SUCCESS STORIES

TANZANIA: Increasing Uptake of Intermittent Preventive Treatment for Pregnant Women through Scaling Up Focused Antenatal Care

PROBLEM:

Maternal and newborn health remains a critical public health concern in Tanzania. Malaria is a major contributor to high morbidity and mortality. Every year, an estimated 1.7 million pregnant women suffer from malaria in the country. Malaria in pregnancy (MIP) is linked with anemia as well as a host of adverse outcomes such as spontaneous abortion, low birth weight and neonatal death. Approximately 20% of maternal deaths in Tanzania are linked to malaria. As a result, Tanzania was selected as one of the first focus countries for the U.S. President's Malaria Initiative (PMI). The short and long term solutions to the problem of MIP depend on changes in policy, capacity to deliver high-quality care, and community demand.

SOLUTIONS:

Antenatal care (ANC) visits offer an ideal platform for preventing and treating MIP. Expectant mothers can receive intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) during these visits. Fortunately, Tanzania has high numbers of pregnant women taking advantage of ANC service, with more than 96% make at least one visit during their pregnancy and 95% come at least twice. In 1999, only 34% of pregnant women received any kind of antimalarial drugs, but in 2000 the Tanzanian Ministry of Health and Social Welfare adopted a policy requiring IPT during ANC. By 2004, 52% of pregnant women had received the first dose of IPT, while 22% had taken both recommended doses.

With funding from the U.S. Agency for International Development through the ACCESS Program,** The ACCESS Program is a five-year, USAID-sponsored global program aimed at reducing maternal and newborn deaths. ACCESS is led by JHPIEGO in partnership with Save the Children, Constella Futures, LLC, the Academy for Educational Development, the American College of Nurse-Midwives and Interchurch Medical Assistance. JHPIEGO began training providers in frontline facilities on focused antenatal care (FANC) in 2004. FANC, a strategy endorsed by the World Health Organization, provides pregnant women with four high-quality antenatal visits, with key best practices including IPT integrated into basic antenatal care. FANC training coverage by JHPIEGO grew from 24 facilities in 2004 to 356 in 2005, and aims to reach all 5,000 health facilities in Tanzania by 2009. Already, data from 56 targeted facilities with JHPIEGO-trained providers showed uptake of IPT at 44%—twice the national average. JHPIEGO expects this percentage to increase; in conjunction with the PMI, JHPIEGO's goal is 85% uptake of IPT.

To ensure that quality FANC services are maintained following training, JHPIEGO also supports the Ministry of Health and Social Welfare in implementing a quality improvement process in which facilities continually assess and improve health services by applying an evidence-based performance standards approach. Using checklists, facilities assess the number of standards achieved (out of a total of 46), identify gaps and propose interventions to address them. Of the 46 standards, 16 specifically target prevention and treatment of MIP. Facilities achieved 40.6% of these MIP standards at baseline and progressed to 58% of MIP standards at follow-up. Capacity building and service quality improvements will enable steady and sustainable improvements in IPT provision within the Tanzanian health service.

Through separate funding from the Centers for Disease Control and Prevention, JHPIEGO introduced a community component in two districts of Tanzania to train health workers in villages on disseminating key messages on reproductive and child health, including MIP. Community health workers hold village-wide health education sessions and give individual counseling with their neighbors. Messages on MIP emphasize to pregnant women and their husbands and families the importance of ANC, of beginning ANC early, of getting both doses of SP and of sleeping under insecticide-treated bed nets. Local health care providers from facilities (health centers and dispensaries) serve as both trainers and supervisors of the community health workers.

LESSONS LEARNED:

Given the high number of women attending ANC in Tanzania, it is possible to prevent malaria in pregnancy on a wide scale. The government has shown the political will to commit to providing IPT, and front-line health workers are willing to identify and address factors that can improve the quality of their services. Not only has training proven to be an effective intervention, but the benefits of training and quality improvement in FANC will spill over into other areas of reproductive and child health services. Challenges such as stock-outs of essential ANC supplies and adequate numbers of trained staff continue to be a problem in many facilities, but increased community demand for IPT as part of ANC will serve as a constant stimulus for fighting malaria in pregnancy.

Useful references:

E Eckert, A Hyslop, R Snow, MEASURE Evaluation, Macro International, APHA 2005

Tanzania Demographic and Health Survey 2004-2005. National Bureau of Statistics, United Republic of Tanzania, MEASURE DHS and ORC Macro.

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