Emergency Obstetric and Newborn Care Assessments in Africa: Focus on Post Partum Hemorrhage & Pre-Eclampsia/Eclampsia

Koye Oyerinde MD, MPH, FAAP Africa Regional Meeting on Maternal and Newborn Health Interventions 2011 OI/MCHIP Meeting Addis Ababa, Ethiopia February 21-25, 2011.

The Averting Maternal Death and Disability Program - AMDD • • • • Mailman School of Public Health, Columbia University, New York City. Helps to strengthen heath systems to provide emergency care for all women experiencing life-threatening obstetric complications. Conducts research and policy analysis, provides technical expertise, and advocates for solutions Collaborates with global, regional, and local institutions – including NGOs & academic centers

Needs Assessment Overview

• The EmONC Needs Assessments are cross-sectional, facility-based studies of the capacity of a health system to provide health services to mothers and newborns • The assessments permit the calculation of a suite of indicators of the performance of health system

Needs Assessment Overview

• ▫ ▫ ▫ ▫ ▫ ▫ Main focus of assessment tools Accessibility/Coverage/Equity 24 hour services Human Resources Equipment and Supplies Infrastructure Aspects of quality of care • Countries customize tools to suite local needs for planning data

Needs Assessment Overview

• Data on the actual performance of a set of life saving services in the last 3 month before the survey are collected • Based on performance, health facilities are classified as: ▫ ▫ ▫ Comprehensive EmOC facilities Basic EmOC facilities Partially functioning facilities •

These studies are funded by the UNFPA MHTF grant, H4 initiatives and funds from other donor agencies

EmONC Needs Assessments by status Completed – pre-2005 and/or sub-national Completed – post-2005 and national Ongoing Planned Current as of February 2011

Some trends from recent EmONC Needs Assessments in Africa

• • Sierra Leone, 2008 • Ethiopia, 2009 Madagascar, 2009

PPH & PE/E

These are two of the top causes of maternal morbidity and mortality in the developing world • PPH is the leading cause of maternal mortality in Africa

Clinical Causes of Maternal Deaths, Sierra Leone Unknown 12% APH/PPH 21% Severe Chronic Anemia 18% Ruptured Uterus 12% Ectopic Pregnancy 3% Complications of Abortion 3% PE/E 25% Puerperal Sepsis 6%

Source: Daoh, Sikana & Smart - Tracking Maternal Deaths – The PCMH Experience, Freetown 2003

• PE/E is often a close second, and in some countries it may be the leading cause of institutional maternal death

Community level challenges to management of PPH & PE/E in Africa ▫ ▫ ▫ ▫ Sociocultural barriers Delayed diagnosis by TBA & relatives Low capacity of community based health workers to deliver first aid Long, difficult and expensive travel to definitive care

Facility management of PPH & PE/E • The ultimate goal of the health system is to treat all maternal and newborn childbirth complications • Irrespective of where the treatment occurs • Due to limitations to delivery of definitive care for most women with PPH & PE/E at home, many will require institutional care • ▫ ▫ ▫

Institutional delivery rate:

▫ Ethiopia 7%, Madagascar 19% Sierra Leone 10% Higher rates in urban areas

Poor access to care at home and in facilities • With poor utilization of facilities and poor access to facilities during emergencies only few complications are treated

100% Met need in EmOC facilities 80% 60%

• •

Met need:

% of expected complications that are treated in any facility or in EmOC facilities Target: 100%

40% 20% 0% 3% Ethiopia 10% 7% Madagascar Sierra Leone

Availability of EmONC facilities

EmONC Availability

• Inadequate no. of facilities offering EmOC signal functions

30% 25%

• Availability is defined as number of fully functioning EmONC facilities as a percentage of recommended EmONC facilities.

20% 15% 10% 5%

▫ Recommended = 5 EmONC facilities per 500,000, at least one of which is comprehensive

0% 11% Ethiopia 11% 24% Madagascar Sierra Leone

1 st level of care vs Referral centers

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Availability of Injectible Diazepam Hospitals Health Centers

•

93% 87% 95% 41% Madagascar Ethiopia

1 st ▫ level of care Inadequate equipment & supplies  10% of health centers in Madagascar had magnesium sulfate ▫ Poor supply of SBA

Inadequate supply of SBA

Ethiopia: % of HCs staffed with at least 2 midwives and 1 health officer, by region Benishangul-Gumuz Gambella Harari Amhara SNNPR Somali Afar Oromia Tigray Addis Ababa Dire Dawa 0% 0% 0% 2% 11% 17% 21% 21% 45% 55%

• Sierra Leone: TBAs and MCH aides conduct most deliveries, especially in health centers. SL has started new midwifery education programs since the NA • Madagascar: has 99 obstetricians, needs 72 more to reach norms.

100%

• Ethiopia: only 35% of the midwives targeted in HSDP III 2010 were in employment, 26% of medical doctors, and 16% of the health officers.

Severe weaknesses at 1 st level of care

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Availability of drugs for management of PPH in health centers 84% Misoprostol Oxytocin Ergometrine 7% 67% 4% 55% 61% Madagascar Ethiopia

• Poor infrastructure • Unlinked to “better resourced” secondary & tertiary level • Poor supplies and equipment management

Secondary / tertiary levels of care

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Availability of drugs for management of PPH in hospitals Misoprostol Oxytocin Ergometrine 16% 91% 72% 9% 94% 71% Madagascar Ethiopia

• Better infrastructure • • • • Better supply of SBA Abusive/ disrespectful care Long waiting times High out-of–pocket expenditure

Secondary / tertiary levels of care

Availability of selected packs in Ethiopian delivery rooms 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% 25% Cervical/perineal repair packs 79% 32% MVA packs Hospitals Health Centers

• Poor laboratories • Poor supply of blood & blood products • Unreliable logistics and supply chain management

Unreliable supply chain management

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Availability of normal saline in hospitals and health centers Hospitals 96% Health Centers 88% 78% 63% Madagascar Ethiopia

70% 60% 50% 40% 30% 20% 10% 0%

Inadequate quality of care in secondary / tertiary levels of care

Practice of AMTSL 66% 30%

• Poor quality of care • Lack of attention to quality improvement • Poor supportive supervision of 1 st care facilities level

Sierra Leone Madagascar

Focus on a functioning health system

3 rd level of care 2 nd Level of care 1 st Level of care Community

• Inadequate communications infrastructure ▫ Remote facility staff are unsupported, unsupervised & unmentored • Non-existent referral systems ▫ ▫ Unnecessary delays with transport Long waiting and fresh evaluations • HMIS systems poorly managed ▫ Limiting surveillance of the quality of care at all levels

Focus on a functioning health system • Prevention and management of PPH & PE/E requires a functioning health system that is connected to homes and communities ▫ The notion of a primary health care system implies the presence of a functioning link between tiers of the system, and the community • Several components of the health system depend on inputs that are beyond the purview of the ministry of health e.g. telecoms, transportation, and roads

Policy environment • Policies must support the development of an enabling environment for the delivery of services to mothers and newborns ▫ Sierra Leone (2008) - Misoprostol was not on the Essential Drug List ▫ Ethiopia (2008) - Ergometrine, oxytocin, diazepam and magnesium sulfate were not included in the Essential Health Commodity Package ▫ In most countries in Africa, midwives are not authorized to perform all basic signal functions

In short …

Outcomes for PPH & PE/E, and MMR will not significantly if the following persist: improve

Chronic severe shortages of SBA all over Africa Inadequate infrastructure Lack of linkages between tiers of the health system Poorly organized, nonexistent or ad hoc referral systems Disabling policy environments

Positive field notes …

Recent developments and opportunities for serious interventions to address PPH & PE/E: • Increasing global focus and funding for MNH ▫ Including the UN Sec. General’s Global Strategy on Maternal and Child Health • Maternal, Infant and Child Health and development in Africa was the theme of the AUSummit, Kampala July 2010 • Recent colloquium of African Social and Public Health Scientists (Dakar, December 2010) focused on maternal mortality

Positive field notes …

• Sierra Leone made health services for pregnant and lactating mothers and children under 5 free in spring 2010 ▫ Initial reports suggest a phenomenal increase in utilization • Madagascar has begun BEmONC training for midwives ▫ With emphasis on supportive supervision • Ethiopia has instituted a new HMIS that captures major obstetric complications and performance of signal functions ▫ Health extension workers supported to provide care in communities

Positive field notes …

• Many countries are beginning to authorize midwives and nurses to perform all basic signal functions ▫ ▫ The MSS in Nigeria deployed over 2000 midwives to rural areas to extend access to SBAs Some countries are considering different varieties of task shifting and task-sharing ▫ Others are training non-physician clinicians e.g. MSc program in Ethiopia • Mobile phone networks are available in most of Africa ▫ Several initiatives are ongoing to explore the use of mobile telephony for remote patient care, supportive supervision and HMIS data capture.

Conclusion

• PPH and PE/E associated mortality will be greatly reduced if more attention is paid to improving health systems in general ▫ Removal of barriers to utilization of services and extension of the reach of SBA in communities and in facilities ▫ Revamping of the supply and logistics chain ▫ Investments in infrastructure – roads, telecommunications, information technology etc.

Many thanks!

Merci beaucoup!

Further resources available from the AMDD website: www.amddprogram .org