Emergency Obstetric Care Signal Functions Research Articles

Availability, utilization and quality of emergency obstetric care services in Sousse, Tunisia.

Introductionemergency obstetric care (EmOC) is a high-impact priority intervention strongly recommended for improving maternal health outcomes. The objectives of this study were to assess the availability, utilization, and quality of emergency obstetric care services in the Governorate of Sousse (Tunisia).Methodsa cross-sectional study was conducted among public health facilities which performed deliveries in Sousse in 2017. Data were collected by consulting clinical records and registers and interviewing staff using WHO EmOC tools. Emergency obstetric care (EmOC) indicators were calculated.Resultsonly the University maternity Unit functioned as full comprehensive EmOC facility. No other public facility provided all the 7 Basic EmOC signal functions 3 months prior to the survey. The unperformed signal functions were: administration of parenteral antibiotics, manual removal of placenta and assisted vaginal delivery. The number of EmOC facilities was 0.72 per 500,000 inhabitants. The met need for EmOC was 89.5%. The proportion of caesarean section was 24.2%. The direct obstetric case fatality rate was 0.159% and intrapartum and very early neonatal death rate was 0.65%.Conclusionraising maternity facilities to a minimum level of basic EmOC status would be a major contributing step towards maternal mortality reduction.

Newborn signal functions in Bangladesh: identification through expert consultation and assessment of readiness among public health facilities—study protocol using Delphi technique

IntroductionThere is a set of globally accepted and nationally adapted signal functions for categorising health facilities for maternal services. Newborn resuscitation is the only newborn intervention which is included in...

Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study

Background: In India, emergency obstetric care (EmOC) services were started under RCH-II program (2004) with the goal to reduce maternal mortality ratio <100/lakh live births and increase institutional deliveries to at least 80% by 2010. Implemented strategy was to enhance availability and accesses to EmOC services. Objective: This study was conducted in one of the blocks of Wardha district in Maharashtra to understand the accessibility for providing EmOC services at primary health center and rural hospital in the last 1 year. Materials and Methods: This cross-sectional qualitative study was conducted from May 2018 to October 2018. Data were collected by key informant interviews of service providers. Notes were transcribed and then translated into English. Respondents' verbatim that is significant and illustrative as per the theme of the study was used for analysis. Results: Equipment and drugs essential for EmOC were available; however, most of these were underutilized due to lack of skill in selected facilities. Basic EmOC training pattern was found inadequate in duration and practical skill. Training and recruitment of staff constantly were observed challenging for higher stakeholders. Of all EmOC signal functions, only parental antibiotics, oxytocics, and assisted vaginal delivery (episiotomy) were provided. Conclusion: Although building infrastructure, drugs, equipment, and transportation facilities were accessible, needy women may fail to receive timely and quality EmOC, due to lack of trained staff, low confidence, and lack of motivation in managing obstetric emergencies.

The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey

The purpose of this health system's study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung District of eastern Nepal. A cross-sectional survey was conducted in 2018 in all 16 public health facilities providing delivery services in the district. Data collection comprised: (1) quantitative data collected from health workers; (2) observation of key items; and (3) record data extracted from the health facility register. Descriptive statistics were used to calculate readiness scores using unweighted averages. Although key health personnel were available, EmOC services at the health facilities assessed were below the minimum coverage level recommended by the World Health Organisation. Only the district hospital provided the nine signal functions of Comprehensive EmOC. The other fifteen had only partially functioning Basic EmOC facilities, as they did not provide all of the seven signal functions. The essential equipment for performing certain EmOC functions was either missing or not functional in these health facilities. The Ministry of Health and Population and the federal government need to ensure that the full range of signal functions are available for safe deliveries in partially functioning EmOC health facilities by addressing the issues related to training, equipment, medicine, commodities and policy.

Practice of emergency obstetric care signal functions and reasons for non-provision among health centers and hospitals in Lake and Western zones of Tanzania

BackgroundThe Lake and Western Zones of Tanzania that encompass eight regions namely; Kagera, Geita, Simiyu, Shinyanga, Mwanza, Mara Tabora and Kigoma have consistently been reported with the poorest Maternal Newborn and Child Health (MNCH) indicators in the country. This study sought to establish the provision of Emergency Obstetric Care (EmOC) signal functions and reasons for the failure to do so among health centers and hospitals in the two zones.MethodsAll the 261 public and private hospitals and health centers providing Obstetric Care services in Lake and Western Zones were surveyed in 2014. Data were collected using questionnaires adapted from the Averting Maternal Deaths and Disabilities (AMDD) tool to assess EmOC indicators. Managers in all facilities were interviewed and services, medicines and equipment were observed. Spatial Mapping was done using a calibrated Global Positioning System (GPS) Essential Software for Android and coordinates represented on digitalized map with Arc Geographical Information System (GIS) software. Population data were according to the 2012 Housing and Population National Census.ResultsIn total 261 health facilities were identified as providers of Obstetric care services, including 69 hospitals and 192 health centres which constitute an overall facility density of 8 per 500,000 population. The three most common EmOC signal functions available in the 3 months preceding the survey were oxytocics (95.7%), injectable antibiotics (88.9%) and basic newborn resuscitation (83.4%). The lowest proportions of facilities performed Cesarean section (25.7%) and blood transfusion (34.6%). Policy restrictions were the most frequent reasons given in relation to nonperformance of blood transfusion and Cesarean section when needed. Lack of training and supplies were the most common reasons for non availability of assisted vaginal delivery and uterine evacuation. Overall the Direct Case fatality Rate for direct obstetric causes was 3%. The referral system highly depended on hired or shared ambulance.ConclusionThe provision of EmOC signal functions in Lake and Western zones of Tanzania is inconsistent, being mainly compromised by policy restrictions, lack of supplies and professional development, and by operating under lowly developed referral services.

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district.

BackgroundImproving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio.MethodsData collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared.ResultsAll 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001).ConclusionsThe analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.

Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth: A cross-sectional study from Madhya Pradesh, India.

Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37–0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03–0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual’s characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.

The dominance of the private sector in the provision of emergency obstetric care: studies from Gujarat, India.

BackgroundIndia has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).MethodsA cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.ResultsEmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.ConclusionsThe private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector.

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'.

BackgroundA variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the ‘EmOC signal functions’, a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example.MethodsWe first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi.ResultsOur strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants’ adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks.ConclusionThe identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.

Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi.

BackgroundShortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi’s efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers’ perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi’s women.MethodsA qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants’ experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.ResultsEighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.ConclusionThis study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

Skilled birth attendants in Tanzania: a descriptive study of cadres and emergency obstetric care signal functions performed.

Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all the level of care. In the district, gaps existed between performance of EmOC signal functions by SBAs as expected by the MOHSW and the actual performance at health facilities. All basic EmOC facilities were not fully functional. Few health care providers performed all the basic EmOC signal functions. Competency-based in-service training of providers in EmOC and provision of enabling environment could improve performance of EmOC signal functions in the district.

Availability and distribution of, and geographic access to emergency obstetric care in Zambia

Objective To assess the availability and coverage of emergency obstetric care (EmOC) services in Zambia. Methods Reported provision of EmOC signal functions in the Zambian Health Facility Census and additional criteria on staffing, opening hours, and referral capacity were used to classify all Zambian health facilities as providing comprehensive EmOC, basic EmOC, or more limited care. Geographic accessibility of EmOC services was estimated by linking health facility data with data from the Zambian population census. Results Few Zambian health facilities provided all basic EmOC signal functions and had qualified health professionals available on a 24-hour basis. Of the 1131 Zambian delivery facilities, 135 (12%) were classified as providing EmOC. Zambia nearly met the UN EmOC density benchmarks nationally, but EmOC facilities and health professionals were unevenly distributed between provinces. Geographic access to EmOC services in rural areas was low; in most provinces, less than 25% of the population lived within 15 km of an EmOC facility. Conclusion A national Health Facility Census with geographic information is a valuable tool for assessing service availability and coverage at national and subnational levels. Simultaneously assessing health worker density and geographic access adds crucial information.

Declining maternal mortality ratio in Uganda: Priority interventions to achieve the Millennium Development Goal

Purpose We conducted a survey to determine availability of emergency obstetric care (EmOC) and to provide data for advocating for improved maternal and newborn health in Uganda. Methods The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions, documented maternal deaths and the related causes. Three levels of health facilities were covered. Findings Few health units had running water; electricity or a functional operating theater. Yet having these items had a protective effect on maternal deaths as follows: theater (OR 0.56, P < 0.0001); electricity (OR 0.39, P < 0.0001); laboratory (OR 0.71, P < 0.0001) and staffing levels (midwives) OR 0.20, P < 0.0001. The availability of midwives had the highest protective effect on maternal deaths, reducing the case fatality rate by 80%. Further, most (97.2%) health facilities expected to offer basic EmOC, were not doing so. This is the likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda. Conclusion Addressing health system issues, especially human resources, and increasingaccess to EmOC could reduce maternal mortality in Uganda and enable the country to achieve the Millennium Development Goal (MDG).

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda

Purpose We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. Methods The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. Findings A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P < 0.002), assisted vaginal delivery (OR 3.3, P < 0.001) and blood transfusion (OR 13.7, P < 0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. Conclusion An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.