Development, Implementation, and Evaluation of an Electronic Obstetric and Neonatal (OBNN) Database at Muhimbili National Hospital, Dar es Salaam, Tanzania: A Special Studies Project Público

Abstract

Background: Tanzania has one of the highest maternal mortality rates (MMR) and neonatal mortality rates (NMR) in the sub-Saharan region with an estimate of 556 maternal deaths per 100,000 live births and 19 neonatal deaths per 1,000 live births. In 2011, the MMR at Muhimbili National Hospital (MNH) was roughly 1,541 per 100,000 live births, considerably higher than national estimates. Previous literature has indicated substandard care factors for women delivering at MNH and has demonstrated a need for quality improvement (QI) initiatives in order to reduce poor maternal and neonatal outcomes in health facilities.

Purpose: Launched in 2018, the Emory-Muhimbili Partnership for Health Administration Strengthening and Integration of Services (EMPHASIS) seeks to collaboratively build capacity for quality improvement, research infrastructure, and business processes at MNH. Collaboratively, the team decided to address the startling need for data collection at MNH as one of the first steps towards improving QI processes. The main purpose of this project was to provide a tool to aid in clinical decision-making in order to improve the ability to undertake QI initiatives. Additionally, the project intended to build capacity for staff-led research and improve hospital and ministry reporting processes for nurses and midwives.

Methods: The database was developed in collaboration with obstetrician-gynecologists and midwives at MNH with use of standard indicators. Implementation took place over a three- month period. Maternity block staff were trained for data collection through group workshops and continuous hands-on education. A one-month pilot with 100% data collection was completed and additional modifications were made to the database. Eighteen qualitative interviews were conducted with staff to evaluate project implementation as well as barriers and facilitators for similar electronic data collection systems at MNH.

Results: A collaborative decision was made with hospital leadership to transition from paper- based data collection to solely electronic data collection in the maternity block roughly three months after implementation began. Staff overwhelmingly reported positive experiences with project implementation and use of the database. Benefits ranged from improving data privacy and security to improved workflow. A key challenge identified was lack of reliable access to network connection.

Discussion: Hospital leaders and staff recognize the need for quality improvement initiatives in the MNH maternity block, but lack high-quality, real-time data in order to inform their decision- making. Successful implementation of the OBNN Database in the Maternity Block may drive the desire for improving data collection systems hospital-wide. Increasing access to data for decision making may improve outcomes for patients at MNH, assist staff with administrative reporting, and provide opportunity for staff-led research.

Table of Contents

CHAPTER 1: INTRODUCTION...................................................................................................1

Problem Statement........................................................................................................................2

Purpose .........................................................................................................................................3

Project Goals ..... ............................................................................................................................4 Significance....................................................................................................................................4

Definition of Terms ........................................................................................................................5

CHAPTER 2: LITERATURE REVIEW ...........................................................................................6

Maternal Health in Tanzania ..........................................................................................................6

Neonatal Health in Tanzania...........................................................................................................8

Quality Improvement (QI) in Low-Resource Settings .......................................................................9

Defining Quality Improvement ........................................................................................................................... 10

Implementing QI Projects in Low-Resource Settings ......................................................................................... 12

Quality Improvement for Maternal and Neonatal Healthcare in Sub-Saharan Africa....................................... 13

Health Facility Focused Quality Improvement in Tanzania ................................................................................ 14

Electronic Health Systems in Low-Resource Settings .....................................................................16

Barriers and Facilitators to eHealth Technologies in Low-Resource Settings .................................................... 17

Effectiveness of eHealth Systems in Low-Resource Settings ............................................................................. 19

eHealth in Tanzania ............................................................................................................................................ 20

CHAPTER 3: DESIGN & IMPLEMENTATION ............................................................................ 23

Introduction ................................................................................................................................23

Design .........................................................................................................................................23

Setting .........................................................................................................................................24

Development ...............................................................................................................................24

Implementation ...........................................................................................................................25

Training ............................................................................................................................................................... 25

Pre-Test............................................................................................................................................................... 26

Pilot-test ............................................................................................................................................................. 27

Project Launch .................................................................................................................................................... 28

Barriers ............................................................................................................................................................... 29

Facilitators .......................................................................................................................................................... 31

CHAPTER 4: EVALUATION.....................................................................................................32

In-Depth Interviews .....................................................................................................................32

Introduction ........................................................................................................................................................ 32 Methods.............................................................................................................................................................. 32

Results ................................................................................................................................................................ 33

Data for Decision-Making.............................................................................................................37

Introduction ........................................................................................................................................................ 37

Methods.............................................................................................................................................................. 38

Results ................................................................................................................................................................ 38

CHAPTER 5: DISCUSSION ...................................................................................................... 41

Introduction ................................................................................................................................41

Project Evaluation........................................................................................................................42

Project Data.................................................................................................................................42

Project Sustainability ...................................................................................................................43 Limitations...................................................................................................................................44

Strengths .....................................................................................................................................44

Recommendations .......................................................................................................................45

REFERENCES ........................................................................................................................46

APPENDIX............................................................................................................................ 54

Qualitative Interview Guide .........................................................................................................54

Data Entry Forms .........................................................................................................................56

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Information Technology Health Sciences, Obstetrics and Gynecology
Palabra Clave	Muhimbili National Hospital data for decision-making database Tanzania
Committee Chair / Thesis Advisor	Sydney Spangler, Emory University

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