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Skip to 0 minutes and 13 seconds EMILY KEYES: We have seen in the course this week that globally, the number of women giving birth in facilities is quite large and is increasing. In this step, we will look at ways of characterising the services that facilities are capable of providing and the care that providers are capable of delivering. Progress toward the Millennium Development Goal to reduce maternal mortality was largely tracked by monitoring the percentage of women delivering with a skilled birth attendant. The assumption was that these skilled attendants would ensure women were provided quality, evidence-based services. It is true that more women are delivering with health workers now than in 1990, and the deliveries are taking place largely in health care facilities.

Skip to 0 minutes and 54 seconds And, ratios of maternal mortality have decreased, yet the relationship between increased facility deliveries and reduced mortality is weak. One explanation could be facility capability. Using data from 50 countries, Oona Campbell and colleagues characterise facilities and describe the availability of critical infrastructure and services where women deliver. Health care facilities vary in many ways, including by size, and the patterns vary across countries. This slide shows the volume of deliveries occurring in facilities of various sizes for 33 countries. In low- and middle-income countries, most of the countries toward the bottom of the chart, a greater proportion of deliveries occur in small facilities, shown in the lightest colour. For example, in Tanzania, just about half of all deliveries occur in small facilities.

Skip to 1 minute and 43 seconds Whereas in most high income countries in this chart, fewer than 20% of deliveries occur in very small facilities. In general, we can assume larger facilities have more capability. Though, facilities with very high volumes could suffer from overburdened staff, overcrowding of the labour ward, and in low- and middle-income countries may even lack basic infrastructure and services. Presence of basic infrastructure is a precondition of good quality services. Results of a systematic review showed that 66% of hospitals in sub-Saharan countries lack electricity. Another study found that 38% of facilities lack improved water, 19% lack improved sanitation, and 35% lack water and soap for hand-washing. We looked at the presence of three elements of basic infrastructure, water, electricity, and 24/7 availability of services.

Skip to 2 minutes and 32 seconds This graph indicates that in these four countries, many deliveries took place in facilities that were open at all times, but lacked both water and reliable electricity. The vast majority of deliveries in Ghana occurred in facilities with all three elements in place, shown in green. In contrast, in Rwanda in 2007, just one quarter of deliveries occurred in facilities with all three elements. Staffing and bed numbers are also important features to assess. Despite global efforts toward the skilled birth attendant strategy, little attention has been paid to routine intrapartum care in facilities.

Skip to 3 minutes and 8 seconds However, signal functions for routine care and basic infrastructure were proposed in 2012, by Gabrysch and colleagues, and are described in the previous step titled “Where and With Whom do Women Give Birth?” The proposed signal functions for routine delivery include infection prevention, the use of a partograph to monitor labour, and routine administration of uterotonic as part of Active Management of the Third Stage of Labour, or AMSTL. This slide shows, for the same four countries as the previous slide, the proportion of deliveries occurring in facilities of various levels of routine delivery capability. In Ghana, just over 13% of deliveries occurred in facilities missing at least one routine signal function. In Rwanda, three-quarters of deliveries did.

Skip to 3 minutes and 55 seconds And in Mozambique, it was about a third. We can also look at signal functions to describe the facility capacity to deliver a package of lifesaving interventions. Commonly referred to as Emergency Obstetric Care, or EmOC, this indicator has been monitored for almost two decades. CEmOC (Comprehensive Emergency Obstetric Care) indicates comprehensive services. BEmOC (Basic Emergency Obstetric Care) indicates a basic level of complication management. This slide shows facilities capabilities to provide EmOC varies and is often poor. In Rwanda, 36% of deliveries occurred in facilities with 0 or 1 basic signal functions, as indicated in red. In Ghana, this proportion was 3%. Women in China were considerably more likely to deliver in facilities providing EmOC than were those in sub-Saharan Africa.

Skip to 4 minutes and 41 seconds In four of eight countries evaluated, most births were in facilities that were not capable of providing five basic EmOC functions, a vital gap in maternal health care provision. High quality care requires that all components of routine and emergency care be provided consistently, respectfully, in a timely fashion, to all women who need them. Individual women’s care can be very poor. This slide shows the time lapse between admission and surgery, in hours, among six women who were admitted with uterine rupture in two hospitals in Ivory Coast. Only one woman was operated on within one hour. The other five waited upwards of four hours with the delay at times dependent upon the woman’s ability to purchase a complete surgical kit.

Skip to 5 minutes and 25 seconds Women unable to raise the funds in time are at a great risk of dying. The World Health Organisation (WHO) recommends that women and newborns be monitored over the first 24 hours after delivery, yet length of stay can be quite short. In Ethiopia in 2008, most women stayed fewer than 12 hours after delivery. In Kenya, almost 75% stayed for at least 24 hours. Women and newborns discharged early are not appropriately monitored during a time that they remain highly vulnerable to life-threatening complications. If a complication develops, whether in the mum or in the baby, they must return to the facility for treatment, which can be very difficult and costly. Many are not able or choose not to make the trip.

Skip to 6 minutes and 7 seconds In conclusion, there are multi-country data with which to characterise features of facilities, including their size, whether they have adequate infrastructure, their capability to provide routine and emergency care, and how long women stay in health facilities. We also know facilities capability to provide timely care is key, but unfortunately, such data are not routinely tracked. We found that most facilities studied in sub-Saharan Africa, but not China, were ill-equipped to provide EmOC, especially lower level facilities. Facilities were generally better equipped to provide routine care than EmOC, but many could lack necessities, such as electricity or water.

Skip to 6 minutes and 48 seconds Facilities in Africa deal with small numbers of deliveries, which can make it hard for providers to maintain skills, to enable high quality and respectful care, and to improve patient and provider satisfaction. These gaps, including the need for timely care, must be remedied.

What is current delivery facility capability?

How can the ability of facilities be characterised in terms of provision of care?

In this step Emily Keyes (FHI 360) presents ways of characterising the key abilities of facilities to provide care including facility size, facility infrastructure and facility capability to provide care for routine deliveries and obstetric emergencies. The step also shows how we can factor in the need for timely care, and the length of stay. It also touches briefly on staffing and the difficulties in obtaining comparative data on staffing and bed numbers.

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The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine