Improving uptake of delivery care services in rural Tanzania through demand creation, ambulance transport and quality of care: a feasibility study

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This is a proposal for a trial development and feasibility study for a complex intervention to improve pregnancy- and birth-related maternal and neonatal health outcomes in rural Tanzania.The intervention aims to prevent emergencies in pregnancy and childbirth by increasing uptake of antenatal and delivery care services in rural Tanzania. Progress has been much too slow towards reducing the high rates of avoidable pregnancy- and birth-related deaths that persist in the region despite 2015 marking the end of the MDG era, which helped place maternal and newborn health on the global agenda. More research is urgently needed to address this important public health issue. The high rates of adverse birth outcomes can largely be attributed to a handful of common complications during pregnancy and labour which are in principle trivially avoided or resolved given adequate antenatal and delivery care. The central barriers to increased uptake of facility-based delivery care are, (1) a lack of awareness of the importance of delivering with assistance from skilled birth attendants, (2) limited access to transport for women in labour, and (3) inadequate quality of delivery care in rural facilities with outdated midwifery skills among many health workers and a lack of essential equipment and consumables, poor supervision structures and inadequate procedures for timely referral to larger facilities.Our intervention consists of the following main components: (1) Campaigning in the community to raise awareness among women and their families of the importance of delivering with skilled birth attendants (which in rural Africa is only available in health facilities). (2) A free-of-charge telephone hotline to the nearest Health Centre (HC) to arrange transport at onset of labour or in case of emergency. (3) Free-of-charge transport for women in labour to the nearest HC using locally produced low-cost motorcycle-drawn ambulance trailers. (4) Strengthening of essential midwifery skills in local HCs thus improving the reputation of the care they provide.To date no feasible, cost-effective intervention has been demonstrated to simultaneously address each of the major barriers to care and improve 'hard' pregnancy outcomes. Robust evidence is needed of a scalable, affordable intervention with a sustained effect. The definitive evaluation in a main trial will estimate effectiveness and cost-effectiveness of the intervention in improving maternal and neonatal health outcomes in a cluster randomised trial with clusters comprising rural HCs and the communities (wards) they serve. The proposed early-phase study is required to strengthen the intervention, generate evidence on its feasibility, and allow us to perfect the design of the evaluation in the main trial. The objectives of this early phase study are:(-) to conduct formative research to feed into the design of the intervention, and to improve participation from potential study participants in the development of the intervention. (-)incorporating observations from the formative research phase, to finalise all aspects of the intervention components and produce a set of standard operating procedures and intervention manuals.(-) to pilot the intervention in its entirety which will help identify and resolve unforeseen challenges, facilitate operational research to evaluate process measures and feasibility of all individual aspects of the intervention.(-)to obtain preliminary indicators as to how successful the intervention is likely to be in creating increased demand for facility-based delivery care.(-)to establish and test the feasibility of survey techniques planned for the main study.