Estimating the met need for emergency obstetric care (EmOC) services in three payams of Torit County, South Sudan: A facility-based, retrospective cross-sectional study

Objective To determine the met need for emergency obstetric care (EmOC) services in three Payams of Torit County, South Sudan in 2015 and to determine the frequency of each major obstetric complication. Design This was a retrospective cross-sectional study. Setting Four primary healthcare centres (PHCCs) and one state hospital in three payams (administrative areas that form a county) in Torit County, South Sudan. Participants All admissions in the obstetrics and gynaecology wards (a total of 2466 patient admission files) in 2015 in all the facilities designated to conduct deliveries in the study area were reviewed to identify obstetric complications. Primary and secondary outcome measures The primary outcome was met need for EmOC, which was defined as the proportion of all women with direct major obstetric complications in 2015 treated in health facilities providing EmOC services. The frequency of each complication and the interventions for treatment were the secondary outcomes. Results Two hundred and fifty four major obstetric complications were admitted in 2015 out of 390 expected from 2602 pregnancies, representing 65.13% met need. The met need was highest (88%) for Nyong Payam, an urban area, compared with the other two rural payams, and 98.8% of the complications were treated from the hospital, while no complications were treated from three PHCCs. The most common obstetric complications were abortions (45.7%), prolonged obstructed labour (23.2%) and haemorrhage (16.5%). Evacuation of the uterus for retained products (42.5%), caesarean sections (32.7%) and administration of oxytocin for treatment of postpartum haemorrhage (13.3%) were the most common interventions. Conclusion The met need for EmOC in Torit County is low, with 35% of women with major obstetric complications not accessing care, and there is disparity with Nyong Payam having a higher met need. We suggest more support supervision to the PHCCs to increase access for the rural population. We conducted a retrospective cross-sectional study of women who had been treated for major direct obstetric complications from five EmOC facilities in three payams of Torit County in 2015. This study was conducted in health facilities located in three payams of Torit County in the former Eastern Equatoria state, Republic of South Sudan—Kudo, Nyong and Himodonge—with a total projected population of 72 071 in 2015.14 Payams in South Sudan are administrative areas that constitute a county, which in turn constitutes a state. Nyong Payam (also called Torit Payam) in which the state capital, Torit, is located was the most populated with 47 253 inhabitants, while Kudo Payam had 13 461 and Himodonge Payam had 11 357. The public healthcare system in South Sudan is structured into five levels: the primary healthcare units (PHCUs), the primary healthcare centres (PHCCs), the county hospitals (CHs), the state hospitals (SHs) and the teaching hospitals (THs).12 PHCUs are the lowest level facilities that provide preventive, promotional and curative services aimed to serve a population of 15 000 people, while PHCCs act as immediate referral points for the PHCUs and aimed to serve a population of 50 000 people with all the services offered in a PHCU, plus diagnostic laboratory, and maternity and inpatient care services. The CHs meant to serve 300 000 people and SHs to serve 500 000 people, act as secondary care units while the THs provide tertiary care. There are a total of 11 public health facilities in the study area, including one SH located in Nyong Payam, which acts as a referral centre. Out of the 11 health facilities, only 5 including Torit State Hospital (TSH) can conduct deliveries and are designated as EmOC facilities; four are basic EmOC facilities, each with six-bed capacity, and one hospital, which is a comprehensive EmOC facility with 22-bed capacity dedicated to obstetric cases. Health service delivery in these facilities is supported by implementing partners under the HPF grant: Save the Children International for the PHCCs and Catholic Organization for Relief and Development Aid for TSH. These partners recruit the necessary human resource and provide the medical supplies, while the government does supportive supervision. The other six public facilities are PHCUs, and together with the private facilities composed mainly of small clinics and drug shops neither conduct deliveries nor admit patients with major direct obstetric complications. All women admitted with major direct obstetric complications in any of the five facilities in the study area between 1 January and 31 December 2015 were included in this study. The admission records of women who were not residents in the study areas were excluded as they were assumed to represent a demand for EmOC services from elsewhere. The population projection for 2015 in this study area was calculated from the 2008 census to be 72 071. Assuming the same crude birth rate for South Sudan of 36.1/1000 population,15 a total of 2602 births were expected in 2015. According to the WHO, an estimated 15% (390) of these were expected to get major obstetric complications.3 Using OpenEpi V.3 for sample size calculation for the proportion who get EmOC services from the facilities and assuming a population size (for finite population correction factor) of 390, a met need of 38.3%±5 for the population is hypothesised, assuming the results of an assessment in Yirol County, Lakes State of South Sudan,16 and design effect (for cluster surveys)=1; allowing 10% for missing data, a sample size of 208 was enough for a 95% confidence level. All the admission records in the obstetrics and gynaecology wards of the health facilities between 1 January and 31 December 2015 were reviewed by one of the researchers (PB) to identify cases of major direct obstetric complications, the interventions used for treatment and the outcomes of treatment. All records had been kept in paper form and written in English. The information collected included the date of admission, and demographic data such as age, parity, ethnic group and the payam of residence. The direct obstetric complications for which the patient was admitted were recorded, and according to WHO these complications include haemorrhage, prolonged or obstructed labour, abortion complications, postpartum sepsis, pre-eclampsia/eclampsia, ruptured uterus and ectopic pregnancy.3 Information was also collected about the pregnancy outcomes at the end of the admission, which included spontaneous vaginal delivery, instrumental vaginal delivery, caesarean section, complete abortion, evacuation of the uterus for retained products of conception, laparotomy for ruptured uterus, laparotomy for ectopic pregnancy, and/or if the woman died or was discharged or escaped from the facility while still pregnant. Maternal and neonatal outcomes during the admission were noted: whether dead or alive, and for the alive neonates whether they required resuscitation at birth. Information was further collected about the other interventions for other obstetric complications, such as administration of parenteral oxytocin, repair of genital tract tears and hysterectomy for postpartum haemorrhage, administration of magnesium sulfate for severe pre-eclampsia and/or eclampsia, administration of parenteral antibiotics for puerperal sepsis, manual removal of the placenta, and blood transfusion for severe haemorrhage. The primary outcome in this study was the met need for EmOC, which was defined as the proportion of all women with major direct obstetric complications in the population treated in the health facilities between 1 January and 31 December 2015. The frequency of each complication and the appropriate interventions to treat them are reported as secondary outcomes. Data were checked, coded, entered and analysed using SPSS V.21. Frequency tables were used to present descriptive statistics such as the number of direct obstetric complications admitted from each payam and treated in each facility, the interventions used for treating the complications, pregnancy outcomes after the admission, as well as maternal and fetal outcomes of the complication. The crude birth rate for the population was used to calculate the expected number of deliveries in a year; 15% of these were assumed to have gotten major obstetric complications.3 The proportion of the complications treated in the facilities was calculated to represent the met need for EmOC services, and the 95% CIs were calculated using the formula for single population proportions.17 The age and parity differences among patients admitted with major obstetric complications from the three payams were compared using analysis of variance (ANOVA). The corresponding CIs and P values were presented in a table format. All significance levels were set at P≤0.05. A waiver of consent for the medical record reviews was obtained. Written consent was obtained from the facility in-charge to review the facility records after giving them written information about the study. Each complicated case reviewed was assigned a unique study number. The data collected from questionnaires were stored under lock and key, and were entered into SPSS in a computer that was password-protected and only accessed by the researchers.