Dar es Salaam—When a pregnant woman with a history of high blood pressure and severe headaches arrived at Tumbi Hospital in Pwani region, she was semiconscious and in the throes of convulsions. Upon examining 19-year-old Saada Shabani, nurse-midwife Julieth Sizya knew this was a serious emergency that needed prompt action. Suspecting Saada was suffering from pregnancy-related hypertension, the nurse-midwife and her colleagues in the labor ward immediately started Saada on an anti-convulsive treatment.
“I had to act fast,” said Sizya. “After calling for assistance, we quickly established an intravenous line and gave the woman a loading dose of magnesium sulfate over a 20-minute period. We followed this with two more injections of the same medicine, and also gave her medicines to lower her blood pressure.”
Saada’s condition improved markedly: she regained consciousness, the convulsions stopped and her blood pressure stabilized. Twelve hours later, she gave birth to a baby girl. And after five days, mother and child left the hospital, safe and healthy.
Severe headache and high blood pressure are among symptoms suggestive of pre-eclampsia—or pregnancy-induced hypertension associated with significant amounts of protein in the urine. Left untreated, or if treatment is delayed, pre-eclampsia can develop into eclampsia—a more severe form of the condition characterized by convulsions or fits, with potentially fatal complications for both the mother and her unborn baby.
Each year in Tanzania, eclampsia, excessive blood loss, infection, abortion-related complications and obstructed labor are the leading causes of more than 13,000 maternal deaths; a quarter-million more women suffer pregnancy- and delivery-related disabling conditions. Yet these deaths and disabilities could be readily prevented or managed through high-impact, low-cost interventions.
In collaboration with the Ministry of Health and Social Welfare (MoHSW), the Jhpiego-led MAISHA (Mothers and Infants, Safe, Healthy and Alive) Program is helping health facilities like Tumbi Hospital and providers like nurse-midwife Sizya improve the health care and services they deliver to women and families.
Funded by the U.S. Agency for International Development (USAID), MAISHA introduces a quality improvement and assurance approach known as Standards-Based Management and Recognition (SBM-R)—through which health facility managers and providers identify areas for improvement and set performance standards. Then, working as a team, with coaching and mentoring, employees devise a plan to achieve the performance standards by improving and strengthening maternal and newborn services and implementing appropriate life-saving actions.
In a country such as Tanzania, with a severe shortage of skilled health care workers, strengthening a range of cadres in the health care sector and empowering them to provide standards-based services consistently is critical. “Prior to SBM-R, few health providers—‘doctors’ only—at Tumbi Hospital were able to provide magnesium sulfate,” said Sizya. “Through SBM-R, many providers—including midwives like myself who in most cases are the first to see women with complications—are now trained and capable of providing timely intervention and preventing needless deaths. What is important is to follow, to the letter, the steps as described in the standards.”
Developed by Jhpiego, a Johns Hopkins University affiliate, and adopted as national quality improvement standards by the country’s MoHSW, SBM-R involves the systematic use of 77 maternal and newborn care performance standards that cover normal labor and delivery, and immediate newborn and postpartum care—as well as management of complications.
Other health care categories addressed by SBM-R include: infrastructure and human resource development; information, education and communication; and support systems. In the course of SBM-R implementation, positive changes, improvements and success stories are shared and rewarded using a combination of measures such as feedback and recognition.
Globally, health systems and facilities implementing the SBM-R approach also establish quality improvement (QI) committees to perform routine monitoring and supportive supervision to ensure ongoing compliance with standards—a component of the approach that proved critical at Tumbi Hospital. For instance, nurse-midwife Sizya and colleagues were reluctant to start providing magnesium sulfate until they were encouraged to do so during one of the supportive supervision sessions.
“I remember . . . Lucy Mabada, a Midwifery Advisor at Jhpiego, . . . came for supportive supervision at Tumbi Hospital and encouraged me and other midwives to start administering magnesium sulfate,” recalled Sizya. “Before that, we didn’t have the courage to get started.”
At a recent workshop held in Dar es Salaam for 50 providers and health administrators from five regions, progress in the implementation of SBM-R was reviewed. With this approach, results are expressed in terms of percentage of standards achieved. In a parallel fashion, indicators from the 77 standards are tracked to verify progress. The latest assessment results show that most of the MAISHA facilities are on course to reach 80% compliance with SBM-R performance standards, drawing them closer to the reward of recognition—the hallmark of SBM-R.