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Background: Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. Method: A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. Results: A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). Conclusions: Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.
This was a retrospective cross-sectional facility-based study which was part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. The project used an ethical framework of Accountability for Reasonableness (AFR) to guide achievement of a fair and legitimate priority setting process that would enhance trust, quality and equity in access to health care [20]. The project was designed to evaluate before and after effect of an intervention by implementation of the AFR process which has been described elsewhere [20]. This study analysed baseline data focused on emergency obstetric care. All facilities offering EmONC services in Kapiri Mposhi were enrolled in the study, that is, four rural health facilities and one urban hospital. The hospital was the main facility that offered childbirth services in the urban area. Two of the rural facilities were government run while two were faith-based. The district Kapiri Mposhi, in the Central Province of Zambia, connects to the northern part of the country via road and railway network. The population was 240,000 in 2010, 35% being urban [21]. Urban was defined according to population census of 2000 as localities of 5,000 inhabitants or more and a majority of the labour force in non-agricultural activities [22]. Kapiri Mposhi is 17 219km2 with a population density of 14.7 persons per km2 [21]. The main economic activity is subsistence agriculture and small-scale trade in the urban area. Health services for childbirth are provided mainly by the public health sector in both urban and rural areas together with a small contribution by mission health facilities in the rural area [17]. The district of Kapiri Mposhi had no comprehensive EmONC service and was not providing caesarean sections at the time of the study. Thus, women with complications in pregnancy were referred and transported by ambulance to Kabwe General Hospital, 50km outside the district. Out of 27 rural and urban health facilities that offered childbirth services, only five offered EmONC services [23]. 37% women in rural and 77% in urban areas had health facility childbirth [17]. The approach uses Major Obstetric Interventions (MOI) for Absolute Maternal Indications (AMI) to assess the health system’s ability to respond to complications in pregnancy and childbirth. Major obstetric interventions included caesarean section, laparotomy or hysterectomy for ruptured uterus, and destructive vaginal operation [11], i.e. life-saving commodities used for absolute maternal indications. This study included all these interventions except destructive vaginal delivery which was not a usual practise in the study setting. The assumption is that a minimum level of life-threatening complications in pregnancy and childbirth require major obstetric intervention. Studies have estimated that this minimum is 1.4% of expected births that require major obstetric interventions for absolute maternal indications in populations such as the study setting [24]. The unmet obstetric need is estimated as: The estimate could be viewed as an approximation since some limitations in the data are likely. The assumption is that the expected number of MOI for a given population over a period of time is known, and that the utilization of services for a particular problem, that is actual numbers of MOI, is also known. On one hand, the expected numbers of MOI is determined by the crude birth rate and the population size. Thus, an upward adjustment of these determinants would result in higher estimates of expected number of MOI and likewise a downward adjustment would result in lower estimates of expected number of MOI. On the other hand, the actual numbers of MOI which reflects the utilization of services for a particular problem depends on accurate recordings in registers and whether most women utilize the services within the area studied. If many of the recordings are inaccurate or inconsistent, or if many women with complications utilize services that are not part of the studied area, there could be an under-estimate of the actual numbers of MOI performed. Data were collected in 2011. All recorded institutional deliveries from 1st January to 31st December 2010 in the EmONC rural health facilities and the urban hospital were obtained. Data on admissions, subsequent deliveries and referrals to the comprehensive EmONC service at Kabwe General Hospital were collected retrospectively and extracted by an obstetrician and two nurse midwives using a data abstraction form. Information on catchment area of origin, mode of delivery, obstetric complications, and outcome for both the mother and the newborn was also obtained. Sources of information were registers of maternity admission and delivery wards, and follow-up from maternity ward and operation theatre in the comprehensive EmONC facility at the general hospital. Further information was obtained from case records when register information was incomplete. Reliability of the data depends on reproducibility, which implies the ability of health care providers to notify the same complications in the same way. This includes whether the same health care provider (test-retest intra-rater reliability), and other health care providers (inter-rater concurrent reliability) notify complications in the same way. Validity of the data depended upon how reliable the recorded diagnoses were made, such as cephalo-pelvic disproportion which could have low specificity. Cephalo-pelvic disproportion is a common and accepted diagnosis and may be used by default in less clear conditions. However, a gauge of reliability and validity of data poses challenges when dealing with women who pass quickly through the system of care providers. On data completeness, it was possible that some women could have utilized other hospitals neighbouring Kapiri Mposhi district, although the geographical distribution of other hospitals made self-referrals less likely. Whereas Kabwe General Hospital was about 50km from Kapiri Mposhi, Ibenga Mission Hospital and Mpongwe Mission Hospital were 94km and 99km away, respectively, and public motor transport was not easily available for the local community (Fig 2). Data obtained from registers mainly agreed with those recorded in case records, such that there was no reason to query the quality of information in the registers. Information on functionality of basic and comprehensive EmONC facilities was also obtained. The rationale for this was based on knowledge that to reduce maternal deaths, certain obstetric functions in facilities must be available. Certain health facilities may be categorised as EmONC by the health system, yet if conditions are not met this may hide inadequacy in coverage of services. Fig 1 shows signal functions that describe basic and comprehensive EmONC facilities. A standard tool was used to obtain information on functions performed at least once in the previous three months prior to the survey by interviewing the nurse-in-charge of the maternity ward [8]. Reasons for not performing any of the signal functions were recorded. Inspection for availability of equipment and drugs in maternity wards was done. The WHO defines a basic EmONC facility as one that performed all seven signal functions in the last three months prior to a survey [8]. A comprehensive EmONC facility performs caesarean section and blood transfusion plus the seven functions in basic EmONC in the last three months. However, if a function such as assisted vaginal delivery is systematically absent in an area due to policy, the functioning of the facilities is indicated as “basic EmONC minus 1” or “comprehensive EmONC minus 1” [8]. Data analysis was done using SPSS for Windows version 20, SPSS Inc. Chicago Illinois. Absolute maternal indications included uterine rupture; obstructed labour due to mal-presentation (transverse lie, oblique lie, shoulder presentation) and cephalo-pelvic disproportion; antepartum and severe postpartum haemorrhage; and abdominal pregnancy. For women who had more than one diagnosis, the main indication that led to intervention was used in the analysis. Maternal complications that could result in a vaginal delivery without causing a maternal death such as eclampsia and foetal indications such as foetal distress, breech presentation and cord presentation/prolapse were not included as absolute maternal indications. Major obstetric interventions included caesarean section, hysterectomy or repair for ruptured uterus and laparotomy for abdominal pregnancy. Abortions were excluded. We compared age and parity between the rural and urban population by using independent t-test; origin of women, absolute maternal and foetal indications for interventions, and outcome of new-borns by using Pearson’s chi square test; and major obstetric interventions by using Fischer’s exact test. Origin of women meant residence either within the catchment area, from 12km to 35km radius of a health facility, or from outside the catchment area. Frequencies and proportions of complications were estimated for rural and urban health facilities. We also calculated the major obstetric interventions for absolute maternal indications as a percentage of population expected births (estimated by multiplying the crude birth rate with population size) [21], and calculated urban rural rate ratio. Based on the reference of 1.4% (95% CI 1.27% to 1.52%), the variance estimate for unmet obstetric need for the total study population was 40.8% (95% CI 34.9% to 45.8%). The variance estimate for the urban area was -48.6% (95% CI -66.7% to -37.5%), and the rural area was 72.6% (95% CI 69.8% to 74.8%). We assessed the functioning of the facilities as EmONC by finding out whether defining procedures were performed in the three months prior to the study. Ethical clearance was obtained from University of Zambia Research Ethics Committee. Permission was also granted by Kapiri Mposhi District Health Management office. This study was specifically approved by the Steering Committee of REACT project, which is also the project review board. Confidentiality and anonymity of study candidates was maintained.
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