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Background. Reduction of maternal mortality ratio by two-thirds by 2015 is an international development goal with unrestricted access to high quality emergency obstetric care services promoted towards the attainment of that goal. The objective of this qualitative study was to assess the availability and quality of emergency obstetric care services in Gambia’s main referral hospital. Methods. From weekend admissions a group of 30 women treated for different acute obstetric conditions including five main diagnostic groups: hemorrhage, hypertensive disorders, dystocia, sepsis and anemia were purposively selected. In-depth interviews with the women were carried out at their homes within two weeks of discharge. Results. Substantial difficulties in obtaining emergency obstetric care were uncovered. Health system inadequacies including lack of blood for transfusion, shortage of essential medicines especially antihypertensive drugs considerably hindered timely and adequate treatment for obstetric emergencies. Such inadequacies also inflated the treatment costs to between 5 and 18 times more than standard fees. Blood transfusion and hypertensive treatment were associated with the largest costs. Conclusion. The deficiencies in the availability of life-saving interventions identified are manifestations of inadequate funding for maternal health services. Substantial increase in funding for maternal health services is therefore warranted towards effective implementation of emergency obstetric care package in The Gambia.
Located in West Africa, Gambia has a population of 1.4 million inhabitants, mainly subsistent farmers. Of 177 countries on the Human Development Index for 2006, The Gambia was classified as a low-income country and ranked 155th [17]. The gross national product per capita is $340. Though resource-constraint, public spending on the health sector continuously increased over the years, currently accounting for 13.9% of government spending, being ranked the second highest in the African Region [18]. However, the proportion of government expenditure specific to maternal health remains unknown. Health has been identified as a priority by the Gambian government and there is great enthusiasm to attain Millennium Development Goals on child and maternal health which has culminated in 2005 the development of a country road map to reduce maternal and neonatal morbidity and mortality [19]. Sadly, for lack of funding this road map is yet to be implemented. Royal Victoria Teaching Hospital (RVTH), the site for the current study located in the capital city Banjul, was selected purposively for being the main obstetric referral hospital in the country and with an overwhelming majority of the country’s health resources. For example, almost all doctors and 45% of midwives in the public sector work at RVTH [20]. It has a separate operating theatre exclusively for maternity cases with up to three teams of four doctors (a consultant obstetrician and three residents) supposedly to provide round the clock obstetric services cover. However, only few junior doctors are available after normal working hours (8:00 – 14:00 hours) and on weekends. EOC service in the hospital is supported by the hosting of the National Reference Laboratory which includes the National Blood Transfusion Services. Unlike other public hospitals around the country, electricity and water supply at RVTH is available round the clock. With these and other facilities, it is widely believed that EOC services at RVTH are more readily available and of superior quality than in other public hospitals. Thus it is not surprising that 35% of births in medical facilities and 79% of cesarean sections performed in the country occur in RVTH [9]. Besides its primary function being an obstetric referral center, RVTH also provides general pregnancy care services to women living within close surroundings. The MMR at this hospital is very high, exceeding 1100 per 100,000 live births [21]. In-depth interviews with women survivors of severe acute obstetric complications or “Near Misses” were held. SAMM case was defined as “any woman who suffered acute obstetric conditions, at any period in pregnancy to six weeks postpartum, severe enough to end in a maternal death. The woman survived due to the care received or good luck”[15]. We included five categories of obstetric emergencies defined according to disease-specific criteria based on management and/or clinical signs and symptoms: hemorrhage at any pregnancy state (leading to transfusion, cesarean section or hysterectomy); hypertensive pregnancy disorders including eclampsia or severe pre-eclampsia with a minimum diastolic pressure of 110 mmHg; puerperal sepsis (peritonitis, septicemia, offensive vaginal discharge); dystocia resulting from prolonged, obstructed labor or mal-presentation (leading to ruptured or pending uterine rupture, cesarean section, instrumental delivery or perinatal laceration) and severe anemia (hemoglobin < 6 g/dl). The lower limit of diastolic pressure and hemoglobin level applied were according to national guidelines [22]. To appreciate round the clock EOC availability, we purposively selected 30 women from weekend admissions between January and June 2006. We ensured inclusion of all the above obstetric conditions. For budgetary reasons and feasibility, only women residing within 30 km of the hospital were recruited which translates to residents of three urban municipalities: Banjul, Kanifing and Western region. Individual consent and women's telephone contacts and traceable addresses were obtained before discharge from the hospital. Interviews were conducted at the women's homes and convenience within two weeks of discharge in the presence of relative(s) who were with her in hospital. The primary author (MC) with local experience performed all the interviews in the local languages which focused on health care seeking process, woman's experience at the hospital from arrival to discharge, estimated time lapse between reception and obtaining definitive treatment. The woman's perceived quality of care received was also explored. Interview guides were semi-structured, open-ended and probing that permitted women to respond freely using their own language. All interviews were transcribed verbatim, translated into English, categorized and analyzed using a Grounded Theory [23]. The frequently emerging themes and concepts were organized accordingly with the aim of identifying pertinent issues of relevance during care seeking and obtaining process. Typical statements were used for citation. Interview reports were supplemented by quantitative data on the number and types of obstetric condition or event each woman had, management and treatment received with their timing abstracted from multiple maternity data sources including case files, theatre and blood transfusion registers and ward daily report books. Ethical approval for this study was obtained from the ethics committees in both Gambia and Norway.
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