title: Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model.
abstract: BACKGROUND
  In Tanzania, maternal mortality ratio (MMR), unmet need for emergency obstetric care and health inequities across the country are in a critical state, particularly in rural areas. This study was established to determine the feasibility and impact of decentralizing comprehensive emergency obstetric and neonatal care (CEmONC) services in underserved rural areas using associate clinicians.
  
  
  METHODS
  Ten health centres (HCs) were upgraded by constructing and equipping maternity blocks, operating rooms, laboratories, staff houses and installing solar panels, standby generators and water supply systems. Twenty-three assistant medical officers (advanced level associate clinicians), and forty-four nurse-midwives and clinical officers (associate clinicians) were trained in CEmONC and anaesthesia respectively. CEmONC services were launched between 2009 and 2012. Monthly supportive supervision and clinical audits of adverse pregnancy outcomes were introduced in 2011 in these HCs and their respective district hospitals.
  
  
  RESULTS
  After launching CEmONC services from 2009 to 2014 institutional deliveries increased in all upgraded rural HCs. Mean numbers of monthly deliveries increased by 151% and obstetric referrals decreased from 9% to 3% (p = 0.03) in HCs. A total of 43,846 deliveries and 2,890 caesarean sections (CS) were performed in these HCs making the mean proportion of all births in EmONC facilities of 128% and mean population-based CS rate of 9%. There were 190 maternal deaths and 1,198 intrapartum and very early neonatal deaths (IVEND) in all health facilities. Generally, health centres had statistically significantly lower maternal mortality ratios and IVEND rates than district hospitals (p < 0.00 and < 0.02 respectively). Of all deaths (maternal and IVEND) 84% to 96% were considered avoidable.
  
  
  CONCLUSIONS
  These findings strongly indicate that remotely located health centres in resource limited settings hold a great potential to increase accessibility to CEmONC services and to improve maternal and perinatal health.
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Tanzanian Training Centre for International Health, Ifakara, Tanzania.|Saint Francis University College for Health and Allied Sciences, Ifakara, Tanzania.
authors.forename: Angelo S
authors.initials: AS
authors.lastname: Nyamtema
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Nguke
authors.initials: N
authors.lastname: Mwakatundu
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Sunday
authors.initials: S
authors.lastname: Dominico
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Hamed
authors.initials: H
authors.lastname: Mohamed
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Tanzanian Training Centre for International Health, Ifakara, Tanzania.|Saint Francis University College for Health and Allied Sciences, Ifakara, Tanzania.
authors.forename: Senga
authors.initials: S
authors.lastname: Pemba
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Department of Obstetrics and Gynaecology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania.
authors.forename: Richard
authors.initials: R
authors.lastname: Rumanyika
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Hubert Kairuki Memorial University, Dar es Salaam, Tanzania.
authors.forename: Clementina
authors.initials: C
authors.lastname: Kairuki
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Department of Obstetrics and Gynaecology, Saint Francis Referral Hospital, Ifakara, Tanzania.
authors.forename: Irene
authors.initials: I
authors.lastname: Kassiga
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Tanzanian Training Centre for International Health, Ifakara, Tanzania.
authors.forename: Allan
authors.initials: A
authors.lastname: Shayo
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Omary
authors.initials: O
authors.lastname: Issa
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Calist
authors.initials: C
authors.lastname: Nzabuhakwa
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.
authors.forename: Chagi
authors.initials: C
authors.lastname: Lyimo
authors.affiliation: World Lung Foundation-Maternal Health Project, Dar es Salaam, Tanzania.|Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.|Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands.
authors.forename: Jos
authors.initials: J
authors.lastname: van Roosmalen
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data; D003625:Data Collection / Q000379:methods / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data; D008428:Maternal Mortality; D009721:Nurse Midwives / Q000706:statistics & numerical data; D018743:Perinatal Care / Q000592:standards* / Q000706:statistics & numerical data; D054238:Perinatal Mortality; D011247:Pregnancy; D011256:Pregnancy Outcome; D012017:Referral and Consultation / Q000706:statistics & numerical data; D019035:Rural Health Services / Q000592:standards* / Q000706:statistics & numerical data; D013636:Tanzania