Midwives lead in
detection and
management of preeclampsia and
eclampsia in Tanzania
Gaudiosa Tibaijuka
Senior Technical Manager
Jhpiego
21 Feb 2011
Presentation Outline
• Magnitude of pre-eclampsia and
eclampsia in Tanzania
• Health policy and guidelines to address
pre- eclampsia and eclampsia
• Midwife's role in detection and
management of pre-eclampsia and
eclampsia
• Challenges and strategies to address them
Magnitude of PE/E in Tanzania
3
Tanzania health policy
The President’s call
STOP NEEDLESS MATERNAL & NEWBORN DEATHS
•Launched WRATZ campaign
in 2008
•Co-chair of the commission
convened by WHO to
improve accountability for
women and children’s health
globally
Tanzania President advocates reduction of
maternal and child deaths
Tanzania Health Policy
• 1994 - health sector reformed to improve
services quality and accessibility, approved by
Parliament in1998
• 2006 MNH prioritized, the Road Map (2008)
emphasizes skilled birth attendance (SBA) and access to
quality Basic and Comprehensive EmONC
• 2007 – 2017 Primary Health Services
Development Program aims include:
Accelerating and strengthening training of SBAs
• Recruitment, rewarding and retention
•
Evidence for advocacy for Skilled Birth
Attendants
• Tanzania has highest maternal mortality rate
and the lowest numbers of skilled health
workers (Joint Learning Initiative, 2004)
• The current ratio of Tanzania skilled worker to
population is 1:2,244 people (Primary Health
Services Development Program, 2007)
• 10% increase of qualified health workers
correlates with a 5% decline of mothers’ deaths
and 2% decline of newborns and under five
children deaths (Joint Learning Initiative, 2004)
Midwives in Tanzania
• Nurse Midwives form 60% of the health sector
workforce
• Nurse Midwives population ratio is1:1,600 vs doctor
population ratio of 1: 8,500
• ANC coverage is 96% (TDHS 2010) from 94% (TDHS
2005) mostly by nurse midwives
• 51% deliveries by a health professional (TDHS 2010)
• Almost all normal deliveries (75%) are attended by
nurse midwives as well as some abnormal deliveries
•1
Midwives Scope of Practice
• Guided by Tanzania Nursing and
Midwives Council
• Adapted International Confederation
of Midwives competencies
• Safeguarded by professional
associations
•
Nurses, midwives , obs/gynaecologists
and paediatricians associations
• Job description include Basic EmONC
Signal Functions (2009)
EmONC Signal Functions (2009)
Basic EmONC
Comprehensive EmONC
1) Administer parenteral antibiotics
Perform EmOC Signal functions 1-7,
plus:
2) Administer uterotonic drugs (e.g.
parenteral oxytocin, misoprostol)
8) Perform surgery (e.g. cesarean
delivery)
3) Administer parenteral
anticonvulsants (e.g. magnesium
sulfate)
9) Perform blood transfusion
4) Perform manual removal of placenta
10) Provision of emergency obstetric
anaesthesia
5) Perform removal of retained products
(e.g. MVA)
6) Perform assisted vaginal delivery
(e.g. vacuum extraction)
7) Perform neonatal resuscitation (e.g.
w/ bag and mask)
10
Midwives provide what women want too
• Clean facilities
• Women friendly care –
kindness, respect,
information , instructions,
counseling
• Availability of drugs and
medical equipment ,
storage and safety,
maintenace
• Culturally appropriate
services
Midwives are improving the quality of BEmONC
• Standardization using current
best evidence (PCPNC)
• Learning resource packages
e.g.
•
Basic care in pregnancy,
childbirth, EmOC
 Knowledge domain
 Decision making
 Psychomotor skills, attitude
• Performance standards
management and recognition
• Multimedia and job aids
• Health facility strengthening
12
In Pre eclampsia and eclampsia
midwives
• Diagnose
• Mild to moderate pre eclampsia
• Severe pre-eclampsia (imminent eclampsia)
• Eclampsia
• Provide management
• Initial
management in pre-eclampsia including
referral from dispensaries at higher level facilities
• Initial assessment, decision making and
management of severe pre-eclampsia & eclampsia
Midwives administer magnesium salphate
in severe pre eclampsia & eclampsia
• Give
• loading dose
• maintenance dose
• Monitor for toxicity each time
before repeat dose while arranging
for transfer of woman to higher
health facility if necessary
Challenges...1
• Human resources in crisis at 32%, high attrition rate
compounded by low production, retirement, movement
for better jobs, HIV and AIDS epidemic
• Weak health systems:
•
•
80% of 121 local government authorities classified as rural geographically hard to reach contributing to MgSO4 stock outs
Calcium gluconate may not be available
• Programmatic barriers; limited advocacy, slow curricula
updates and implementation, unsatisfactory training
institutions, unsupportive working environment such as
congestion
Challenges...2
Non adherence to
performance standards
•
•
•
Overcrowded clinics/wards
- ANC, PNC
- Labour, delivery
Shortage of equipment and
supplies; medicines, BP
machines, albustics
Not addressing danger signs
Magnitude of PE/E in Tanzania
2010 findings at 2 district hospitals in Dar es
Salaam
• about a third of MM was due to eclampsia
• responses of 2 midwives in the ANC clinic;
It is a challenge not to have MgSO4 at ANC clinic,
we see 2-3 women in fits in a week, usually referred
from the neighbourhood’ while the other one said
• eclampsia is not treated as emergency at this
hospital; I run up and about to get MgSO4
prescription and the drug itself after the fit!
•
Strategies to address the challenges
• MOH investing in Primary Health Services
Development Program 2007 – 2017 which invites
stakeholders to support implementation of EmONC
through improving;
Infrastructure – construction, renovation
• Training- competence based
• Logistics- eliminate stock outs
• Facilitative supervision with built in service quality
improvement, monitoring, recognition strategies
• Strengthen community linkages
•
Summary
• The magnitude of pre-eclampsia and
eclampsia in Tanzania is devastating, the
third among other killers despite the
enabling environment; the health policy and
guidelines to address pre- eclampsia and
eclampsia
• Midwive's roles in detection and
management of pre-eclampsia and
eclampsia are enormous if one are is
properlly trained.
• Challenges and strategies to address the
Asanteni Sana