Estomih Mduma

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality in Tanzania. Accurate diagnosis, proper documentation, and effective patient communication including disclosure and informed consent are essential for quality PPH care. However, evidence on these practices among healthcare providers (HCPs) is limited. This study assessed HCPs practices related to PPH diagnosis, documentation, disclosure and consent in Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) facilities. Methods: A facility-based cross-sectional study was conducted between October and November 2024 among healthcare provider working in maternity ward in 142 CEmONC facilities implementing the Safer Births Bundle of Care across five regions in Tanzania. Healthcare providers providing care to birthing women were voluntarily invited to participate. Convenience sampling was used in recruitment. Data were collected using a structured, pre-tested questionnaire administered using Open Data Kit. Descriptive statistics summarized HCPs characteristics and practices. Chi-square tests was used to assess the associations between practices and HCPs characteristics, with statistical significance set at p < 0.05. Results: A total of 446 HCP participated in the study. Most HCPs 371 (83.2%) received training on PPH diagnosis. Visual estimation of blood loss was the predominant diagnostic method 435 (97.5%). However, only 194 (43.5%) reported good diagnostic practices based on the assessed criteria. Documentation was suboptimal, with only 79 (17.7%) consistently recording all PPH diagnoses, while 234 (52.5%) documented only severe cases requiring blood transfusion. Regarding patient communication, 356 (79.8%) reported consistently disclosing PPH diagnoses, and 295 (66.1%) obtained consent before invasive procedures. Communication practices were significantly associated with cadre (p=0.012) and education level (p=0.034). Conclusion: Despite high levels of reported training, substantial gaps were identified in diagnostic, documentation, and patient communication practices in PPH management. Strengthening objective diagnostic approaches, improving documentation systems and effective communication practices are needed to improve quality of care.

Background: The Pediatric Advanced Warning Score (PAWS) facilitates early recognition of critically ill children and has been validated for predicting intensive care admission. However, its prognostic performance for in-hospital mortality and the incremental value of health-system factors such as triage–transit delay remains uncertain in resource-limited settings. We evaluated the prognostic performance of admission PAWS for predicting in-hospital mortality and determined whether incorporation of triage–transit delay and patient characteristics improved mortality risk prediction.Methods: We conducted a secondary prognostic analysis of a previously established prospective emergency department cohort comprising 110 children admitted to pediatric critical care at a tertiary referral hospital in Tanzania. Admission PAWS was recorded once at Emergency Medical Department presentation before inpatient treatment. The primary outcome was in-hospital mortality. Candidate predictors included admission PAWS, age, sex, referral status, and Emergency Medical Department (EMD)-to-ward transfer delay (>6 hours). Prognostic performance was evaluated using multivariable logistic regression with Firth penalized regression as a sensitivity analysis. Model discrimination, calibration, bootstrap internal validation, decision curve analysis, and restricted cubic spline modelling were performed.Results: Among 110 critically ill children, 58 (52.7%) died during hospitalization, while 59 (53.6%) experienced EMD-to-ward transfer delays exceeding six hours. Admission PAWS demonstrated moderate discrimination for predicting in-hospital mortality (AUC 0.657; 95% CI 0.551–0.753), with high sensitivity but limited specificity. Incorporation of age, referral status, sex, and triage–transit delay improved discrimination (AUC 0.746), with acceptable calibration and an optimism-corrected AUC of 0.701 following bootstrap internal validation. Decision curve analysis demonstrated greater net clinical benefit for the final multivariable model than PAWS alone across clinically relevant threshold probabilities. Younger age remained independently associated with mortality, whereas triage–transit delay was not independently associated with death after multivariable adjustment.Conclusions: Admission PAWS provides clinically meaningful but incomplete prognostic information for critically ill children. Integrating physiological assessment with patient characteristics and selected health-system variables improves prognostic performance, calibration, and clinical utility compared with PAWS alone. These findings extend the application of PAWS beyond intensive care triage towards individualized mortality risk prediction and support external validation of context-specific prognostic models for pediatric critical care in resource-limited settings.

This paper examines changes in the completeness of documentation in clinical practice before and during the implementation of the Safer Births Bundle of Care (SBBC) project. This observational study enrolled parturient women with a gestation age of at least 28 weeks at the onset of labour. Data collectors extracted information from facility registers and then a central data manager summarised and reported weekly statistics. Variables of clinical significance for CQI were selected, and the proportion of non-documentation was analysed over time. A Pearson chi-square test was used to test for significant differences in non-documentation between the periods. Between 1 March 2021 and 31 July 2022, a total of 138,442 deliveries were recorded. Overall, 75% of all patient cases had at least one missing variable among the selected variables across both periods. A lack of variable documentation occurred more frequently at the district hospital level (81% of patient cases) and health centres (74%) than at regional referral hospitals (56%) (p < 0.001). Non-documentation decreased significantly from 79% to 70% after the introduction of the SBBC (p < 0.001). A tendency towards negative correlations was noted for most variables. We noted an increased attention to data quality and use which may have a positive impact on the completeness of documentation. However, halfway through the project’s implementation, the completeness of documentation was still low. Our findings support the recommendation to establish short-spaced feedback loops of locally collected data using one data platform.

Suctioning of newborns immediately after birth, as part of delivery room resuscitation, is only recommended if the airway is obstructed. The aim of this study was to describe the use of suctioning during newborn resuscitation among survivors versus those who died within 3 days and potential suction-related heart rate responses and associations to newborn characteristics. This was a retrospective observational study from July 2013 to July 2016 in a referral hospital in rural Tanzania. Research assistants observed and documented all deliveries, newborn resuscitations were video-recorded, and newborn heart rates were captured with a dry-electrode electrocardiogram. Liveborn infants ≥34 weeks gestation who received ventilation and with complete datasets were eligible. All 30 newborns who died were included, and a total of 46 survivors were selected as controls. Videos were annotated and heart rate patterns were observed before and after the suction events. Suctioning was performed more frequently than recommended. No differences were found in suctioning characteristics between newborns who died versus those who survived. In 13% of suction events, a significant heart rate change (i.e., arrhythmia or brief/sustained >15% fall in heart rate) was observed in relation to suctioning. This represents a potential additional harm to already depressed newborns undergoing resuscitation.

Background: Micronutrients (iron, iodine, vitamin B12 and folate) deficiency is prevalent globally affecting more than two billion people majority being from low- and middle-income countries. Women of reproductive age are in an increased risk of iron deficiency. About 29.4% of women aged 15– 49 years worldwide are estimated to be affected by iron deficiency. Food fortification with micronutrients is important in addressing micronutrients deficiency. Aim: To evaluate if the quadruple fortified with iodine, iron, vitamin B12, and folic acid (QFS), will be more effective in improving the hemoglobin level of women aged 18 to 49 years compared to the double fortified with iodine and iron (DFS) and iodized salt in rural Tanzania. Methods: A double-blinded three-arm randomized controlled trial was conducted between July 2020 and December 2021 at the Haydom Lutheran Hospital catchment area. We randomized women aged 18– 49 years with haemoglobin between 8 and 12 g/dl who were neither pregnant nor lactating into three groups 55 Iodized salts (IS), 57 Double fortified salt (DFS), and 57 quadruple fortified salt (QFS). The participants used study salt for 10 months. Results: Over the ten months of use of study salts, the overall mean haemoglobin level of women was significantly higher in QFS by 0.43g/dl compared to IS. The ferritin levels were significantly higher in QFS and DFS by 9.60ng/mL and 9.09ng/mL, respectively, compared to IS. Vitamin B12 was insignificantly higher in QFS by 52.19pg/mL compared to DFS, and folate concentration were insignificantly higher in QFS by 7.57nmoL/L and 4.51nmoL/L compared to DFS and IS groups, respectively. Conclusion: Salt fortification with iron, iodine, folate, and Vitamin B12 is feasible and has the potential to increase the serum ferritin, Vitamin B12 and folate levels with subsequent improvement of haemoglobin levels of individuals with relatively low haemoglobin. ClinicalTrial.org Number: NCT04404751.

Introduction: Birth asphyxia–related deaths is a major global concern. Rapid initiation of ventilation within the “Golden Minute” is important for intact survival but reported to be challenging, especially in low-/middle-income countries. Helping Babies Breathe (HBB) is a simulation-based training program for newborn resuscitation. The aim of this HBB quality improvement (QI) intervention was to decrease time from birth to ventilation and document potential changes in perinatal outcomes. Method: Prospective observational QI study in a rural Tanzanian hospital, October 1, 2017, to August 31, 2021, first-year baseline, second-year QI/simulation intervention, and 2-year postintervention. Trained research assistants observed wide-ranging information from all births (N = 12,938). The intervention included monthly targeted HBB simulation training addressing documented gaps in clinical care, clinical debriefings, and feedback meetings. Results: During the QI/simulation intervention, 68.5% nonbreathing newborns were ventilated within 60 seconds after birth compared with 15.8% during baseline and 42.2% and 28.9% during the 2 postintervention years (P < 0.001). Time to first ventilation decreased from median 101 (quartiles 72–150) to 55 (45–67) seconds (P < 0.001), before increasing to 67 (49–97) and 85 (57–133) seconds after intervention. More nonbreathing newborns were ventilated in the intervention period (12.9%) compared with baseline (8.5%) and the postintervention years (10.6% and 9.4%) (P < 0.001). Assumed fresh stillborns decreased significantly from baseline to intervention (3.2%–0.7%) (P = 0.013). Conclusions: This QI study demonstrates an increase in nonbreathing newborns being ventilated within the Golden Minute and a significant reduction in fresh stillborns after introduction of an HBB QI/simulation intervention. Improvements are partially reversed after intervention, highlighting the need for continuous simulation-based training and research into QI efforts essential for sustainable changes.

: At least a third of tuberculosis (TB) cases remain undiagnosed, disproportionately so in children and adolescents, which is hampering global elimination goals. Prolonged symptom duration presents a high-risk scenario for childhood TB in endemic areas, but the prolonged period of symptoms and its impact on educational attainment are rarely documented. Using a mixed method approach, we aimed to quantify the duration of respiratory symptoms and describe their impact on education among children from a rural area of Tanzania. We used data from a prospectively enrolled cohort of children and adolescents aged 4–17 years in rural Tanzania at the start of active TB treatment. We report on the cohort’s baseline characteristics and explore the correlation between duration of symptoms and other variables. In-depth qualitative interviews were designed on the basis of a grounded theory approach to explore the impact of TB on educational attainment among school-aged children. In this cohort, children and adolescents diagnosed with TB experienced symptoms for a median of 85 days (interquartile range: 30, 231 days) prior to treatment initiation. In addition, 56 participants (65%) had a TB exposure in the household. Of the 16 families with school-aged children who were interviewed, 15 (94%) reported a significant negative impact of TB on the schooling of their children. Children in this cohort experienced a long duration of TB symptoms; the extent of illness impacted absenteeism at school. Screening initiatives for households affected by TB may lead to a shortened duration of symptoms and may minimize the impact on school attendance.

Background: SaferBirths Bundle of Care (SBBC) is a package of innovative clinical and training tools coupled with low-dose high-frequency simulation-based on-job training guided by local data. This bundle of care is a new initiative being implemented in 30 health facilities from five regions of Tanzania aiming at improving birth outcomes. Objective: To assess the perception of healthcare workers and facility leaders on the “SaferBirths Bundle of Care” towards saving women’s and newborns’ lives at birth. Method: We used a qualitative approach using focused group discussion (FGD) and individual interviews. A total of 21 FGD and 43 individual interviews were conducted between August and November 2022. In total, 94 midwives and 12 doctors were involved, some of whom were in leadership roles. The framework method for the analysis of qualitative data was used for analysis. Results: Healthcare workers and facility leaders received the bundle well and regarded it as effective in saving lives and improving healthcare provision. Five themes emerged as facilitators to the acceptance of the bundle: (1) the bundle is appropriate to our needs, (2) the training modality and data use fit our context, (3) use of champions and periodic mentorship, (4) learning from our mistakes, and (5) clinical and training tools are of high quality but can be further improved. Conclusion: The relevance of SaferBirths Bundle of Care in addressing maternal and perinatal deaths, the quality and modality of training, and the culture that enhances learning from mistakes were among the facilitators of the acceptability of the SBBC. A well-accepted intervention has huge potential for bringing the intended impact in health provision.