BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008999 on 12 February 2016. Downloaded from Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality, in Forrural peer Tanzania? review The ETATMBA Project.only Journal: BMJ Open Manuscript ID: bmjopen-2015-008999 Article Type: Research Date Submitted by the Author: 05-Jun-2015 Complete List of Authors: Ellard, David; Warwick Medical School, Clinical trials Unit Shemdoe, Aloisia; Ifakara Health Institute, Mazuguni, Festo; Ifakara Health Institute, Mbaruku, Godfrey; Ifakara Health Institute, Davies, David; The University of Warwick, Educational Development & Research Team, Warwick Medical School Kihaile, Paul; Ifakara Health Institute, Pemba, Senga; Tanzanian Training centre for International Health, Bergström, Staffan; Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Department of Public Health Sciences Nyamtema, Angelo; Tanzanian Training centre for International Health, Mohamed, Hamed-Mahfoudh; Ifakara Health Institute, http://bmjopen.bmj.com/ O'Hare, Paul; University of Warwick, Warwick Medical School Group, The ETATMBA Study; University of Warwick, Warwick Medical School <b>Primary Subject Global health Heading</b>: Secondary Subject Heading: Obstetrics and gynaecology, Medical education and training human resources, maternal mortality, Tanzania, Non-physician clinicians, on October 1, 2021 by guest. Protected copyright. Keywords: Associate clinicians, medical education and training For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 23 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008999 on 12 February 2016. Downloaded from 1 2 Can training non-physician clinicians/associate clinicians (NPCs/ACs) in 3 emergency obstetric, neonatal care and clinical leadership make a difference to 4 5 practice and help towards reductions in maternal and neonatal mortality, in rural 6 Tanzania? The ETATMBA Project. 7 8 David R Ellard* PhD 9 Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University 10 of Warwick, Coventry, CV4 7AL, UK 11 [email protected] 12 13 Aloisia Shemdoe,MSc 14 Ifakara Health Institute, Dar es Salaam, Tanzania 15 [email protected] peer review only 16 17 Festo Mazuguni, BSc 18 Ifakara Health Institute, Dar es Salaam, Tanzania 19 [email protected] 20 21 Godfrey Mbaruku, PhD 22 Ifakara Health Institute, Dar es Salaam, Tanzania 23 [email protected] 24 25 David Davies, PhD 26 Educational Development & Research Team, Warwick Medical School, The University of Warwick, 27 Coventry, CV4 7AL, UK 28 [email protected] 29 30 Paul Kihaile, MD,PhD 31 Ifakara Health Institute, Dar es Salaam, Tanzania 32 [email protected] 33 34 Senga Pemba, PhD http://bmjopen.bmj.com/ 35 Tanzanian Training centre for International Health 36 Ifakara, Tanzania 37 [email protected] 38 39 40 Staffan Bergström, MD,PhD 41 Department of Public Health Sciences, Karolinska Institutet, Sweden 42 [email protected] 43 on October 1, 2021 by guest. Protected copyright. 44 Angelo Nyamtema, MD,PhD 45 Tanzania Training centre for International Health 46 Ifakara, Tanzania 47 [email protected] 48 49 Hamed-Mahfoudh Mohamed, MD 50 Ifakara Health Institute, Dar es Salaam, Tanzania 51 [email protected] 52 53 Joseph Paul O'Hare, MD 54 Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, 55 Coventry, CV4 7AL, UK 56 [email protected] 57 58 On behalf of The ETATMBA Study Group 59 *corresponding author 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 23 BMJ Open: first published as 10.1136/bmjopen-2015-008999 on 12 February 2016. Downloaded from 1 2 Abstract 3 4 Objectives 5 6 The enhancing human resources and the use of appropriate technologies for maternal and perinatal 7 8 survival in sub-Saharan Africa (ETATMBA) project is training Non-Physician Clinicians (NPCs)/ 9 10 Associate Clinicians (ACs) as advanced clinical leaders in emergency obstetric care in Tanzania and 11 12 13 Malawi. The main aim of this study in Tanzania was to evaluate the effect of the ETATMBA training 14 15 on health outcomesFor including peer maternal and neonatalreview morbidity and mortalityonly in the facilities where 16 17 trainees were based. 18 19 Design 20 21 A mixed methods study was carried out in health facilities in rural Tanzania where trainees were 22 23 based. The study included a before and after examination of key mortality indicators, and a survey of 24 25 infrastructure and the availability of equipment, supplies, and drugs. 26 27 Participants 28 29 30 During late 2010 and 2011 approximately 18 pairs (36 trainees) of assistant medical officers (AMOs) 31 32 and nurse midwives/nurses (anaesthesia) were recruited from districts across Tanzania and invited to 33 34 join the ETATMBA training programme. 35 http://bmjopen.bmj.com/ 36 37 Results 38 39 36 trainees completed the training, thereafter returning to 17 facilities. Maternal deaths show a non- 40 41 significant downward trend over the two years (282 to 232 cases per 100,000 live births). There were 42 43 no significant differences for any of the key maternal, neonatal and birth complication variables on October 1, 2021 by guest. Protected copyright. 44 45 across the lifetime of the project. The survey of facilities revealed that most have important shortages 46 47 in some areas, while some had serious shortages. 48 49 Conclusion 50 51 This study demonstrates that enhancing the knowledge and skills of NPCs/ACs in maternal and 52 53 neonatal care and in clinical leadership is possible in Tanzania, with the new skills and knowledge 54 55 being applied into practice. There were significant challenges not least the need for more investment 56 57 in infrastructure. 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 23 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008999 on 12 February 2016. Downloaded from 1 2 Key words: Non-physician clinicians, Associate clinicians, maternal mortality, training, medical 3 4 education, human resources, Tanzania. 5 6 Strengths and limitations of the study 7 8 9 • This is one of the first study taking an in-depth look at the impact on health outcomes, in 10 11 districts across rural Tanzania, of a programme of knowledge, skills and clinical leadership 12 13 training for non-physician clinicians/Associate clinicians (NPCs, ACs); 14 15 • LookingFor to see if thepeer up-skilling of thisreview important cadre of healthonly workers can impact on 16 17 district maternal and neonatal mortality ratios and key obstetric and birth complications; 18 19 • The study highlighted a number of challenges in delivering the training and in working in 20 21 22 rural Tanzania; 23 24 • This cadre is an important component in helping relieve the chronic shortages of trained 25 26 medical professionals in sub-Saharan Africa and helping countries move towards realisation 27 28 of millennium development goals. Further evaluations of the up-skilling of this cadre are 29 30 needed. 31 32 33 34 35 http://bmjopen.bmj.com/ 36 37 38 39 40 41 42 43 on October 1, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 23 BMJ Open: first published as 10.1136/bmjopen-2015-008999 on 12 February 2016. Downloaded from 1 2 Background 3 4 In 2013 it was estimated that there was a global shortage of 7.2 million health-care workers, and that 5 6 by 2035 this is expected to rise to 12.9 million. [1] A recent review of global surgery, obstetric, and 7 8 anaesthesia workforce literature highlights the crisis. Countries like Tanzania only have a physician 9 10 density of 1 per 100,000 people. [2] It is estimated that currently there is a shortage of one million 11 12 healthcare workers in sub-Saharan Africa.[3] This shortage is partly because not enough people are 13 14 appropriately trained but is aggravated by meagre salaries, poor working conditions, low morale, 15 For peer review only 16 inadequate remuneration and few opportunities for continuous professional development. [4] Even 17 18 with a proliferation of new medical and nursing schools in recent years, the rise is not proportional to 19 20 the existing large populations. [5] For those working in rural areas there is professional isolation, 21 22 inadequate communication with peers and consultants in the cities, and a lack of appropriate 23 24 equipment and technologies. [3] 25 26 27 28 In Tanzania, the lack of basic items in many health facilities has been hindering timely and 29 30 appropriate quality obstetric and neonatal care, particularly in rural and remote health facilities. A 31 32 number of studies conducted in the country have also indicated that poor quality of care has been 33 34 experienced at health facilities due to the lack of an enabling environment (drugs, equipment, and http://bmjopen.bmj.com/ 35 36 supplies), poor skills of providers or hostile attitudes of providers, and a lack of trained staff. [6-9] 37 38 Many African countries have a cadre of mid-level health workers hitherto called Non Physician 39 40 Clinicians (NPCs), now more usually referred to as Associate Clinicians (ACs). In Tanzania