Sierra Leone

Delivery of Maternal and Newborn
Care Services in Africa:
What are the facilities telling us?
Koye Oyerinde MD, MPH, FAAP
Symposium on Maternal Mortality, Dakar
The Averting Maternal Death and
Disability Program - AMDD
• Mailman School of Public Health, Columbia University,
New York City.
• Help to strengthen heath systems to provide emergency
care for all women experiencing life-threatening obstetric
complications.
• Conduct research and policy analysis, provide technical
expertise, and advocate for solutions
• Collaborate with global, regional, and local institutions –
including NGOs & academic centers
The Alliance
• Memorandum of Understanding signed June 2008
between UNICEF, UNFPA, AMDD
• Alliance supports country plans for the strengthening of
EmONC service delivery as a strategy for attaining
MDGs 4 and 5.
• WHO collaborates on alliance activities at country and
regional level.
Needs Assessment Overview
• The EmONC Needs Assessments are facility based crosssectional studies of the capacity of a health system to
provide health services to mothers and newborns
• Main focus – health system.
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Accessibility/Coverage/Equity
24 hour services
Human Resources
Equipment and Supplies
Infrastructure
Aspects of quality of care
EmONC Needs Assessments
Completed – pre-2005 and/or sub-national
Completed – post-2005 and national
Ongoing
Planned
Current as of December 2010
The Needs Assessment Process
The AMDD team:
Phase III: From
Data to Action
• Conducting the Needs Assessment
• provides customized
technical support and
training through these phases
Phase II:
Conducting the
• works remotely and inNeeds Assessment
country to support the MOH
to conduct the assessments.
Phase I:
Advocacy and
Planning
Some trends from the recent
EmONC Needs Assessments in
Africa
Low no. of facilities offering EmONC
signal functions
The recommended number of EmONC facilities is 5 per
500,000, at least one of which is Comprehensive (CEmONC).
EmONC coverage
30%
24%
25%
20%
15%
11%
11%
Ethiopia
Madagascar
10%
5%
0%
Sierra Leone
Coverage is defined as available EmONC facilities as a percentage of
recommended EmONC facilities. There may be further disparities between
urban and rural areas.
Low no. of EmONC facilities
 Better CEmOC coverage than BEmOC coverage

But CEmOC requires BEmOC to function properly
BEmOC – 4 per 500,000
Actual
Recomm. Coverage
CEmOC – 1 per 500,000
Actual
Recomm. Coverage
Ethiopia
25
591
4%
58
148
39%
Madagascar
3
155
2%
19
39
49%
Sierra Leone
0
48
0%
14
12
120%
Low utilization
• Institutional delivery rate:
• Variety within and among countries:
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Ethiopia 7%,
Madagascar 19%
Sierra Leone 10%
Higher rates in urban areas
Met need in EmOC facilities
100%
80%
60%
• Met need:
% of expected complications
that are treated in EmOC
facilities. Target: 100%
40%
20%
3%
10%
7%
Madagascar
Sierra Leone
0%
Ethiopia
Missing signal functions
• MVA and AVD are most commonly missing SFs,
especially at the health center level.
Sierra Leone, 2008: Proportion of hospitals and CHCs by signal
functions performed in last 3 months
Low HR availability
• Sierra Leone: TBAs and MCH aides conduct most deliveries, especially in health
centers. SL has started new midwifery education programs since the NA
• Madagascar: has 99 obstetricians, needs 72 more to reach norms.
• Ethiopia: only 35% of the midwives targeted in HSDP III 2010 had been trained,
26% of medical doctors, and 16% of the health officers.
Ethiopia: % of HCs staffed with at least 2 midwives and 1 health officer, by region
Inadequate commodities and supplies
Percentages of facilities with:
Misoprostol
Mag Sulph
Contraceptives
7% use for
obstetric
indications
3% use as
parenteral
anticonvulsant
90% have at least
3 methods
Madagascar
11% (but 0% use
for MVA)
0.68% use as
parenteral
anticonvulsant
95% have oral
contraceptives
Sierra Leone
21%
64%
No info
Ethiopia
Stock outs
Ethiopia: causes of delay of supplies in hospitals
‘stock out at
central store’ (41%)
‘financial problems’
(26%)
‘administrative
difficulties’ (15%)
Madagascar: 73% of hospitals and 65% of health centers had not
had a stock out of oxytocin, ergometrine, or atropine in the 12
months before the study.
Limited data collection
• HMIS indicators
▫ Often important indicators are not collected
▫ When collected the data are unused for planning
▫ HMIS data often considered unreliable
 A common outcome of the Needs Assessment is
HMIS revision.
• Data collection at front-lines
▫ Facility registers often unclear and incomplete
▫ 51% of health centers in Ethiopia had drug and
inventory registers
Fee for Service
• Fees are often considered a barrier, especially for the
poorest.
• “Some women when told to go to the hospital would not because they
do not have money; so they have problems during delivery” - Sierra
Leone Needs Assessment, qualitative data:
• Sierra Leone made health services for pregnant and lactating
mothers and children under 5 free in spring 2010
▫ Initial reports suggest a phenomenal increase in
utilization; thus raising concerns for potential fall in
quality of care
Socio-cultural barriers
• NA results are made more meaningful when
combined with social science research
• Socio-cultural barriers – including abusive /
disrespectful care - have been shown to delay
utilization and limit benefits derived from the
health system
An anthropologic question
Selected Average Sub-Saharan Health Indicators
80%
70%
46%
Antenatal Coverage
Skilled Birth
Attendance
BCG Vaccination
Coverage
Conclusion
• Needs Assessments have potential to surface
gaps and indicate ways forward
• A systems science/health systems perspective is
critical – we need strong health systems to
support women during labor.
Conclusion
• Health facilities in Africa are saying:
▫ Not enough, not the right type and not in the right
place
▫ Not adequately staffed, not with the right skills
▫ Not adequately stocked, not with the right tools,
drugs, and supplies
Many thanks!
Merci beaucoup!
Further resources available from the
AMDD website: www.amddprogram .org