Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey.

BACKGROUND: Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation's lowest scores on key development and health indicators and presents a substantial challenge to Uganda's stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. METHODS: A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. RESULTS: There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. CONCLUSIONS: To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming.

BACKGROUND: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda. METHODS: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified. RESULTS: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery. CONCLUSION: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

Alternative measures of spatial distribution and availability of health facilities for the delivery of emergency obstetric services in island communities.

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.

A qualitative evaluation of the choice of traditional birth attendants for maternity care in 2008 Sierra Leone: implications for universal skilled attendance at delivery.

Maternal and newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities; and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.

The status of maternal and newborn care services in Sierra Leone 8 years after ceasefire.

OBJECTIVE: To conduct a needs assessment for emergency obstetric care (EmOC) to address the unacceptably high maternal and newborn mortality indices in Sierra Leone 8 years after the end of the civil war. METHODS: From June to August 2008, a cross-sectional survey was conducted of health facilities in Sierra Leone offering delivery services. Assessment tools were local adaptations of tools developed by the Averting Maternal Death and Disability program at Columbia University, New York, USA. RESULTS: There were enough comprehensive EmOC (CEmOC) facilities in the country but they were poorly distributed. There were no basic EmOC (BEmOC) facilities. Few facilities (37% of hospitals and 2% of health centers) were able to perform assisted vaginal delivery (AVD), and 3 potentially BEmOC facilities did not meet the standard only because they did not perform AVD. Severe shortages in staff, equipment, and supplies, and unsatisfactory supply of utilities severely hampered the delivery of quality EmOC services. Demand for maternity and newborn services was low, which may have been related to the poor quality and the high/unpredictable out-of-pocket cost of such services. CONCLUSION: Significant increases in the uptake of institutional delivery services, the linkage of remote health workers to the health system, and the recruitment of midwives, in addition to rapid expansion in the training of health workers (including training in midwifery and obstetric surgery skills), are urgently needed to improve the survival of mothers and newborns.