Delivery of Maternal and Newborn Care Services in Africa: What are the facilities telling us?Koye Oyerinde MD, MPH, FAAPSymposium on Maternal Mortality, Dakar

The Averting Maternal Death and Disability Program - AMDDMailman 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 solutionsCollaborate with global, regional, and local institutions including NGOs & academic centers

The AllianceMemorandum of Understanding signed June 2008 between UNICEF, UNFPA, AMDDAlliance 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 OverviewThe EmONC Needs Assessments are facility based cross-sectional studies of the capacity of a health system to provide health services to mothers and newborns

Main focus health system.Accessibility/Coverage/Equity24 hour servicesHuman ResourcesEquipment and SuppliesInfrastructureAspects of quality of care

EmONC Needs AssessmentsCompleted pre-2005 and/or sub-nationalCompleted post-2005 and nationalOngoingPlanned

Current as of December 2010

The Needs Assessment ProcessConducting the Needs AssessmentPhase I: Advocacy and PlanningPhase II: Conducting the Needs AssessmentPhase III: From Data to ActionThe AMDD team:

provides customized technical support and training through these phases

works remotely and in-country to support the MOH to conduct the assessments.

Some trends from the recent EmONC Needs Assessments in Africa

Low no. of facilities offering EmONC signal functionsCoverage is defined as available EmONC facilities as a percentage of recommended EmONC facilities. There may be further disparities between urban and rural areas. The recommended number of EmONC facilities is 5 per 500,000, at least one of which is Comprehensive (CEmONC).

Low no. of EmONC facilitiesBetter CEmOC coverage than BEmOC coverageBut CEmOC requires BEmOC to function properly

BEmOC 4 per 500,000CEmOC 1 per 500,000ActualRecomm.CoverageActualRecomm.CoverageEthiopia255914%5814839%Madagascar31552%193949%Sierra Leone0480%1412120%

Low utilizationInstitutional delivery rate: Variety within and among countries: Ethiopia 7%, Madagascar 19%Sierra Leone 10%Higher rates in urban areas

Met need: % of expected complications that are treated in EmOC facilities. Target: 100%

Missing signal functionsMVA 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 availabilitySierra Leone: TBAs and MCH aides conduct most deliveries, especially in health centers. SL has started new midwifery education programs since the NAMadagascar: 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.

Inadequate commodities and suppliesPercentages of facilities with:

MisoprostolMag SulphContraceptivesEthiopia7% use for obstetric indications3% use as parenteral anticonvulsant90% have at least 3 methodsMadagascar11% (but 0% use for MVA)0.68% use as parenteral anticonvulsant95% have oral contraceptivesSierra Leone21%64%No info

Stock outsEthiopia: causes of delay of supplies in hospitals

stock out atcentral 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 collectionHMIS indicatorsOften important indicators are not collectedWhen collected the data are unused for planningHMIS data often considered unreliableA common outcome of the Needs Assessment is HMIS revision.

Data collection at front-linesFacility registers often unclear and incomplete 51% of health centers in Ethiopia had drug and inventory registers

Fee for ServiceFees 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 2010Initial reports suggest a phenomenal increase in utilization; thus raising concerns for potential fall in quality of care

Socio-cultural barriersNA 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

ConclusionNeeds 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.

ConclusionHealth facilities in Africa are saying:Not enough, not the right type and not in the right placeNot adequately staffed, not with the right skillsNot adequately stocked, not with the right tools, drugs, and supplies

Many thanks!Merci beaucoup!Further resources available from the AMDD website: www.amddprogram .org

***Ethiopia 2009 report (2008 data) Madagascar 2010 report (2009 data) Malawi 2010 report REPORT STILL IN DRAFT FORM (and 2010 data).*Ethiopia 2009 report (2008 data) Madagascar 2010 report (2009 data) Malawi 2010 report REPORT STILL IN DRAFT FORM (and 2010 data).*In the graph, met need is calculated for all facilities. It can also be calculated only for those births that take place in EmOC facilities. For example, in Malawi, 50% of expected complications were treated in facilities, but 22% were treated in EmOC facilities. *Figure and data from Ethiopia 2008 report*Figure and data from Ethiopia 2008 report*Ideally, a NA would not be necessary to get a picture of EmONC services in a country!

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