Samuel Mills

The state of emergency obstetric care services in Nairobi informal settlements and environs: Results from a maternity health facility survey

BackgroundMaternal mortality in Sub-Saharan Africa remains a challenge with estimates exceeding 1,000 maternal deaths per 100,000 live births in some countries. Successful prevention of maternal deaths hinges on adequate and quality emergency obstetric care. In addition to skilled personnel, there is need for a supportive environment in terms of essential drugs and supplies, equipment, and a referral system. Many household surveys report a reasonably high proportion of women delivering in health facilities. However, the quality and adequacy of facilities and personnel are often not assessed. The three delay model; 1) delay in making the decision to seek care; 2) delay in reaching an appropriate obstetric facility; and 3) delay in receiving appropriate care once at the facility guided this project. This paper examines aspects of the third delay by assessing quality of emergency obstetric care in terms of staffing, skills equipment and supplies.MethodsWe used data from a survey of 25 maternity health facilities within or near two slums in Nairobi that were mentioned by women in a household survey as places that they delivered. Ethical clearance was obtained from the Kenya Medical Research Institute. Permission was also sought from the Ministry of Health and the Medical Officer of Health. Data collection included interviews with the staff in-charge of maternity wards using structured questionnaires. We collected information on staffing levels, obstetric procedures performed, availability of equipment and supplies, referral system and health management information system.ResultsOut of the 25 health facilities, only two met the criteria for comprehensive emergency obstetric care (both located outside the two slums) while the others provided less than basic emergency obstetric care. Lack of obstetric skills, equipment, and supplies hamper many facilities from providing lifesaving emergency obstetric procedures. Accurate estimation of burden of morbidity and mortality was a challenge due to poor and incomplete medical records.ConclusionThe quality of emergency obstetric care services in Nairobi slums is poor and needs improvement. Specific areas that require attention include supervision, regulation of maternity facilities; and ensuring that basic equipment, supplies, and trained personnel are available in order to handle obstetric complications in both public and private facilities.

Barriers to Formal Emergency Obstetric Care Services’ Utilization

Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder womens access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.

Maternal mortality in the informal settlements of Nairobi city: what do we know?

BackgroundCurrent estimates of maternal mortality ratios in Kenya are at least as high as 560 deaths per 100,000 live births. Given the pervasive poverty and lack of quality health services in slum areas, the maternal mortality situation in this setting can only be expected to be worse. With a functioning health care system, most maternal deaths are avoidable if complications are identified early. A major challenge to effective monitoring of maternal mortality in developing countries is the lack of reliable data since vital registration systems are either non-existent or under-utilized. In this paper, we estimated the burden and identified causes of maternal mortality in two slums of Nairobi City, Kenya.MethodsWe used data from verbal autopsy interviews conducted on nearly all female deaths aged 15–49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). In describing the distribution of maternal deaths by cause, we examined maternal and late maternal deaths according to the ICD-10 classification. Additionally we used data from a survey of health care facilities that serve residents living in the surveillance areas for 2004–2005 to examine causes of maternal death.ResultsThe maternal mortality ratio for the two Nairobi slums, for the period January 2003 to December 2005, was 706 maternal deaths per 100,000 live births. The major causes of maternal death were: abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus. Only 21% of the 29 maternal deaths delivered or aborted with assistance of a health professional. The verbal autopsy tool seems to capture more abortion related deaths compared to health care facility records. Additionally, there were 22 late maternal deaths (maternal deaths between 42 days and one year of pregnancy termination) most of which were due to HIV/AIDS and anemia.ConclusionMaternal mortality ratio is high in the slum population of Nairobi City. The Demographic Surveillance System and verbal autopsy tool may provide the much needed data on maternal mortality and its causes in developing countries. There is urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor. There is also need to strengthen access to HIV services alongside maternal health services since HIV/AIDS is becoming a major indirect cause of maternal deaths.

Using the community-based health planning and services program to promote skilled delivery in rural Ghana: Socio-demographic factors that influence women utilization of skilled attendants at birth in Northern Ghana.

BackgroundThe burden of maternal mortality in sub-Saharan Africa is enormous. In Ghana the maternal mortality ratio was 350 per 100,000 live births in 2010. Skilled birth attendance has been shown to reduce maternal deaths and disabilities, yet in 2010 only 68% of mothers in Ghana gave birth with skilled birth attendants. In 2005, the Ghana Health Service piloted an enhancement of its Community-Based Health Planning and Services (CHPS) program, training Community Health Officers (CHOs) as midwives, to address the gap in skilled attendance in rural Upper East Region (UER). The study determined the extent to which CHO-midwives skilled delivery program achieved its desired outcomes in UER among birthing women.MethodsWe conducted a cross-sectional household survey with women who had ever given birth in the three years prior to the survey. We employed a two stage sampling techniques: In the first stage we proportionally selected enumeration areas, and the second stage involved random selection of households. In each household, where there is more than one woman with a child within the age limit, we interviewed the woman with the youngest child. We collected data on awareness of the program, use of the services and factors that are associated with skilled attendants at birth.ResultsA total of 407 households/women were interviewed. Eighty three percent of respondents knew that CHO-midwives provided delivery services in CHPS zones. Seventy nine percent of the deliveries were with skilled attendants; and over half of these skilled births (42% of total) were by CHO-midwives. Multivariate analyses showed that women of the Nankana ethnic group and those with uneducated husbands were less likely to access skilled attendants at birth in rural settings.ConclusionsThe implementation of the CHO-midwife program in UER appeared to have contributed to expanded skilled delivery care access and utilization for rural women. However, women of the Nankana ethnic group and uneducated men must be targeted with health education to improve women utilizing skilled delivery services in rural communities of the region.

Is there any role for community involvement in the community-based health planning and services skilled delivery program in rural Ghana?

BackgroundIn Ghana, between 1,400 and 3,900 women and girls die annually due to pregnancy related complications and an estimated two-thirds of these deaths occur in late pregnancy through to 48 hours after delivery. The Ghana Health Service piloted a strategy that involved training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). CHO-midwives collaborated with community members to provide skilled delivery services in rural areas. This paper presents findings from a study designed to assess the extent to which community residents and leaders participated in the skilled delivery program and the specific roles they played in its implementation and effectiveness.MethodsWe employed an intrinsic case study design with a qualitative methodology. We conducted 29 in-depth interviews with health professionals and community stakeholders. We used a random sampling technique to select the CHO-midwives in three Community-based Health Planning and Services (CHPS) zones for the interviews and a purposive sampling technique to identify and interview District Directors of Health Services from the three districts, the Regional Coordinator of the CHPS program and community stakeholders.ResultsCommunity members play a significant role in promoting skilled delivery care in CHPS zones in Ghana. We found that community health volunteers and traditional birth attendants (TBAs) helped to provide health education on skilled delivery care, and they also referred or accompanied their clients for skilled attendants at birth. The political authorities, traditional leaders, and community members provide resources to promote the skilled delivery program. Both volunteers and TBAs are given financial and non-financial incentives for referring their clients for skilled delivery. However, inadequate transportation, infrequent supply of drugs, attitude of nurses remains as challenges, hindering women accessing maternity services in rural areas.ConclusionsMutual collaboration and engagement is possible between health professionals and community members for the skilled delivery program. Community leaders, traditional and political leaders, volunteers, and TBAs have all been instrumental to the success of the CHPS program in the UER, each in their unique way. However, there are problems confronting the program and we have provided recommendations to address these challenges.

Can community health officer-midwives effectively integrate skilled birth attendance in the community-based health planning and services program in rural Ghana?

BackgroundThe burden of maternal mortality in sub-Saharan Africa is very high. In Ghana maternal mortality ratio was 380 deaths per 100,000 live births in 2013. Skilled birth attendance has been shown to reduce maternal mortality and morbidity, yet in 2010 only 68 percent of mothers in Ghana gave birth with the assistance of skilled birth attendants. In 2005, the Ghana Health Service piloted a strategy that involved using the integrated Community-based Health Planning and Services (CHPS) program and training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). The study assesses the feasibility of and extent to which the skilled delivery program has been implemented as an integrated component of the existing CHPS, and documents the benefits and challenges of the integrated program.MethodsWe employed an intrinsic case study design with a qualitative methodology. We conducted 41 in-depth interviews with health professionals and community stakeholders. We used a purposive sampling technique to identify and interview our respondents.ResultsThe CHO-midwives provide integrated services that include skilled delivery in CHPS zones. The midwives collaborate with District Assemblies, Non-Governmental Organizations (NGOs) and communities to offer skilled delivery services in rural communities. They refer pregnant women with complications to district hospitals and health centers for care, and there has been observed improvement in the referral system. Stakeholders reported community members’ access to skilled attendants at birth, health education, antenatal attendance and postnatal care in rural communities. The CHO-midwives are provided with financial and non-financial incentives to motivate them for optimal work performance. The primary challenges that remain include inadequate numbers of CHO-midwives, insufficient transportation, and infrastructure weaknesses.ConclusionsOur study demonstrates that CHOs can successfully be trained as midwives and deployed to provide skilled delivery services at the doorsteps of rural households. The integration of the skilled delivery program with the CHPS program appears to be an effective model for improving access to skilled birth attendance in rural communities of the UER of Ghana.

Increased coverage of maternal health services among the poor in western Uganda in an output-based aid voucher scheme

Vouchers stimulate demand for health care services by giving beneficiaries purchasing power. In turn, health facilities’ claims are reimbursed for providing beneficiaries with improved quality of health care. Efficient strategies to generate demand from new, often poor, users and supply in the form of increased access and expanded scope of services would help move Uganda away from inequity and toward universal health care. A reproductive health voucher program was implemented in 20 western and southwest Ugandan districts from April 2008 to March 2012. Using three years of data, this impact evaluation study employed a quasi-experimental design to examine differences in utilization of health services among women in voucher and nonvoucher villages. Two key findings were a 16-percentage-point net increase in private facility deliveries and a decrease in home deliveries among women who had used the voucher, indicating the project likely made contributions to increase private facility births in villages with voucher clients. No statistically significant difference was seen between respondents from voucher and nonvoucher villages in the use of postnatal care services, or in attending four or more antenatal care visits. A net 33-percentage-point decrease in out-of-pocket expenditure at private facilities in villages with voucher clients was found, and a higher percentage of voucher users came from households in the two poorest quintiles. The greater uptake of facility births by respondents in voucher villages compared with controls indicates that the approach has the potential to accelerate service uptake. A scaled program could help to move the country toward universal coverage of maternal health care.