Jan Hofman

Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: Do they reduce delay and what do they cost?

To assess whether motorcycle ambulances placed at rural health centers are a more effective method of reducing referral delay for obstetric emergencies than a car ambulance at the district hospital, and to compare investment and operating costs with those of a 4 wheel drive car ambulance at the district hospital.

Availability, Utilisation and Quality of Basic and Comprehensive Emergency Obstetric Care Services in Malawi

Objective To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Methods Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). Results There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. Conclusions The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.

Status of emergency obstetric care in six developing countries five years before the MDG targets for maternal and newborn health.

Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

Methodology and tools for quality improvement in maternal and newborn health care

To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low‐income countries.

The impact of emergency obstetric care training in Somaliland, Somalia

To provide and evaluate in‐service training in “Life Saving Skills – Emergency Obstetric and Newborn Care” in order to improve the availability of emergency obstetric care (EmOC) in Somaliland.

Ensuring effective Essential Obstetric Care in resource poor settings

Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use – What is EOC? Is it evidence‐based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi‐experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5.

Sexual reproductive health service provision to young people in Kenya; health service providers’ experiences

BackgroundAddressing the sexual and reproductive health (SRH) needs of young people remains a challenge for most developing countries. This study explored the perceptions and experiences of Health Service Providers (HSP) in providing SRH services to young people in Kenya.MethodsQualitative study conducted in eight health facilities; five from Nairobi and three rural district hospitals in Laikipia, Meru Central, and Kirinyaga. Nineteen in-depth interviews (IDI) and two focus group discussions (FGD) were conducted with HSPs. Interviews were tape recorded and transcribed. Data was coded and analysed using the thematic framework approach.ResultsThe majority of HSPs were aware of the youth friendly service (YFS) concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people’s rights to accessing and obtaining SRH services.ConclusionSupporting youth friendly policies and competency based training of HSP are two common approaches used to improve SRH services for adolescents. However, these may not be sufficient to change HSPs’ attitude to adolescents seeking help. There is need to address the cultural, religious and traditional value systems that prevent HSPs from providing good quality and comprehensive SRH services to young people. Training updates should include sessions that enable HSPs to evaluate how their personal and cultural values and beliefs influence practice.

Young people’s perception of sexual and reproductive health services in Kenya

BackgroundAddressing the Sexual and Reproductive Health (SRH) needs of young people remains a big challenge. This study explored experiences and perceptions of young people in Kenya aged 10–24 with regard to their SRH needs and whether these are met by the available healthcare services.Methods18 focus group discussions and 39 in-depth interviews were conducted at health care facilities and youth centres across selected urban and rural settings in Kenya. All interviews were tape recorded and transcribed. Data was analysed using the thematic framework approach.ResultsYoung people’s perceptions are not uniform and show variation between boys and girls as well as for type of service delivery. Girls seeking antenatal care and family planning services at health facilities characterise the available services as good and staff as helpful. However, boys perceive services at health facilities as designed for women and children, and therefore feel uncomfortable seeking services. At youth centres, young people value the non-health benefits including availability of recreational facilities, prevention of idleness, building of confidence, improving interpersonal communication skills, vocational training and facilitation of career progression.ConclusionProviding young people with SRH information and services through the existing healthcare system, presents an opportunity that should be further optimised. Providing recreational activities via youth centres is reported by young people themselves to not lead to increased uptake of SRH healthcare services. There is need for more research to evaluate how perceived non-health benefits young people do gain from youth centres could lead to improved SRH of young people.

O477 STATUS OF EMERGENCY OBSTETRIC CARE IN SIX DEVELOPING COUNTRIES 5 YEARS BEFORE THE MDG TARGETS FOR MATERNAL AND NEWBORN HEALTH

Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

O012 FACILITY BASED MATERNAL DEATH REVIEWS IN MALAWI: A REVIEW OF CAUSES OF DEATH AND CONTRIBUTORY FACTORS

were studied using a structured questionnaire. Analysis was by SPSS 16.0 computer package. Methods: It was a cross-sectional study conducted at Federal Medical Centre, Birnin-Kebbi, Nigeria. Using a structured questionnaire data were obtained on socio-demographic characteristics and expenditure on various aspects of care for the obstetric emergency from respondents and their husbands. Results: Mean age of respondents was 25.8yrs (range 14–45 yrs). Most of the patients had no antenatal care (86.7%, N=124) and were multiparous women (65.1%, N=93). Majority were not engaged in any income generating activity (53.1%, 76). Average monthly family income was about N13’000 (USD81.3). Complications managed were prolonged and/obstructed labour (23.1%, N=33), obstetric haemorrhages (21%), N =30), eclampsia (16.1%, N=23). Reasons for hospital presentation were mainly ‘labour too long’, heavy bleeding, and fitting in 30.1%, 23.8%, and 11.2% of respondents respectively, average length of hospital stay was about 9 days. A total of 42% (N=60) had an operative delivery. 62.2% (N=89) had visited one or more health facility prior to presentation thus adding to the cost of care. Mean total expenditure on care was about N39’000 (243.8USD) (maximum N 98’000, 608.7 USD); many of the patients (46.7% N=67) had spent more than this average on care, and it was more than the monthly income of 94.4% (N=135) of families studied. Mean expenditure on care was significantly higher for victims who had had surgery compared to those who had not, (c =33.2, p < 0.05). Only 32.8% of the respondent said they could comfortably afford any expenditure that was greater than N20’000 (123.5USD). Conclusions: The expenditure on maternity care in this study was high and it was more than the average monthly income for most families studied. The ‘free maternity care’ programme should take into consideration these spendings on some aspects of emergency obstetric care and budget appropriately if a reduction in maternal mortality is to be achieved.