1. JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and Interchurch Medical Assistance Increasing access to quality focused ANC: Tanzania experience 2000/07 FLEMAFA Conference, Kisarawe Gaudiosa Tibaijuka Senior Midwifery Advisor 31 Aug 2007

2. Objectives of FLEMAFA Conference  Raise awareness regarding issues contributing to Maternal and Newborn morbidity and mortality.  Share efforts underway to improve maternal-newborn-child health in Tanzania and Kisarawe in particular  Hear from selected RCH partners in Tanzania (WRA, ACCESS/JHPIEGO)  Identify ways to improve efforts done by MOHSW and other reproductive and child health partners  Generate and share plan of action demonstrating the commitment of all participants to continue engagement within the local community and among individuals and organizations participating in the conference) in Kisarawe District

3. Objectives of Focused ANC presentation Share ACCESS/JHPIEGO experience in providing technical assistance to the MOHSW in the implementation of Focused ANC National Programme including malaria and syphilis in pregnancy through:  Introducing ACCESS Programme  Describing the rationale for focused ANC  Listing Partners and collaborators in Focused ANC strategies used in implementing rogramme i  Listing strategies used in implementing FANC programme in Tanzania  Share program achievements and results  Discuss challenges and opportunities

4. “I’m going to fetch a baby. It’s a dangerous journey and I may not return.” ~ Traditional African saying

5. This conference is the beginning of a journey … for us and for her representing women in Kisarawe!!

6. Are we committed to making her journey/ their journey safe?

7. Introduction  ACCESS is a five-year global program in its third year of implementation aimed at reducing maternal and newborn deaths and improving the health of mothers and newborns  JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse Midwives and Interchurch Medical Assistance.

8. Focused Antenatal Care An approach to ANC that emphasizes  Evidence-based  Goal-directed actions  Individualized woman-centered care  Quality versus quantity of visits  Care by a skilled provider

9. Goal of Focused Antenatal Care To promote maternal and newborn health and survival through  Early detection and provision of treatment for existing diseases  Promotion and maintenance of the physical, mental and social health of mother and baby through enhanced interpersonal skills on nutrition, PMTCT etc.  Development of individual birth plans and complication readiness plans.  Early detection and management of complications during pregnancy, labour, delivery and post partum through identification of danger signs

10. Partners Ministry of Health and Social Welfare at all levels  National- RCHS, NMCP, NACP, HSIU and HRDD  Zonal- ZRCH teams, ZTCs  Regional- RHM teams  District- DHM teams and others Other Collaborating Organizations:  White Ribbon Alliance  IMA  CSSC and other Tanzanian FBOs  JSI/DELIVER

11. Routine practices proved not to be significant  Numerous visits - Burdens women and health care system - Reduced number does not seem to affect pregnancy outcomes (WHO multi-center study, Villar et al 2001 )  Some measurements and examinations  Care based on risk assessment

12. Risk Approach Not an effective ANC strategy because  Complications cannot be predicted hence, all pregnant women are at risk for developing complications  Many “low risk” women develop complications  Do not know how to recognize/respond to problems  Have false sense of security  Most “high risk” women give birth without complications  Inefficient use of scarce resources

13. FANC Best practices Focused antenatal visits by skilled provider Detection and management of coexisting conditions and complications Birth preparedness and complication readiness planning Family planning, breastfeeding, danger signs, HIV/STIs, and nutrition counseling Tetanus toxoid Iron and folate Mebendazole -Helminth presumptive treatment SP for IPT of Malaria

14. IPT GOAL Presidential Malaria Initiative goal  85% IPTp uptake by 2009 MOHSW targets  60% by 2007 ACCESS is collaborating with other partners in reaching the PMI targets for IPT coverage in Tanzania

15. Birth Preparedness, and Complication Readiness  Preparing for Normal Birth  Identifying a skilled attendant and place of delivery  Arranging finance, essential items  Nutrition  Readiness for Complications  Early detection –danger signs  Designated decision maker(s)  Emergency funds, communication  Transport, blood donors

16. Tanzania Focused ANC Program Strategies and approaches ACCESS uses Focused Antenatal Care as a platform for increasing access to quality maternal and newborn services through:  Influencing policy change, development of guidelines and standards for Focused ANC, Malaria & Syphilis during pregnancy and Infection Prevention  Advocacy and joint planning- working with policy makers at all levels; national, regional, district and facility advocacy meetings  Partnership and collaboration with stakeholders

17. Tanzania Focused ANC Program Strategies and approaches cont…  Incorporating into pre service midwifery education: Curriculum and learning package development  In-service and pre-service training in public and private (Faith Based Organizations) sectors  Introducing Standards based management approach for Performance Quality Improvement (PQI)  Collaborate with community organisations mainly through White Ribbon Alliance

18. Program strategies and approaches cont…  Comprehensive coverage with FANC/MIP/SIP  Regional advocacy meetings  Regional TOTs for District trainers including RCH clinic in charges, RCH coordinators  District based clinical training for ANC service providers  ANC & PSE Quality improvement processes  Follow-up of trained facilities and schools using QI tools to monitor service trend

19. Program achievements  Policy change for Focused ANC; Malaria Intermittent Preventive Treatment, syphilis screening and treatment, infection prevention standard precaution practices  Infection prevention national guidelines, training of national core team  Job aids on FANC, Malaria and syphilis during pregnancy  Provision of integrated ANC services- PMTCT, MIP, SIP, nutrition, STIs, FP etc  RCH trainers, supervisors (zonal, regional and district RCHCos) and providers trained on Focused ANC clinical and teaching skills

20. Program achievements : training  Focused ANC introduced in Nursing Midwifery Certificate and Diploma national curricula  All 55 Nursing and Midwifery Schools in Tanzania updated in focused ANC clinical and teaching skills- (110 tutors and 110 preceptors)  All 22 cert schools and half of the remaining schools are equipped with training equipment, reference books and anatomical pelvic models  System for rolling out Focused ANC nationwide established  Standards-based management process for performance and quality improvement introduced to 15 regions.

21. Standards Based Management: A Performance and quality Improvement Model Desired performance Actual performance Gap Cause analysis Intervention identification & implementation

22. Indicator for success of program  Intermittent preventive treatment for malaria increased from 0% to 18.4%  50% of Tanzania households own a mosquito net  14% of families own Insecticide Treated Nets  47.1% gave birth at health facility  80% received TT at least once  61.1% received iron supplementation  94.3% received ANC from a health professional at least once. Source: TDHS 2004/05

23. Challenges and Opportunities  Limited numbers of skilled providers  Shortages especially of Sulfadoxine Pyrimethamine, RPR kits  Poor data management; recording, processing and use  Quality antenatal care platform suited to introduction of other services e.g. PMTCT of HIV, Intermittent Preventive Treatment of malaria among infants  National system for expanding quality ANC in place

24. Thank you for active listening!