International Journal of Gynecology and Obstetrics 128 (2015) 251–255
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria Dele Abegunde a, Ibrahim A. Kabo b,⁎, William Sambisa c, Toyin Akomolafe c, Nosa Orobaton c, Masduk Abdulkarim c, Habib Sadauki b a b c
Health and Economics Consultants, Ilorin, Nigeria Jhpiego Targeted States High Impact Project, Bauchi, Nigeria John Snow Incorporated Research and Training Institute Targeted States High Impact Project, Bauchi, Nigeria
a r t i c l e
i n f o
Article history: Received 19 March 2014 Received in revised form 16 September 2014 Accepted 24 November 2014 Keywords: Availability Emergency obstetric services Maternal mortality Nigeria Northern Nigeria Quality Utilization
a b s t r a c t Objective: To report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. Methods: Between June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. Results: Only 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n = 380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. Conclusion: Availability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system’s capacity to manage emergency obstetric complications needs to be strengthened. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Overcoming the high burden of maternal and reproductive health problems remains a challenge in Sub-Saharan Africa, particularly in Nigeria. This country has a population of 160 million and an estimated maternal mortality ratio (MMR) of 545 deaths per 100 000 live births [1]. Nigeria constitutes 2.0% of the global population, but accounts for 10% of the world’s maternal and childhood mortality burden [2]. Nigeria—along with Somalia, Mali, the Democratic Republic of the Congo, and Niger—is ranked among the 10 “worst places in the world to be a mother” [3], even though high priority has been given to maternal and child health at a national level for decades. Despite Nigeria’s substantial investment in primary health care and the country’s commitment to the global maternal and child health agenda [4], the health system seems to be inadequate for provision of lifesaving emergency maternal and child health services [2]. Use of health services has also been too low to have any meaningful impact on the ⁎ Corresponding author at: No. 3 Emir Sulaiman Adamu Street, Off Airport Road, GRA, Bauchi, Nigeria. Tel.: +234 9065667373. E-mail address: [email protected] (I.A. Kabo).
high levels of maternal and child mortality and mobility. Approximately 35% of all births occur in health facilities and one in five births is unassisted [1]. Access to quality maternal and child healthcare services is worse in the underserved rural areas where 70% of the country’s population live [2]. Maternal health profiles are much worse in northern Nigeria than in other regions. For example, the MMRs in the states of Sokoto and Bauchi in northern Nigeria are 1500 and 1540 deaths per 100 000 live births, respectively [1]. Similarly, the total fertility rates in Bauchi (7.2) and Sokoto (8.1) are higher than the national average of 5.7 [1]. The median age at first birth among women in the states of Bauchi and Sokoto is 17.5 years and 18.2 years, respectively, compared with the national average of 20.4 years. Finally, only 8% of births in the northwest of Nigeria occur in a health facility [1]. A key intervention to reduce the occurrence of institutional maternal deaths is the strengthening of facility-based services designed to provide lifesaving emergency obstetric care (EmOC). However, tracking the effectiveness of this strategy in resource-constrained settings through measurement of the MMR can be a challenge [5], because the MMR in itself is not a robust indicator of the impact of maternal health interventions [6]. The United Nations Population Fund, the United Nations Children’s Fund, and WHO have proposed proxy indicators for the monitoring of
http://dx.doi.org/10.1016/j.ijgo.2014.09.029 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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EmOC services for the treatment of complications of pregnancy and childbirth [7]. This guidance classifies facilities into basic EmOC (BEmOC) or comprehensive EmOC (CEmOC) facilities. BEmOC facilities provide seven lifesaving or “signal” functions (parenteral antibiotics, oxytocics, anticonvulsants, neonatal resuscitation, assisted vaginal delivery, manual removal of the placenta, and removal of retained products). CEmOC facilities provide cesarean delivery and blood transfusion in addition to the seven BEmOC signal functions. The guidance recommends that at least five EmOC facilities, including one CEmOC facility, are available per 500 000 individuals, and that this combination of facilities is evenly distributed across a country and its subnational geographic areas [7]. The UN guidance has been used in many countries to estimate the availability, accessibility, utilization, and quality of EmOC services, and to monitor and evaluate the impact of interventions that aim to improve maternal and child health outcomes. The purpose of the present study is to report on the availability, utilization, and quality of EmOC services in Bauchi State in northern Nigeria, where various interventions to improve maternal and child health are in place. Baseline data are used from the Targeted States High Impact Project (2009–2014). This intervention—funded by the US Agency for International Development—provides technical assistance to the government, focusing on the improvement of quality ofcare processes and the strengthening of maternal, neonatal, and child health delivery systems in Bauchi and Sokoto States in northern Nigeria. 2. Materials and methods Between June and July 2012, a cross-sectional facility-based needs assessment survey of EmOC services was conducted as a baseline evaluation for the Targeted States High Impact Project. Data were obtained from 59 public health facilities (20 general hospitals and 39 public primary healthcare centers) in Bauchi State. Of the 23 general hospitals in the state, three were excluded because they were inaccessible owing to insecurity. The public primary healthcare centers administratively located around the included hospitals were purposively sampled from the 318 primary healthcare centers distributed across the state’s three senatorial zones. Only primary centers that provided delivery services were included. The target units of the survey were departments that provided obstetric and newborn care services and administrative services within a facility. Ethics approval of the research protocol was obtained from the Bauchi State Health Research Ethics Committee prior to commencement of the study. Written informed consent was obtained from the heads of the health facilities before the interviews. All data were processed with strict confidentiality. The data were collected using structured, pre-established EmOC tools developed by Averting Maternal Death and Disability [8]. These tools are based on the EmOC indicators specified in the international guidelines for monitoring the availability and use of obstetric and neonatal services [7]. The modular questionnaire was adapted to the context of the healthcare system in Bauchi State and covered EmOC signal functions and other essential services, provider knowledge and competency for maternal and newborn care, cesarean deliveries, and maternal deaths (Supplementary Material S1). Eighteen research assistants were trained for 7 days in June 2012. Six research teams were formed, with two teams per senatorial zone. In each zone, one team obtained data on the performance of EmOC services in hospitals, whereas the other team focused on the selected primary healthcare facilities. In addition to obtaining data through individual interviews of the facility heads (managers), the research assistants extracted data from the facilities’ records, including registers of labor and delivery, partographs, the operating room, and the prenatal ward. Data on maternal complications and deaths at each facility were collected retrospectively on a monthly basis for 12 months (June 2011 to May 2012). In addition, direct observations were carried out to determine availability of the core infrastructure, drugs, and supplies required to perform the signal functions [9].
Data from the completed questionnaires were captured with Epi Info version 7 (Centers for Disease Control and Prevention, Atlanta, GA, USA) by trained data clerks. Descriptive analyses including frequency distributions and bivariate analyses were performed with SPSS version 15 (SPSS Inc, Chicago, IL, USA). The χ 2 test was used for comparative analyses. P b 0.05 was considered statistically significant. 3. Results On the basis of the UN process indicators and the minimum acceptable level of EmOC [7], Bauchi State—with a population of 5 715 292 [10,11]—should have at least 46 fully functioning BEmOC facilities and 11 CEmOC facilities. However, only 6 (10.2%) of the 59 sampled facilities met the UN requirements for EmOC centers (Table 1). Lack of training and equipment were the major reasons for not providing EmOC services (data not shown). In general, EmOC signal functions were provided in secondary-care facilities more often than in primary-care centers (Fig. 1). Administration of parenteral oxytocics was performed at all facilities. Parenteral antibiotics were provided at 54 (91.5%) facilities. All 39 primary healthcare centers were expected to provide BEmOC services, however only 7 (17.9%) provided assisted vaginal delivery, 8 (20.5%) neonatal resuscitation, 9 (23.1%) removal of retained products, and 17 (43.6%) anticonvulsants. However, 8 (21%) primary-level facilities were providing blood transfusion—a CEmOC signal function. Only 3 (15.0%) of the 20 hospitals were fully functioning CEmOC facilities. Estimating from the data, none of the three senatorial zones met the minimum acceptable level of one CEmOC facility per 500 000 population. Overall, 31 465 (13.1%) of the expected 239 930 annual births took place in a health facility, and 10 517 (4.4%) took place in an EmOC facility. The proportion of births that took place in an EmOC health facility varied significantly in the three zones (P b 0.001) (Table 2). The UN [7] recommends that the proportion of births by cesarean delivery occurring in EmOC facilities should be a minimum of 5% and a maximum of 15% of all births in a population. Cesarean delivery in the present study accounted for only 3.6% (n = 380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Similar estimates were obtained for the individual senatorial zones (Table 2). In total, 1416 (3.9%) of the expected 35 990 women with obstetric complications were managed in EmOC facilities (i.e. their needs were met). The proportion whose needs were met varied by zone (Table 2). The intrapartum and very early neonatal death rates reflect the quality of intrapartum care. No UN benchmarks have been proposed. Overall, 24 intrapartum and very early neonatal deaths per 1000 deliveries were recorded in the EmOC facilities. The number of deaths varied by zone (Table 3). The direct obstetric case fatality rate in the EmOC facilities was 3.2% (Table 3), which exceeds the UN-recommended maximum of less than 1% [7]. Again, the case fatality rate varied by zone (Table 3). Overall, 13.5% of all maternal deaths in EmOC facilities were attributable to indirect causes (Table 3). In total, 14 649 obstetric complications were recorded in all the sampled facilities, 7045 (48.1%) of which were direct obstetric
Table 1 Availability of EmOC by type of facility.a Type of EmOC provided
All facilities (n = 59)
Hospitals (n = 20)
Health centers (n = 39)
Comprehensive EmOC Basic EmOC Non-EmOC
3 (5.1) 3 (5.1) 53 (89.8)
3 (15.0) 1 (5.0) 16 (80.0)
0 2 (5.1) 37 (94.9)
Abbreviation: EmOC, emergency obstetric care. a Values are given as number (percentage).
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Parenteral oxytocics Parenteral antibiotics Manual removal of retained placenta Parenteral anticonvulsants Removal of retained products Blood transfusion Newborn resuscitation Assisted vaginal delivery Cesarean delivery 0%
20%
40%
60%
80%
100%
Percentage of facilities Source: Survey data
Secondary care
Primary care
Fig. 1. Percentage of hospitals and health centers performing emergency obstetric care signal functions in Bauchi State, Nigeria.
complications. Among the women with direct obstetric complications, 2414 (34.2%) had obstructed/prolonged labor, 1537 (21.8%) hemorrhage, 664 (9.4%) a retained placenta, 553 (7.8%) complications of abortion, 181 (2.6%) a ruptured uterus, and 149 (2.1%) pre-eclampsia/ eclampsia. Among the 7604 women with indirect complications, 5121 (67.3%) had malaria and 2344 (30.8%) had severe anemia. Of the 379 maternal deaths from direct and indirect obstetric complications, 317 (83.6%) were attributable to major direct obstetric complications. Pre-eclampsia/eclampsia, which accounted for
only 2.1% of all direct obstetric complications, resulted in almost half of the deaths due to direct complications in both EmOC and non-EmOC facilities (Table 4). Hemorrhage caused almost one-fifth of maternal deaths due to direct complications in non-EmOC facilities (Table 4). Although obstructed/prolonged labor was the cause of more than one-third of all direct obstetric complications, it accounted for only 24 (7.6%) of all deaths from direct complications. Severe anemia accounted for 56 (90.3%) of 62 deaths attributable to indirect causes.
Table 2 Deliveries and obstetric complications in EmOC facilities.a Variable
Whole state
Southern zone
Central zone
Northern zone
Total population Births Expected number In EmOC facilities In non-EmOC facilities All facility births Cesarean delivery Complications Total expected number of direct complications Direct complications treated in EmOC facilities (met need) Direct complications treated in non-EmOC facilities All direct complications treated in facilities
5 909 612
1 830 324
1 911 535
2 167 752
239 930 10 517 (4.4) 20 948 (8.7) 31 465 (13.1) 380 (0.2)
68 271 7589 (11.1) 5838 (8.6) 13 428 (19.7) 61 (0.1)
71 300 2312 (3.2) 8289 (11.6) 10 493 (14.7) 240 (0.3)
80 857 7 (b0.1) 6820 (8.4) 7544 (9.3) 79 (0.1)
35 990 1416 (3.9) 3958 (11.0) 5374 (14.9)
10 241 514 (5.0) 1061 (10.4) 1575 (15.4)
10 695 639 (6.0) 1914 (17.9) 2553 (23.9)
12 129 263 (2.2) 983 (8.1) 1246 (10.3)
Abbreviation: EmOC, emergency obstetric care. a Values are given as number or number (percentage).
Table 3 Maternal and neonatal deaths in EmOC facilities. Variable
Whole state
Southern zone
Central zone
Northern zone
Intrapartum and very early neonatal death rate, per 1000 deliveries Stillbirth rate, per 1000 deliveries Direct obstetric case fatality rate a Proportion of maternal deaths attributable to indirect causes b
24.4 34.6 45/1416 (3.2) 7/52 (13.5)
17.0 28.2 4/514 (0.8) 1/5 (20.0)
46.3 59.4 24/639 (3.8) 6/30 (20.0)
35.9 26.2 17/263 (6.5) 0/17
Abbreviation: EmOC, emergency obstetric care. a Values are given as number of women dying of direct obstetric complications in EmOC facilities/number of women treated for direct obstetric complications at the same facilities during the same period (percentage). b Values are given as number of maternal deaths due to indirect causes in EmOC facilities/total number of maternal deaths (percentage).
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Table 4 Obstetric complications treated in sampled health facilities, and direct and indirect causes of maternal death.a Obstetric complication
Direct complications Prepartum/postpartum hemorrhage Retained placenta Obstructed/prolonged labor Ruptured uterus Postpartum sepsis Severe pre-eclampsia/eclampsia Complications of abortion Ectopic pregnancy Other Indirect complications Malaria HIV/AIDS-related Severe anemia Diabetes mellitus Hepatitis Other indirect complications
Non-EmOC facilities
EmOC facilities
Women affected
Women affected
Cause of death
Cause of death
4934 272 1110 (22.5) 52 (19.1)
1053 45 427 (40.6) 4 (8.9)
557 (11.3) 2280 (46.2) 165 (3.3) 81 (1.6) 128 (2.6) 359 (7.3) 6 (0.1) 248 (5.0) 6633 4766 (71.9) 76 (1.1) 1740 (26.2) 0 0 51 (0.8)
107 (10.2) 134 (12.7) 16 (1.5) 24 (2.3) 21 (2.0) 194 (18.4) 6 (0.6) 124 (11.8) 971 355 (36.6) 0 604 (62.2) 0 0 12 (1.2)
4 (1.5) 16 (5.9) 1 (0.4) 23 (8.5) 128 (47.1) 1 (0.4) 0 47 (17.3) 55 4 (7.3) 0 49 (89.1) 0 0 2 (3.6)
1 (2.2) 8 (17.8) 2 (4.4) 5 (11.1) 21 (46.7) 1 (2.2) 0 (0) 3 (6.7) 7 0 0 7 (100.0) 0 0 0
Abbreviation: EmOC, emergency obstetric care. a Values are given as number or number (percentage).
4. Discussion In the present study, the level of provision for almost all signal functions was below the UN-recommended acceptable level [7]. Poor availability of essential EmOC services, a high unmet need for EmOC, and an inadequate number of CEmOC and BEmOC facilities all contributed to a high maternal mortality. Inadequacy in the number of EmOC (CEmOC and BEmOC) facilities seems to be a universal finding in many EmOC studies [9,12,13]. Interventions that increase the number of available BEmOC facilities and improve the services at existing facilities are essential because most obstetric complications can be managed at the basic level, and BEmOC facilities are generally also more easily accessible than are CEmOC centers. Administration of antibiotics and oxytocics were the most frequently available signal functions, whereas assisted vaginal delivery was rarely performed, reflecting the pattern in most African countries [14]. The low rate of assisted vaginal delivery could have resulted in an increase in the cesarean delivery rate [15], because CEmOC services were more likely to be provided in sufficient quantity than were BEmOC services, similar to the global pattern [16]. In the present survey, only approximately 4% of deliveries occurred at EmOC facilities, a percentage that is much lower than the 15% minimum acceptable level [7]. The highest percentage reached in one of the senatorial zones was approximately 11%. The low utilization of delivery services at EmOC facilities is reflected in the low proportion of women with direct complications who were treated in EmOC facilities. The present findings are comparable with the results of the Nigeria Demographic and Health Surveys [1,17]—which showed that 62% and 63% of deliveries in 2008 and 2013, respectively, occur at home where many women deliver with nobody else present [18]— and the results reported for most parts of Sub-Saharan Africa [19]. At 0.2%, the cesarean delivery rate—a strong indicator of the accessibility and utilization of EmOC services and for identifying gaps in obstetric care—was clearly below the UN-recommended minimum of 5% [7, 20]. Furthermore, the direct obstetric case fatality rate—which reflects the quality of care—exceeded the UN-recommended maximum [7]. Indeed, the rate of approximately 3% could be an underestimation, because 25 of the 59 sampled facilities had incomplete records. In addition, many maternal deaths could be occurring outside facilities. There is a need to explore the demand-side factors affecting the utilization of EmOC services and to improve health information management
systems at the facility level to support interventions that are aimed at achieving an optimal coverage of lifesaving obstetric interventions for pregnant women. As is the case in several other Sub-Saharan African countries [21], malaria and severe anemia were leading indirect causes of maternal death and accounted for the majority of obstetric complications. Malaria during pregnancy is more frequent and more severe in northern Nigeria [22]. The intensification of facility- and community-based malaria and anemia treatment, and the prevention of malaria and anemia during pregnancy are crucial if maternal morbidity and mortality in Nigeria are to be reduced and progress toward Millennium Development Goal 5 made. A few limitations could affect the generalizability of the present results. First, convenience sampling was used to select the primary-care facilities. However, any potential bias was mitigated by the use of predefined selection criteria. Second, only public sector facilities directly subject to government policies were studied, although a few private health facilities could well perform EmOC services, especially in urban areas. Private health facilities are few in number in the rural areas, where public facilities predominate. The present findings nonetheless provide strong insights into the state of EmOC services in Bauchi State and in most of northern Nigeria. In conclusion, the suboptimal availability and quality of lifesaving obstetric services remains a challenge for maternal and child health in northern Nigeria, especially in Bauchi State, and reflects broader health system constraints. Renewed efforts are needed to strengthen the health system, scale up EmOC services, achieve the maximum possible reduction in maternal morbidity and mortality in northern Nigeria, and attain global commitments. Process indicators should be periodically estimated to monitor efforts to improve the accessibility, utilization, and quality of EmOC services. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijgo.2014.09.029. Acknowledgments Funds for the present study were provided by the US Agency for International Development through the Targeted States High Impact Project. Conflict of interest The authors have no conflicts of interest. References [1] National Population Commission, ICF Macro. Nigeria Demographic and Health Survey 2008: Key Findings. Calverton, MD: National Population Commission, ICF Macro; 2009. [2] Okoli U, Abdullahi MJ, Pate MA, Abubakar IS, Aniebue N, West C. Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria. Int J Gynecol Obstet 2012;117(1):61–5. [3] Save the Children. Surviving the First Day: State of the World’s Mothers 2013. http:// www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/ SOWM-FULL-REPORT_2013.PDF. Published May 2013. Accessed September 10, 2014. [4] Federal Republic of Nigeria, Ministry of Health. Saving Newborn Lives in Nigeria: Newborn Health in the context of the Integrated Maternal, Newborn and Child Health Strategy. 2nd Edition. http://www.countdown2015mnch.org/documents/ nigeria/nigeria-full-report.pdf. Published 2011. Accessed September 10, 2014. [5] Maine D, Akalin MZ, Ward VM, Kamara A. The Design and Evaluation of Maternal Mortality Programs. http://www.amddprogram.org/v1/resources/DesignEvalMMEN.pdf. Published June 1997. Accessed September 10, 2014. [6] Olsen ØE, Ndeki S, Norheim OF. Availability, distribution and use of emergency obstetric care in northern Tanzania. Health Policy Plan 2005;20(3):167–75. [7] World Health Organization, United Nations Population Fund, United Nations Children’s Fund, Averting Maternal Death and Disability. Monitoring Emergency Obstetric Care: A handbook. Geneva: World Health Organization; 2009. [8] Averting Maternal Death and Disability. Needs Assessments of Emergency Obstetric and Newborn Care: Overview and Introduction to Materials. http://www.
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Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria Dele Abegunde a, Ibrahim A. Kabo b,⁎, William Sambisa c, Toyin Akomolafe c, Nosa Orobaton c, Masduk Abdulkarim c, Habib Sadauki b a b c
Health and Economics Consultants, Ilorin, Nigeria Jhpiego Targeted States High Impact Project, Bauchi, Nigeria John Snow Incorporated Research and Training Institute Targeted States High Impact Project, Bauchi, Nigeria
a r t i c l e
i n f o
Article history: Received 19 March 2014 Received in revised form 16 September 2014 Accepted 24 November 2014 Keywords: Availability Emergency obstetric services Maternal mortality Nigeria Northern Nigeria Quality Utilization
a b s t r a c t Objective: To report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. Methods: Between June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. Results: Only 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n = 380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. Conclusion: Availability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system’s capacity to manage emergency obstetric complications needs to be strengthened. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Overcoming the high burden of maternal and reproductive health problems remains a challenge in Sub-Saharan Africa, particularly in Nigeria. This country has a population of 160 million and an estimated maternal mortality ratio (MMR) of 545 deaths per 100 000 live births [1]. Nigeria constitutes 2.0% of the global population, but accounts for 10% of the world’s maternal and childhood mortality burden [2]. Nigeria—along with Somalia, Mali, the Democratic Republic of the Congo, and Niger—is ranked among the 10 “worst places in the world to be a mother” [3], even though high priority has been given to maternal and child health at a national level for decades. Despite Nigeria’s substantial investment in primary health care and the country’s commitment to the global maternal and child health agenda [4], the health system seems to be inadequate for provision of lifesaving emergency maternal and child health services [2]. Use of health services has also been too low to have any meaningful impact on the ⁎ Corresponding author at: No. 3 Emir Sulaiman Adamu Street, Off Airport Road, GRA, Bauchi, Nigeria. Tel.: +234 9065667373. E-mail address: [email protected] (I.A. Kabo).
high levels of maternal and child mortality and mobility. Approximately 35% of all births occur in health facilities and one in five births is unassisted [1]. Access to quality maternal and child healthcare services is worse in the underserved rural areas where 70% of the country’s population live [2]. Maternal health profiles are much worse in northern Nigeria than in other regions. For example, the MMRs in the states of Sokoto and Bauchi in northern Nigeria are 1500 and 1540 deaths per 100 000 live births, respectively [1]. Similarly, the total fertility rates in Bauchi (7.2) and Sokoto (8.1) are higher than the national average of 5.7 [1]. The median age at first birth among women in the states of Bauchi and Sokoto is 17.5 years and 18.2 years, respectively, compared with the national average of 20.4 years. Finally, only 8% of births in the northwest of Nigeria occur in a health facility [1]. A key intervention to reduce the occurrence of institutional maternal deaths is the strengthening of facility-based services designed to provide lifesaving emergency obstetric care (EmOC). However, tracking the effectiveness of this strategy in resource-constrained settings through measurement of the MMR can be a challenge [5], because the MMR in itself is not a robust indicator of the impact of maternal health interventions [6]. The United Nations Population Fund, the United Nations Children’s Fund, and WHO have proposed proxy indicators for the monitoring of
http://dx.doi.org/10.1016/j.ijgo.2014.09.029 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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EmOC services for the treatment of complications of pregnancy and childbirth [7]. This guidance classifies facilities into basic EmOC (BEmOC) or comprehensive EmOC (CEmOC) facilities. BEmOC facilities provide seven lifesaving or “signal” functions (parenteral antibiotics, oxytocics, anticonvulsants, neonatal resuscitation, assisted vaginal delivery, manual removal of the placenta, and removal of retained products). CEmOC facilities provide cesarean delivery and blood transfusion in addition to the seven BEmOC signal functions. The guidance recommends that at least five EmOC facilities, including one CEmOC facility, are available per 500 000 individuals, and that this combination of facilities is evenly distributed across a country and its subnational geographic areas [7]. The UN guidance has been used in many countries to estimate the availability, accessibility, utilization, and quality of EmOC services, and to monitor and evaluate the impact of interventions that aim to improve maternal and child health outcomes. The purpose of the present study is to report on the availability, utilization, and quality of EmOC services in Bauchi State in northern Nigeria, where various interventions to improve maternal and child health are in place. Baseline data are used from the Targeted States High Impact Project (2009–2014). This intervention—funded by the US Agency for International Development—provides technical assistance to the government, focusing on the improvement of quality ofcare processes and the strengthening of maternal, neonatal, and child health delivery systems in Bauchi and Sokoto States in northern Nigeria. 2. Materials and methods Between June and July 2012, a cross-sectional facility-based needs assessment survey of EmOC services was conducted as a baseline evaluation for the Targeted States High Impact Project. Data were obtained from 59 public health facilities (20 general hospitals and 39 public primary healthcare centers) in Bauchi State. Of the 23 general hospitals in the state, three were excluded because they were inaccessible owing to insecurity. The public primary healthcare centers administratively located around the included hospitals were purposively sampled from the 318 primary healthcare centers distributed across the state’s three senatorial zones. Only primary centers that provided delivery services were included. The target units of the survey were departments that provided obstetric and newborn care services and administrative services within a facility. Ethics approval of the research protocol was obtained from the Bauchi State Health Research Ethics Committee prior to commencement of the study. Written informed consent was obtained from the heads of the health facilities before the interviews. All data were processed with strict confidentiality. The data were collected using structured, pre-established EmOC tools developed by Averting Maternal Death and Disability [8]. These tools are based on the EmOC indicators specified in the international guidelines for monitoring the availability and use of obstetric and neonatal services [7]. The modular questionnaire was adapted to the context of the healthcare system in Bauchi State and covered EmOC signal functions and other essential services, provider knowledge and competency for maternal and newborn care, cesarean deliveries, and maternal deaths (Supplementary Material S1). Eighteen research assistants were trained for 7 days in June 2012. Six research teams were formed, with two teams per senatorial zone. In each zone, one team obtained data on the performance of EmOC services in hospitals, whereas the other team focused on the selected primary healthcare facilities. In addition to obtaining data through individual interviews of the facility heads (managers), the research assistants extracted data from the facilities’ records, including registers of labor and delivery, partographs, the operating room, and the prenatal ward. Data on maternal complications and deaths at each facility were collected retrospectively on a monthly basis for 12 months (June 2011 to May 2012). In addition, direct observations were carried out to determine availability of the core infrastructure, drugs, and supplies required to perform the signal functions [9].
Data from the completed questionnaires were captured with Epi Info version 7 (Centers for Disease Control and Prevention, Atlanta, GA, USA) by trained data clerks. Descriptive analyses including frequency distributions and bivariate analyses were performed with SPSS version 15 (SPSS Inc, Chicago, IL, USA). The χ 2 test was used for comparative analyses. P b 0.05 was considered statistically significant. 3. Results On the basis of the UN process indicators and the minimum acceptable level of EmOC [7], Bauchi State—with a population of 5 715 292 [10,11]—should have at least 46 fully functioning BEmOC facilities and 11 CEmOC facilities. However, only 6 (10.2%) of the 59 sampled facilities met the UN requirements for EmOC centers (Table 1). Lack of training and equipment were the major reasons for not providing EmOC services (data not shown). In general, EmOC signal functions were provided in secondary-care facilities more often than in primary-care centers (Fig. 1). Administration of parenteral oxytocics was performed at all facilities. Parenteral antibiotics were provided at 54 (91.5%) facilities. All 39 primary healthcare centers were expected to provide BEmOC services, however only 7 (17.9%) provided assisted vaginal delivery, 8 (20.5%) neonatal resuscitation, 9 (23.1%) removal of retained products, and 17 (43.6%) anticonvulsants. However, 8 (21%) primary-level facilities were providing blood transfusion—a CEmOC signal function. Only 3 (15.0%) of the 20 hospitals were fully functioning CEmOC facilities. Estimating from the data, none of the three senatorial zones met the minimum acceptable level of one CEmOC facility per 500 000 population. Overall, 31 465 (13.1%) of the expected 239 930 annual births took place in a health facility, and 10 517 (4.4%) took place in an EmOC facility. The proportion of births that took place in an EmOC health facility varied significantly in the three zones (P b 0.001) (Table 2). The UN [7] recommends that the proportion of births by cesarean delivery occurring in EmOC facilities should be a minimum of 5% and a maximum of 15% of all births in a population. Cesarean delivery in the present study accounted for only 3.6% (n = 380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Similar estimates were obtained for the individual senatorial zones (Table 2). In total, 1416 (3.9%) of the expected 35 990 women with obstetric complications were managed in EmOC facilities (i.e. their needs were met). The proportion whose needs were met varied by zone (Table 2). The intrapartum and very early neonatal death rates reflect the quality of intrapartum care. No UN benchmarks have been proposed. Overall, 24 intrapartum and very early neonatal deaths per 1000 deliveries were recorded in the EmOC facilities. The number of deaths varied by zone (Table 3). The direct obstetric case fatality rate in the EmOC facilities was 3.2% (Table 3), which exceeds the UN-recommended maximum of less than 1% [7]. Again, the case fatality rate varied by zone (Table 3). Overall, 13.5% of all maternal deaths in EmOC facilities were attributable to indirect causes (Table 3). In total, 14 649 obstetric complications were recorded in all the sampled facilities, 7045 (48.1%) of which were direct obstetric
Table 1 Availability of EmOC by type of facility.a Type of EmOC provided
All facilities (n = 59)
Hospitals (n = 20)
Health centers (n = 39)
Comprehensive EmOC Basic EmOC Non-EmOC
3 (5.1) 3 (5.1) 53 (89.8)
3 (15.0) 1 (5.0) 16 (80.0)
0 2 (5.1) 37 (94.9)
Abbreviation: EmOC, emergency obstetric care. a Values are given as number (percentage).
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Parenteral oxytocics Parenteral antibiotics Manual removal of retained placenta Parenteral anticonvulsants Removal of retained products Blood transfusion Newborn resuscitation Assisted vaginal delivery Cesarean delivery 0%
20%
40%
60%
80%
100%
Percentage of facilities Source: Survey data
Secondary care
Primary care
Fig. 1. Percentage of hospitals and health centers performing emergency obstetric care signal functions in Bauchi State, Nigeria.
complications. Among the women with direct obstetric complications, 2414 (34.2%) had obstructed/prolonged labor, 1537 (21.8%) hemorrhage, 664 (9.4%) a retained placenta, 553 (7.8%) complications of abortion, 181 (2.6%) a ruptured uterus, and 149 (2.1%) pre-eclampsia/ eclampsia. Among the 7604 women with indirect complications, 5121 (67.3%) had malaria and 2344 (30.8%) had severe anemia. Of the 379 maternal deaths from direct and indirect obstetric complications, 317 (83.6%) were attributable to major direct obstetric complications. Pre-eclampsia/eclampsia, which accounted for
only 2.1% of all direct obstetric complications, resulted in almost half of the deaths due to direct complications in both EmOC and non-EmOC facilities (Table 4). Hemorrhage caused almost one-fifth of maternal deaths due to direct complications in non-EmOC facilities (Table 4). Although obstructed/prolonged labor was the cause of more than one-third of all direct obstetric complications, it accounted for only 24 (7.6%) of all deaths from direct complications. Severe anemia accounted for 56 (90.3%) of 62 deaths attributable to indirect causes.
Table 2 Deliveries and obstetric complications in EmOC facilities.a Variable
Whole state
Southern zone
Central zone
Northern zone
Total population Births Expected number In EmOC facilities In non-EmOC facilities All facility births Cesarean delivery Complications Total expected number of direct complications Direct complications treated in EmOC facilities (met need) Direct complications treated in non-EmOC facilities All direct complications treated in facilities
5 909 612
1 830 324
1 911 535
2 167 752
239 930 10 517 (4.4) 20 948 (8.7) 31 465 (13.1) 380 (0.2)
68 271 7589 (11.1) 5838 (8.6) 13 428 (19.7) 61 (0.1)
71 300 2312 (3.2) 8289 (11.6) 10 493 (14.7) 240 (0.3)
80 857 7 (b0.1) 6820 (8.4) 7544 (9.3) 79 (0.1)
35 990 1416 (3.9) 3958 (11.0) 5374 (14.9)
10 241 514 (5.0) 1061 (10.4) 1575 (15.4)
10 695 639 (6.0) 1914 (17.9) 2553 (23.9)
12 129 263 (2.2) 983 (8.1) 1246 (10.3)
Abbreviation: EmOC, emergency obstetric care. a Values are given as number or number (percentage).
Table 3 Maternal and neonatal deaths in EmOC facilities. Variable
Whole state
Southern zone
Central zone
Northern zone
Intrapartum and very early neonatal death rate, per 1000 deliveries Stillbirth rate, per 1000 deliveries Direct obstetric case fatality rate a Proportion of maternal deaths attributable to indirect causes b
24.4 34.6 45/1416 (3.2) 7/52 (13.5)
17.0 28.2 4/514 (0.8) 1/5 (20.0)
46.3 59.4 24/639 (3.8) 6/30 (20.0)
35.9 26.2 17/263 (6.5) 0/17
Abbreviation: EmOC, emergency obstetric care. a Values are given as number of women dying of direct obstetric complications in EmOC facilities/number of women treated for direct obstetric complications at the same facilities during the same period (percentage). b Values are given as number of maternal deaths due to indirect causes in EmOC facilities/total number of maternal deaths (percentage).
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Table 4 Obstetric complications treated in sampled health facilities, and direct and indirect causes of maternal death.a Obstetric complication
Direct complications Prepartum/postpartum hemorrhage Retained placenta Obstructed/prolonged labor Ruptured uterus Postpartum sepsis Severe pre-eclampsia/eclampsia Complications of abortion Ectopic pregnancy Other Indirect complications Malaria HIV/AIDS-related Severe anemia Diabetes mellitus Hepatitis Other indirect complications
Non-EmOC facilities
EmOC facilities
Women affected
Women affected
Cause of death
Cause of death
4934 272 1110 (22.5) 52 (19.1)
1053 45 427 (40.6) 4 (8.9)
557 (11.3) 2280 (46.2) 165 (3.3) 81 (1.6) 128 (2.6) 359 (7.3) 6 (0.1) 248 (5.0) 6633 4766 (71.9) 76 (1.1) 1740 (26.2) 0 0 51 (0.8)
107 (10.2) 134 (12.7) 16 (1.5) 24 (2.3) 21 (2.0) 194 (18.4) 6 (0.6) 124 (11.8) 971 355 (36.6) 0 604 (62.2) 0 0 12 (1.2)
4 (1.5) 16 (5.9) 1 (0.4) 23 (8.5) 128 (47.1) 1 (0.4) 0 47 (17.3) 55 4 (7.3) 0 49 (89.1) 0 0 2 (3.6)
1 (2.2) 8 (17.8) 2 (4.4) 5 (11.1) 21 (46.7) 1 (2.2) 0 (0) 3 (6.7) 7 0 0 7 (100.0) 0 0 0
Abbreviation: EmOC, emergency obstetric care. a Values are given as number or number (percentage).
4. Discussion In the present study, the level of provision for almost all signal functions was below the UN-recommended acceptable level [7]. Poor availability of essential EmOC services, a high unmet need for EmOC, and an inadequate number of CEmOC and BEmOC facilities all contributed to a high maternal mortality. Inadequacy in the number of EmOC (CEmOC and BEmOC) facilities seems to be a universal finding in many EmOC studies [9,12,13]. Interventions that increase the number of available BEmOC facilities and improve the services at existing facilities are essential because most obstetric complications can be managed at the basic level, and BEmOC facilities are generally also more easily accessible than are CEmOC centers. Administration of antibiotics and oxytocics were the most frequently available signal functions, whereas assisted vaginal delivery was rarely performed, reflecting the pattern in most African countries [14]. The low rate of assisted vaginal delivery could have resulted in an increase in the cesarean delivery rate [15], because CEmOC services were more likely to be provided in sufficient quantity than were BEmOC services, similar to the global pattern [16]. In the present survey, only approximately 4% of deliveries occurred at EmOC facilities, a percentage that is much lower than the 15% minimum acceptable level [7]. The highest percentage reached in one of the senatorial zones was approximately 11%. The low utilization of delivery services at EmOC facilities is reflected in the low proportion of women with direct complications who were treated in EmOC facilities. The present findings are comparable with the results of the Nigeria Demographic and Health Surveys [1,17]—which showed that 62% and 63% of deliveries in 2008 and 2013, respectively, occur at home where many women deliver with nobody else present [18]— and the results reported for most parts of Sub-Saharan Africa [19]. At 0.2%, the cesarean delivery rate—a strong indicator of the accessibility and utilization of EmOC services and for identifying gaps in obstetric care—was clearly below the UN-recommended minimum of 5% [7, 20]. Furthermore, the direct obstetric case fatality rate—which reflects the quality of care—exceeded the UN-recommended maximum [7]. Indeed, the rate of approximately 3% could be an underestimation, because 25 of the 59 sampled facilities had incomplete records. In addition, many maternal deaths could be occurring outside facilities. There is a need to explore the demand-side factors affecting the utilization of EmOC services and to improve health information management
systems at the facility level to support interventions that are aimed at achieving an optimal coverage of lifesaving obstetric interventions for pregnant women. As is the case in several other Sub-Saharan African countries [21], malaria and severe anemia were leading indirect causes of maternal death and accounted for the majority of obstetric complications. Malaria during pregnancy is more frequent and more severe in northern Nigeria [22]. The intensification of facility- and community-based malaria and anemia treatment, and the prevention of malaria and anemia during pregnancy are crucial if maternal morbidity and mortality in Nigeria are to be reduced and progress toward Millennium Development Goal 5 made. A few limitations could affect the generalizability of the present results. First, convenience sampling was used to select the primary-care facilities. However, any potential bias was mitigated by the use of predefined selection criteria. Second, only public sector facilities directly subject to government policies were studied, although a few private health facilities could well perform EmOC services, especially in urban areas. Private health facilities are few in number in the rural areas, where public facilities predominate. The present findings nonetheless provide strong insights into the state of EmOC services in Bauchi State and in most of northern Nigeria. In conclusion, the suboptimal availability and quality of lifesaving obstetric services remains a challenge for maternal and child health in northern Nigeria, especially in Bauchi State, and reflects broader health system constraints. Renewed efforts are needed to strengthen the health system, scale up EmOC services, achieve the maximum possible reduction in maternal morbidity and mortality in northern Nigeria, and attain global commitments. Process indicators should be periodically estimated to monitor efforts to improve the accessibility, utilization, and quality of EmOC services. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijgo.2014.09.029. Acknowledgments Funds for the present study were provided by the US Agency for International Development through the Targeted States High Impact Project. Conflict of interest The authors have no conflicts of interest. References [1] National Population Commission, ICF Macro. Nigeria Demographic and Health Survey 2008: Key Findings. Calverton, MD: National Population Commission, ICF Macro; 2009. [2] Okoli U, Abdullahi MJ, Pate MA, Abubakar IS, Aniebue N, West C. Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria. Int J Gynecol Obstet 2012;117(1):61–5. [3] Save the Children. Surviving the First Day: State of the World’s Mothers 2013. http:// www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/ SOWM-FULL-REPORT_2013.PDF. Published May 2013. Accessed September 10, 2014. [4] Federal Republic of Nigeria, Ministry of Health. Saving Newborn Lives in Nigeria: Newborn Health in the context of the Integrated Maternal, Newborn and Child Health Strategy. 2nd Edition. http://www.countdown2015mnch.org/documents/ nigeria/nigeria-full-report.pdf. Published 2011. Accessed September 10, 2014. [5] Maine D, Akalin MZ, Ward VM, Kamara A. The Design and Evaluation of Maternal Mortality Programs. http://www.amddprogram.org/v1/resources/DesignEvalMMEN.pdf. Published June 1997. Accessed September 10, 2014. [6] Olsen ØE, Ndeki S, Norheim OF. Availability, distribution and use of emergency obstetric care in northern Tanzania. Health Policy Plan 2005;20(3):167–75. [7] World Health Organization, United Nations Population Fund, United Nations Children’s Fund, Averting Maternal Death and Disability. Monitoring Emergency Obstetric Care: A handbook. Geneva: World Health Organization; 2009. [8] Averting Maternal Death and Disability. Needs Assessments of Emergency Obstetric and Newborn Care: Overview and Introduction to Materials. http://www.
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