Child Survival & Health Grants_Diana DuBois_10.14.11


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  • Great staff in Tanzania – Jolene Mullins and 20 staff & IPD (LE)
  • WellShare established 31 years – worked in 7 countries, including US (lot work with Somali community) Have worked on 8 CS grants in past in Haiti, Nicaragua, Kenya, and Uganda
  • Karatu is approximately 140 km from Arusha City MMR = Maternal mortality rate is high 454 / 100,000 in Karatu vs. 17 /100,000 in US NMR = Neonatal mortality rate is 32 /1,000 live births in Karatu vs. 5 /1,000 live births in US Only 2-4 doctors for 219,000 people (several of them do administrative work)
  • These are some of the perceived barriers of working with TBAs. NONE OF THESE ARE TRUE.
  • Trained over 236 Traditional Birth Attendants in referral, safe delivery, and Home-based Lifesaving Skills (HBLSS) curriculum Educated male truck drivers about key health issues – they became involved and assisted in transport for emergencies Created a village-level pregnancy & vital statistics register Maternal Newborn Care training done in partnership with the Karatu district’s Reproductive and Child Health Coordinator – over 6 days Initial master training for HBLSS conducted by the American College of Nurse Midwives included district staff (3 weeks key staff) TOT HBLSS – trained Master trainers who in turn trained others (many TBAs received 5-day training) Developed Pictoral Village Pregnancy Register (prenatal best practices, birth planning) Some BCC in trainings ** Key point: TBAs received a skill set in order to be competent maternal advocates; in an uncomplicated delivery, if necessary could assist woman to deliver ** TBAs were different ages; WellShare worked with local village leaders to select TBAs
  • Skilled health provider is a health worker who has been professionally trained to deliver babies (e.g. nurse midwife). ** Skilled births already high, but showed a statistically significant increase. This is difficult indicator to move. ** Our TBAs developed good relationship with HF staff; helped bring more women in to HFs; helped assist at births at times Skilled births contributed to other health facility-based outcomes (AMSTL – Active Management of the Third Stage of Labor). Trained TBAs contributed to other Maternal, Newborn, FP and child health outcomes.
  • TBAs provide many kinds of support on health and social issues to women and men in their community. In the child survival project, we found that women and men approached TBAs for advice on many different subjects. It was often the men who would request the TBAs to come and talk with their wives. TBAs do not want to deliver babies for a variety of reasons including 1) fear of infection from exposure to blood, 2) security issues because they often have to travel at night for deliveries, 3) they recognize the value of a higher level of care in health facilities TBAs often contribute from their own resources to deliver babies including 1) supplying razor blades, kangas and other items needed by the mother during delivery, 2) paying for transport when needed, 3) taking time away from their other income-generating activities. While families may provide some type of compensation for the services provided by TBAs, it may be less than what the TBA has contributed herself or just break even. Therefore, in addition to the other reasons mentioned, they do not feel that it causes a decrease in their income to NOT deliver babies. In the context of our project, which maintained the status of TBAs in the community as maternal advocates, the TBAs also felt that not delivering babies did not reduce their status in the community. On the contrary, the TBAs frequently accompanied the mothers to the health facility for delivery and served as an advocate for the mom. In some villages with lower level health facilities, the TBAs assisted the health workers in delivery. One example is a TBA who received a visit from a mother who was having a breech birth. The TBA referred the woman to the district hospital. The health worker there told the TBA that the woman was fine and there was nothing wrong. The TBA knew that was not the case and kept after the health worker to pay attention to the mother. As a result, the health worker finally realized there was a problem and two lives were saved.
  • Presidential support – while the MOH is promoting health facility births and many health workers are reluctant to work with TBAs, the President of Tanzania has provided verbal support for TBAs. He has noted that TBAs deliver many of the babies, and support the health profession working with them. TBAs were trained in groups and leaders were selected for additional HBLSS training. TBAs participated in different health activities at the village level including serving on the health facility management committees and presented health information at community events, etc. Community support to TBA activities included communities acknowledged and appreciated TBAs’ work publicly and excused them from community development obligations as compensation **TBAs felt that they played supportive role in getting some of the HFs built; advocated run properly and have medications **1 lead TBA per village helped with report that went to HF; (5-10 TBAs per village)
  • TBAs care deeply about the women in their communities and the role they play in promoting the wellbeing of their communities. As such, they are one of the most important community-based resources to capture to improve community health. TBAs can be educated to promote health knowledge and behaviors which contribute to the overall goal of building healthy communities, reaching government targets, and achieving MDG 4 & 5 (Millennium Development Goals)
  • Child Survival & Health Grants_Diana DuBois_10.14.11

    1. 1. Promotion of Skilled Birth Attendants: Lessons from the Wellshare Tanzania Child Survival Project CORE Group Fall Meeting October 14, 2011 Diana DuBois Executive Director
    2. 2. WellShare’s Mission | To improve the health of women, children, and their communities around the world Photo: Jolene Mullins
    3. 3. Background <ul><li>Karatu District, Tanzania (2006-2011) </li></ul><ul><li>Population: ~220,000 </li></ul><ul><li>MMR: 454/100,000 </li></ul><ul><li>NMR: 32/1,000 live births </li></ul><ul><li>Intervention areas </li></ul><ul><li>Maternal and newborn care (35%) </li></ul><ul><li>Malaria (20%) </li></ul><ul><li>Family planning (15%) </li></ul><ul><li>Control of diarrheal diseases (15%) </li></ul><ul><li>Pneumonia (15%) </li></ul>
    4. 4. Some Common Perceived Barriers to Training TBAs <ul><li>Traditional Birth Attendants… </li></ul><ul><li>Unwilling or uninterested in changing current practices </li></ul><ul><li>Will lose income or status if they refer pregnant women for health facility care and delivery </li></ul><ul><li>Not capable of learning and applying appropriate skills due to limited education </li></ul><ul><li>Unable to work alongside health facility workers </li></ul><ul><li>WellShare found that none of these were true! </li></ul>
    5. 5. Child Survival Project <ul><li>Training of TBAs </li></ul><ul><ul><li>Maternal and newborn care </li></ul></ul><ul><ul><li>Home-based lifesaving skills (some) </li></ul></ul><ul><ul><li>Adult education facilitation </li></ul></ul><ul><ul><li>Providing referrals </li></ul></ul><ul><li>Roles of TBAs </li></ul><ul><ul><li>Reproductive & child health education and counseling </li></ul></ul><ul><ul><li>Promotion of antenatal care and health facility delivery </li></ul></ul><ul><ul><li>Maternal advocacy </li></ul></ul><ul><ul><li>Post partum follow up </li></ul></ul><ul><ul><li>Post partum family planning promotion including partner counseling </li></ul></ul><ul><ul><li>Survive and Thrive Group facilitation </li></ul></ul><ul><ul><li>Pregnancy vital statistics data collection (Village Pregnancy Register) </li></ul></ul>
    6. 6. KPC Results *Statistically significant at 95% confidence level Indicator Baseline Final % of children whose births were attended by a skilled health provider. 70 82* % of mother of children 0-23 months who received AMTSL during the birth of her youngest child. 28 56* % of children 0-23 months who were dried and wrapped with a warm cloth or blanket immediately after birth. 37 86* % of mothers who received PPC within 72 hours of their most recent delivery. 20 83* % of non-pregnant mothers of children 0-23 months who desire no children in the next two years OR are not sure AND who are using a modern method of child spacing. 31 65*
    7. 7. Lessons Learned <ul><li>Traditional Birth Attendants… </li></ul><ul><li>Typically more eager than health workers to learn new skills </li></ul><ul><li>Competent and resourceful </li></ul><ul><li>Provide many kinds of support to women in their communities </li></ul><ul><li>Well-respected by the community (including by men) </li></ul><ul><ul><li>Can discuss sensitive topics </li></ul></ul><ul><ul><li>Can promote healthy household and relationship behaviors </li></ul></ul><ul><li>Do not actually want to deliver babies </li></ul><ul><li>Do not see a decrease in income or status when they do not deliver babies </li></ul><ul><li>Capable of assisting deliveries at health facilities </li></ul><ul><li>Function best working in a supportive group settings with a leader </li></ul>
    8. 8. Enabling Factors <ul><li>Supportive environment for TBAs </li></ul><ul><ul><li>Presidential support </li></ul></ul><ul><ul><li>District health management team </li></ul></ul><ul><ul><ul><li>Constructed and staffed 6 new health facilities (MCH) during the life of project </li></ul></ul></ul><ul><ul><ul><li>Set tone by conducting initial TBA trainings </li></ul></ul></ul><ul><ul><ul><li>Supported TBA / health facility linkages </li></ul></ul></ul><ul><li>Trained groups of TBAs (5-10 per village) and developed TBA leadership </li></ul><ul><li>Participation in village health activities </li></ul><ul><li>Community support to TBA activities </li></ul>
    9. 9. Recommendations <ul><li>Wider use of trained TBAs to: </li></ul><ul><ul><li>Provide health education </li></ul></ul><ul><ul><li>Provide referrals </li></ul></ul><ul><ul><li>Fill gaps in maternal and neonatal health services </li></ul></ul><ul><li>Use of TBAs as “maternal advocates” </li></ul><ul><ul><li>Can lobby for construction/staffing of health facilities </li></ul></ul><ul><ul><li>Provision of family counseling </li></ul></ul><ul><ul><ul><li>e.g., Family planning, prevention of mother-to-child transmission (integrate MNC and FP) </li></ul></ul></ul><ul><ul><li>Raise awareness of MCH issues </li></ul></ul>
    10. 10. Conclusions <ul><li>TBAs are the primary maternal advocate in developing communities </li></ul><ul><li>Trained TBAs do contribute to the overall health of their communities, reaching government maternal and newborn care targets, and helping to achieve MDGs 4 & 5 </li></ul>
    11. 11. WellShare-trained Traditional Birth Attendant with Village Pregnancy Register