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Trop Med Int Health. 2019 May;24(5):636-646. doi: 10.1111/tmi.13220. Epub 2019 Mar 11.

Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania.

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Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Ifakara Health Institute, Dar es Salaam, Tanzania.
Tanzania Health Promotion Support, Dar es Salaam, Tanzania.


in English, French


Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub-optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth.


In this cluster-randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in-service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference-in-differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation.


The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup.


We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.


Tanzania; Tanzanie; cluster-randomised controlled trial; essai contrôlé randomisé en grappes; evaluation; maternal and newborn health; quality; qualité; santé maternelle et néonatale; utilisation; évaluation

[Available on 2020-05-01]
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