title: Health system support for childbirth care in Southern Tanzania: results from a health facility census.
abstract: BACKGROUND
  Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth.
  
  
  RESULTS
  Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2-3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months.
  
  
  CONCLUSIONS
  Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage.
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK. Claudia.Hanson@ki.se.
authors.forename: Claudia
authors.initials: C
authors.lastname: Hanson
authors.forename: Carine
authors.initials: C
authors.lastname: Ronsmans
authors.forename: Suzanne
authors.initials: S
authors.lastname: Penfold
authors.forename: Werner
authors.initials: W
authors.lastname: Maokola
authors.forename: Fatuma
authors.initials: F
authors.lastname: Manzi
authors.forename: Jenny
authors.initials: J
authors.lastname: Jaribu
authors.forename: Godfrey
authors.initials: G
authors.lastname: Mbaruku
authors.forename: Hassan
authors.initials: H
authors.lastname: Mshinda
authors.forename: Marcel
authors.initials: M
authors.lastname: Tanner
authors.forename: Joanna
authors.initials: J
authors.lastname: Schellenberg
mesh_terms: D019352:Censuses; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006761:Hospitals; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000458:organization & administration*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D011787:Quality of Health Care / Q000458:organization & administration*; D012424:Rural Population; D013636:Tanzania / Q000453:epidemiology