Increasing Demand for Early ANC Bookings through Community Health Worker Education Sessions in Temeke Municipal Council

The urban population is concentrated primarily in the regions of Dar es Salaam and Dodoma, where there are higher rates of maternal and child mortality. The World Health Organization recommends a minimum of eight antenatal care (ANC) visits during pregnancy, with the first contact before 12 weeks of gestational age. In Tanzania, 98 percent of women attended at least one ANC visit for their first birth, but only 51 percent attended four or more ANC visits, and only 24 percent made their first visit during the first trimester of pregnancy. Routine ANC visits are critical to prevent adverse health outcomes for women and their newborns, particularly in settings with high HIV prevalence, such as Tanzania. Routine HIV testing during ANC visits is essential to ensure that HIV-positive pregnant women know their status, initiate antiretroviral therapy, and are retained in antiretroviral therapy to prevent mother-to-child HIV transmission. In 2021, the Government of Tanzania President's Office, Regional Administration and Local Governance (PORALG) requested support from the United States Agency for International Development (USAID) Mission in Tanzania and UNICEF/Tanzania to modify and scale up a quality improvement/quality assurance (QI/QA) process. The QI process focuses on using data for decision making, and Data.FI Tanzania is supporting PORALG to scale up a data use for QI initiative at different levels of the health system. The QI approach involves monitoring the implementation of change ideas to improve top-level indicators and measure indicator performance on a regular basis using run charts to monitor progress, interpret results, and respond accordingly. In Temeke Municipal Council, the CHMT observed that the percentage of pregnant women attending their first ANC visits before 12 weeks between January and July 2021 was 16 percent, less than the national target of 40 percent. The CHMT identified the root causes that contributed to the low rate of ANC bookings before 12 weeks, including low awareness among women of the importance of early ANC, low health-seeking behavior due to competing priorities, and the opportunity cost of seeking care at a health facility in the first trimester of pregnancy. The CHMT implemented several change ideas to improve early ANC booking, including reviving targeted ANC outreach and integrating it in the ongoing COVID-19 vaccination campaign, emphasizing the importance of linking women whose urine pregnancy tests (UPTs) are positive to the ANC clinic for the initiation of ANC, and incorporating messaging on the importance of starting ANC care prior to 12 weeks of gestation into the community health worker (CHW) messaging package for CHWs to disseminate in the community. One of the change ideas implemented was to improve CHW training and engagement to increase the rate of early ANC bookings. The CHMT incorporated ANC messages encouraging early ANC booking in CHW education packages, organized CHW-led ANC education sessions to the public through community meetings and household visits, and encouraged CHWs to identify pregnant women and refer them to ANC facilities as part of their daily responsibilities. The CHMT conducted supportive supervision of ANC across 10 high-volume facilities using technical and financial support from Data.FI. These facilities were chosen because they had a large number of ANC clients and high levels of delayed ANC bookings. Data.FI supported the CHMT to actively monitor the implementation of their change ideas in these facilities, and support coaching on topics such as QI data collection, analysis, and follow-up to facility staff. The implementation of change ideas related to ANC outreach services by CHWs increased in the 10 facilities supported by Data.FI, with more streets reached with ANC education and sensitization messages on early ANC booking.