Bixby Project 2004
Kigoma, Tanzania
Andy Anglemyer, Nadia DiamondSmith, Jessica Jeffrey
Study Overviews
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Maternal Mortality in Kigoma
TACARE’s Community Based
Distribution (CBD) Program
Maternal Mortality in Kigoma
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Kigoma is located on the eastern
shores of Lake Tanganyika
Annual per capita income is $140,
$80 in very rural areas
One of the four highest maternal
mortality rates in the country
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300/100,000
490,816 residents
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25% are women between 15 and 45
Regional Health Facilities
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Maweni is the only public hospital in
the region
• 75 registered villages, spread over
11,600 km²
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4 health clinics
54 village dispensaries
Previous Interventions
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Between 1984-1991 at Maweni
Hospital
Health worker involvement and
effective utilization of local resources
MM rate fell from 933 to
186/100,000 residents
Replication of Intervention
Methods
Pre-intervention survey in 1999
Considered lessons learned from previous
intervention
Health centers and dispensaries focal
points for data collection
Information collected on:
• Community perceptions of antenatal care,
emergency OB care, FP, TBA, equipment
availability for emergency OB care in
peripheral health units
Methods (cont)
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Sisterhood method used to determine
maternal mortality in rural
A post-intervention survey conducted in
2003 using same methods and health
units
2 health units from each division selected
(12 total selected)
• Records reviewed
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Individuals interviewed
• 40 health workers, 20 TBA’s from 2 randomly
selected villages, 480 community members
Suggested Risk Factors
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Lack of community education
regarding maternal mortality
Gender imbalances
Knowledge of obstetric health issues
--low quality of care
Transportation difficulties
• 50% of villages only accessible by boat
• Qualified personnel unwilling to work in
remotest areas
Risk Factors (cont)
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Health facilities lack proper
equipment
• Partial supply of OB care equipment and
drugs
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Lack of a blood transfusion program
• Results in anemia and hemorrhaging
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Facilities in disrepair with lack of
funding
Deficit of qualified staff
Interventions
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Subsidized mosquito nets
Village leaders’ meetings
Community referral funds
Transportation options
• 3 ambulance cars
• Subsidized boat costs
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Additional health care workers in
rural areas
Interventions (cont)
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Benefits for health care workers
• Education and leave
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Locals trained in maternal health
• 20 TBA’s, 102 VHW’s
• OB complications and specialized training
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DHO flights to rural communities
New hospital equipment
Blood transfusion centers
Health facilities renovated
Results
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MM rate decrease using “sisterhood
method” 166 to 137/100,000
Increased referral compliance among
community leaders
Increase in trained personnel
Number of health units with
appropriate personnel (29%-60%)
Prenatal care sought more often
• 25 in 1999, 201 in 2003
Results (cont)
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Deliveries by trained personnel
increased
• 5,823 in 1999; 7,225 in 2003
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Partographs used routinely
Increase of referrals from health
units to hospital
• 160 in 1999; 1,583 in 2003
Referrals
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Most common reasons:
• Primi gravidae, multiparous
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Self referrals increased
• Average of 8/month in 2002; 12/month
in 2003
Discussion
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Leading causes of maternal death
• Anemia, malaria-induced and malnutrition
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Long term impact expected
Self referrals
• More faith in the health care system
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Drawbacks
• Lack of comparison group
• Inconsistent data
• Maternal deaths occur in villages
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Rates are rough estimates
Conclusion
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Low-cost interventions
Potential for replication
Much can be done with little
Increased awareness and education
the most significant aspect to
lowering maternal mortality
TACARE’s CBD Program
Participating Regional Health Facilities
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4 Health Centers
--IUD’s and injectables
54 Village Dispensaries
--oral contraceptives, injectables,
condoms
Health Centers
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Usually staffed by a nurse or clinical
officer
Provides basic inpatient health care
Village Dispensaries
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54 total in Kigoma Region
The majority of population relies on
these for FP services and health care
Patient referrals
Provide basic medications and
contraceptives
Family Planning Access
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Contraceptives provided by funds
from USAID (1970’s) and the
Ministry of Health (1995)
Contraceptives available at no cost in
health facilities
Contraceptive Prevalence estimated
at 4%, Birth Rate 2.8%
Acceptance Rate for FP ~ 14%
Accessibility Obstacles
What must a CBD program overcome?
• Great traveling distances
• Accessible only by boat or 4WD
• Work Priorities
• Local religious opposition
• Patriarchal society
TACARE’s CBD Program
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Lake Tanganyika Catchment
Reforestation and Education Project
--original purpose of promoting
sustainable land-use practices
and preserving indigenous forests
In 1999 CBD project initiated
--currently 14 villages, 40 agents
The Agent
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Village selected
Kiswahili literate and 7 years of
education
Must have a willingness to openly
discuss FP topics among community
Attend 3 week training session
CBD Supervisor
Services Offered
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Counseling and education in family
planning and sexual health
--info about oral contraceptives,
condoms, IUD’s, injectables,
Norplant, tubal ligation,
vasectomies
--alternatives discussed:
withdrawal, “standard days”
method
Services Offered (cont)
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Client referrals to dispensaries
Oral contraceptives’ side effects
management
STI/HIV information
Info on breastfeeding, ORT,
vaccinations, and nutrition
The Approach
Individual Counseling
--2183 sessions in 2003
Household Counseling
--673 sessions in 2003
Group Counseling
--134 sessions in 2003
Client Preferences
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Spacing births
Condoms and pills preferred
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IUD’s considered uncomfortable
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injectables seen as a plausible alternative
Possible stigma attached if referred
“Standard Days” method difficult
Access and Restrictions
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CBDA’s responsibility to motivate
couples seeking services
Women given contraceptives
regardless of partner’s approval
• The well, market, or kids’ vaccinations
• Single women have access
• 15 years or older
Supply Chain
Central Medical Store in Kigoma(2400 km from
Kigoma)
Zone Medical Store in Tabora (600 km from
Kigoma)
District Medical Office in Kigoma
Village Dispensaries in Kigoma Rural
Community Based Distribution Agents in Villages
Funding
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Funds dried-out in 2002
• Training ceased in 2003
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FY 2004 funded by Packard
Foundation and USAID
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$63,486 total for FP and HIV programs
CBDA Concerns
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Transportation
• Addressed in FY 2004 Budget
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Safety
• Umbrellas, flashlights, boots
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Refresher courses
• Restarted in FY 2004
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Other
• Safe Motherhood Training, more information
about malaria for children > 5
CBDA Concerns (cont)
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Salary
• Experimental incentive program failed in
2002
• Could include compensation such as
sugar or rice