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. 3 Magnitude of PE/E in Tanzania

4. 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

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 – 2017 Primary 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 Basic EmONCComprehensive 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 placenta10) 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)

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. 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