Project background

Although Tanzania has made significant progress in reducing maternal mortality, the number of women dying during child birth is still high at 556 per100,000 live births: 21 per cent of all deaths of women of reproductive age (MoHCDGEC). Among the many complications that can arise, excessive bleeding, otherwise know as post partum haemorrhaging (PPH), is understood to account for 25–28 per cent of these deaths (TDHS-MIS). Taking the projected number of births in Tanzania and calculating those that would experience PPH, it is believed that an estimated 115,609 women’s lives could be saved each year by averting the problem. In response, Jhpiego and Massachusetts General Hospital (MGH) introduced the innovative Every Second Matters (ESM) uterine balloon tamponade (UBT), a life-saving, low-cost device that can be used in low-resource facilities where blood transfusion or surgery may not be available. The ESM-UBT comprises a catheter connected to a silicone balloon that is inserted into the uterus and when it is inflated with clean water to fill the cavity it minimises blood flow. The ESM-UBT is simple to use and can be implemented by health workers with minimal training.

Project description

Jhpiego has distributed ESM-UBT kits to 23 hospitals and 62 health centres in Mara and Kagera Regions. In addition to providing the device itself, the overall project package included a three-hour training curriculum, which incorporated the World Health Organization’s standards for PPH management; a PPH wall poster checklist; a job-aid checklist; a trainer’s teaching flipchart; and a learner’s booklet.

Project results

• All 85 health facilities took up use of the device and during the project period, 118,013 women delivered with the ESM-UBT available if needed.
• Bleeding was stopped in 13 of the 16 cases where the ESM-UBT was used.
• The project trained a total of 32 district trainers who, in turn, trained 510 health-care workers to use the device. These included: nurse-midwives (83 per cent), doctors (4 per cent), assistant medical officers (5 per cent), clinical officers (6 per cent) and assistant clinical officers (2 per cent).

Key Lessons

• Encourage accurate recording of PPH data: In general, data related to PPH is poorly documented and reported through the current health management information system (HMIS). Throughout implementation, the project team conducted mentorship to facility staff to ensure that quality data were collected correctly in order to inform decision-making to improve the quality of care in the long term.
• Build training into staff handovers and checks as part of supervision visits: At one stage during implementation one district (Tarime Town Council) was left without any ESM-UBT trainers. The systematic transfer of knowledge from former staff to new could have helped to mitigate this problem. Some of the health facilities that Jhpeigo worked with experienced high turnovers of staff. Building an ESM-UBT component into district supervision visits may also have helped strengthen knowledge and support retention of ESM-UBT skills at supported facilities.
• Address the challenge of storage: Health facilities needed to keep the ESM-UBT devices in a secure place yet make them accessible in cases of emergency. In some cases where the device kits were kept in open cabinets, parts were lost, making them unusable.

Gender equity and social inclusion

Although Jhpeigo set out to explore the feasibility of training health-care workers at all levels including those in the lower cadre, the project particularly empowered nurse-midwives – most commonly women – to use the device. Jhpeigo found that these nurse-midwives performed at the same levels as doctors and they inserted 68 per cent of the ESM-UBTs observed as part of their study.

Principles for digital development

Design with the user: Jhpiego engaged stakeholders at all levels during the project’s implementation. This was important to ensure that the national, regional and district stakeholders were well informed at all stages of the process, which led to the buy-in and success of the intervention.

Next steps

Jhpiego conducted a feasibility study to understand how the ESM-UBT intervention could be scaled up across Tanzania. The findings highlighted a number of key areas that Jhpiego needs to address before pursuing scale-up, including how to integrate the tool into other clinical training programmes and how to better measure its impact. The findings – from the need to update guidelines and protocols to addressing supply chain management for tracking and ordering supplies – have been shared with the government’s public procurement department and MoHCDGEC as a way of starting a conversation regarding expansion.