Author: Alwar, J.; Mtonga, V.; Sikatoye, B.
In 1997, the UNICEF Zambia Country Program set up the Essential Obstetric Care Project, with financial assistance from Irish Aid, to demonstrate an approach to reduce maternal morbidity and mortality in rural areas. Three rural districts, Lufwanyama, Mpongwe and Masaiti were selected as the first phase project areas. The criteria used to identify the pilot districts included: high maternal mortality rate; large catchment population; willingness and capacity of District and Provincial staff to intervene on MMR reduction; and other confounding factors, including the spatial distribution of the population, transport and access problems. The overall goal of the project was to contribute to a reduction of maternal mortality through improving access to, and quality of, essential obstetric care at first referral facilities.
Purpose / Objective
To examine the extent to which project activities have met planned goals, purposes and outputs as agreed in the project documents. To make recommendations for future implementation, scaling up and integration into routine health services.
A three-tier approach was used to gather data. First, a survey and review of secondary literature was carried out to document any independent assessment of achievement in the Strengthening of Essential Obstetric Care (EOC) Project in the three districts. This was followed by collection, summary and analysis of quantitative data from records, reports and any minutes of consultative meetings to derive process- and impact-related indicators already identified in the proposal document and project plans. Last, primary data was collected from health facilities in the four identified districts and communities served by a sample of local health facilities, and focused on the quality of implementation of project activities and the levels. The project sites were visited to carry out the following:
- Key informant interviews with personnel at UNICEF, Irish AID, Ministry of Health (MoH), Central Board of Health (CBoH), the three District Health Management Team (DHMT), MCH, ANC and labor ward clinical staff and selected members of health facility neighborhood committees.
- Observations and interviews were carried out at ANC clinics, labor wards, pharmacies, laboratories, stores and HMIS records offices.
- Focus Group Discussions were carried out in the selected communities around the sampled health facilities, and targeted women of fertility age group, men and adolescents.
- Further interviews were held with other stakeholders involved in either Safe Motherhood or Family Planning programs, where necessary.
Key Findings and Conclusions
Although Ante Natal Clinic (ANC) attendance is high, there are fewer deliveries, low postnatal attendance in Essential Obstetric Care (EOC) health facilities and a high number of deliveries supervised by untrained staff. These are attributed to traditional beliefs and taboos, preference for trained and untrained Traditional Birth Attendants (TBA), late ANC booking and long distances to health facilities. Subsequent to the initial EOC training of 60 (17%) staff, the trained staff continue orienting other health workers (298) on the EOC concept, use of Safe Motherhood formats and EOC protocols.
The incidence of multiple pregnancies is unusually high. Indeed, it is one of the ways that communities judge good TBA. Other complications that are primarily medical diseases in pregnancy, such as cardiac disease, occur rarely but appear to have high case fatality rates.
Of the planned supervisory visits, the districts conducted at least one out of four. Also, one joint CBOH and district supervisory visit was conducted in the implementation period. One of the results of the supervisory visits was the recommendation to the neighborhood committees to form Safe Motherhood Subcommittees in order to strengthen community mobilization for EOC. Meetings were held with health center and referral hospital staff to monitor the performance of health centers. These meetings were facilitated by UNICEF and attended by the CBOH. They helped to expedite implementations and to standardize the procedures.
Overall, significant achievements have been made in this project, considering that this is the third year of implementation and that, in fact, actual activity initiation was delayed by the on-going reform within the health sector. The first major achievement of this project was the successful facilitation of the situation analysis of the state of obstetric care by supporting a Safe Motherhood Needs Assessment and providing supplementary funds for the expedient completion of the study on "Factors Associated with Maternal Mortality in Zambia." These studies reinforced the formative process in this project, which is still the stage at which this project can logically be placed.
From the second study, it is clear that the post natal period in home deliveries contributes to the highest proportion (61%) of maternal deaths. Maternal deaths most commonly occur in young mothers, with the peak age of death at 25 to 29 years. The largest proportion of death occurs on the same day (35%), within 72 hours (62%) or within one week (88%) of delivery. The findings suggest that the causes are, therefore, mostly problems that can be averted by better management of labor. Looking at the nature of complications, again home deliveries are the biggest contributors, with the problems of obstructed labor, excess bleeding and infections (42.1%), all of which can be prevented.
These findings indicate that, with good strategy, the global goal of reduction of maternal mortality by 50% can be met within the next three years. Some of the required strategy, such as improvement of antiseptic techniques during delivery, better management of labor to avoid prolonged labor and subsequent PPH, and treatment for malaria and anemia have been suggested and will be soon implemented. In addition to the problems of home delivery, the research revealed that causes of delay in referral have been identified at the home and health center level. The main two are distance from the health facility and the lack of means of transport or the cost of it, which many rural mothers are unable to afford.
As already demonstrated, there was gradual strengthened capacity of the districts to provide EOC services. As shown especially by data from Lufwanyama, the original impression that the rate of attendance of ANC is very high is a misconception, due to the fact that health data from urban populations tend to overshadow those from rural areas, which perhaps never reach the data banks. The project has, however, demonstrated that with active community mobilization and demonstration of improvement of care of clients, use of modern health care will be popularized. Moreover, this is at a critical point because popularization of EOC may be used as an entry point to communities for the acceleration and sustenance of uptake of preventive child health and other reproductive health interventions.
Some unexpected positive outcomes were also observed; for example, community involvement through formation of Safe Motherhood Committees (SMC). The SMC worked with the DHMT to sensitize communities to utilize EOC. They were also beginning to adapt innovative ways of overcoming the major obstruction to EOC, such as lack of money for transport to EOC and child spacing, specifically to improve maternal and child health rather than reduction of family size.
Most health centers lacked delivery rooms or concealed units where mothers could be examined, delivered or counseled in confidence. Lack of infrastructure for delivery rooms and storage of equipment and drugs. Lack of radio communication equipment. Lack of effective referral system.
Poor communication strategy for Safe Motherhood perpetuated the lack of awareness on the importance of early antenatal care, professional delivery care for all births and the importance of postnatal clinics leads to low utilization of ANC care in the first trimester, delivery services and PN clinics in HCs. Strong cultural beliefs affecting decisions on early ANC and institutional deliveries.
It is necessary to ensure that the radio communication equipment currently available in some health centers function at all times. Since the operations of the Flying Doctors Services of Zambia had been scaled down, all units that were served by the organization should be supplied with motor vehicle ambulances to enable the transfer of emergencies that still prefer to go to these centers.
Postnatal and child health clinics should be integrated to enhance efficiency.
EOC equipment supplied should be reassessed for relevance of the technology required and the type of energy they need to operate, in order to rationalize their distribution to the right places or replacement with more appropriate ones.
Relationship with local communities should be strengthened to enhance utilization of EOC especially with the current limitation caused by the predominance of male nurses in the peripheral health facilities.
Documentation of EOC data should be improved between the community and health center levels. A system should be developed for recording cases from communities that go directly to referral hospitals when complications arise, in order to ensure that the data is not lost to their home health centers and districts, particularly when mortality arise.
Back referrals from hospitals to health centers should be strengthened, especially in cases where the clients did not pass through health centers. This will improve case management by providing feedback education to the health center staff and TBA.
Infrastructure for deliveries and storage of drugs i.e. Oxytocics at health center level should be improved by making use of opportunities provided by micro projects.
Activities of TBA should be strengthened and they should be given recognition by staff in the referral hospitals, who often keep them waiting when they take their clients with obstetric complications, thereby delaying intervention as well as demoralizing the TBA and the patients.
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Health - Pre/Post Natal Care