proportion of which drops with level of care. The leading source of water supply by region remains to be rainy water harvest constituting from as low as 47% (in Simiyu region) to as high as 69% (in Kagera region).
43 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 37: Proportion of Health facilities with water supply
44 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
CONCLUSION AND RECOMMENDATIONS
The presence of a large number of non-fully functioning health facilities in lake and western zone regions provides an ample opportunity for upgrading some of these HFs to at least reach a minimum recommended level.
Most health facilities were not well prepared to effectively manage the major obstetric causes of maternal and perinatal morbidity and mortality.
All regions involved in the assessment had not attained Caesarean section rate that is within the recommended range of 5-15%.
Most of deaths occurred in dispensaries and health centres which indicate that referral of severely ill patients to hospitals is not taking place appropriately.
The fact that 40.5% of health facilities lack Partographs in labour suggests that labour is commonly not closely monitored.
Ambulance services are unreliable due to poor communication infrastructure, lack of fuel, unaffordability to pay, and the ambulance being busy when needed.
It was observed that there is a weak supportive infrastructure to provided neonatal care in neonatal rooms
Most of the labour ward did not have toilets and for those with toilets were universally clean.
Most of Health facilities use 3-decontamination buckets and over 50% of Health facilities prepared disinfectant within 24-hours
Recommendations
1. EmONC indicators should be part of routine health information system.
2. Improve functional EmONC facilities through upgrading of the existing HFs
3. To improve data recordind and keeping including HMIS to enable to put a in place a system at the district and regional levels that analyses the information regularly and give feedback for improvement with the recognition of HFs that consistently does well in indicator performance.
4. To channel most resources on improving service quality rather than quantity
5. To reinforce community awareness campaign with emphasis on early identification of severe obstetric complications and reporting to appropriate HFs. This campaign should aim at increasing the met need for EmONC.
6. To conduct a community based study to understand why women with severe complications are not treated in EmONC health facilities. The study should also focus on training needs of healthcare workers.
45 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
7. To improve communication infrastructure and strengther ambulance systems in order to promptly refer patients to points where they can be adequately managed. 8. To train and carry a sustainable system for continual education of health care workers
9. Blood is key in managing many causes of maternal deaths. There was need to promote availability of blood for Hemorrhage and anemia.
46 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Appendix 1: A full list of the surveyed potential EmONC health facilities with their Geographic location by districts
Region Council Health Facility Name HF Latitude Longitude Ownership
Mwanza Mwanza cc AGA KHAN Health Centre private -2.52267 32.90691
Mara Musoma MC Akimu maternity and nursing private -1.49763 33.77844 a hom
Mara Tarime DC Alpha prinmat private -1.25217 34.4751
Simiyu Busega DC Badugu dispensary public -2.47975 33.6788
Mwanza Sengerema DC Balatogwa dispensary public -2.70646 32.6498
Kigoma Kigoma MC Bangwe Dispensary public -4.90672 29.61353
Mara Rorya DC Baraki sisters Health Centre private -1.36805 33.96816
Simiyu Bariadi TC Bariadi District Hospital public -2.75344 34.00904
Kigoma Uvinza DC Basanza dispensary public -4.97907 30.29283
Mara Musoma MC Beth said a Health Centre private -1.53549 33.79371
Kagera Biharamulo Biharamulo CDH private -2.63341 31.31418 DC
Kigoma Buhigwe DC Biharu Health Centre private -4.32506 30.01874
Mara Butiama DC Bisumwa dispensary public -1.60306 33.80987
Kigoma Kigoma DC Bitale Health Centre public -4.74882 29.69468
Mwanza Sengerema DC Bitoto Dispensary public -2.77142 32.78423
Mara Serengeti DC Bonchugu Dispensary public -1.87418 34.78317
Mwanza Magu DC BUBINZA dispensary public -2.54378 33.49942
Mara Rorya DC Bubombi dispensary public -1.08241 34.07585
Kagera Missenyi DC BUGANDIKA DISPENSARY public -1.25642 31.65768
Geita Bukombe DC Bugando Dispensary public -3.59496 31.95412
Mwanza Mwanza cc Bugando medical centre private -2.52934 32.90792
Kagera Missenyi DC Bugango Dispensary public -1.00143 31.01009
Shinyanga Kishapu DC Buganika Dispensary public -3.45776 33.54521
Kagera Ngara DC Bugarama dispensary public -2.86681 30.5311
47 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Shinyanga Msalala DC Bugarama dispensary public -3.27019 32.4245
Geita Bukombe DC Bugelenge Dispensary public -3.64667 32.01241
Mwanza Kwimba DC Bugembe dispensary public -3.10283 33.39571
Mara Rorya DC Bugire dispensary public -1.19879 34.26054
Shinyanga Shinyanga DC Bugisi dispensary private -3.82593 33.07304
Mwanza Ukerewe DC Bugorola dispensary public -1.98515 33.01855
Kagera Missenyi DC Bugorora dispensary public -1.20812 31.58552
Mwanza Ukerewe DC Bugula dispensary public -2.01431 32.88144
Shinyanga Shinyanga MC Buhangija dispensary private -3.68587 33.41363
Mara Musoma MC Buhare Dispensary public -1.51658 33.78559
Kagera Bukoba MC Buhembe dispensary public -1.28672 31.80767
Kigoma Buhigwe DC Buhigwe dispensary public -4.45099 29.92598
Kigoma Kasulu DC Buhoro Dispensary public -4.39914 30.18316
Mwanza Kwimba DC Bujingwa dispensary public -2.82704 33.29631
Kagera Bukoba DC Bujugo dispensary public -1.40037 31.71565
Tabora Igunga DC Bukama dispensary public -4.17902 33.82998
Geita Mbogwe DC Bukandwe dispensary public -3.65546 32.2876
Kagera Karagwe DC Bukangara dispensary public -1.71926 31.02425
Tabora Nzega DC Bukene Health Centre public -4.22515 32.88701
Mwanza Ukerewe DC Bukiko dispensary public -1.836 33.0941
Mara Musoma MC Bukima dispensary public -1.81046 33.4077
Kagera Ngara DC Bukiriro dispensary public -2.78012 30.54788
Kagera Bukoba MC Bukoba refferal regional public -1.3329 31.81039 hospital
Tabora Igunga DC Bukoko dispensary public -4.38008 33.73699
Mwanza Sengerema DC Bukokwa dispensary public -2.4938 32.43924
Geita Geita DC Bukoli Health Centre public -3.19601 32.32704
Geita Bukombe DC Bukombe District Hospital public -3.46244 31.89501
Geita Bukombe DC Bukombe Dispensary public -3.51474 32.04834
48 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Shinyanga Ushetu DC Bukomela dispensary public -4.09792 32.33354
Mwanza Ukerewe DC Bukonyo dispensary public -1.94333 32.90944
Mwanza Misungwi DC Bukumbi hospital private -2.71486 32.92202
Simiyu Meatu DC Bukundi Health Centre public -3.90206 34.52023
Kagera Missenyi DC Bukwali dispensary private -1.22902 31.53582
Mara Rorya DC Bukwe Health Centre private -1.33168 34.24757
Geita Nyanghwale Bukwimba dispensary public -3.3378 32.61016 DC
Tabora Igunga DC Bulangamilwa dispensary private -4.11849 33.37401
Geita Geita TC Bulela Dispensary public -2.89541 32.48831
Shinyanga Msalala DC Bulige dispensary public -3.52732 32.66988
Simiyu Busega DC Bulima AICT dispensary private -2.37499 33.56286
Shinyanga Ushetu DC Bulungwa Health Centre public -4.00391 32.23053
Mara Butiama DC Bumangi dispensary public -1.72215 34.00952
Kagera Muleba DC Bumbile Dispensary public -1.63267 31.84485
Shinyanga Kishapu DC Bunambiyu Health Centre public -3.41651 33.30896
Simiyu Bariadi TC Bunamhala Chuoni dispensary public -2.85709 34.01381
Kagera Missenyi DC Bunazi Health Centre public -1.21012 31.4092
Mara Bunda DC Bunda DDH private -2.02898 33.87598
Geita Geita TC Bunegezi Dispensary public -2.95826 32.34197
Geita Geita TC Bung'wangoko Dispensary public -2.79468 32.38497
Kagera Muleba DC BURIGI DISPENSARY public -2.13522 31.44492
Geita Chato DC Busaka Dispensary public -2.96952 31.73078
Mwanza Magu DC BUSALANGA dispensary public -2.6487 33.54699
Shinyanga Msalala DC Busangi dispensary public -3.65814 32.55751
Shinyanga Kishapu DC Busangwa dispensary public -3.44525 33.40727
Shinyanga Ushetu DC Busenda dispensary public -4.0706 32.5979
Kagera Muleba DC BUSHEKYA dispensary private -1.54344 31.70311
Kagera Kyerwa DC Businde Dispensary private -1.13631 30.94366
49 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mwanza Sengerema DC Busisi Dispensary public -2.72735 32.86774
Mwanza Sengerema DC Busisi Heath Center public -2.72867 32.85078
Geita Nyanghwale Busolwa dispensary public -2.99842 32.62802 DC
Tabora Nzega DC Busondo Health Centre public -4.68051 33.17797
Mwanza Misungwi DC Busongo Health Centre public -3.12147 32.94883
Kigoma Kibondo DC Busunzu dispensary public -3.95379 30.60507
Geita Chato DC Butarama Health Centre public -2.47872 31.74873
Mara Butiama DC Butiama District Hospital public -1.76759 33.96036
Kagera Missenyi DC BUYANGO DISPENSARY public -1.14456 31.64272
Kagera Bukoba MC Buyekera Dispensary public -1.33774 31.81128
Geita Chato DC Buziku Dispensary public -2.98064 31.66335
Geita Chato DC Buzirayombo Dispensary public -2.78108 31.78035
Mwanza Ilemela DC Buzurugwa Health Centre public -2.53222 32.94091
Mara Musoma DC Bwai dispensary public -1.6963 33.59309
Geita Chato DC Bwanga Health Centre public -3.03453 31.76097
Mara Musoma DC Bwasi SDA dispensary private -1.86191 33.3741
Geita Mbogwe DC Bwelwa dispensary public -3.37541 32.16982
Mara Musoma MC Bweri Health Centre public -1.53005 33.83177
Mwanza Ukerewe DC Bwisya Health Centre public -1.87143 33.02398
Simiyu Bariadi DC Byuna Health Centre public -2.57252 34.15545
Shinyanga Kahama TC Cathodic mbulu dispensary private -3.83343 32.64243
Mwanza Mwanza cc CF hospital private -2.52102 32.89867
Shinyanga Shinyanga MC Chamaguha dispensary public -3.67768 33.44447
Shinyanga Ushetu DC Chambo dispensary public -4.20387 32.65902
Kagera Karagwe DC ChaMChuzi dispensary public -1.77654 30.86351
Mwanza Magu DC CHANDULU dispensary public -2.6646 33.62344
Mara Rorya DC Changuge Health Centre public -1.24382 34.22561
Kigoma Kigoma DC Chankambwimba dispensary public -4.78913 29.72723
50 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Geita Chato DC Chato District Hospital public -2.63878 31.76911
Shinyanga Msalala DC Chela Health Centre public -3.54057 32.54778
Geita Geita DC Chikobe Health Centre public -2.76812 31.91612
Tabora Igunga DC Choma Health Centre public -4.02229 33.35809
Kagera Karagwe DC Chonyonyo dispensary public -1.56442 31.04856
Mara Musoma MC Coptic Medical Health Centre private -1.50844 33.80574
Simiyu Bariadi TC Ditima dispensary public -2.65205 33.87065
Simiyu Maswa DC Dodoma dispensary public -3.06547 33.78331
Simiyu Bariadi DC Dutwa dispensary private -2.51757 33.97105
Kagera Bukoba MC Ekisha Nursing and Maternity private -1.32398 31.81978 Home
Kagera Muleba DC ELCT Ndolage Hospital private -1.60465 31.64571
Mwanza Ilemela DC ELCT nyakato Health Centre private -2.53626 32.96081
Kagera Bukoba MC FFU Nshambya dispensary public -1.31622 31.80044
Shinyanga Shinyanga MC Galamba dispensary public -3.65991 33.52835
Mara Tarime TC Gamasara dispensary public -1.34858 34.32767
Simiyu Bariadi DC Gambosi dispensary public -2.6075 33.84855
Mara Serengeti DC Gantamome Dispensary public -1.58284 34.42612
Simiyu Itilima DC Gaswa dispensary public -2.76917 34.19476
Geita Geita DC Geita District Hospital public -2.87431 32.22594
Mara Tarime DC Genkuru dispensary public -1.43571 34.61093
Mara Butiama DC Giorgio frassat dispensary private -1.76493 33.85985
Tabora Uyui DC Goweko dispensary public -5.33024 33.15288
Simiyu Bariadi TC Guduwe dispensary public -2.68361 33.92674
Simiyu Maswa DC Gula dispensary private -3.44844 33.98273
Mara Bunda DC Guta dispensary public -2.07405 33.73446
Kigoma Kakonko DC Gwalama Dispensary. public -3.09493 30.8813
Kigoma Kakonko DC Gwanumpu Health Centre public -3.25927 30.90755
Simiyu Bariadi DC Halawa dispensary public -2.47756 34.23553
51 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kigoma Buhigwe DC Heri adventist hospital private -4.44468 29.7936
Kigoma Kasulu TC Heru juu dispensary public -4.53686 30.04834
Kigoma Kigoma MC Hospitali Teule ya Baptist public -4.85998 29.63702
Mwanza Ilemela DC Huduma Health Centre private -2.48891 32.90792
Mara Bunda DC Hunyari dispensary public -1.98515 34.07847
Shinyanga Shinyanga MC Ibada dispensary public -3.62833 33.49702
Kagera Kyerwa DC Ibamba dispensary private -1.25531 30.93592
Tabora Uyui DC Ibiri dispensary public -4.92666 32.59814
Mwanza Misungwi DC Ibongoya dispensary public -2.73642 33.12907
Kagera Bukoba DC Ibosa dispensary public -1.24938 31.84222
Geita Mbogwe DC Iboya Health Centre public -3.34968 32.18428
Shinyanga Ushetu DC Idahina dispensary public -3.85312 32.18296
Tabora Tabora MC Ifucha Dispensary public -5.03451 32.9355
Tabora Kaliua DC Igagala Dispensary public -4.93235 31.6302
Mwanza Ukerewe DC Igala dispensary public -2.04211 32.95
Shinyanga Kishapu DC Igalilimi heath center private -3.83028 32.60799
Simiyu Busega DC Igalukilo Health Centre public -2.41064 33.77479
Mwanza Ilemela DC Igogwe dispensary public -2.46516 32.99635
Mwanza Mwanza cc Igoma Health Centre public -2.54394 32.98312
Shinyanga Ushetu DC Igunda dispensary public -3.97718 32.46718
Mara Bunda DC Igundu dispensary public -2.07083 33.35911
Tabora Igunga DC Igunga District Hospital public -4.30226 33.48864
Tabora Urambo DC Igunguli dispensary public -4.81314 32.07596
Tabora Igunga DC Igurubi Health Centre public -3.99631 33.70525
Geita Chato DC Ihanga Dispensary public -2.95469 31.63949
Simiyu Busega DC IJIHA dispensary public -2.46055 33.45447
Kagera Bukoba MC Ijuganyondo dispensary public -1.3664 31.79354
Simiyu Itilima DC Ikindilo Health Centre public -2.84112 34.15891
Mara Bunda DC Ikizu Health Centre public -1.90479 34.02129
52 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mara Rorya DC Ikoma dispensary public -1.19729 34.34517
Simiyu Maswa DC Ikulilo dispensary public -3.48218 34.0082
Geita Mbogwe DC Ikunguigazi dispensary public -3.23685 31.92701
Simiyu Bariadi DC Ikungulyambeshi dispensary public -2.57984 33.72819
Geita Bukombe DC Ikuzi Dispensary public -3.38487 31.58501
Kigoma Uvinza DC Ilagala Health Centre public -5.20008 29.835
Mwanza Ilemela DC Ilemela dispensary public -2.45455 32.91277
Tabora Uyui DC Ilolangulo dispensary public -5.09395 32.6343
Geita Mbogwe DC Ilolanguru dispensary public -3.29984 32.07832
Mwanza Kwimba DC Inala dispensary public -2.7073 33.29603
Tabora Sikonge DC Ipole dispensary public -5.78958 32.73222
Geita Mbogwe DC Iponya dispensary public -3.71043 32.10266
Mara Serengeti DC Iramba Health Centre public -1.69546 34.28582
Mara Musoma MC Iringo dispensary public -1.4981 33.81256
Mwanza Ukerewe DC Irugwa dispensary public -1.73154 33.35893
Shinyanga Kahama TC Isagehe dispesary public -3.90846 32.76883
Tabora Nzega DC Isagenhe dispensary public -4.34107 32.89534
Mwanza Misungwi DC Isamilo dispensary public -2.73179 32.94393
Tabora Tabora MC Isevya Dispensary public -5.01416 32.81951
Tabora Uyui DC Isikzya dispensary public -4.86439 33.09961
Kagera Kyerwa DC Isingiro hospital private -1.27512 30.69004
Tabora Urambo DC Isongwa dispensary public -5.22153 32.30064
Mara Serengeti DC Isseco Dispensary private -2.00718 34.34215
Mara Serengeti DC Issenye dispensary public -1.99005 34.3525
Shinyanga Kishapu DC Isungangholo Dispensary public -3.78889 33.97902
Kigoma Kibondo DC Itaba dispensary public -3.60485 30.6
Tabora Tabora MC Itaga Dispensary public -4.94072 32.7456
Tabora Nzega DC Itanana Health Centre private -4.17904 32.90049
Tabora Urambo DC Itebulanda dispensary public -5.21066 32.08
53 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Simiyu Meatu DC ITINJE Dispensary public -3.41899 34.11669
Tabora Nzega DC Itobo Health Centre public -4.15099 33.05724
Tabora Igunga DC Itumba dispensary public -4.56276 33.86009
Tabora Urambo DC Itundu dispensary public -5.08789 32.15174
Shinyanga Kahama TC Iyenze dispensary public -3.98127 32.67505
Geita Bukombe DC Iyogelo Dispensary public -3.54821 31.97354
Kagera Muleba DC Izigo Health Centre public -1.62943 31.71611
Kagera Bukoba DC IZIMBYA DDH private -1.55432 31.4589
Geita Geita DC Izumacheli dispensary public -2.41663 31.96185
Shinyanga Msalala DC Jana dispensary public -3.79827 32.98195
Kigoma Buhigwe DC Janda Health Centre public -4.62413 29.8733
Tabora Urambo DC Jioneemwenyewe dispensary public -4.93861 32.16769
Mara Bunda DC Kabale nursing maternity private -2.01438 33.86136 home
Kigoma Kasulu TC Kabanga reffaral hosptal private -4.50933 30.10508
Geita Nyanghwale Kabiga dispensary private -3.07733 32.75229 DC
Mwanza Magu DC KABILA Health Centre public -2.72925 33.61654
Kigoma Kakonko DC Kabingo Dispensary public -3.3185 30.9189
Simiyu Meatu DC Kabondo Dispensary public -3.59582 34.07737
Mwanza Ilemela DC Kabusungu dispensary public -2.43135 33.01987
Geita Chato DC Kachwamba Health Centre public -2.65991 31.57784
Geita Nyanghwale Kafita dispensary public -3.2354 32.58492 DC
Mwanza Sengerema DC Kafunzo Dispensary public -2.44369 32.16418
Kagera Bukoba MC Kagemu dispensary public -1.35569 31.8014
Kagera Missenyi DC Kagera Sugar Hospital private -1.21347 31.27501
Kigoma Kasulu DC Kagerankanda Dispensary public -4.58096 30.58158
Kigoma Kibondo DC Kagezi dispensary public -3.7843 30.502
Mwanza Sengerema DC Kagunga Health Centre public -2.91629 32.62473
54 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mwanza Ukerewe DC Kagunguli Health Centre public -2.00909 33.07472
Shinyanga Kahama TC Kahama District Hospital public -3.82619 32.59535
Mwanza Ilemela DC Kahama dispensary public -2.49342 32.9907
Mwanza Magu DC KAHANGARA Health Centre public -2.57892 33.35349
Kagera Bukoba MC Kahororo dispensary public -1.30293 31.84229
Mwanza Sengerema DC Kahumulo Dispensary public -2.6807 32.80716
Kagera Muleba DC Kaigara Health Centre public -1.82347 31.6747
Kagera Muleba DC Kaigara Health Centre public -1.83287 31.67049
Kagera Kyerwa DC KAISHO DISPENSARY public -1.26355 30.68808
Kagera Kyerwa DC Kakanja dispensary public -1.42208 30.91085
Mwanza Sengerema DC Kakobe Health Centre private -2.37301 32.32772
Tabora Tabora MC Kakola Dispensary public -4.86957 32.82224
Kigoma Kakonko DC Kakonko Health Centre public -3.27294 30.90265
Geita Nyanghwale Kakora dispensary public -3.08934 32.72148 DC
Geita Geita DC Kakubilo dispensary public -2.61108 32.07663
Kagera Missenyi DC Kakunyu dispensary public -1.03257 30.93973
Shinyanga Msalala DC Kalagwa dispensary public -3.69493 32.49041
Kigoma Kigoma DC Kalalangabo dispensary public -4.84439 29.6235
Kigoma Kasulu DC Kalela Dispensary public -4.81407 29.93238
Kagera Bukoba DC Kalema dispensary public -1.21476 31.82796
Simiyu Busega DC Kalemela dispensary public -2.29659 33.71281
Kigoma Uvinza DC Kalenge Dispensary public -4.95686 29.87916
Kigoma Kigoma DC Kalinzi dispensary public -4.61689 29.72557
Tabora Kaliua DC Kaliua government Health public -5.05639 31.7946 Centre
Tabora Kaliua DC Kaliua mission Health Centre private -5.03574 31.79716
Tabora Tabora MC Kalunde Dispensary public -4.97552 32.69719
Kagera Muleba DC Kamachumu dispensary public -1.62659 31.61415
Kigoma Kigoma DC Kamala dispensary public -4.8539 29.73849
55 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Tabora Urambo DC Kamalendi dispensary public -5.17178 31.90228
Shinyanga Shinyanga MC Kambarage Health Centre public -3.66034 33.41411
Mara Butiama DC Kamugegi dispensary public -1.73518 33.79436
Kagera Kyerwa DC Kamuli Health Centre public -1.29359 30.85249
Kagera Ngara DC Kanazi dispensary public -2.56193 30.58074
Kigoma Kasulu DC Kanazi dispensary public -4.49965 30.21248
Kagera Bukoba DC Kanazi Health Centre public -1.46524 31.73825
Tabora Kaliua DC Kangeme dispensary public -5.41921 31.60989
Mwanza Misungwi DC Kanyelele dispensary public -2.66881 33.09762
Kigoma Kakonko DC Kanyonza Dispensary public -3.2532 31.01137
Kigoma Uvinza DC Karago Dispensary public -5.28404 29.80053
Mara Bunda DC Karukekere dispensary public -2.06704 33.54475
Mwanza Ilemela DC Karume Health Centre public -2.39715 32.96616
Kigoma Kibondo DC Kasaka dispensary public -3.74838 30.59523
Geita Chato DC Kasala Dispensary public -2.89906 31.79032
Geita Geita TC Kasamwa Health Centre public -2.85121 32.39532
Geita Geita TC Kasamwa SDA Dispensary private -2.84775 32.42915
Kigoma Kakonko DC Kasanda Dispensary. public -3.36409 30.86462
Geita Geita DC Kasang'hwa dispensary public -2.72191 31.85087
Mara Bunda DC Kasaunga Health Centre public -2.15061 33.51128
Geita Chato DC Kasenga Dispensary public -2.63999 31.44896
Mwanza Ukerewe DC Kaseni dispensary public -1.94133 32.84715
Kagera Bukoba MC Kashai dispensary public -1.32167 31.8183
Geita Geita DC Kashishi Health Centre public -3.07495 32.20142
Shinyanga Msalala DC Kashishii dispensary public -3.52788 32.7402
Kagera Bukoba DC Kashozi Health Centre private -1.22819 31.80842
Tabora Kaliua DC Kasimana dispensary public -4.59867 32.1206
Kigoma Kakonko DC Kasongati Dispensary public -3.30533 30.79337
Kagera Biharamulo Kasozibakaya Dispensary public -2.81064 31.68877
56 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
DC
Mara Bunda DC Kasuguti Health Centre public -2.1654 33.58215
Kigoma Kasulu DC Kasulu District Hospital public -4.56328 30.09264
Kigoma Buhigwe DC Kasumo dispensary private -4.36226 30.10765
Kigoma Kakonko DC Katanga Dispensary public -3.45438 30.6761
Kagera Bukoba DC Katare dispensary public -1.08909 31.8386
Geita Chato DC Katete Dispensary public -2.37523 31.68534
Kagera Biharamulo Katoke dispensary public -2.65797 31.36196 DC
Geita Geita DC Katoro Health Centre public -3.0087 31.93233
Kagera Bukoba DC Katoro Health Centre public -1.39867 31.49738
Mwanza Sengerema DC Katunguru Heath Center public -2.50921 32.67545
Kagera Karagwe DC Kayanga Health Centre public -1.53496 31.15278
Tabora Kaliua DC Kazaroho Dispensary public -4.98873 31.8535
Kigoma Uvinza DC Kazuramimba Dispensary public -4.99287 29.99455
Mara Serengeti DC Kebanchabancha Health public -1.68825 34.5615 Centre
Mara Serengeti DC Kemgesi Health Centre public -1.77169 34.41334
Mara Tarime TC Kenyamanyori dispensary public -1.38411 34.40586
Kagera Muleba DC Kerebe Dispensary public -1.46446 32.1144
Geita Nyanghwale Kharumwa Health Centre public -3.19952 32.65772 DC
Mara Butiama DC Kiabakari dispensary public -1.77261 33.84973
Mara Butiama DC Kiagata Health Centre public -1.66048 34.10769
Kigoma Buhigwe DC Kibande dispensary public -4.37845 29.89961
Kagera Kyerwa DC Kibare dispensary public -1.06672 30.81467
Geita Chato DC Kibehe Dispensary public -2.47667 31.72807
Kagera Kyerwa DC Kibimba dispensary public -1.32788 30.95092
Kigoma Kibondo DC Kibondo District Hospital public -3.59135 30.71762
Mara Tarime TC Kibumayi dispensary public -1.37475 34.41808
57 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kagera Karagwe DC Kibwera dispensary public -1.318 31.1216
Kigoma Buhigwe DC Kibwigwa dispensary public -4.42307 29.84052
Kigoma Kibondo DC Kichananga dispensary public -3.84031 30.59001
Kigoma Kakonko DC Kiduduye Dispensary. public -3.50133 30.52927
Kigoma Kibondo DC Kifura Health Centre public -3.81989 30.64003
Kigoma Kasulu DC Kigadye Dispensary public -4.06074 30.26354
Kigoma Kibondo DC Kigaga dispensary public -3.7953 30.535
Kigoma Kasulu TC Kiganamo Health Centre public -4.54857 30.12887
Kagera Karagwe DC Kigarama dispensary public -1.28797 31.02348
Kagera Missenyi DC Kigarama dispensary private -1.04508 31.75936
Mara Musoma DC Kigeraetuma dispensary private -1.60003 33.6864
Tabora Uyui DC Kigwa b dispensary public -5.11987 33.10996
Kagera Ngara DC Kihinga dispensary public -2.79534 30.51234
Mwanza Misungwi DC Kijima dispensary private -3.08182 33.13202
Mwanza Kwimba DC Kikubiji dispensary public -3.35218 33.09886
Kagera Missenyi DC Kikukwe dispensary public -1.10887 31.72869
Kigoma Kigoma MC Kikunku Health Centre public -4.85992 29.63711
Shinyanga Kahama TC Kilago dispensary public -3.94544 32.58692
Mwanza Ilemela DC Kiloleli chamwenda public -2.50139 32.92368 dispensary
Shinyanga Kishapu DC Kiloleli Dispensary public -3.86364 33.70717
Simiyu Busega DC Kiloleli Dispensary public -2.47671 33.47773
Mwanza Ilemela DC Kiloleli juu Health Centre private -2.49554 32.92518
Tabora Tabora MC Kiloleni Dispensary public -5.00668 32.81336
Simiyu Bariadi TC Kilulu dispensary private -2.85252 34.0578
Kagera Muleba DC Kimeya Heath centre public -2.05574 31.51145
Kagera Kyerwa DC Kimuli dispensary public -1.40649 30.93971
Kigoma Kasulu DC Kimwanya Health Centre public -4.37742 30.36365
Shinyanga Kahama TC Kinaga dispensary public -3.73419 32.65628
58 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Simiyu Itilima DC Kinamweli dispensary public -2.94853 33.74173
Mara Rorya DC Kinesi Health Centre public -1.46475 33.86336
Tabora Tabora MC Kipalapala Dispensary private -5.09591 32.795
Mwanza Ilemela DC Kirumba dispensary public -2.50335 32.89572
Kagera Karagwe DC Kiruruma dispensary public -1.64859 30.95118
Kagera Ngara DC Kirusha dispensary public -2.45981 30.55473
Simiyu Meatu DC Kisesa Dispensary public -3.02171 34.13831
Mwanza Magu DC KISESA Health Centre public -2.55606 33.05044
Kagera Bukoba DC Kishanje Health Centre public -1.11513 31.84132
Shinyanga Kishapu DC Kishapu Health Centre public -3.61185 33.86871
Mara Bunda DC Kisorya Health Centre public -2.10852 33.21973
Shinyanga Ushetu DC Kisuke dispensary public -4.07416 32.4343
Geita Nyanghwale Kitongo dispensary public -3.14724 32.71895 DC
Tabora Sikonge DC Kitunda Health Centre public -6.83971 33.25
Kagera Kyerwa DC Kitwechenkura dispensary public -1.46387 30.83823
Shinyanga Shinyanga MC Kizumbi dispensary public -3.72507 33.40331
Shinyanga Shinyanga MC Kolandoto DDH private -3.59807 33.53448
Tabora Kaliua DC Kombe Dispensary public -5.0597 31.53241
Mwanza Sengerema DC Kome Health Centre public -2.37545 32.48773
Mwanza Misungwi DC Koromije Health Centre public -2.69245 33.1643
Mara Rorya DC Kowak hospital private -1.36175 34.15401
Mara Tarime DC Kubiterere dispensary public -1.22504 34.41326
Kigoma Kibondo DC Kumkugwa dispensary public -3.52219 30.77493
Kigoma Kibondo DC Kumuhasha dispensary public -3.6491 30.83622
Mara Rorya DC Kuruya dispensary public -1.49023 33.99106
Mara Musoma MC Kwangwa dispensary public -1.52525 33.79884
Kagera Missenyi DC KYAKA DISPENSARY public -1.25454 31.42029
Kagera Bukoba DC Kyamalange dispensary public -1.0475 31.84959
59 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kagera Bukoba DC Kyamulaire dispensary public -1.41093 31.40228
Kagera Muleba DC Kyota dispensary public -2.0939 31.66859
Simiyu Itilima DC Lagangabilili dispensary public -2.95933 34.13978
Simiyu Maswa DC Lalago Health Centre public -3.4515 33.94558
Tabora Kaliua DC Limbula dispensary public -5.12416 31.7409
Shinyanga Kahama TC Lowa Health Centre private -3.89673 32.45829
Tabora Uyui DC Loya dispensary public -5.05786 33.83251
Shinyanga Shinyanga MC Lubaga dispensary public -3.65279 33.39558
Simiyu Meatu DC Lubiga Dispensary public -3.30078 34.21473
Geita Mbogwe DC Lugunga dispensary public -3.51956 32.22651
Simiyu Itilima DC Luguru dispensary public -2.92031 33.95813
Kagera Ngara DC Lukole Health Centre public -2.57482 30.82874
Simiyu Busega DC Lukungu dispensary public -2.22223 33.86045
Mwanza Magu DC LUMEJI dispensary public -2.63943 33.52293
Shinyanga Msalala DC Lunguya Health Centre public -3.38253 32.39843
Kagera Biharamulo Lusahunga dispensary public -2.90544 31.20123 DC
Tabora Nzega DC Lusu dispensary public -4.02558 33.21851
Shinyanga Shinyanga DC Lyabukande dispensary public -3.56639 32.92931
Mwanza Kwimba DC Lyoma dispensry public -3.03786 33.43419
Geita Nyanghwale Lyulu dispensary public -3.39087 32.67799 DC
Kigoma Kibondo DC Mabamba Health Centre public -3.59748 30.49883
Kagera Ngara DC Mabawe Health Centre public -2.58376 30.49808
Mara Serengeti DC Maburi Dispensary public -1.80912 34.36946
Mara Serengeti DC Machochwe Health Centre public -1.67259 34.69536
Kagera Muleba DC MADOLENA KOLPING private -2.10339 31.4932 DISPENSARY
Kagera Ngara DC Magamba dispensary public -2.97946 30.76542
Tabora Uyui DC Magiri dispensary public -4.94382 33.04735
60 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mara Tarime DC Magoto Health Centre public -1.35724 34.56051
Mwanza Magu DC Magu District Hospital public -2.59425 33.43226
Kigoma Kibondo DC Mahembe dispensary public -4.81267 29.7342
Simiyu Bariadi TC Majahida dispensary private -2.83475 33.99264
Mara Serengeti DC Majimoto Dispensary public -1.63053 34.35075
Kigoma Kasulu DC Makere Dispensary public -4.27873 30.41955
Simiyu Maswa DC MALAMPAKA Health Centre public -3.74408 33.51439
Simiyu Maswa DC Malita dispensary public -3.0835 33.87336
Mwanza Kwimba DC Malta Health Centre public -2.97731 33.52398
Tabora Nzega DC Mambali dispensary public -4.53864 32.69032
Mwanza Kwimba DC Manawa. Dispensary public -2.76541 33.41513
Mara Bunda DC Manchimweru dispensary public -1.87145 34.28662
Tabora Tabora MC Manoleo Dispensary public -4.98182 32.92511
Mara Bunda DC Manyamanyama Health public -1.97715 33.85893 Centre
Kagera Bukoba DC Maruku dispensary public -1.40904 31.79509
Kigoma Kasulu TC Marumba dispensary. public -4.67289 29.98577
Mara Tarime DC Masanga Health Centre private -1.44734 34.69892
Simiyu Maswa DC Masanwa dispensary public -3.33331 33.78888
Mara Rorya DC Masike dispensary public -1.31087 34.04371
Mara Musoma DC Masinono Dispensary public -1.95097 33.58948
Geita Mbogwe DC Masumbwe Health Centre public -3.64795 32.16592
Simiyu Maswa DC Maswa District Hospital public -3.1858 33.78252
Simiyu Bariadi TC Matale dispensary public -2.80737 34.08141
Kigoma Kigoma DC Matendo dispensary public -4.8553 29.90092
Kigoma Kigoma DC Matyazo Health Centre private -4.64012 29.75285
Kagera Biharamulo Mavota Dispensary public -3.2392 31.4929 DC
Kigoma Kigoma MC Maweni Regional Hospital public -4.90148 29.6543
Tabora Sikonge DC Mazinge Health Centre public -5.64198 32.74176
61 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mara Serengeti DC Mbalibali Dispensary public -1.7468 34.70852
Mwanza Misungwi DC Mbalika Health Centre public -2.91388 32.83813
Tabora Nzega DC Mbogwe dispensary public -4.16242 33.2645
Tabora Igunga DC Mbutu dispensary public -4.23393 33.89734
Simiyu Meatu DC Meatu District Hospital public -3.5187 34.30795
Mara Bunda DC Mekomariro dispensary public -1.83601 34.20324
Simiyu Busega DC Menonite dispensary private -2.24715 33.84763
Kigoma Uvinza DC Mganza Dispensary public -5.13863 30.8959
Tabora Sikonge DC Mibono dispensary public -5.81499 32.97197
Simiyu Itilima DC Migato. Dispensary public -2.98548 34.31931
Tabora Nzega DC Miguwa dispensary public -4.2083 33.30257
Kagera Bukoba DC Mikoni dispensary public -1.54489 31.58723
Mwanza Kwimba DC Milyungu. Dispensary public -3.20123 33.1961
Kigoma Kibondo DC Minyinya dispensary public -3.54466 30.66136
Mara Butiama DC Mirwa dispensary public -1.76944 34.14411
Mwanza Misungwi DC Misasi Health Centre public -3.01402 33.08798
Mwanza Misungwi DC Misungwi District Hospital public -2.84699 33.09759
Tabora Uyui DC Miswaki dispensary public -4.81687 33.74991
Simiyu Itilima DC Mitobo dispensary public -2.90266 34.12753
Tabora Sikonge DC Mitwigu dispensary public -5.73485 32.70214
Simiyu Itilima DC Mkoma Health Centre public -3.04935 33.99673
Simiyu Busega DC Mkula Hospital private -2.33503 33.87542
Shinyanga Ushetu DC Mkwangulwa dispensary public -4.23903 32.28785
Kigoma Uvinza DC Mlela Dispensary public -4.91807 29.85859
Kigoma Buhigwe DC Mnanila dispensary public -4.43656 29.78295
Geita Geita DC Mnekezi dispensary public -3.07644 32.00386
Shinyanga Kishapu DC Mondo Dispensary public -3.36626 33.54114
Shinyanga Kahama TC Mpera Health Centre private -3.93186 32.76074
Tabora Sikonge DC Mpombwe dispensary public -5.36558 32.69709
62 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Shinyanga Ushetu DC Mpunze dispensary public -3.9055 32.40516
Kigoma Kasulu TC Msambara dispensary. private -4.47723 30.16301
Kagera Ngara DC Mshikamano dispensary public -2.42322 30.81232
Mara Tarime DC Mtana dispensary public -1.38459 34.28545
Simiyu Bariadi DC Mtongo dispensary public -2.36334 34.08601
Kagera Missenyi DC MUGANA DDH private -1.21402 31.69582
Mara Musoma DC Mugango dispensary public -1.68505 33.68855
Kagera Ngara DC Muganza dispensary public -2.91174 30.6427
Mara Bunda DC Mugeta Health Centre public -1.93386 34.2189
Mara Serengeti DC Mugumu DDH public -1.84064 34.66345
Kigoma Kakonko DC Muhange Dispensary public -3.16279 30.86203
Kigoma Kasulu TC Muhunga dispensary public -4.62606 30.03127
Kagera Ngara DC Mukarehe dispensary public -2.59767 30.55366
Mwanza Ukerewe DC Mukunu dispensary public -2.01093 32.97242
Kigoma Buhigwe DC Mulera Health Centre private -4.42145 29.94203
Simiyu Busega DC Mungu kwanza private -2.24736 33.8442
Mara Musoma DC Murangi Health Centre public -1.83661 33.5168
Kagera Ngara DC Murgwanza DDH private -2.49295 30.64478
Mara Tarime DC Muriba Health Centre public -1.39658 34.64307
Mwanza Ukerewe DC Muriti dispensary public -1.99349 32.93144
Kagera Kyerwa DC Murongo Health Centre public -1.06372 30.66773
Kigoma Kasulu TC Murufiti dispensary public -4.62105 30.21647
Kagera Ngara DC Murusagamba Health Centre public -2.96418 30.83974
Mara Musoma MC Musoma regional referal public -1.49158 33.80808 hospital
Simiyu Bariadi TC Muungano Health Centre public -2.79786 33.9917
Kigoma Buhigwe DC Muyama Health Centre public -4.32675 30.07465
Kagera Muleba DC Muyenje Dispensary public -1.74601 31.69033
Kigoma Kasulu DC Muyovosi Health Centre public -4.38612 30.25373
63 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kigoma Kasulu DC Mvinza Dispensary public -4.49693 30.59592
Kigoma Kasulu DC Mvugwe Dispensary public -4.20109 30.487
Simiyu Meatu DC Mwabagalu Dispensary public -3.64082 34.3413
Shinyanga Shinyanga DC Mwabenda dispensary public -3.40923 32.83244
Simiyu Maswa DC Mwabomba dispensary public -3.48411 33.76236
Mwanza Magu DC MWABULENGA dispensary public -2.61802 33.54383
Simiyu Meatu DC Mwabuzo Dispensary public -3.83611 34.17177
Tabora Nzega DC Mwaisela heathy centre private -4.21564 33.189
Simiyu Bariadi TC Mwakibuga dispensary public -2.5637 33.98334
Simiyu Meatu DC Mwakipopo Dispensary public -3.79094 34.30974
Shinyanga Shinyanga DC Mwakitolyo dispensary public -3.39289 32.72938
Kigoma Uvinza DC Mwakizenga Dispensary public -5.11667 29.8167
Shinyanga Msalala DC Mwalugulu dispensary public -3.85848 32.72307
Mwanza Magu DC MWAMABANZA dispensary public -2.67505 33.48564
Shinyanga Shinyanga DC Mwamakaranga dispensary public -3.56868 33.19902
Tabora Nzega DC Mwamala dispensary public -4.08337 32.95397
Shinyanga Shinyanga MC Mwamalili dispensary public -3.54681 33.45274
Simiyu Itilima DC Mwamapalala dispensary private -3.03147 33.90839
Mwanza Kwimba DC Mwamashamba Health Centre public -3.2311 33.12088
Shinyanga Kishapu DC Mwamashele Dispensary public -3.74386 33.83371
Tabora Igunga DC Mwamashimba dispensary public -4.08321 33.82338
Simiyu Meatu DC Mwambiti Dispensary public -3.60958 34.28196
Kigoma Uvinza DC Mwamila Dispensary public -5.045 30.16046
Simiyu Bariadi DC Mwamlapa dispensary public -2.59575 33.69545
Mwanza Mwanza cc Mwananchi hospital limited private -2.54395 32.98311
Mwanza Misungwi DC Mwanangwa dispensary public -2.96196 33.16108
Kigoma Kigoma DC Mwandiga dispensary public -4.82505 29.65682
Simiyu Meatu DC Mwandoya Health Centre public -3.22005 34.21044
Kigoma Kasulu TC Mwangà dispensary. public -4.44157 30.10579
64 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mwanza Sengerema DC Mwangika Health Centre public -2.43052 32.12122
Tabora Nzega DC Mwangoye dispensary public -4.05754 33.0846
Mwanza Kwimba DC Mwanhalanga dispensary public -3.01195 33.38533
Simiyu Meatu DC Mwanjoro Dispensary public -3.71555 34.42626
Mwanza Kwimba DC Mwankulwe. Dispensary public -3.11922 33.43766
Mwanza Mwanza cc Mwanza hospital private -2.51601 32.90644
Tabora Igunga DC Mwanzugi R.C dispensary private -4.35671 33.88117
Simiyu Maswa DC Mwasayi Health Centre public -3.34516 33.69001
Simiyu Bariadi DC Mwasinasi dispensary public -2.6621 34.27325
Shinyanga Shinyanga DC Mwasingu dispensary public -3.51953 33.1851
Simiyu Itilima DC Mwaswale dispensary public -2.82017 34.32455
Shinyanga Shinyanga MC Mwawaza dispensary public -3.69223 33.33293
Mwanza Misungwi DC Mwawile dispensary public -3.25219 32.89891
Kigoma Buhigwe DC Mwayaya dispensary public -4.47571 29.83673
Kagera Bukoba DC Mwemage Health Centre private -1.48157 31.61298
Mara Butiama DC Mwibagi dispensary public -1.8565 33.83919
Kigoma Kasulu TC Mwibuye dispensary. public -4.48942 30.05982
Shinyanga Kahama TC Mwime dispensary public -3.86116 32.6483
Mara Musoma MC Mwisenge dispensary public -1.50915 33.78361
Tabora Igunga DC Nanga Health Centre public -4.26221 33.61432
Simiyu Itilima DC Nangale dispensary public -2.91813 34.26637
Mara Bunda DC Nansimo dispensary public -2.1494 33.34692
Mwanza Ukerewe DC Nansio District Hospital public -2.10715 33.09088
Simiyu Busega DC NASA Health Centre public -2.37383 33.58511
Tabora Nzega DC Nata dispensary public -4.03108 33.13322
Mara Serengeti DC Natta Health Centre public -2.02387 34.4493
Tabora Nzega DC Ndala mission hospital private -4.77138 33.23876
Geita Geita DC Ndelema dispensary public -3.12074 32.31963
Tabora Igunga DC Ndembezi dispensary public -4.31986 33.41774
65 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Tabora Tabora MC Ndevelwa Dispensary public -5.10602 32.88261
Shinyanga Kishapu DC Ndoleleji Dispensary public -3.75411 33.95361
Tabora Uyui DC Ndono dispensary public -5.11406 32.44502
Kagera Biharamulo Ngararambe Dispensary public -2.77839 31.00621 DC
Shinyanga Shinyanga DC Nghomango dispensary public -3.63148 33.11739
Shinyanga Kahama TC Ngogwa dispensary public -3.77483 32.48538
Shinyanga Shinyanga MC Ngokolo Health Centre private -3.66583 33.43564
Mwanza Sengerema DC NgomaB Dispensary public -2.58622 32.78589
Mwanza Kwimba DC Ngudu District Hospital public -2.96216 33.3302
Mwanza Misungwi DC Nguge Dispensary public -2.84265 33.15975
Simiyu Maswa DC Nguliguli dispensary public -3.1325 33.95647
Simiyu Bariadi TC Ngulyati Health Centre public -2.69479 33.83944
Kigoma Uvinza DC Nguruka Health Centre public -5.11115 31.04289
Shinyanga Kishapu DC Nhobola Health Centre public -3.72312 33.59019
Shinyanga Shinyanga DC Nindo Health Centre public -3.53998 33.13975
Tabora Igunga DC Nkinga referral hospital private -4.42616 33.4386
Tabora Urambo DC Nkokoto dispensary public -5.09141 31.90273
Simiyu Bariadi DC Nkololo dispensary public -2.64145 34.16044
Geita Geita DC Nkome dispensary public -2.4995 32.00813
Kagera Kyerwa DC Nkwenda Health Centre public -1.48051 30.88833
Kagera Muleba DC Nshamba Health Centre public -1.80356 31.5501
Shinyanga Shinyanga DC Ntobo A dispensary public -3.64955 32.45818
Kagera Bukoba DC Ntoma dispensary private -1.44842 31.78079
Mwanza Misungwi DC Ntulya dispensary public -2.86937 33.27817
Kigoma Kibondo DC Nyabitaka dispensary public -3.6215 30.4978
Geita Chato DC Nyabugera Dispensary private -2.35709 31.74143
Kagera Biharamulo Nyabusozi Health Centre public -2.83957 31.45818 DC
Tabora Sikonge DC Nyahua Dispensary public -5.41571 33.28768
66 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kagera Karagwe DC Nyaishozi dispensary public -1.76528 31.12953
Geita Geita TC Nyakabale Dispensary public -2.84875 32.15143
Kagera Bukoba DC Nyakabanga dispensary public -1.56522 31.54319
Geita Geita DC Nyakaduha dispensary public -2.71093 32.39197
Kagera Karagwe DC Nyakagoyagoya dispensary public -1.68328 30.98327
Kagera Karagwe DC Nyakahanga DDH private -1.604 31.14084
Kagera Biharamulo Nyakahura Health Centre public -2.8295 30.98516 DC
Kagera Karagwe DC Nyakaiga hospital private -1.73099 30.96328
Mwanza Sengerema DC Nyakaliro Health Centre public -2.44465 32.44052
Kagera Biharamulo Nyakanazi Health Centre public -3.03581 31.20732 DC
Kagera Karagwe DC Nyakasimbi dispensary public -1.84128 31.12853
Mwanza Sengerema DC Nyakasungwa dispensary public -2.52704 32.47691
Mara Musoma DC Nyakatende Dispensary public -1.61844 33.73815
Mara Musoma MC Nyakato dispensary public -1.51741 33.81024
Mwanza Ilemela DC Nyakato dispensary public -2.53818 32.95756
Kigoma Kakonko DC Nyakayenzi Dispensary. public -3.19631 30.88661
Kigoma Buhigwe DC Nyakimwe dispensary. public -4.47426 29.76856
Kagera Ngara DC Nyakisasa dispensary public -2.69991 30.69163
Kigoma Kasulu DC Nyakitonto Health Centre public -4.48171 30.27585
Simiyu Busega DC Nyaluhande dispensary public -2.50563 33.61139
Shinyanga Ushetu DC Nyalwelwe dispensary public -3.98899 32.02699
Mwanza Sengerema DC Nyamadoke Dispensary public -2.53895 32.24305
Mwanza Mwanza cc Nyamagana District Hospital public -2.5636 32.9133
Mara Rorya DC Nyamagaro dispensary public -1.24501 33.91251
Mwanza Misungwi DC Nyamainza dispensary public -3.02837 32.93729
Mwanza Ukerewe DC Nyamanga dispensary public -1.82525 33.05356
Simiyu Bariadi TC Nyamata dispensary public -2.73729 33.96866
Mara Serengeti DC Nyamatoke Dispensary public -1.81148 34.42633
67 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Geita Geita DC Nyambalime dispensary public -3.0809 32.36773
Mwanza Kwimba DC Nyambiti Health Centre public -2.82872 33.42653
Shinyanga Kahama TC Nyambula dispensary public -3.74243 32.51318
Mara Serengeti DC Nyamburi Dispensary public -1.79008 34.75356
Kagera Ngara DC Nyamiaga hospital public -2.49736 30.66924
Mwanza Kwimba DC Nyamikoma dispensary public -2.75631 33.52475
Simiyu Busega DC Nyamikoma dispensary public -2.32206 33.6717
Mwanza Kwimba DC Nyamilama. Health Centre public -3.08298 33.34427
Geita Chato DC Nyamilembe dispensary public -2.52609 31.71667
Kagera Kyerwa DC Nyamiyaga dispensary public -1.05726 30.73459
Mwanza Sengerema DC Nyamizeze dispensary public -2.60147 32.60049
Mara Tarime DC Nyamongo dispensary public -1.48621 34.55225
Mara Tarime DC Nyamwaga dispensary public -1.39602 34.56881
Geita Geita DC Nyamwilolelwa dispensary public -2.80617 32.00722
Mwanza Ilemela DC Nyamwilolelwa dispensary public -2.43837 32.9529
Kigoma Kasulu DC Nyamyusi Dispensary public -4.53159 30.25908
Mara Rorya DC Nyanchabakenye dispensary public -1.45752 34.12174
Geita Nyanghwale Nyangalamila dispensary public -3.15026 32.7412 DC
Mara Bunda DC Nyangere dispensary public -1.96322 34.01143
Geita Mbogwe DC Nyang'holongo dispensary public -3.4187 32.04792
Mwanza Misungwi DC Nyang'homango dispensary public -3.01229 32.82238
Geita Nyanghwale Nyang'hwale Health Centre public -3.06057 32.57891 DC
Simiyu Bariadi TC Nyangokolwa dispensary public -2.73638 34.08254
Mara Tarime DC Nyangoto Health Centre public -1.46991 34.52365
Mwanza Magu DC NYANGUGE Health Centre public -2.53792 33.17569
Geita Mbogwe DC Nyanhwiga dispensary public -3.64168 32.38685
Mara Serengeti DC Nyankomogo Dispensary public -1.89325 34.31813
Geita Geita TC Nyankumbu Health Centre public -2.90603 32.23239
68 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kagera Biharamulo Nyantakara Dispensary public -3.19246 31.36313 DC
Mara Tarime DC Nyantira dispensary public -1.35588 34.64066
Kigoma Kakonko DC Nyanzige Health Centre public -2.94529 30.91743
Mara Tarime DC Nyarero Health Centre private -1.39041 34.54017
Kigoma Kigoma DC Nyarubanda dispensary public -4.56106 29.75146
Kigoma Buhigwe DC Nyaruboza dispensary public -4.55731 29.79658
Geita Geita DC Nyarugusu dispensary public -3.11967 32.23161
Kigoma Kasulu DC Nyarugusu Health Centre private -4.22349 30.39049
Mara Tarime DC Nyarwana Health Centre public -1.42085 34.44088
Geita Mbogwe DC Nyasato dispensary public -3.41534 32.21158
Shinyanga Shinyanga DC Nyashimbi dispensary public -3.88661 33.03896
Mara Musoma MC Nyasho Health Centre public -1.50462 33.80587
Mara Butiama DC Nyasirori dispensary public -1.86178 33.95744
Mwanza Sengerema DC Nyatukala heath center public -2.65384 32.63804
Mara Bunda DC NyatwarHealth Centre public -2.15763 33.83556
Simiyu Bariadi DC Nyawa dispensary public -2.45954 34.13062
Mara Musoma DC Nyegina Dispensary public -1.54647 33.72112
Mwanza Sengerema DC Nyehunge Heath Center public -2.52595 32.29715
Kigoma Kasulu DC Nyenge Health Centre public -4.62199 30.26518
Mwanza Ilemela DC Nyerere dispensary public -2.51688 32.97247
Geita Nyanghwale Nyijundu dispensary public -3.09154 32.66266 DC
Geita Nyanghwale Nyugwa dispensary public -3.21831 32.73843 DC
Kigoma Kasulu TC Nyumbigwa dispensary public -4.66369 30.1218
Tabora Nzega DC Nzega District Hospital public -4.21777 33.17919
Geita Geita DC Nzera Health Centre public -2.57677 32.12817
Simiyu Bariadi TC Old maswa dispensary private -2.68237 33.9943
Shinyanga Shinyanga MC Old Shinyanga dispensary public -3.56087 33.41165
69 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Shinyanga Shinyanga MC Old Shinyanga JWTZ public -3.5558 33.40784 dispensary
Mara Musoma MC Omega Health Centre. private -1.50443 33.8035
Kagera Muleba DC Omurunazi Dispensary public -1.71725 31.4984
Kigoma Kigoma DC Pamila dispensary public -4.88229 29.92096
Tabora Sikonge DC Pangale dispensary public -5.29266 32.71099
Mwanza Ilemela DC Pasiansi dispensary public -2.47419 32.90979
Mwanza Ilemela DC Pasiansi SDA Health Centre private -2.47858 32.9106
Kagera Bukoba MC PRINMAT Clinic private -1.32119 31.7915
Tabora Igunga DC Prinmat felamo martenity private -4.28268 33.87853 home
Geita Geita TC Prinmat Florida Maternity private -2.84151 32.42202 Home
Mara Rorya DC Rao District Hospital private -1.15762 34.03392
Mara Serengeti DC Robanda Health Centre public -2.14959 34.69915
Mara Tarime DC Rosana dispensary private -1.37657 34.47927
Kagera Bukoba DC Rubale Health Centre public -1.6004 31.52077
Kagera Muleba DC Rubya DDH private -1.75193 31.6211
Kagera Muleba DC RUGANDO DISPENSARY public -1.5906 31.59358
Kagera Ngara DC Ruganzo dispensary public -2.5479 30.68614
Kagera Biharamulo Ruganzu Dispensary public -3.10964 31.13695 DC
Mwanza Magu DC RUGEYE dispensary public -2.55326 33.25216
Kagera Karagwe DC Ruhita dispensary public -1.53413 31.15563
Kigoma Kasulu TC Ruhita dispensary. public -4.56004 30.21389
Mara Rorya DC Ruhu dispensary public -1.35452 33.82639
Kagera Biharamulo Rukaragata Health Centre public -2.65085 31.30935 DC
Kagera Ngara DC Rulenge hospital FBO private -2.72035 30.63206
Kigoma Kakonko DC Rumashi Dispensary public -3.16279 30.86203
Kagera Biharamulo Runazi Dispensary public -2.79683 31.43211
70 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
DC
Kigoma Kasulu DC Rungwe mpya Dispensary public -4.78628 30.21066
Kigoma Kasulu DC Rusesa Health Centre public -4.82073 30.0164
Kagera Muleba DC Rushwa dispensary public -1.78332 31.49387
Kagera Karagwe DC Rwambaizi Health Centre private -1.34695 31.11939
Kagera Bukoba MC Rwamishenye Health Centre public -1.32264 31.79516
Mara Tarime DC Rwamlimi Dispensary public -1.53132 33.81834
Kagera Kyerwa DC Rwele dispensary public -1.38101 30.89672
Geita Geita TC Sabeeve prinmaty Clinic private -2.86746 32.23425
Mara Tarime TC Sachita Health Centre private -1.34146 34.38061
Mwanza Mwanza cc Sahwa dispensary public -2.60275 32.97101
Simiyu Meatu DC Sakasaka dispensary public -3.17042 34.37846
Simiyu Bariadi DC Sakwe dispensary public -2.76736 33.85973
Shinyanga Shinyanga DC Salawe Health Centre public -3.31741 32.87108
Shinyanga Shinyanga DC Samuye Health Centre public -3.80894 33.32864
Mwanza Ilemela DC Sangabuye Health Centre public -2.38652 33.04432
Shinyanga Kahama TC Sangilwa dispensary public -3.86554 32.72766
Simiyu Maswa DC Sayusayu dispensary private -3.17133 33.73315
Shinyanga Msalala DC Segese Dispensary public -3.53232 32.4197
Mwanza Mwanza cc Sekou Toure Hospital public -2.51047 32.90484
Mwanza Sengerema DC Sengelema DDH private -2.63956 32.65539
Simiyu Maswa DC Sengwa dispensary public -3.42211 33.70399
Mwanza Mwanza cc Shadi dispensary public -2.64076 32.88154
Tabora Nzega DC Shila dispensary public -4.24936 33.10349
Shinyanga Shinyanga MC Shinyanga Regional public -3.66741 33.42702
Mara Rorya DC Shirati KMT DDH private -1.15366 34.0307
Simiyu Maswa DC Shishiyu dispensary public -2.95221 33.6024
Kigoma Kasulu DC Shunga Health Centre private -4.66998 29.99709
Tabora Sikonge DC Sikonge District Hospital private -5.62737 32.75742
71 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Tabora Igunga DC Simbo Health Centre public -4.65574 33.43128
Kigoma Buhigwe DC Simoni mkirene dispensary private -4.43332 29.79779
Mara Tarime DC Sirari Health Centre public -1.26197 34.47471
Mara Butiama DC Sirorisimba dispensary private -1.73647 34.22885
Mara Rorya DC Sokorabolo dispensary public -1.26043 34.08962
Shinyanga Shinyanga DC Solwa dispensary public -3.40335 32.89731
Shinyanga Kishapu DC Somagedi Dispensary public -3.80864 34.09952
Tabora Urambo DC Songambele dispensary public -4.93329 32.09255
Kigoma Buhigwe DC Songambele dispensary public -4.47753 29.97362
Simiyu Bariadi DC Songambele Health Centre private -2.66256 34.27286
Shinyanga Kishapu DC Songwa Health Centre public -3.4982 33.52304
Tabora Tabora MC St Anne's Mission Hospital private -5.01507 32.84274
Mara Musoma MC St clarat dispensary private -1.49604 33.77315
Kagera Muleba DC ST Joseph Hospital Kagondo private -1.5483 31.70519
Mara Bunda DC St maria Kibara hospital private -2.15466 33.46762
Kagera Missenyi DC St Therese Omukajunguti private -1.24289 31.483 dispensary
Mara Rorya DC St.Jude thadeus Health Centre private -1.25717 34.00743
Mara Rorya DC St.Marys Masonga Health private -1.10783 34.03872 Centre
Kagera Biharamulo ST.Otto Dispensary private -2.66853 31.36325 DC
Mara Rorya DC St.valentine dispensary private -1.4497 33.90435
Mwanza Kwimba DC Sumve DDH private -2.75021 33.22878
Kigoma Uvinza DC Sunuka Dispensary public -5.34924 29.78476
Mara Tarime DC Suruba dispensary public -1.44773 34.22801
Tabora Tabora MC Tabora Regional Referral public -5.02916 32.8083 Hospital( TRRH)
Mara Tarime TC Tarime District Hospital public -1.34679 34.36904
Mara Tarime TC Tarime goodwill foundation private -1.3472 34.38312
72 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mara Musoma DC Tegeruka dispensary public -1.75259 33.7347
Shinyanga Shinyanga DC Tinde Health Centre public -3.8709 33.1955
Kigoma Kasulu DC Tithe Dispensary public -4.67523 30.29505
Mwanza Mwanza cc TMR URAFIKI Health Centre private -2.54807 32.98224
Shinyanga Msalala DC Trust God dispensary private -3.24329 32.46086
Kagera Biharamulo Tumain Dispensary private -3.03715 31.22215 DC
Kagera Ngara DC Tumaini Health Centre private -2.71887 30.6337
Tabora Tabora MC Tumbi Dispensary public -5.07504 32.69652
Tabora Sikonge DC Tumbili dispensary public -5.46051 32.77166
Tabora Sikonge DC Tutuo amec health care private -5.49022 32.67697 Dispensary
Tabora Sikonge DC Tutuo Health Centre public -5.49317 32.67585
Shinyanga Kishapu DC Uchunga Dispensary public -3.59816 33.7633
Kigoma Kigoma MC Ujiji Health Centre public -4.91629 29.6814
Shinyanga Ushetu DC Ukune Health Centre public -4.0217 32.52423
Tabora Kaliua DC Ulindwanoni Dispensary public -5.01924 31.70078
Tabora Kaliua DC Ulyankulu Health Centre public -4.65372 32.174
Tabora Tabora MC Undomo dispensary public -4.14306 33.21488
Geita Geita TC Upendo Health Centre private -2.87483 32.27096
Tabora Uyui DC Upuge Health Centre public -4.91964 32.97642
Mara Tarime DC Urafiki prinmat private -1.37992 34.5103
Tabora Urambo DC Urambo District Hospital public -5.08077 32.07441
Tabora Uyui DC Usagali dispensary public -4.88612 32.50935
Shinyanga Shinyanga DC Usanda dispensary public -3.83458 33.27589
Tabora Sikonge DC Usanganya dispensary public -5.39802 32.61712
Shinyanga Ushetu DC Ushetu Health Centre public -4.18713 32.244
Geita Mbogwe DC Ushirika dispensary public -3.3682 32.26196
Geita Bukombe DC Ushirombo Health Centre public -3.47124 31.90075
Tabora Kaliua DC Usimbe Dispensary public -4.99498 31.92822
73 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Tabora Kaliua DC Usinge Dispensary public -5.09613 31.30504
Tabora Urambo DC Usisya dispensary public -5.0862 32.23592
Tabora Urambo DC Usoke Health centre public -5.09295 32.31405
Tabora Igunga DC Ussongo Health Centre private -4.3021 33.48865
Mara Rorya DC Utegi Health Centre public -1.31821 34.22314
Tabora Sikonge DC Utimule dispensary public -5.97841 32.79111
Kigoma Uvinza DC Uvinza Dispensary public -5.05219 30.46629
Kigoma Uvinza DC Uvinza Health Centre public -5.07672 30.37036
Tabora Urambo DC Uyogo dispensary public -4.91528 32.02919
Shinyanga Ushetu DC Uyogo dispensary public -4.17881 32.3465
Geita Bukombe DC Uyovu Health Centre public -3.33566 31.52631
Geita Geita TC WAJA Hospital private -2.87296 32.26566
Mara Musoma DC Wanyere dispensary public -1.84605 33.72926
Mara Bunda DC Wariku dispensary public -1.9364 33.77791
Simiyu Itilima DC Wazazi dispensary private -2.90747 33.93617
Shinyanga Kishapu DC Wazazi Ukenyenge Dispensary private -3.68052 33.67273
Mara Butiama DC Wegero dispensary public -1.6108 34.19522
Shinyanga Kishapu DC Williamson Diamond Ltd private -3.53643 33.60071 Hospital
Mara Tarime DC Will's memorial Health Centre private -1.25576 34.46387
Simiyu Itilima DC Zagayu Health Centre public -2.97578 33.77178
Kigoma Kigoma DC Zahanati ya bubango public -4.71939 29.66954
Kagera Bukoba MC Zamzam Health Centre public -1.32706 31.8127
Tabora Igunga DC Ziba dispensary public -4.24036 33.40579
Tabora Nzega DC Zogolo Health Centre public -4.09927 33.15078
Tabora Tabora MC Zonal Military Hospital public -4.99376 32.79752
Shinyanga Kahama TC Zongomela dispensary public -3.86112 32.55161
Tabora Kaliua DC Zugimlole dispensary public -5.325 31.6521
74 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Appendix 2: Remarks made by HF managers whose facilities rely on hired ambulances from other Health Facilities or the Districts to referral points
Note: Represents facilitylevel remarks Some words may be misspelled Geita
Communication network problems Lack of ambulance, infrastructure. Lack of ambulance Communication to ambulance service Transport To refer its depends with availability and person in charge how shape he/she is to respond to emergency Rough road to reaching area Lack of transportation Lack of transport Late of Ambulance, network coverage Transport not at all,therefore the community find there own transport Sometimes ambulance have no fuel Transport Health centre near by has no ambulance till district ambulance No ambulance at a specific time, conflict of interest they don't belong to District Council instead Town Council Transport sometimes not available Transport Transportation and infranstructure Rough road, communication to get ambulance Commuty they don't to be referred due to local believes such as traditional believes Sometimes ambulance have no fuel Absence of fuel in the ambulance cana delay the process No HI issuarance they have no mtuha no. Transportation Lack of transport Sometimes there was no fuel in nearby ambulance Delaying to ambulance communication
Geita Network coverage delays of near by ambulance Lack of reliable transport Get ambulance during night, Network coverage Sometime when they call the ambulance the reply is there is no fuel or it is not there or it has other responsibility. Transport Difficulties in communication with ambulance It very hard sometime to get a car for referal you can wait for 3 to 6 hrs No Ambulance in the facility so they advise the patient to take motorcycle because ambulance from other facility doesn't come in time or come 3-6 hrs later Very rarely the ambulance could late that were they take motorcycle Clients refuse to be referred,thus they feet to be operated in district hospital. Delayment of nearby ambulance. n/a Rough road difficult to reach. Location is not recorded in software IT informed but was Altitude 1209.2m Poor infrastructure of the road Clients refused to be refered
75 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kagera Stigma from other health facituy Income,transport. Ambulance not available at time when the referral occur Network not available on rain season when they call near by ambulance Care and ambulance not available on time Pt delay to decide on refferal Ambulance comes late after calling for help Transport problem In case of ambulance is unavailable mother is not prepared for cost to reach hospital High cost invade of private transport Ambulance and others car not available at the time when needed Transport problem and the remoteness of the place to the referral facility Absence of ambulance Kagera No fuel to dependent amnulance Rough road Transport Patients fails to pay for refferal Trasport They refuse early referal due worry of being delivered by caesarian section in a referal hospital Transport,communication problem When nearby ambulance is not available the client is not ready to go by private car due cost Transport problem Poor road infrastructure Availability of transport on time The facility has no own transport to transfer emonc patient Ambulance is not reliable Remoteness of the area, no escort allowance for referral services Rough road Transport TRANSPORT Rough road Sometimes people fails to pay for their refferal The fare for health workers from hospital to HF for private transport.when escort the client. Transport, Cost Income,distance. Client delays to decide to be referred wording about cost & distance Pregnant mother refuses early refferal due to local believe, ignorance and poverty Absence of privately owned motor vehicles in this village Transport, Income due to poverty. Transport, Cost
Kigoma No ambulance,sometimes the nearby ambulance out of oik Unreachable transport, poor road network. No variable transport to reach refferal point Ambulance is not available sometimes when needed it founded on another root. Community they can't afford coast for transport People can not afford charges of oil for ambulance from nearby referral h/f Many patients complains of lack of money to pay for transport when was referred to health centre. 76 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
n/a Long distance to refferal point.people can not afford transport expenses. .No variable Car Ambulance a the facility, poor road infrastructure Transport, no escort nurse They don't have own transport they need motorcycle ambulance to solve the problems. They can't afford coast for petrol n/a There is no ambulance so sometimes relative have to find other means of transport Refferal can occur late due to waiting donation of money from relative, and nearby ambulance could be on other issue Ambulance comes from municipal headquarters and used for multiple activities It take long channel system to communicate to referral point.Information go DMO Kakonko first ,then he/she communicate with DMO at Kibondo when they accept,is when he send feedback to Kiduduye that Financial problem Unreliable transport The near by hospital is Kibondo that's why when the get referral escape to go to Kakonko to avoid expense. Lack of transport sometimes when they need ambulance from nearby failed and make decision to take private care. Sometimes client resist the referral because they don't have money to go for health facility.
Also fear of been blamed to have pregnancy in old age. No ambulance,poverty. Some times Ambulance not available so mother delay go to Hosp . No ambulance so it take a lot of time for ambulance from maweni hosp The major challenges includes rough road especially during the rain seasonal which may cause delay to reach near by hospital on time. Sometimes Ambulance not inorder and lack of reliable electricity Some people they don't have enough money to take private transport .
Dispensary they don't have own transport. Poor road network Network is major problem when they want to communicate about referral they failed and cause more problems. Lack of owned transport which make People to heare private ambulance and been charged 80000 to rich the health facility on time which is very expensive to them. H/f have no ambulance which referral to delay
Kigoma It is difficult to refer cases at night hours due to havent security Problem of transport during rain season Unreliable transport Patient delay to go to hospital because the h\f have no ambulance Transport and financial issues They have no ambulance
Mara Fuel for health facility for motorcycle ambulance Means of trance Port to referal point is the problem 77 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
No nurse to escot patient When calling the public ambulance causes delaying in reaching referral health facility (about 5 hours) very costly when using private transport about 150,000\=tsh n/a n/a Transport and infrastructure Poor infrastructure and unreliable transport Transportation Needs of transport n/a Infrastructure and transport Transport not reliable and poor infrastructure Some time the ambulance delay to reach heath facility. Delaying to reach referral site due to long distance Distance, unreliable transport poor infrastructure Transport is problem also escort when mothers used motorcycle Speed of motorcycle ambulance is very low, so as consumable of fuel rise up. As well as there is no Driver the assistance clinical officer is act as driver if referral happen. Poor infrastructure and transport problem Transport Communication to nearby ambulance is problem Sometimes waiting time is prolonged Delay of ambulance to arrive at health facility
Mara Transport Transportation and infrastructure Most of client are unable to manage costs for private transport. Transport system is good Transport problem, poor infrastructure Poor infrastructure,unreliable transport Sometimes ambulance delays also some fail costs. Transport and infrastructure Transportation system is the challenge. Means of transport to referral point is the problem in referral system. Transportation Delay of transport
Mwanza Depend nyamagana Hosp.ambulance which is far from referral point Delay to get ambulance from nyamagana hospital,they hire motorcycle to buhongwa then taxi to nyamagana district hospital Means of. Transport During the rain season its difficult to pass Transport Transport,Need motor cycle ambulance Mwanza Road,mean of transport, Transport Transport Transport Means. Of transport. Ambulance in. The facility Transport Means. Of transport Delay on ambulance arrival Unavailability of ambulance, the HF is very far from the main 78 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
road ,very rough road difficult to move in rain season,inadequate beds,there is only one bed in whole hosp Unpassable roods during rain season Transport Means of transport Ambulance car and motor cycle ambulance not working, Delay or absence of ambulance Availability of Transport Transport, Need driver Transport Corrugation road Transport Delay of ambulance to reach the area,,, Corrugation of the road Network,transport Means of transport
Mwanza
Facility not have phone,challenge of ambulance from near referal hospital.such as no fuel,another emergency case need the same transport Rough road,corrogestion road sometime during rain season Delay of the ambulance,,some sometimes in availability of ambulance. which cause client to hire private transport Transport,fuel and driver for motor cycle ambulance Delay of ambulance Transport Means of transport They need ambulence for own facility Unavailability of ambulance,some times it doesn't reach in time,absence of ambulance most of the time, n/a Transport ambulance delay Unpasable rood
Shinyanga No amburance Unaffordable cost for refferal Repayment of transport Delaying of transport ( ambulance) Shortage of fuel Fuel is a problem Shortage of fuel Sometime refer to Region hosp Difficult to get transport during the night Sometimes vehicle delays Financial problems to client on referral of patient No amburance Patients failed to reach referral facility Difficult to get transport especially during the night
Shinyanga No amburance Delay of transport Inconsistent availability of transport for referrals Ambulance is difficult to get due to fuel or having client so they hire a car Car not easily accessible,rough roads during rain season. Referral forms and reliable transport are needed in the facility for referral system 79 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Delay of transport for referal Not reliable transport Inadequate transport Transport Delay of transport Delayment of transport(ambulance) No ambulance Shortage of fuel Delay of transport Ambulance not always available a when needed. Ambulance is on service at that time Shortage of fuel supply Transport problem Delay of transport Delay of transport Delay and lack of transport Delay of transport Delay of transport, network problems Shortage supply of fuel Delay to get transiport Difficult to access ambulance in time. Network problem Delayed ambulance Shortage of fuel supply
Simiyu Poor infructure Lack of own facility Lack of own ambulance Inadequate transport system and lack of funds. Take more time toget ambulance, poor network communication,communication cost Bad during rain season Shortage of staff / transport from HF to hospital To get ambulance at right time No Ambulance Transport problem infrastructure No Ambulance n/a Ambulance needed Poor infrastructure , high cost from private car. Can not afford cost of transport. Poor communication between facilities and district hospital Network problem, needs owner ambulance, Cost telephone communication, prolonged time toget ambulance People can not afford to pay the trasport Cost telephone communication, delayed of ambulance Cost telephone communication, delay ambulance Repayment of getting transport Sometimes clients refused to be referal Prolonged time toget ambulance, cost of charge, No Ambulance Transport for refferal is the problem Only one car, from near by facilty Some of client failed to be referred because they don't have money to afford cost. Lack of transport/ due to poor infrastructure
Simiyu 80 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
No any types of transport They requesting Own ambulance car to overcome challenge of maternal death. Irregular availability of fuel for ambulance, telephone cost Delayed to have ambulance from near by. Long distance,lough road Delayed to have ambulance from near by Transport problem Magu sometimes reject to receive client Prolonged time toget ambulance,lough road. Take more time to get ambulance, cost change of phone, Bad road during rain season n/a Poor infrastructure /- shortage of transport Transportation for referral cases is the problem During the rain season roads are flooded. No public transport and Ambulance Client complaining about high cost The problem of geting Ambulance in time Difficult to a ambulance from refferal point Lack of ambulance on time Problem of hiring transport. No Ambulance Transport is a big challenge Prolonged time toget ambulance, during seasone flat of rivers,no phone comunication(network problem) Trasnspot is the problem
Tabora Delay transport on time Delaly transport on time Delay transport on time Transport Transport problem Long distance to reach referral point, no ambulance Transport and fund Delay of transport Transport problem Transport problem Delay transport on time Transport Inadequate personnel to escort patient to referral point Transport problem Transport problem Transport problem Transport Transport Transport Transport Delay transport on time Costs during admission is a challenge Delay transport in time Delay transport on time Transport-ambulance
Road during rain is not easily accessible Delay transport on time Patient/relatives not willing to abide to refferal. If they use private transport, the cost is Tshs.5,000 Delay transoport on time
Tabora Transport 81 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Transport problem Transport Delay transport on time Delaying of transport Inadequate personnel to escort patients to referral point if a nurse is unavailable from the referral point Transport Long distance to reach refferal Hosp, no ambulance Do not have means of transportation- ambulance Transportation cost Ambulance of district not so much reliable No ambulance Transport Appendix 3: Number of Maternal deaths reported per the major causes of maternal deaths by regions and place of death in Lake and Western Zones
Figure 1: : Number and place of deaths from Hemorrhage
Figure2 : Number and place of deaths from hypertensive disorders in pregnancy
82 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 3: :Number and place of deaths from sepsis
Figure 4 : Number and place of deaths from obstructed labour
83 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 5 : Number and place of deaths from abortion complications
84 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Figure 6: Number and Place of deaths from Anemia
Figure 7: : Number and place of deaths for other medical conditions
Appendix 4 ; A list of Hospitals and Health Centres that did not provide CEMONC services in last three months
Region District Registered_name
Geita Bukombe_dc Uyovu Health Centre Bukombe Hospital Chato_dc Kachwamba Health Center Chato District Hospital Bwanga Health Centre Butarama Health centre Geita_dc Katoro
85 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Geita district hospital Chikobe Bukoli health centre Geita_tc Upendo Health Centre Kasamwa Health Centre Mbogwe_dc Masumbwe Iboya Nyanghwale_dc Nyang'hwale Kagera Biharamulo_dc Rukaragata Health Centre Nyakanazi Health Centre Nyakahura Health Centre Nyabusozi Health Centre Kagera Bukoba_dc Rubale health center Mwemage health centre Kishanje health center Katoro health center Kashozi health center Kanazi health centre IZIMBYA DDH Bukoba_mc Zamzam Health Center Rwamishenye Health Centre Karagwe_dc Nyakaiga hospital Nyakahanga designated hospital Kayanga health centre Kyerwa_dc Nkwenda health centre Murongo health centre Isingiro hospital Missenyi_dc Bunazi Health Center Muleba_dc Rubya Designated Hospital Nshamba health centre Kamachumu Health Centre Kaigara Health Centre Kaigara Health centre Izigo health centre Kagera Muleba_dc ELCT Ndolage Hospital ELCT NDOLAGE HOPITAL Ngara_dc Rulenge hospital FBO Murusagamba health center Murgwanza DDH Mabawe health centre Lukole health centre
Kigoma Kakonko_dc Kakonko Health Centre. Kasulu_dc Nyarugusu Health Centre Kimwanya Health Centre Kasulu District Hospital Kasulu_tc Kiganamo health centre Kabanga reffarà l hosptal 86 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Kibondo_dc Mabamba health centre Kifura Kigoma_dc Matyazo health center Bitale health center Kigoma_mc Maweni Regional Hospital
Kigoma Uvinza_dc Uvinza Hc Nguruka Health centre Ilagala Health centre Mara Bunda_dc Nyatwari h/c Mugeta h/c Kisorya h/c Kasuguti h/c Kasaunga h/c Ikizu h/c Butiama_dc Kiagata Musoma_mc Nyasho Health centre Coptic Medical health centre Bweri health centre Beth said a health center Akimu maternity and nursing a hom Rorya_dc St.Jude thadeus health centre Kowak hospital Kinesi health centre Baraki sisters health center
Serengeti_dc Robanda Health centre Natta health center Machochwe Health center Mara Serengeti_dc Kebanchabancha Health center Iramba Health center Tarime_dc Urafiki prinmat Sirari Nyangoto Magoto Alpha prinmat Tarime_tc Sachita health centre Mwanza Ilemela_dc Sangabuye health center Kiloleli juu health center Karume health center Huduma health center ELCT nyakato health center Kwimba_dc Nyambiti health centre Misungwi_dc Misungwi district hospital Misasi health centre Mbalika health centre Busongo Health centre Bukumbi hospital 87 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Mwanza_cc TMR URAFIKI HEALTH CENTRE Nyamagana district hospital Mwanza Mwanza_cc Mwananchi hospital limited Igoma health centre Bugando medical centre Sengerema_dc Nyehunge Heath Center Nyatukala heath center Nyakaliro Health center Mwangika Health Center Kome Health Center Katunguru Heath Center Kakobe Health Center Kagunga Health Center Busisi Heath Center Busisi Dispensary Shinyanga Kahama_tc Lowa health center Kahama hospitali Kishapu_dc Williamson Diamond Ltd Hospital Songwa Health Center Nhobola Health Center Kishapu Health Center Bunambiyu Msalala_dc Lunguya health centre Chela health centre Shinyanga_dc Tinde Shinyanga Shinyanga_dc Salawe Nindo Ushetu_dc Ukune Bulungwa Simiyu Bariadi_dc Songambele Byuna health centre Bariadi_tc Ngulyati Muungano Bariadi District Hospital Busega_dc NASA Mungu kwanza Mkula Hospital Igalukilo Itilima_dc Zagayu health center Ikindilo health center
Maswa_dc Mwasayi health center MALAMPAKA RHC Lalago health centre Meatu_dc Mwandoya Simiyu Meatu_dc MEATU Tabora Kaliua_dc 88 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Ulyankulu health center Kaliua mission health center Kaliua government health centre Nzega_dc Zogolo health center Mwaisela heathy centre Itobo health center Itanana health center Busondo health center Bukene health center Sikonge_dc Tutuo health center Mazinge health center Kitunda health center Tabora_mc Zonal Military Hospital St Anne's Mission Hospital Urambo_dc Usoke. Health centre Urambo district hospital Uyui_dc Upuge Health centre
89 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Appendix 5: List of Regions, Districts, Research Assistants, and Supervisors Name of Region District Regional Name of District supervisor Geita Region Bukombe District Council Upendo Mwasanu Geita Region Chato District Council Seraphina Lutta* Geita Region Geita District Council Janeth Wilsonsuda Magreth J Geita Region Geita Town council Kagashe Geita Region Mbogwe District Council Ngaya Dilangale Geita Region Nyang'hwale District Council Latifa Mfungavo Kagera Region Biharamulo District Council Zaharani Shangali Kagera Region Bukoba District Council Ilona Elisante Alfreda Kagera Region Bukoba Municipal Council Kabakama* Kagera Region Karagwe District Council Tatu Mamba Kagera Region Kyerwa District Council Patric Stima Castro Charles Kagera Region Missenyi District Council Chagonja Kagera Region Muleba District Council Modest Mwinuka Kagera Region Ngara District Council Nicodem Komba Kigoma Region Buhigwe District Council Juliana S. Biseko Kigoma Region Kakonko District Council Eunice Lema Kigoma Region Kasulu District Council Yonita Kamundi Kigoma Region Kasulu Town Council Rachel Mjata Kigoma Region Kibondo District Council Stella lwiga Kigoma Region Kigoma District Council Grace Chirwa Eugenia Kigoma Region Kigoma Municipal Council Kidyalla* Kigoma Region Uvinza District Council Joyce Komba Mara Region Bunda District Council Amina Bwesso Mara Region Butiama District Council Vicky Mogoti Mara Region Musoma District Council Bushiri Mmari Mara Region Musoma Municipal Council Steria Joliga* Mara Region Rorya District Council Gift Lukumay Mara Region Serengeti District Council Blandina Michael Mara Region Tarime District Council Zakaria Kyamwaya Mara Region Tarime Town Council Juma Mtipa Mwanza Region Ilemela District Council Shamim Londa Mwanza Region Kwimba District Council Bilhuda Mona Mwanza Region Magu District Council Mary Mponda Mwanza Region Misungwi District Council Florence Mungereza Mwanza Region Mwanza City Council Rehema Panga Ally Said Mwanza Region Sengerema District Council Aweza Mtunguli Mwanza Region Ukerewe District Council Stella Ibrahim Shinyanga Region Kahama Town Council John Chuma
90 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Shinyanga Region Kishapu District Council Hilda Haule Shinyanga Region Msalala District Council Emma Mauki Shinyanga Region Shinyanga District Council Mary Nyenga Shinyanga Municipal Shinyanga Region Council Judith Msovera Shinyanga Region Ushetu District Council Hellen Mkama Simiyu Region Bariadi District Council Elizabeth Mattle Simiyu Region Bariadi Town Council Winfrida Newa Simiyu Region Busega District Council Noel Mushi Simiyu Region Itilima District Council Maria Mwamanda Simiyu Region Maswa District Council Mariamu Rusimbi Simiyu Region Meatu District Council Queen Liwa Tabora Region Igunga District Council Ezekiel Morris Tabora Region Kaliua District Council Tulha Abdallah Juma Tabora Region Nzega District Council Catherine allan Tabora Region Sikonge District Council Gilbert Lyimo Tabora Region Tabora Municipal Council Diana Kasembe Tabora Region Urambo District Council Martha Leole Tabora Region Uyui District Council Baraka D. Kapinga
91 | P a g e Ministry of Health and Social Welfare Tanzania EmONC Assessment report, 2015
Appendix 6: The Survey Questionnaire
Rapid Assessment Tool for Emergency Obstetric and Newborn Care (EmONC)
[Note: Unless otherwise stated, “Last/past year” refers to January-December, 2014 and “Last/past 3 months” refers to January-March, 2015]
Date of initiating the interview: ______Date of completion------SECTION A: GENERAL INFORMATION/ GENERAL OFFICE Region: ______District:______Council:______Ward:______Zone: Village/Mtaa:______MTUHA HF Code Telephone #:______Lake *If not known write NK Western 1.1 Registered/Official Facility Name:
1.2 Common Facility Name:
1.3 Geographic Coordinates: Point ID : ______Altitude(Elev): ______
Latitude(S):__ __. ______Longitude (E): __ __. ______
1.4 Service Population: ______
1.5 Type of Health Facility(HF) 1.6 Ownership
Clinic Regional Hospital (a) Public (b) Private
Dispensary Referral Hospital Government For profit
Health Centre Maternity Home Military Faith based Organization (FBO)
District Other Hospital Parastatal NGOs Hospital specify;______Other Specify:______
Designated District Hospital (DDH)
1.7 Does this facility conduct deliveries? 1.Yes 0.No , If no stop there and thank the
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1.8 Is this facility expected to provide Caesarean Section services? 1.Yes (CEmONC facility) 0. No (BEmONC Facility)
1.9 Does this facility accept Health Insurance 1.10 If yes which type of Health Insurance is accepted? (Multiple clients response)
1.Yes 0.No (a) NHIF (b) CHF (c) Others, Specify:______
1.11 Total Bed Capacity of HF:______
1.12 Does this facility referrer EmONC cases to other facility?: 1.Yes 0.No
If no, give explanation______
1.13 Means of Transport to Referral Point: 1.14 Nearest Referral Health Facility:______(Multiple response)-for EmONC cases Type Hospital
Health Centre
Not applicable ( if Tertiary Hospital)
1.15Major Challenges/Remarks to reach at referral point:_ Public Transport 1.Yes 0.No Private Transport If Yes, explain______1.16 Cost for Transport to referral facility within the region Private Ambulance [consider the most accessible transport. This question is not for Health Facility Owned Transport Regional and tertiary HFs). ______Tsh 1.18 Does the health facility has governing board/ committee? Ambulance from nearby or Referral 1.Yes 0.No Facility Any meeting in the last quarter (only if board available) Other means of Transport, 1.Yes 0.No, Specify:______If yes see minutes Yes, Minutes seen None Yes, Minutes not seen 1.17 Distance to referral hospital/Health Centre (Not Applicable for Tertiary hospital)
1.19 Does the health facility has quality improvement : Walking (hrs:Minutes) : committee? 1.Yes 0.No Transport in dry Any meeting in the last quarter ( only if 1.19 yes) season(hrs:Min): 1.Yes 0.No If yes see minutes Yes, Minutes seen
No, Minutes not seen Transport in rain season(hrs:Min):
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1.20 Any Community referral system or arrangement? (probe) 1.Yes 0.No * If Yes, Explain ______Service charges ( in Tshs.) of the following services(exclude fast track in public facilities) 2.1 Normal delivery:Sh 2.5 Haemoglobin Testing: Sh 2.2 Assisted delivery:Sh 2.6 Blood transfusion: Sh 2.3 Caesarean section:Sh 2.7 Postnatal care: Sh 2.4 Antenatal clinic: Sh 2.8 Family planning consultation: Sh 2.9 Additional Comment:______
Health Facility Staffing Staff available in the health facility Cadre Total in HF 3.1 Registered Nurse 3.2 Enrolled Nurse
3.3 Medical Attendant
3.4 Clinical Officer
3.5 Assistant Clinical Officer
3.6 Anaesthetist
3.7 Anaesthetist Assistant
3.8 Assistant Medical Officer
3.9 Medical Officer
3.10 Obstetrician
3.11 Paediatrician
3.12 Surgeon
3.13 Laboratory Technician
3.14 Laboratory Assistant
3.15 Radiographer
3.16 Sonographer
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3.17 Pharmacist
3.18 Pharm Technologist
3.19 Pharm Tech Assistant
Continuing Professional Development (CPD) How many members of staff were trained in any of the following areas in the past five Total in HF years?
3.20 BEmONC training (2weeks)
3.21 EmONC refresher course(3-4 days)
3.22 CEmONC Training (3weeks)
3.23 PNC Training (1week)
3.24 Comprehensive post abortion care including MVA
3.25 Focused antenatal care (1week)
3.26 Family planning including contraceptive technology updates (2 weeks)
3.27 Prevention of Mother to Child Transmission (Option B+)
3.28 Essential Newborn care (5days)
3.29 Help Baby Breath (2days)
3.30 Integrated Management of Child Illness (11days)
3.31 Infant feeding (5days)
3.32 Kangaroo mother care
3.33 VCT for HIV
Referral System (Interview the midwife or in-charge or deputy of the facility and physical checking (√)
Yes NO Functional Not working 4.1 Telephone (landline) available? 4.2 Mobile phone available belonging to health facility?
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4.3 Short wave radio communication available? 4.4 Car ambulance available? 4.5 Radio ambulance in the car available? 4.6 Motor cycle ambulance available? 4.7 Bicycle ambulance available? 4.8 Referral forms available? 4.9 How often is feedback given on referred patient Routinely Occasionally by referral facility? Not at all
4.10 Additional comments: 1.Yes0.No: If Yes explain
......
Outreach Services to Community
5.1 List type of services provided as outreach RMNCH
Gynaecological
Surgery
Ophthalmology
Medicine
VCT
Other, Specify______
5.2 No. of community health workers available in CHWs catchment area used in outreach
5.3 No. of outreach RMNCH clinic sites? Outreachs
5.4 How many RMNCH outreach visits were Visits conducted in last 3 months (Jan-March 2015)?
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Physical Infrastructure(Check physically and availability on site)
6.1 Is the water supply in the health facility available? 1.Yes 0.No 6.2 If yes what is the source of supply? Multiple responsePiped water Rain water harvest Borehole Other (specify) ______6.3 Piped water available in maternity? 1.Yes 0.No
6.4 Piped water available in operating theatre? 1.Yes 0.No
6.5 Water storage tank available? 1.Yes 0.No yes, capacity in litres?:______6.6 Water pump available? 1.Yes 0.No
6.7 Borehole available in compound? 1.Yes 0.No
6.8 Electricity available in labour ward? 1.Yes 0.No
6.9 Electricity available in nursery? 1.Yes 0.No
6.10 Electricity available in operating theatre? 1.Yes 0.No / NA
6.11 Is the functional Generator available? 1.Yes 0.No
6.12 Solar power system available? 1.Yes 0.No
6.13 Toilet available in maternity functional? 1.Yes 0.No
6.14 Is the functional Computer(s) Available? 1.Yes 0.No
6.15 Toilet available in labour room? 1.Yes 0.No
6.16 Mention methods of sterilization used in health facility: (Multiple response) Autoclave Steam sterilizer Boiling Others, specify______6.17 Is functioning incinerator available?1.Yes 0.No
6.18 Placenta pit available?1.Yes 0.No
6.19 Rubbish pit available? (describe under comment) 1.Yes 0.No
6.20 General summary of the infrastructure:1.Yes 0.No Write summary here:......
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Emergency System(OPD or Emergency section)
Availability in last 3 months
S/N Item to assess Yes No Not assessed
7.43 Facility own functional ambulance
7.44 Facility gets ambulance from the nearby facility
7.45 Presence of reliable ambulance for referral
7.46 Ambulance fitted with a client bed 7.47 Ambulance fitted with provider seat to manage the client
7.48 Ambulance fitted with chair for relative
7.49 Intubation equipment
7.50 Clinical thermometer
7.51 Presence of source of oxygen supply for adult and infant
7.52 Adult resuscitation bag
7.53 Infant resuscitation bag
7.54 New-born resuscitation bag
7.55 Facilities for hand washing/alcohol hand rub
7.56 Portable and fixed suction apparatus
7.57 Collapsible Wheelchair
7.58 Collapsible stretcher
7.59 Pulsoxymeter
7.60 Sphygmomanometer &stethoscope
7.61 Cotton wool
7.62 Bandage
7.63 Antiseptic
7.64 Adhesive plaster
7.65 Face Mask
7.66 Surgical Gloves
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7.67 Cannulae sizes 16 or 18
7.68 Safety boxes
7.69 Disposable bags for vomiting
7.70 I.V. Fluids NS or Ringer’s Lactate
7.71 Inj. Adrenaline
7.72 Inj. Frusemide
7.73 IV Aminophylline
7.74 Female Catheter’s sizes 12 or 14 or 16
7.75 Suction Machine: Manual or Electric Operated
7.76 Adult Nasogastric Tube
7.77 Infant Nasogastric Tube
7.78 New-born Nasogastric Tube
Additional Comments:______
SECTION B: RCH SERVICES
RCH Clinic: Availability Of Human Resource And Services [RCH include: ANC clinic, Post-natal clinic, PMTCT and under five clinic and Family planning.] (Interview a Nurse in charge of the unit)
Staffing Indicate number of staff available for RCH services Staff available in the unit Cadre RCH clinic
8.1 Registered Nurse 8.2 Enrolled Nurse
8.3 Medical Attendant
8.4 Clinical Officer
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8.5 Assistant Clinical Officer
8.6 Assistant Medical Officer
8.7 Medical Officer
8.8 Obstetrician
8.9 Paediatrician
8.10 Laboratory personnel
RCH Clinic: Continuing Professional Development (CPD) Indicate number of staff trained Were relevant members of staff trained in any of the following areas in the past 5 years?(Only staff who are currently working in this particular section) 8.11 BEmONC training (2weeks)
8.12 EmONC refresher course(3-4 days)
8.13 CEmONC Training (3weeks)
8.14 PNC Training (1week)
8.15 Comprehensive post abortion care including MVA
8.16 Focused antenatal care (1week)
8.17 Family planning including contraceptive technology updates (2 weeks) 8.18 Prevention of Mother to Child Transmission (Option B+)
8.19 Essential Newborn care (5days)
8.20 Help Baby Breath (2days)
8.21 Integrated Management of Child Illness (11days)
8.22 Infant feeding (5days)
8.23 Kangaroo mother care
8.24 VCT for HIV
Antenatal care
9.1 How many days a week are ANC services days *1-6 provided? (1,2,3...6) Are the following services ROUTINELY offered Routinely done Was this service regularly provided in the during antenatal clinic (ANC)? Indicate with a tick last 3 months (January, February and (√). March 2015)? 1.Yes 0.Not 1.Yes 0. No 9.2 Ferrous supplementation
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9.3 Folic acid tablet supplementation 9.4 Combination of Ferrous and Folic acid ( e.g FEFOL) 9.5 Syphilis screening 9.6 Haemoglobin check 9.7 Urine tests (albumin& sugar) 9.8 Tetanus vaccination 9.9 IPTp for malaria 9.10 HIV testing and counselling 9.11 ARV treatment for PMTCT 9.12 Checking for BP 9.13 Malaria Checking using Malaria Rapid test (mRDT) 9.14 MoHSW ANC card no 4 issued Ask and observe to establish the following 9.15 Is there a functional BP machine and 1.Yes 0.No, stethoscope? 9.16 Is there a functional weighing scale? 1.Yes 0.No, 9.17 Verify by reviewing 4 ANC Cards at Exit for 1.Yes 0.No, services provided on last visit 9.18 Are there functional toilets for clients? 1.Yes 0.No, 9.19 Verify if the toilets are clean. 1.Yes 0.No, 9.20 Decontamination of reusable instruments with disinfectant (3 buckets system) 1.Yes 0.No, 9.21 If Yes, Verify date of preparation of Within 24 hrs Not within 24hrs disinfectant if its within 24 hrs
Antenatal Data: (Ask or obtain some of this information from ANC register with assistance of Nurse Midwife in charge. This information refers to services given to clients in last 3 months (January, February, and March 2015). 9.22 No. of Women who made their first ANC visits before 12 weeks gestation 9.23 No. of Women who made their 4th ANC visits 9.27 No of TT2 9.28 No of Intermittent Preventive Treatment in pregnancy second dose (IPTp2) 9.29 No of pregnant women screened for syphilis 9.30 No of pregnant women tested syphilis positive? 9.31 No of pregnant women tested for HIV 9.32 No of pregnant women tested HIV positive?
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9.33 No of pregnant women HIV positive on ART 9.34 Total no. of ANC clients 9.35 No. of post natal reviews in first 48 hours(refferer MTUHA)- post natal 9.36 No. of post natal visit in first 7 days RCH Clinic: Availability Of Essential Medical Equipment
RCH Clinic Yes No Functional Not working
(Number) (number) 9.37 Adult weighing scale 9.38 Children weighing scale 9.39 Blood pressure machine 9.40 Stethoscope 9.41 Examination couch 9.42 Vaginal speculum (Sim’s) 9.43 Movable light source on light 9.44 Container sharp (safety box) 9.45 Patellar reflex hammer 9.46 Measuring tape 9.47 IUD insertion set 9.48 Implant insertion set 9.49 Operating table
9.50 Operating lamp
9.51 Anaesthesia machine (indicate type)
9.52 Anaesthesia trolley
9.53 Blood pressure machine
9.54 Stethoscope
9.55 Foetal stethoscope
9.56 i.v. drip stand
9.57 Laryngoscope set
9.59 Oropharyngeal airway set
9.60 Oxygen giving set
9.61 Instrument trolley
9.62 Mayo instrument tray (readjustable)
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9.63 Bowl stand (double) with stainless steel bowl
9.64 Foot stand
9.65 Patient trolley
9.66 Delivery set 9.67 Mini laparotomy set (complete)
9.68 Baby cot in neonatal ward
9.69 Wall clock
9.70 Theatre boots
9.71 Autoclave (specify type)
9.72 Dressing drum (large)
9.73 Dressing drum (medium)
9.74 Dressing drum (small)
9.75 Theatre gowns
9.76 Theatre caps
9.77 Plastic aprons
9.78 Face masks
9.79 Protective goggles
6.21 Additional comments available on equipment/instruments
1.Yes0.No: If Yes explain ......
Family Planning Method Availability Currently Within last 3 Months (January-March, 2015)
10.25 Oral contraceptive 1.Yes0.No 1.Yes0.No
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10.26 Injection contraceptive 1.Yes0.No 1.Yes0.No
10.27 Condoms 1.Yes0.No 1.Yes0.No
10.28 Implant/Norplant 1.Yes0.No 1.Yes0.No
10.29 Tubal ligation (female 1.Yes0.No 1.Yes0.No sterilization)
10.30 Vasectomy (male sterilization) 1.Yes0.No 1.Yes0.No
10.31 Natural family planning (example: 1.Yes0.No 1.Yes0.No Billings method)
10.32 Emergency contraception 1.Yes0.No 1.Yes0.No
10. 33 Postpartum Intra Uterine 1.Yes0.No 1.Yes0.No Contraceptives Device (IUCD)
insertion
19.19 Give brief description of infrastructure (building) and space for provision of RCHS services
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………..
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SECTION D: MATERNITY SERVICES
Maternity section includes labor/delivery ward, antenatal, postnatal ward, neonatal ward. The nurses in charge of these units/wards can be invited for interviewing in one session in the labour ward.
Human Resource and Services
Please give the total number of the staff cadre available for services in this unit
Cadre Total staff in Labour and Antenatal and Maternity delivery ward postnatal wards wards (without double counting) 11.1 Registered Nurse 11.2 Enrolled Nurse
11.3 Medical Attendant
11.4 Clinical Officer
11.5 Assistant Clinical Officer
11.6 Anaesthetist
11.7 Assistant Medical Officer
11.8 Medical Officer
11.9 Obstetrician
11.10 Paediatrician
11.11 Surgeon
11.12 Laboratory personnel
Continuing Professional Development (CPD) How many members of staff who provide services in this Total staff in unit were trained in any of the following areas in the past 5 Labour and Antenatal and Maternity years (2009-2015)?.( Staff who are currently working in this delivery ward postnatal wards particular section) wards (without double
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counting)
11.13 BEmONC training (2weeks)
11.14 EmONC refresher course(3-4 days)
11.15 CEmONC Training (3weeks)
11.16 PNC Training (1week)
11.17 Comprehensive post abortion care including MVA
11.18 Focused antenatal care (1week)
11.19 Family planning including contraceptive technology updates (2 weeks) 11.20 Prevention of Mother to Child Transmission (Option B+) 11.21 Essential Newborn care (5days)
11.22 Help Baby Breath (2days)
11.23 Integrated Management of Child Illness (11days)
11.24 Infant feeding (5days)
11.25 Kangaroo mother care
11.26 VCT for HIV
11.27 Postpartum IUCD insertion set
Labour And Delivery (Maternity) 11.28 Are maternity services provided for 24 hours? 1.Yes 0.No
11.29 No. of beds in antenatal ward ______beds
11.30 Does the labour room has functional BP machine 1.Yes 0.No and stethoscope?
11.31 Does the antenatal ward has a copy of pre- 1.Yes 0.No eclampsia/eclampsia management protocol?
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11.32 Is a labour room having a wall thermometer? 1.Yes 0.No
11.33 Is the labour ward having a functional wall 1.Yes 0.No clock? 11.34 No. of beds in delivery room ______beds 11.35 Is there privacy in the labour ward? (delivery 1.Yes 0.No room with closed door, separation of cubicles)
11.36 Companion allowed with a labouring mother? 1.Yes 0.No
11.37 Mother allowed taking food during labour? 1.Yes 0.No
11.38 Mother allowed moving around during labour? 1.Yes 0.No
11.39 Mother allowed choosing birthing position? 1.Yes 0.No
11.40 Tea or porridge routinely allowed after 1.Yes 0.No delivery? 11.41 Are Partograph forms available in this Health 1.Yes 0.No facility? 11.42 Are partograph being used in the labour ward? 1.Yes 0.No, If no Skip to 11.58
11.43 What type of partograph is available? Modified WHO partograph WHO partograph with latent phase Other type, Specify______(multiple response)
Partograph use ( Four most recent) Review 4 used partographs for quality of services with the following score in each category. 0 = not done, 1= partially done, 2= Completely done. Circle the right response in each score Partograph 1 Partograph 2 Partograph 3 Partograph 4 11.44 Foetal heart rate monitored hourly 0 1 2 0 1 2 0 1 2 0 1 2
Please check if Maternal vital signs were monitored at least three hourly: 0 = not monitored, 1= occasionally monitored, 2= Regularly monitored (at least 3 hourly) 11.45 Pulse rate 0 1 2 0 1 2 0 1 2 0 1 2
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11.46 Blood Pressure 0 1 2 0 1 2 0 1 2 0 1 2 11.47 Temperature 0 1 2 0 1 2 0 1 2 0 1 2 11.49 Urine 0 1 2 0 1 2 0 1 2 0 1 2 11.50 Cervix dilatation was monitor four hourly 0 1 2 0 1 2 0 1 2 0 1 2
11.51 Uterine Contractions monitored at least 0 1 2 0 1 2 0 1 2 0 1 2 hourly 11.52 Was the descent checked and recorded 0 1 2 0 1 2 0 1 2 0 1 2 between admission and delivery?
11.53 Labour outcome was correctly reported 0 1 2 0 1 2 0 1 2 0 1 2 for newborn condition, BWT, maternal outcome Additional Comments:______ ______
11.54 Are there functional toilets and 1.Yes 0.No , If no skip to 11.56 showers for clients in labour room? 11.55 Verify if the toilets and showers are Clean Dirty clean 11.56 Decontamination of reusable 1.Yes 0.No instruments with disinfectant (3 buckets system) 11.57 Verify date of preparation of disinfectant if Within 24 hrs Not within 24 hrs its within 24 hrs EmONC information [from HMIS data and registers]
11.58 No. of all women who delivered in HF in past one year (Jan-Dec 2014) 11.59 No. of live births that occurred in past one year
11.60 No. of twin deliveries that occurred in HF in past one year (Jan- Dec 2014) 11.61 No. of triplets deliveries that occurred in HF in past one year (Jan-Dec 2014) 11.62 No. of assisted vacuum deliveries that occurred in HF in past one year 11.63 No. of caesarean sections that occurred in HF in past one year(Jan-Dec 2014) 11.64 No. of assisted breech deliveries that occurred in HF in past one year(Jan-Dec 2014) 11.65 No. of macerated stillbirths that occurred in HF in past one year(Jan-Dec 2014) 11.66 No of fresh stillbirths that occurred in HF in past one year(Jan- Dec 2014) 11.67 No. of early (1st week) neonatal deaths in past one year (Jan- Dec 2014)
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11.68 No of Newborn babies with APGAR Score less than 7(Jan-Dec 2014) 11.69 No of Newborn babies with infections (e.g. Cord sepsis, etc (Jan-Dec 2014)) 11.70 No of Premature deliveries (Jan-Dec 2014) 11.71 No of babies provided with Kangaroo MC (Jan-Dec 2014)
Emergency complications managed in last one year (Jan-December 2014)
Complications No. cases No. of deaths
11.72 No. of APH cases 11.73 No. of postpartum haemorrhage 11.74 No. of High Blood Pressure 11.75 No. of eclampsia 11.76 No. postpartum sepsis 11.77 No. of obstructed labour 11.78 No. of ruptured uterus 11.79 No. of abortions related complications 11.80 No. of ectopic pregnancies 11.81 No. of severe malaria in pregnancy 11.82 No. of severe anaemia in pregnancy 11.83 Other severe medical emergencies(e.g diabetes, cardiac problems 11.84 Total no. of obstetric emergencies 11.85 Total no. of emergency obstetric referred in 11.86 Total no. of emergency obstetric referred out Availability of Emergency Obstetric Care Functions (Signal Functions) Are the following functions routinely done in this 1.Yes 0.Not Was this service done in the last maternity/facility? routinely done routinely 3 months? done 1.Yes 0.No 12.1 Ergometrine 12.2 Oxytocin Are the following functions routinely done in this 1.Yes 0.Not Was this service done in the last maternity/facility? routinely done routinely 3 months? done 1.Yes 0.No
12.3 Misoprostol D2. Injection antibiotics for treatment of sepsis 12.4 Injection ampicillin? 12.5 Injection benzyl penicillin? 12.6 Injection gentamycin? 12.7 Injection metronidazole? 12.8 Injection cephalosporin e.g ceftriaxone
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12.9 Any other injection antibiotics? Management of Eclampsia 12.10 Injection magnesium sulphate 12.11 Injection Calcium Gluconate (Antidote) to 12.12 InjectionMg SO4) Hydralazine 12.13 Tablet Aldomet/Nifedipine 12.14 Injection Diazepam 12.15 Which of the following ANC corticosteroid are available to manage pre-term labour?
12.16 Do women with or suspected to have pre- 1.Yes 0.No term (before 37 weeks) labour given If no skip to 12.18 antenatal corticosteroids? 12.17 If yes, who prescribes Antenatal corticosteroids? (Multiple response) MD Nurse Midwife AMO CO 12.18 Observe if there is consistent vital sign monitoring for eclampsia patients: review the last three case files and tick the appropriate response: (Multiple response)
Pulse rate 1.Yes 0.No
Blood pressure 1.Yes 0.No
12.19 Are WomenRespiration with severe pre 1.- eclampsia/eclampsiaYes 0.No kept in the hospital for at least 4 days from the last fit? 1.Yes 0.No Reflexes 1.Yes 0.No Vacuum Extraction (For labour ward) 12.20 Is functional Vacuum Extractor (V/E) 1.Yes 0.No available? 12.21 Staffs trained to use V/E (number) 1.Yes0.No ,
If yes give the number of trained staff ------12.22 Are Nurses/midwives doing Vacuum 1.Yes 0.No 2. N/A Extraction? 12.23 Who performs Vacuum Extraction? Multiple answers are allowed MD 1.Yes 0.No 2. N/A Nurse Midwife 1.Yes 0.No 2. N/A AMO 1.Yes 0.No 2. N/A CO 1.Yes 0.No 2. N/A
12.24 No of V/E performed in last 3 months ______Manual Removal of Placenta (MRP) (For labour ward) 12.25 Long gloves available? 1.Yes0.No
12.26 Staff trained to perform MRP? (Number) 1.Yes0.No , If yes give the number of trained staff______1.Yes0.No , If yes give the number of trained staff______12.27 Are Nurses/midwives doing MRP? 1.Yes 0.No 2. N/A
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12.28 Who performs MRP? Multiple answers are allowed
MD 1.Yes 0.No 2. N/A
Nurse Midwife 1.Yes 0.No 2. N/A AMO 1.Yes 0.No 2. N/A
CO 1.Yes 0.No 2. N/A 12.29 No of MRP performed in last 3 months (Jan- ______March 2015)?
Equipment for resuscitations (For labour ward)
12.30 Ambubag (size 250 ml) and mask (size 0 and 1) 1.Yes0.No for newborn resuscitation?
12.31 Ambubag and mask for Adult resuscitation? 1.Yes0.No
12.32 Resuscitation table for newborn baby in Labour 1.Yes0.No ward
12.33 Heating source/warmer in resuscitation area 1.Yes0.No functioning
12.34 Penguin suction 1.Yes0.No 12.35 Suction Machines ( Foot operated or electrical) 1.Yes0.No Available? 12.36 Is Suction Machines functional 1.Yes0.No 12.37 Newborn Suction catheter 1.Yes0.No 12.38 Adult suction catheter 1.Yes0.No
12.39 Source of oxygen/oxygen cylinders 1.Yes0.No Neonatal ward
13.1 No. of bed in neonatal ward? beds 13.2 No. of incubators? Incubators 13.3 Phototherapy machine available? 1.Yes0.No
13.4 Suction machine available? 1.Yes0.No 13.5 Kangaroo care practice available? 1.Yes0.No
13.6 Does the ward have source of oxygen/oxygen 1.Yes0.No
cylinders?
13.7 Is the room fitted with temperature monitor 1.Yes0.No (room thermometer)?
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13.8 Does the room have pulse oxymeter? 1.Yes0.No 13.9 Is the weighing scale available? 1.Yes0.No
13.10 Newborn ambubag (250ml) with mask (size 0 1.Yes0.No
and 1) is it available?
Postnatal care (PNC) ward 14.1 How many hours are normally delivered women monitored in this maternity? 14.2 Is it routine in this HF to assess delivered women 1.Yes0.No within 48 hours?
14.3 Does the ward have functional BP machine and 1.Yes0.No stethoscope? (Confirm by observing)
14.4 No. of post natal reviews in first 48 reviews hours(referrer MTUHA) 14.5 Number of beds for resting women after beds delivery(post natal) 14.6 Total number of post natal beds reserved for CS beds Caesarean Section (CS) patients? 14.7 Are there functional toilets for clients in 1.Yes0.No postnatal ward 14.8 Verify if the toilets are clean. CleanDirty
14.9 Verify Decontamination of reusable instruments with 1.Yes0.No disinfectant (3 buckets system)
Gynaecology Ward/Emergency Ward: Removal of retained product of conception 15.1 Is a functional MVA set available? 1.Yes0.No
15.2 Has staffs been trained to use MVA? 1.Yes0.No 15.3 Is the functional D&C set available? 1.Yes0.No
Summary of the Availability of EmONC Signal Functions
BEmONC: Now summarize the above information and establish why EmONC functions were not performed. Answers in this sub-section must be cross-checked with answers given in previous sub-sections.
Item Performed in If not performed in past 3 months, why? (Multiple response)* past 3 months? (Jan-March, 2015) 16.1 Administer injectable 1.Yes 1.Trainingissues antibiotics to treat sepsis 0.No 2.Supplies,equipment,drugsissue 3.Managementissue
4.Policyissues 5.Noindication
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16.2 Administer uterotonic drugs 1.Yes 1.Trainingissues (i.e.injection oxytocin) for active 0.No 2.Supplies,equipment,drugsissue management of third stage of 3.Managementissue labour 4.Policyissues 5.Noindication 16.3 Administer injectable anti- 1.Yes 1.Trainingissues convulsants for pre-eclampsia 0.No 2.Supplies,equipment,drugsissue and eclampsia (i.e.magnesium 3.Managementissue sulfate) 4.Policyissues 5.Noindication 16.4 Perform manual removal of 1.Yes 1.Trainingissues placenta 0.No 2.Supplies,equipment,drugsissue 3.Managementissue 4.Policyissues 5.Noindication 16.5 Perform removal of 1.Yes 1.Trainingissues retained products (e.g. 0.No 2.Supplies,equipment,drugsissue manual vacuum aspiration, 3.Managementissue dilation and curettage) for 4.Policyissues post abortion care 5.Noindication 16.6 Perform assisted vaginal 1.Yes 1.Trainingissues delivery (e.g.vacuum 0.No 2.Supplies,equipment,drugsissue extraction) 3.Managementissue 4.Policyissues 5.No indication 16.7 Perform newborn 1.Yes 1.Trainingissues resuscitation 0.No 2.Supplies,equipment,drugsissue (e.g.with bag and mask) 3.Managementissue 4.Policyissues 5.Noindication
CEmONC Item Performed in If not performed in past 3 months, why? past 3 months? 16.8 Perform blood transfusion 1.Yes 1.Trainingissues 0.No 2.Supplies,equipment,drugsissue 3.Managementissue 4.Policyissues 5.Noindication
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16.9 Perform surgery 1.Yes 1.Trainingissues (e.g. caesarean section) 0.No 2.Supplies,equipment,drugsissue 3.Managementissue 4.Policyissues 5.Noindication
KEY* Training issues: Authorized cadre is available but not trained, or there is lack of confidence in providers’ skills.
Supplies, equipment issue: Supplies or equipment are not available, not functional or broken, or needed drugs are unavailable.
Management issues: Providers desire compensation to perform this function, providers are encouraged to perform alternative procedures, or providers uncomfortable or unwilling to perform procedure for reasons unrelated to training.
Policy issues: Required level of staff is not posted to this facility in adequate numbers (or at all), or national or hospital policies do not allow function to be performed.
No indication: No client needing this procedure came to the facility during this period.
Quality of Care in Maternity Wards (Interview the midwife/ or in charge/or deputy of the unit and perform physical checking) Friendliness of EmONC services 17.1 Privacy in labour ward is maintained by: Curtain Screens Single room x YES NO 17.2 Companion allowed with a labouring mother? 17.3 Mother allowed taking food during labour?
17.4 Mother allowed moving around during labour?
17.5 Mother allowed choosing birthing position?
17.6 Tea or porridge given after delivery?
Baby friendliness of EmONC services (open ended question: How is the baby treated after birth?) 17.7 Do mothers keep their newborns skin to skin contact? 1.Yes 0.No
17.8 Newborn wiped dry and wrapped up immediately after 1.Yes 0.No birth?
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17.9 Newborn on breast immediately (within 60 minutes) after 1.Yes 0.No birth? 17.10 Newborn is not bathed before 24 hours after delivery? 1.Yes0.No
Quality improvement activities: Are there printed protocols for the following? Verify by observing 17.11 Active management of third stage of labour (AMTSL) 1.Yes 0.No
17.12 Post Partum Haemorrhage (PPH) 1.Yes 0.No
17.13 Antepartum Haemorrhage (APH) 1.Yes 0.No
17.14 Eclampsia 1.Yes 0.No
17.15 Obstructed Labour 1.Yes 0.No
17.16 Puerperal sepsis 1.Yes 0.No
17.17 Helping baby to breath(HBB) 1.Yes 0.No
17.18 Kangaroo mother care(KMC) 1.Yes 0.No
17.19 Was the facility supervised by CHMT during the last 3 1.Yes 0.No months? (check supervision book) 17.20 Is facility maternal death review conducted? 1.Yes 0.No , If yes, how long after death:______17.21 Are perinatal deaths review conducted? 1.Yes 0.No , If yes, on average how long after death:______
17.22 Additional comments: 1.Yes0.No ; If Yes, explain
......
Availability of Essential Medical Equipment In Maternity Wards
Maternity Labour and Antenatal and Total delivery ward postnatal wards
17.23 Adult weighing scale 17.24 Children weighing scale 17.25 Blood pressure machine 17.26 Stethoscope 17.27 Examination couch 17.28 Vaginal speculum (Sim’s) 17.29 Movable light source on light 115
17.30 Container sharp (safety box) 17.31 Patellar reflex hammer 17.32 Measuring tape 17.33 IUD insertion 17.34 Implant insertion set 17.35 Operating lamp
17.36 Foetal stethoscope
17.37 i.v. drip stand
17.38 Laryngoscope set
17.39 Oropharyngeal airway set
17.40 Oxygen giving set
17.41 Instrument trolley
17.42 Mayo instrument tray (readjustable)
17.43 Bowl stand (double) with stainless steel bowl 17.44 Step Ladder
17.45 Patient stretcher
17.46 Delivery set
17.47 Sterile gloves
17.48 Baby cot in neonatal ward
17.49 Wall clock
17.50 Boots
17.51 Autoclave (specify type)
17.52 Dressing drum (large)
17.53 Dressing drum (medium)
17.54 Dressing drum (small)
17.55 Gowns
17.56 Caps
17.57 Plastic aprons
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17.58 Face masks
17.59 Protective goggles
17.60 Give brief description of infrastructure (building) and space for provision of EmONC services:Maternity and Labour Wards ......
SECTION E: OBSTETRIC THEATRE
Obstetric Theatre: Caesarean section (CS) 18.1 Functional theatre facility available? 1.Yes 0.No
18.2 Services available 24hrs a day and 7 days in a 1.Yes 0.No week 18.3 How many sets of CS are available? ______Sets
18.4 No. of CS performed in last 3 months ______C/S
18.5 Which cadre performs CS? Medical Specialist MD AMO CO Others, Specify______18.6 No. of beds in recovery room in Theatre ______beds
18.7 Does operating theatre have assured of electric power supply for 24-hours 1.Yes 0.No If no, mention an alternative source available ______Anaesthesia and Equipment in Theatre 18.8 Is there skilled personnel to provide safe anaesthesia*? 1.Yes 0.No * Minimum training of one year in recognized Institution 18.9 How many skilled personnel providing safe Staff anaesthesia? 18.10 Which type of anaesthesia is commonly used in performing to the most caesarean section?.
Spinal anaesthesia General anaesthesia with intubation ketamine infusion Other, specify______
18.11 If spinal anaesthesia available, which agents(medicine) are used?
Bupivacane 1.Yes 0.No
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Lidocane 1.Yes 0.No
Others 1.Yes 0.No
18.12 No of patients given spinal anaesthesia in last 3 Patients months 18.13 No of patients given general anaesthesia in last Patients 3 months 18.14 Is there functional anaesthetic machine? 1.Yes 0.No
18.15 Which type anaesthetic machine?(multiple responses) EMO machine with vaporizer Boyles machine Others 18.19 Laryngoscope is available? 1.Yes 0.No
18.20 Is pulse-oxymeter available? 1.Yes 0.No
18.21 Is adult ambu bag and mask available? 1.Yes 0.No
18.22 Is the newborn ambu bag and mask (size 0 and 1) available? 1.Yes 0.No
18.23 Give brief description of infrastructure (building) and space for Operating theatre:......
SECTION F: BLOOD BANK
Laboratory Services For CEmONC HF Blood Transfusion Services (This section is appropriate for CEmONC facilities only) 19.1 CEmONC facility? Yes No, if No, skip this section
19.2 What is the source of the facility need of safe blood?. (Multiple responses) From nearby zonal blood transfusion centre From replacement blood donors 19.3 If the Blood is from blood donors who collects the blood? (Multiple responses) Skilled lab personnel **Nurse midwives Clinical Officer Medical attendant Other, specify______(** This means minimum training of two years in a recognized institution) 19.4 In the laboratory who handles/tests the blood? Skilled lab personnel**(Multiple responses) Nurse midwives Clinical Officer Medical attendant Other, specify______** Minimum training of two years in a recognized institution
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19.5 If the blood is collected from replacement donor, where is it tested to make it free of transfusion transmissible infection? Health facility do perform testing samples of blood sent to zonal centre for testing Other agents, specify,______19.6 The blood from replacement donor if tested by the health facility or other agent other than zonal blood transfusion centre, which tests are performed to make it safe? HIV Hepatitis B (HBV) Hepatitis C (HCV) Syphilis 19.7 Which of the following tests are performed to prepare blood for transfusion? (Multiple response) Blood grouping Cross matching None
19.8 How many blood units have been utilized in the units maternity units for the past 3 months (Jan- March 2015)? Yes No
19.9 Reagents for grouping/x matching available? 19.10 Blood bags for blood collection available? 19.11 Functional refrigerator to store blood is available? 19.12 Minimum and maximum thermometer is available to maintain temperature in refrigerator between 0-10 Celsius? 19.13 A standby stock of blood units seen?
19.14 Have you experienced any stock out of blood in the last 3 month (Jan-March, 2015)? 19.15 If the answer is “yes” on stock outs, what measures were taken? ______
19.16 Additional comments on availability of equipment for CEmONC and needs for support:
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