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In Tanzania, maternal mortality has stagnated over the last 10 years, and some of the areas with the worst indicators are in the Lake and Western Zones. This study investigates the factors associated with institutional deliveries among women aged 15-49 years in two regions of the Lake Zone. Data were extracted from a cross-sectional household survey of 1,214 women aged 15-49 years who had given birth in the 2 years preceding the survey in Mara and Kagera regions. Logistic regression analyses were conducted to explore the influence of various factors on giving birth in a facility. About two-thirds (67.3%) of women gave birth at a health facility. After adjusting for possible confounders, six factors were significantly associated with institutional delivery: region (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.54 [0.41-0.71]), number of children (aOR, 95% CI: 0.61 [0.42-0.91]), household wealth index (aOR, 95% CI: 1.47 [1.09-2.27]), four or more antenatal care visits (aOR, 95% CI: 1.97 [1.12-3.47]), knowing three or more pregnancy danger signs (aOR, 95% CI: 1.87 [1.27-2.76]), and number of birth preparations (aOR, 95% CI: 6.09 [3.32-11.18]). Another three factors related to antenatal care were also significant in the bivariate analysis, but these were not significantly associated with place of delivery after adjusting for all variables in an extended multivariable regression model. Giving birth in a health facility was associated both with socio-demographic factors and women's interactions with the health care system during pregnancy. The findings show that national policies and programs promoting institutional delivery in Tanzania should tailor interventions to specific regions and reach out to low-income and high-parity women. Efforts are needed not just to increase the number of antenatal care visits made by pregnant women, but also to improve the quality and content of the interaction between women and service providers.

Background Despite the global progress in bringing health services closer to the population, mothers and their newborns still receive substandard care leading to morbidity and mortality. Health facilities’ capacity to deliver the service is a prerequisite for quality health care. This study aimed to assess health facilities’ readiness to provide comprehensive emergency obstetric and newborn care (CEmONC), comprising of blood transfusion, caesarean section and basic services, and hence to inform improvement in the quality of care interventions in Tanzania. Methods A cross-sectional assessment of 30 CEmONC health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out between December 2020 and January 2021. We adapted the World Health Organization’s Service Availability and Readiness Assessment tool to assess amenities, equipment, trained staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher’s exact test; for readiness scores, differences were tested by a linear mixed model analysis, taking into account dependencies within the regions. We used p  < 0.05 as our level of significance. Results The overall readiness to provide CEmONC was 69.0% and significantly higher for regional hospitals followed by district hospitals. Average readiness was 78.9% for basic amenities, 76.7% for medical equipment, 76.0% for diagnosis and treatment commodities, 63.6% for staffing and 50.0% for guidelines. There was a variation in the availability of items at the individual health facility level and across levels of facilities. We found a significant difference in the availability of basic amenities, equipment, staffing, and guidelines between regional, and district hospitals and health centres ( p  = 0.05). Regional hospitals had significantly higher scores of medical equipment than district hospitals and health centers ( p  = 0.02). There was no significant difference in the availability of commodities for diagnosis and treatment between different facility levels. Conclusion Facilities’ readiness was inadequate and varied across different levels of the facility. There is room to improve the facilities’ readiness to deliver quality maternal and newborn care. The responsible authorities should take immediate actions to address the observed deficiencies while carefully choosing the most effective and feasible interventions and monitoring progress in readiness.

Background Therapeutic efficacy studies (TESs) and detection of molecular markers of drug resistance are recommended by the World Health Organization (WHO) to monitor the efficacy of artemisinin-based combination therapy (ACT). This study assessed the trends of molecular markers of artemisinin resistance and/or reduced susceptibility to lumefantrine using samples collected in TES conducted in Mainland Tanzania from 2016 to 2021. Methods A total of 2,015 samples were collected during TES of artemether-lumefantrine at eight sentinel sites (in Kigoma, Mbeya, Morogoro, Mtwara, Mwanza, Pwani, Tabora, and Tanga regions) between 2016 and 2021. Photo-induced electron transfer polymerase chain reaction (PET-PCR) was used to confirm presence of malaria parasites before capillary sequencing, which targeted two genes: Plasmodium falciparum kelch 13 propeller domain ( k13 ) and P. falciparum multidrug resistance 1 ( pfmdr1 ). Results Sequencing success was ≥ 87.8%, and 1,724/1,769 (97.5%) k13 wild-type samples were detected. Thirty-seven (2.1%) samples had synonymous mutations and only eight (0.4%) had non-synonymous mutations in the k13 gene; seven of these were not validated by the WHO as molecular markers of resistance. One sample from Morogoro in 2020 had a k13 R622 I mutation, which is a validated marker of artemisinin partial resistance. For pfmdr1, all except two samples carried N86 (wild-type), while mutations at Y184 F increased from 33.9% in 2016 to about 60.5% in 2021, and only four samples (0.2%) had D1246 Y mutations. pfmdr1 haplotypes were reported in 1,711 samples, with 985 (57.6%) NYD, 720 (42.1%) N F D, and six (0.4%) carrying minor haplotypes (three with NY Y , 0.2%; Y F D in two, 0.1%; and N FY in one sample, 0.1%). Between 2016 and 2021, NYD decreased from 66.1% to 45.2%, while N F D increased from 38.5% to 54.7%. Conclusion This is the first report of the R622I (k13 validated mutation) in Tanzania. N86 and D1246 were nearly fixed, while increases in Y184 F mutations and N F D haplotype were observed between 2016 and 2021. Despite the reports of artemisinin partial resistance in Rwanda and Uganda, this study did not report any other validated mutations in these study sites in Tanzania apart from R622I suggesting that intensified surveillance is urgently needed to monitor trends of drug resistance markers and their impact on the performance of ACT.

Background Newborn resuscitation is a life-saving intervention for birth asphyxia, a leading cause of neonatal mortality. Improving provider newborn resuscitation skills is critical for delivering quality care, but the retention of these skills has been a challenge. Tanzania implemented a national newborn resuscitation using the Helping Babies Breathe (HBB) training program to help address this problem. Our objective was to evaluate the effectiveness of two training approaches to newborn resuscitation skills retention implemented across 16 regions of Tanzania. Methods An initial training approach implemented included verbal instructions for participating providers to replicate the training back at their service delivery site to others who were not trained. After a noted drop in skills, the program developed structured on-the-job training guidance and included this in the training. The approaches were implemented sequentially in 8 regions each with nurses/ midwives, other clinicians and medical attendants who had not received HBB training before. Newborn resuscitation skills were assessed immediately after training and 4–6 weeks after training using a validated objective structured clinical examination, and retention, measured through degree of skills drop, was compared between the two training approaches. Results Eight thousand, three hundred and ninety-one providers were trained and assessed: 3592 underwent the initial training approach and 4799 underwent the modified approach. Immediately post-training, average skills scores were similar between initial and modified training groups: 80.5 and 81.3%, respectively ( p -value 0.07). Both groups experienced statistically significant drops in newborn resuscitation skills over time. However, the modified training approach was associated with significantly higher skills scores 4–6 weeks post training: 77.6% among the modified training approach versus 70.7% among the initial training approach ( p -value < 0.0001). Medical attendant cadre showed the greatest skills retention. Conclusions A modified training approach consisting of structured OJT, guidance and tools improved newborn resuscitation skills retention among health care providers. The study results give evidence for including on-site training as part of efforts to improve provider performance and strengthen quality of care.

Background The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival. Methods The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live. Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99. Discussion Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope. Trial registration Name of Trial Registry: ISRCTN Registry. Trial registration number: ISRCTN30541755 . Date of Registration: 12/10/2020. Type of registration: Prospectively Registered.

Introduction: Newborn mortality is unacceptably high, especially in low- and middle-income countries. The Safer Births Bundle of Care (SBBC) was implemented in Tanzania, including training of healthcare workers on neonatal resuscitation by means of frequent in situ simulation training using improved training tools. We aimed to assess the acceptability of this training model among healthcare providers in selected health facilities under SBBC intervention. Methods: A cross-sectional study was conducted among healthcare workers in labor wards and obstetric theaters in selected facilities one year after the introduction of the SBBC model. The theoretical framework for assessment of the acceptability of healthcare interventions was used to assess the acceptability of the training model and accompanying tools. The chi-square test was used to assess the association between acceptability in specific constructs and average individual practice per month, while a modified Poisson regression analysis was used to assess factors associated with acceptability in specific framework constructs. Results: A total of 227 healthcare workers were enrolled in the study. Overall, 223 (98.2%) accepted the intervention. However, 207 (91.2%) reported that the intervention increased their work burden, while 39 (17.2%) reported that it interfered with other equally important activities. The level of health facility was independently associated with the reporting that engaging in simulation practice interfered with other equally important activities. Conclusions: In situ, low-dose, high-frequency facility-based simulation training for neonatal resuscitation was highly acceptable among healthcare providers. However, the perceived increased work burden of this intervention and interference with other equally important activities were identified as potential threats to successful implementation.

Background Tanzania has a maternal mortality ratio of 556 per 100,000 live births, representing 21% of all deaths of women of reproductive age. Hemorrhage, mostly postpartum hemorrhage (PPH), is estimated to cause at least 25% of maternal deaths in Tanzania. In 2008, the Ministry of Health, Community Development, Gender, Elderly and Children launched interventions to improve efforts to prevent PPH. Competency-based training for skilled birth attendants and ongoing quality improvement prioritized the practice of active management of the third stage of labor (AMTSL). Methods A cross-sectional study was conducted in 52 health facilities in Tanzania utilizing direct observations of women during labor and delivery. Observations were conducted in 2010 and, after competency-based training and quality improvement interventions in the facilities, in 2012. A total of 489 deliveries were observed in 2010 and 558 in 2012. Steps for AMTSL were assessed using a standardized structured observation checklist that was based on World Health Organization guidelines. Results The proportion of deliveries receiving all three AMTSL steps improved significantly by 19 percentage points ( p  < 0.001) following the intervention, with the most dramatic increase occurring in health centers and dispensaries (47.2 percentage point change) compared to hospitals (5.2 percentage point change). Use of oxytocin for PPH prevention rose by 37.1 percentage points in health centers and dispensaries but remained largely the same in hospitals, where the baseline was higher. There was substantial improvement in the timely provision of uterotonics (within 3 min of birth) across all facilities ( p  = 0.003). Availability of oxytocin, which was lower in health centers and dispensaries than hospitals at baseline, rose from 73 to 94% of all facilities. Conclusion The quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up-to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality.

Summary Background In the last decade, Tanzania has observed a dramatic increase in overweight and obesity among women of childbearing age, a demographic shift that has been associated with intrapartum obstetric complications in high‐income countries. Similar increases in maternal morbidity including postpartum haemorrhage, hypertensive disorders of pregnancy, and rates of caesarean delivery have not yet documented in Tanzania. This analysis describes intrapartum obstetric complications associated with maternal obesity among pregnant women delivering at teaching hospital in Northern Tanzania. Methods A retrospective cohort analysis was conducted using the hospital's antenatal care (ANC) and birth registries from 2000 to 2015. The World Health Organization (WHO) body mass index (BMI) categories were applied to classify BMI status of pregnant women within 16 weeks of gestational age at their first ANC visit. Relative risk (RR) of obstetric complications with corresponding 95% confidence intervals (CIs) were estimated using multivariable log‐binomial regression, adjusting for clustering effect for the correlation between multiple deliveries of the same woman. Results Among 11 873 women who delivered babies in the hospital during the study period, 3139 (26.5%) fit the definition of overweight and 1464 (12.3%) women with obesity. Compared with women with normal weight, women with obesity were at over 2.6 times at risks of experiencing pre‐eclampsia/eclampsia (RR: 2.66; 95% CI, 2.08‐3.40), pregnancy‐induced hypertension (RR 2.13; 95% CI, 1.26‐3.62), and postpartum haemorrhage (RR 1.22; 95% CI, 1.00‐1.49). Additionally, women with obesity had also higher risk of either elective (RR 2.40; 95% CI, 1.88‐3.06) or emergency (RR: 1.53; 95% CI, 1.34‐1.75) caesarean delivery. Conclusion Maternal obesity is an emerging health problem in Tanzania. This study clearly demonstrates an association between increased risk of intrapartum complications and obesity. A review of guidelines around ANC screening and intrapartum care practices considering BMI, as well as appropriate messages for women with obesity, should be considered to improve maternal and newborn outcomes.

Negative experiences of care may act as a deterrent to current and/or future utilization of facility-based health services. To examine the situation in Tanzania, we conducted a sub-analysis of a cross-sectional household survey conducted in April 2016 in the Mara and Kagera regions of Tanzania. The sample included 732 women aged 15–49 years who had given birth in a health facility during the previous two years. Log binomial regression models were used to investigate the association between women’s experiences of care during childbirth and the receipt of early postnatal checks before discharge. Overall, 73.1% of women reported disrespect and abuse, 60.1% were offered a birth companion, 29.1% had a choice of birth position, and 85.5% rated facility cleanliness as good. About half of mothers (46.3%) and newborns (51.4%) received early postnatal checks before discharge. Early postnatal checks for both mothers and newborns were associated with no disrespect and abuse (RR: 1.23 and 1.14, respectively) and facility cleanliness (RR: 1.29 and 1.54, respectively). Early postnatal checks for mothers were also associated with choice of birth position (RR: 1.18). The results suggest that a missed opportunity in providing an early postnatal check is an indication of poor quality of the continuum of care for mothers and newborns. Improved quality of care at one stage can predict better care in subsequent stages.

Background: Maternal and newborn morbidity and mortality remain a pressing challenge with uneven progress globally and in Tanzania. The capacity of health facilities to provide quality care is critical to improving outcomes. This study aimed to assess changes in health facilities’ readiness to provide quality maternal and newborn care, and hence aimed to inform improvements in quality-of-care interventions in Tanzania. Methods: A before and after assessment of 28 comprehensive emergency obstetric and newborn care health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out in December 2020 and January 2023. We adapted the World Health Organization’s Service Availability and Readiness Assessment tool, which covered amenities, equipment, staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher’s exact test; for readiness scores, differences were tested by linear fixed and mixed model analyses, considering dependencies within the regions. We used p < 0.05 as our level of significance and measured change from baseline using a paired t-test. Results: The overall readiness improved significantly from 67.6% to 83.7% (p < 0.05). Statistically significant improvements were seen in medical equipment (77.1% to 94.0%), diagnostic/treatment commodities (69.3% to 83.1%), and availability of guidelines (50.8% to 96.7%). Changes in amenities (78.1% to 84.2%) and staff (63.0% to 61.7%) were not significant. The overall readiness improved in all facility types and the change was statistically significant in district hospitals and health centres (p < 0.05). There were significant differences in improvement between regions (p < 0.05) Conclusions: The overall readiness has improved significantly, reflecting a positive change. However, there remains a need for further enhancement, particularly in terms of staffing, to ensure high-quality maternal and newborn care. Authorities should take swift action to address the identified gaps, selecting the most effective and practical interventions while closely monitoring progress in readiness and sustaining the gains.