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
Clinical Causes of Maternal Deaths,
Sierra Leone
• PPH is the leading cause of
maternal mortality in Africa
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
• Met need:
% of expected complications
that are treated in any
facility or in EmOC facilities
• Target: 100%
Met need in EmOC facilities
100%
80%
60%
40%
20%
10%
3%
7%
0%
Ethiopia
Madagascar Sierra Leone
Availability of EmONC facilities
EmONC Availability
• Inadequate no. of facilities
offering EmOC signal
functions
• Availability is defined as
number of fully functioning
EmONC facilities as a
percentage of recommended
EmONC facilities.
30%
25%
24%
20%
15%
10%
11%
11%
5%
▫ Recommended = 5 EmONC
facilities per 500,000, at
least one of which is
comprehensive
0%
Ethiopia
Madagascar Sierra Leone
1st level of care vs Referral centers
Availability of Injectible Diazepam
Hospitals
100%
90%
80%
Health Centers
93%
87%
95%
70%
60%
50%
40%
41%
30%
20%
• 1st level of care
▫ Inadequate
equipment &
supplies
 10% of health centers
in Madagascar had
magnesium sulfate
▫ Poor supply of SBA
10%
0%
Madagascar
Ethiopia
Inadequate supply of SBA
Ethiopia: % of HCs staffed with at
least 2 midwives and 1 health
officer, by region
Benishangul-Gumuz
0%
Gambella
0%
Harari
0%
Amhara
SNNPR
Somali
• Madagascar: has 99 obstetricians,
needs 72 more to reach norms.
2%
11%
21%
Oromia
21%
Addis Ababa
Dire Dawa
• Ethiopia: only 35% of the
midwives targeted in HSDP III 2010
were in employment, 26% of medical
doctors, and 16% of the health
officers.
17%
Afar
Tigray
• Sierra Leone: TBAs and MCH
aides conduct most deliveries,
especially in health centers. SL has
started new midwifery education
programs since the NA
45%
55%
100%
Severe weaknesses at 1st level of care
Availability of drugs for management of
PPH in health centers
90%
Misoprostol
80%
Oxytocin
84%
Ergometrine
70%
67%
60%
55%
50%
• Poor supplies and
equipment
management
30%
20%
7%
4%
0%
Madagascar
• Unlinked to “better
resourced” secondary
& tertiary level
61%
40%
10%
• Poor infrastructure
Ethiopia
Secondary / tertiary levels of care
Availability of drugs for management of
PPH in hospitals
Misoprostol
Oxytocin
Ergometrine
100%
90%
94%
91%
80%
70%
72%
60%
71%
50%
• Better supply of SBA
• Abusive/ disrespectful
care
• Long waiting times
40%
30%
20%
10%
• Better infrastructure
16%
0%
Madagascar
9%
Ethiopia
• High out-of–pocket
expenditure
Secondary / tertiary levels of care
Availability of selected packs in
Ethiopian delivery rooms
80%
60%
• Poor supply of blood &
blood products
79%
70%
64%
50%
• Unreliable logistics and
supply chain management
40%
30%
20%
• Poor laboratories
32%
25%
10%
0%
Cervical/perineal
repair packs
MVA packs
Hospitals
Health Centers
Unreliable supply chain management
100%
Availability of normal saline in hospitals and health
centers
Hospitals
96%
90%
80%
88%
78%
70%
60%
Health Centers
63%
50%
40%
30%
20%
10%
0%
Madagascar
Ethiopia
Inadequate quality of care in secondary /
tertiary levels of care
Practice of AMTSL
70%
60%
66%
• Lack of attention to
quality improvement
50%
40%
30%
30%
20%
10%
0%
Sierra Leone
• Poor quality of care
Madagascar
• Poor supportive
supervision of 1st level
care facilities
Focus on a functioning health system
3rd level
of care
2nd Level
of care
• Inadequate communications
infrastructure
▫ Remote facility staff are unsupported,
unsupervised & unmentored
• Non-existent referral systems
1st Level of
care
▫ Unnecessary delays with transport
▫ Long waiting and fresh evaluations
• HMIS systems poorly managed
Community
▫ 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 improve
significantly if the following persist:
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 taskshifting 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