Transcript Slide 1
Delivery of Maternal and Newborn
Care Services in Africa:
What are the facilities telling us?
Koye Oyerinde MD, MPH, FAAP
Symposium on Maternal Mortality, Dakar
The Averting Maternal Death and
Disability Program - AMDD
• Mailman School of Public Health, Columbia University,
New York City.
• Help to strengthen heath systems to provide emergency
care for all women experiencing life-threatening obstetric
complications.
• Conduct research and policy analysis, provide technical
expertise, and advocate for solutions
• Collaborate with global, regional, and local institutions –
including NGOs & academic centers
The Alliance
• Memorandum of Understanding signed June 2008
between UNICEF, UNFPA, AMDD
• Alliance supports country plans for the strengthening of
EmONC service delivery as a strategy for attaining
MDGs 4 and 5.
• WHO collaborates on alliance activities at country and
regional level.
Needs Assessment Overview
• The EmONC Needs Assessments are facility based crosssectional studies of the capacity of a health system to
provide health services to mothers and newborns
• Main focus – health system.
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Accessibility/Coverage/Equity
24 hour services
Human Resources
Equipment and Supplies
Infrastructure
Aspects of quality of care
EmONC Needs Assessments
Completed – pre-2005 and/or sub-national
Completed – post-2005 and national
Ongoing
Planned
Current as of December 2010
The Needs Assessment Process
The AMDD team:
Phase III: From
Data to Action
• Conducting the Needs Assessment
• provides customized
technical support and
training through these phases
Phase II:
Conducting the
• works remotely and inNeeds Assessment
country to support the MOH
to conduct the assessments.
Phase I:
Advocacy and
Planning
Some trends from the recent
EmONC Needs Assessments in
Africa
Low no. of facilities offering EmONC
signal functions
The recommended number of EmONC facilities is 5 per
500,000, at least one of which is Comprehensive (CEmONC).
EmONC coverage
30%
24%
25%
20%
15%
11%
11%
Ethiopia
Madagascar
10%
5%
0%
Sierra Leone
Coverage is defined as available EmONC facilities as a percentage of
recommended EmONC facilities. There may be further disparities between
urban and rural areas.
Low no. of EmONC facilities
Better CEmOC coverage than BEmOC coverage
But CEmOC requires BEmOC to function properly
BEmOC – 4 per 500,000
Actual
Recomm. Coverage
CEmOC – 1 per 500,000
Actual
Recomm. Coverage
Ethiopia
25
591
4%
58
148
39%
Madagascar
3
155
2%
19
39
49%
Sierra Leone
0
48
0%
14
12
120%
Low utilization
• Institutional delivery rate:
• Variety within and among countries:
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Ethiopia 7%,
Madagascar 19%
Sierra Leone 10%
Higher rates in urban areas
Met need in EmOC facilities
100%
80%
60%
• Met need:
% of expected complications
that are treated in EmOC
facilities. Target: 100%
40%
20%
3%
10%
7%
Madagascar
Sierra Leone
0%
Ethiopia
Missing signal functions
• MVA and AVD are most commonly missing SFs,
especially at the health center level.
Sierra Leone, 2008: Proportion of hospitals and CHCs by signal
functions performed in last 3 months
Low HR availability
• 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.
• Ethiopia: only 35% of the midwives targeted in HSDP III 2010 had been trained,
26% of medical doctors, and 16% of the health officers.
Ethiopia: % of HCs staffed with at least 2 midwives and 1 health officer, by region
Inadequate commodities and supplies
Percentages of facilities with:
Misoprostol
Mag Sulph
Contraceptives
7% use for
obstetric
indications
3% use as
parenteral
anticonvulsant
90% have at least
3 methods
Madagascar
11% (but 0% use
for MVA)
0.68% use as
parenteral
anticonvulsant
95% have oral
contraceptives
Sierra Leone
21%
64%
No info
Ethiopia
Stock outs
Ethiopia: causes of delay of supplies in hospitals
‘stock out at
central store’ (41%)
‘financial problems’
(26%)
‘administrative
difficulties’ (15%)
Madagascar: 73% of hospitals and 65% of health centers had not
had a stock out of oxytocin, ergometrine, or atropine in the 12
months before the study.
Limited data collection
• HMIS indicators
▫ Often important indicators are not collected
▫ When collected the data are unused for planning
▫ HMIS data often considered unreliable
A common outcome of the Needs Assessment is
HMIS revision.
• Data collection at front-lines
▫ Facility registers often unclear and incomplete
▫ 51% of health centers in Ethiopia had drug and
inventory registers
Fee for Service
• Fees are often considered a barrier, especially for the
poorest.
• “Some women when told to go to the hospital would not because they
do not have money; so they have problems during delivery” - Sierra
Leone Needs Assessment, qualitative data:
• 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; thus raising concerns for potential fall in
quality of care
Socio-cultural barriers
• NA results are made more meaningful when
combined with social science research
• Socio-cultural barriers – including abusive /
disrespectful care - have been shown to delay
utilization and limit benefits derived from the
health system
An anthropologic question
Selected Average Sub-Saharan Health Indicators
80%
70%
46%
Antenatal Coverage
Skilled Birth
Attendance
BCG Vaccination
Coverage
Conclusion
• Needs Assessments have potential to surface
gaps and indicate ways forward
• A systems science/health systems perspective is
critical – we need strong health systems to
support women during labor.
Conclusion
• Health facilities in Africa are saying:
▫ Not enough, not the right type and not in the right
place
▫ Not adequately staffed, not with the right skills
▫ Not adequately stocked, not with the right tools,
drugs, and supplies
Many thanks!
Merci beaucoup!
Further resources available from the
AMDD website: www.amddprogram .org