Delivery of Maternal and Newborn Care Services in Africa: What are the facilities telling us?

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

2. 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

3. 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.

4. Needs Assessment Overview • The 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/Equity • 24 hour services • Human Resources • Equipment and Supplies • Infrastructure • Aspects of quality of care

5. EmONC Needs Assessments Completed – pre-2005 and/or sub-national Completed – post-2005 and national Ongoing Planned Current as of December 2010

6. The Needs Assessment Process Phase III: From Data to Action • The AMDD team: • provides customized technical support and training through these phases • works remotely and in-country to support the MOH to conduct the assessments. • Conducting the Needs Assessment Phase II: Conducting the Needs Assessment Phase I: Advocacy and Planning

7. Some trends from the recent EmONC Needs Assessments in Africa

8. 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). Coverage is defined as available EmONC facilities as a percentage of recommended EmONC facilities. There may be further disparities between urban and rural areas.

9. Low no. of EmONC facilities • Better CEmOC coverage than BEmOC coverage • But CEmOC requires BEmOC to function properly

10. Low utilization • Institutional 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%

11. 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

12. 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

13. Inadequate commodities and supplies Percentages of facilities with:

14. 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 healthcentershad not had a stock out of oxytocin, ergometrine, or atropine in the 12 monthsbefore the study.

15. 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

16. 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

17. 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

18. An anthropologic question

19. 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.

20. 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

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