Midwives lead in detection and management of pre- eclampsia and eclampsia in Tanzania

1. Midwives lead in detection and management of pre-eclampsia and eclampsia in Tanzania Gaudiosa Tibaijuka Senior Technical Manager Jhpiego 21 Feb 2011

2. 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

3. Magnitude of PE/E in Tanzania

4. Tanzania health policy The President’s callSTOP 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

5. Tanzania President advocates reduction of maternal and child deaths

6. 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 – 2017Primary Health Services Development Program aims include: • Accelerating and strengthening training of SBAs • Recruitment, rewarding and retention

7. 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)

8. 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

9. 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)

10. EmONC Signal Functions (2009) 10

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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!

18. 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

19. 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

20. Asanteni Sana