Emergency Obstetric and Newborn Care Assessments in Africa: Focus on Post Partum Hemorrhage & Pre- Eclampsia/Eclampsia Koye Oyerinde MD, MPH, FAAP Africa Regional Meeting on Maternal and Newborn Health Interventions 2011 OI/MCHIP Meeting Addis Ababa, Ethiopia February 21-25, 2011.
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Emergency Obstetric and Newborn Care Assessments in Africa: Focus on Post Partum Hemorrhage & Pre-Eclampsia/Eclampsia
Koye Oyerinde MD, MPH, FAAP
Africa Regional Meeting on Maternal and Newborn Health Interventions 2011
• The ultimate goal of the health system is to treat all maternal and newborn childbirth complications
• Irrespective of where the treatment occurs
• Due to limitations to delivery of definitive care for most women with PPH & PE/E at home, many will require institutional care
Poor access to care at home and in facilities
• With poor utilization of facilities and poor access to facilities during emergencies only few complications are treated
• Met need: % of expected
complications that are treated in any facility or in EmOC facilities
• Target: 100%
Availability of EmONC facilities• Inadequate no. of facilities
offering EmOC signal functions
• Availability is defined as number of fully functioning EmONC facilities as a percentage of recommended EmONC facilities.
▫ Recommended = 5 EmONC facilities per 500,000, at least one of which is comprehensive
1st level of care vs Referral centers
•1st level of care▫Inadequate
equipment & supplies 10% of health
centers in Madagascar had magnesium sulfate
▫Poor supply of SBA
Inadequate supply of SBA• 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 were in employment, 26% of medical doctors, and 16% of the health officers.
Severe weaknesses at 1st level of care
• Poor infrastructure
• Unlinked to “better resourced” secondary & tertiary level
• Poor supplies and equipment management
Secondary / tertiary levels of care• Better infrastructure
• Better supply of SBA
• Abusive/ disrespectful care
• Long waiting times
• High out-of–pocket expenditure
Secondary / tertiary levels of care
• Poor laboratories
• Poor supply of blood & blood products
• Unreliable logistics and supply chain management
Unreliable supply chain management
Inadequate quality of care in secondary / tertiary levels of care
• Poor quality of care
• Lack of attention to quality improvement
• Poor supportive supervision of 1st level care facilities
Focus on a functioning health system
• Inadequate communications infrastructure▫ Remote facility staff are unsupported,
unsupervised & unmentored
• Non-existent referral systems▫ Unnecessary delays with transport ▫ Long waiting and fresh evaluations
• HMIS systems poorly managed▫ Limiting surveillance of the quality of
care at all levels
3rd level of
care
2nd Level of care
1st Level of care
Community
Focus on a functioning health system • Prevention and management of PPH & PE/E
requires a functioning health system that is connected to homes and communities▫The notion of a primary health care system
implies the presence of a functioning link between tiers of the system, and the community
• Several components of the health system depend on inputs that are beyond the purview of the ministry of health e.g. telecoms, transportation, and roads
Policy environment
• Policies must support the development of an enabling environment for the delivery of services to mothers and newborns▫Sierra Leone (2008) - Misoprostol was not on the
Essential Drug List
▫Ethiopia (2008) - Ergometrine, oxytocin, diazepam and magnesium sulfate were not included in the Essential Health Commodity Package
▫In most countries in Africa, midwives are not authorized to perform all basic signal functions
In short …Outcomes for PPH & PE/E, and MMR will not improve significantly if the following persist:
Chronic severe shortages of SBA all over Africa
Inadequate infrastructure
Lack of linkages between tiers of the health system
Poorly organized, nonexistent or ad hoc referral systems
Disabling policy environments
Positive field notes …Recent developments and opportunities for serious interventions to address PPH & PE/E:
• Increasing global focus and funding for MNH▫ Including the UN Sec. General’s Global Strategy on
Maternal and Child Health
• Maternal, Infant and Child Health and development in Africa was the theme of the AUSummit, Kampala July 2010
• Recent colloquium of African Social and Public Health Scientists (Dakar, December 2010) focused on maternal mortality
Positive field notes …• 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
• Madagascar has begun BEmONC training for midwives▫ With emphasis on supportive supervision
• Ethiopia has instituted a new HMIS that captures major obstetric complications and performance of signal functions▫ Health extension workers supported to provide care in
communities
Positive field notes …• Many countries are beginning to authorize midwives
and nurses to perform all basic signal functions▫ The MSS in Nigeria deployed over 2000 midwives to rural
areas to extend access to SBAs ▫ Some countries are considering different varieties of task-
shifting and task-sharing▫ Others are training non-physician clinicians e.g. MSc
program in Ethiopia
• Mobile phone networks are available in most of Africa▫ Several initiatives are ongoing to explore the use of mobile
telephony for remote patient care, supportive supervision and HMIS data capture.
Conclusion• PPH and PE/E associated mortality will be
greatly reduced if more attention is paid to improving health systems in general▫Removal of barriers to utilization of services and
extension of the reach of SBA in communities and in facilities
▫Revamping of the supply and logistics chain
▫Investments in infrastructure – roads, telecommunications, information technology etc.
Many thanks!Merci beaucoup!
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