Author: Chisembele, M. C.
The Safe Motherhood Needs Assessment (SMNA) was part of a global initiative whereby countries would assess their capacity to provide maternal care, with the aim of fulfilling the 1990 global objective of reducing maternal mortality by 50% by the year 2000. Following the SMNA of 1996, UNICEF (Zambia), in 1997, set up the Essential Obstetric Care (EOC) Project to demonstrate an approach to reduce maternal morbidity and mortality in rural areas by improving access to, and quality of, essential obstetric care at first referral facilities. The EOC project was planned as a continuation and improvement to the Safe Motherhood Project.
Purpose / Objective
The objectives of the EOC Needs Assessment were:
- To obtain up-to-date information on maternal health services, in particular, the availability, use and quality of care
- To identify any gaps in maternal health services on the basis of a minimum framework set forth in the draft document on Safe Motherhood Policies, Strategies and Guidelines
- To obtain information, including operational recommendations, to assist in the development of concrete action plans for maternal health services, in particular EOC in Chadiza, Katete and Lundazi districts
- To obtain baseline information for monitoring the implementation of EOC activities in Chadiza, Katete and Lundazi districts
The EOC Needs Assessment was carried out using WHO guidelines adapted to local conditions. Scheduled interviews of clients, TBAs, health workers and DHMTs were conducted. In addition, review of medical records, observations of activities at health facilities, assessment of health facilities, and focus group discussions involving the community were also carried out. In total, 15 health centres and 2 district hospitals were selected for comprehensive survey, although the 49 health centres providing maternal care in the three districts were surveyed using the health facility management form.
Key Findings and Conclusions
Up-to-date information on maternal services; the availability, use and quality of care:
The basic infrastructure for the provision of maternal services was found to be present. Most of the health centres had a room specifically for deliveries (82.6%). However, there were gaps noted in the provision of quality delivery services. Whilst most centres had delivery sets, only a few had complete sets (19.6%) and while partograms were readily available (60.9% of health centres), very few centres used them, with the majority of health workers expressing lack of knowledge with regard to usage of partograms (surveyor observations).
Relatives (84.0%) conducted most of the deliveries at home. The main barriers to delivery at health centres were found to be the long distance from the health facility, payment for care and presence of male health worker at the health facility (focus group discussion and surveyor observations).
With regard to quality of care as assessed by state of infrastructure, presence of EOC elements at health facilities, and knowledge and skills of health workers, this was found to be poor. However, most clients who attended antenatal care and delivered at a health facility expressed satisfaction with the care received but preferred to be delivered by a female health worker (focus group discussion and surveyor observations).
Gaps in maternal health services on the basis of minimum framework based on the Draft Document on Safe Motherhood Policies, Strategies and Guidelines:
Gaps were identified at all levels of the draft policy document, though it was recognized that the policy is still in draft form and the implementation of strategy and guidelines should follow the policy.
Some of the gaps noted were as follows:
- Safe motherhood services were not integrated at all health facilities (67.5% integration). There were specific days for antenatal care and postnatal care.
- Safe motherhood services were not accessible, both in terms of distance and acceptability of care, and not always considered affordable by clients.
- Not all facilities had adequate staff and, in most cases, many were not trained in safe motherhood skills (only 25.0%). There was no efficient referral system in place. Most clients had to find their way to the next level of care when referred, especially where there was no radio communication.
- Males are still not involved in safe motherhood activities, except for the male health workers.
- Though the DHMTs said they carry out quarterly visits (every three months), the health workers felt that more needs to be done in terms of support to them, and very few had had in-service training or updates since being deployed to their centres.
Preparedness of Traditional Birth Assistants (TBA), health centres and hospitals to deal with obstetric complications or emergencies:
Very few of the TBAs sampled were happy with the services they were providing, though they had been trained. 86.0% were not satisfied. They wanted to be paid for their services and also to be provided with a source of light (a lamp) for night deliveries as well as a bicycle for transportation. Only 30.0% of the TBAs had had a refresher course since their six weeks basic training.
The two hospitals in the survey also had a shortfall of key resource personnel. St. Francis Mission hospital in Katete had 47.7% of the establishment for midwives while Lundazi hospital had only 12 midwives. The required establishment was not known. There was one obstetrician/gynaecologist at St. Francis but Lundazi had no establishment for one.
Emergency obstetric care is offered 24 hours a day, including weekends, at both hospitals, with most medical and surgical supplies being available most of the time. However, the case fatality rates for postpartum haemorrhage and ruptured uterus were too high at Lundazi hospital, indicating that comprehensive care was not completely available.
Views of clients concerning the service provided them:
Most of the clients who delivered at a health centre or hospital expressed satisfaction with the delivery and said that the attitude of the health worker was good (94.8%). The same was observed for women attending antenatal care. 84.6% were happy with the attitude of the attending staff. However, a good number of clients would have preferred to be delivered by a female health worker and this was a contributing factor to the reduced number of deliveries at health centres.
The availability of resources for health services impacting on Safe Motherhood:
Resources are grossly inadequate, starting with the human resource. There were hardly any midwives at the health centres. Midwives comprised 20.6% (both registered and enrolled) of the total number of health workers. Katete had the highest number of midwives at 54.8% of the few midwives in the three districts. The majority of health workers were enrolled nurses (40.6%).
Communication and transport were far from adequate at the health centres. Only 26% of health centres surveyed had radios. Ambulances were stationed at specific health facilities; however, accessibility to them was not always easy by all health centres. The road infrastructure is impassable in the rainy season and poses a great challenge to road users even in the dry season. Clients still have to cover great distances to reach a referral health facility.
Drugs and medical surgical supplies were available in most centres. The drug kits were regularly supplied every month and, in some cases, there was an oversupply of drugs. However, there was a lack of basic delivery equipment such as complete delivery sets, cord clamps and plastic sheet for the delivery bed.
Management structures and their functions, including the availability of guidelines or protocols:
A good number of health centres (33%) are run by one qualified health worker in most cases, supported by one or two casual workers and trained TBAs. Consequently, most safe motherhood activities are carried out by TBAs or female casual workers and, as a result, the quality of record keeping is affected (surveyor observations).
Although IEC materials pertaining to family planning and HIV/AIDS/STIs were present at most health centres, very few health centres had guidelines or protocols on essential obstetric care or on safe motherhood.
Training of health workers in EOC/Safe Motherhood in the three districts: in particular, obstetric emergencies (signs and symptoms, first aid management), life saving skills, management of normal labour and use of the partograph. Basic skills in newborn resuscitation and infection prevention should be part of the training.
Transport and Communication: Both the community, in conjunction with the respective DHMTs, will need to sit together and work out how they will address this concern. It may require the writing of project proposals for funding but the element of cost sharing will have to be addressed. The road infrastructure will also need to be looked at and may need the cooperation of key ministries, such as the roads department, and other stakeholders such as the Feeder Roads Project.
The DHMTs will need to develop project proposals for the funding of basic delivery equipment for each health centre. Alternatively, this can be included in the Action Plan budget. In addition, a sustainable method of maintaining infection prevention supplies, such as jik, will have to be worked out. Laboratory supplies should be sourced as a matter of urgency by the DHMTs.
IEC materials highlighting guidelines and protocols on EOC, in the form of flow charts, will have to be developed for the health centres with the help of cooperating partners such as UNICEF. IEC materials on infection prevention are also recommended.
TBAs and neighbourhood committees will have to be used more effectively than has been happening so far. TBAs can be used to encourage the women they deliver to come to the clinics for postnatal care and also they can be used to collect audits of births/deaths in the community, which is currently lacking in the HMIS records at the health facilities. The collection of the audits will have to be closely supervised by the health centre staff. Supervisory visits by the DHMT should ensure that this information is collected. TBAs can also be encouraged to distribute family planning methods and haematinics in the community. Re-training of TBAs in safe motherhood to include life saving skills is recommended.
Incentives to encourage health centre delivery and postnatal care attendance should be worked out by the DHMTs, together with the neighbourhood committees.
Male involvement in care will have to be actively pursued by the districts with the help of the neighborhood committees. Men should be encouraged to attend antenatal care or deliveries. They should be part of the birth planning process.
PDF files require Acrobat Reader.
Health - Pre/Post Natal Care