The quality of free antenatal and delivery services in Northern Sierra Leone

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Study Justification:
– The study was conducted to address the high maternal mortality ratio in Sierra Leone, particularly in the Northern Region.
– It aimed to assess the quality of free antenatal and delivery services provided in the region.
– The study aimed to identify barriers and challenges in accessing emergency obstetric care.
– The findings of the study would provide valuable insights for improving the quality of maternal healthcare services and reducing maternal deaths.
Study Highlights:
– The quality of antenatal and delivery services in the Northern Region of Sierra Leone was found to be poor.
– Only 27% of women received an adequate examination during antenatal care.
– Delivery services lacked essential infrastructure, skilled staff, and necessary supplies.
– None of the basic emergency obstetric care facilities met national standards.
– Geographic inequities in access to comprehensive emergency obstetric care were observed.
Study Recommendations:
– The health sector should monitor the quality of antenatal interventions in addition to measuring coverage.
– Improvements in infrastructure, staffing, and supply chain management are needed to enhance the quality of delivery services.
– Efforts should be made to address geographic inequities in access to comprehensive emergency obstetric care.
– The health sector should investigate and address the barriers influencing the uptake of antenatal and delivery services.
– More sustainable funding mechanisms should be explored to ensure the availability and quality of maternal healthcare services.
Key Role Players:
– Ministry of Health and Sanitation
– District Health Management Teams
– Health facility managers and staff
– Maternal health experts and researchers
– Community leaders and organizations
– Donor agencies and international partners
Cost Items for Planning Recommendations:
– Infrastructure improvement (e.g., construction or renovation of delivery rooms)
– Staff training and capacity building
– Procurement of delivery kits, equipment, and supplies
– Supply chain management and logistics
– Outreach and awareness campaigns
– Monitoring and evaluation systems
– Research and data collection
– Advocacy and policy development
Please note that the provided cost items are general categories and may vary based on specific needs and context.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a cross-sectional survey conducted in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. The survey included interviews with antenatal care providers and pregnant women, as well as observations of antenatal and delivery services. The study used national standards to assess the adequacy of services and also calculated the distance between delivery facilities and comprehensive emergency obstetric care facilities. The findings highlight poor quality of services, inadequate infrastructure and staff, and geographic inequities. To improve the evidence, the study could have included qualitative data collection and explored the reasons behind the identified inequities. Additionally, collecting data on the structural and intermediary determinants of health inequities would have provided a more comprehensive understanding of the factors influencing maternal outcomes.

Background: The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone. Methods: A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities. Results: The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care. Conclusion: The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

The cross-sectional health facility survey was conducted from March to April 2014 in Bombali District, one of five districts in the Northern Region of Sierra Leone. The survey included all public and missionary health facilities in the district. In total, 100 health facilities were surveyed, consisting of three district hospitals, 94 public peripheral health units and three not-for-profit health facilities. The survey team interviewed the officers-in-charge on the day of the survey and observed two or three antenatal providers at work within each of the 97 peripheral health units. Face-to-face interviews were conducted with 486 pregnant women who accessed antenatal services in the surveyed health facilities on the day of the study. They were interviewed immediately after they received antenatal services. We adapted and field tested the WHO safe motherhood questionnaires and the antenatal care observation checklist developed by the USAID Maternal and Child Health Integrated programme [17, 18]. We collected data on the numbers of beds assigned to pregnant women in facilities; the infrastructure, equipment, drugs and supplies of the clinic; antenatal and delivery services; complications that occurred; laboratory services; emergency obstetric services and referrals; and family planning and educational materials in the clinic. We observed and assessed current practice in antenatal clinics using the antenatal checklist. In the antenatal client exit interview, women were asked about their age, how they got to the clinic, the cost of using the services, their maternity and delivery history, the services and counselling they received in the clinic, and their knowledge of pregnancy-related danger signs. Several records, including antenatal cards, delivery register, normal delivery and complicated delivery records, were reviewed retrospectively. Data were collected on maternal and newborn outcomes, including mode of delivery, live births, Apgar scores, birth weight, fresh stillbirths, macerated stillbirths, immediate neonatal deaths, maternal outcome and referrals. Quantitative data were analysed using SPSS. The summary measures were proportions calculated for quantitative variables. Confidence intervals were calculated for proportions. National standards [19] for antenatal interventions in peripheral health units during antenatal clinics were adapted and used to assess the adequacy of antenatal services offered to women in three domains. A woman who was examined for the recommended six physical signs on her first antenatal visit was rated as having received an adequate examination. If fewer signs were examined for, she was rated as having been inadequately examined. Women who were observed to receive the four recommended basic tests on their first antenatal visit were adequately screened and fewer tests were rated as inadequately screened. If three interventions were offered to women in their third trimester, women were considered to have received adequate interventions. Fewer interventions were considered an inadequate level of care. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility. Then, the proportion of facilities in a chiefdom within 15 km of each CEOC facility was calculated. A thematic map was developed to show inequities in CEOC facility service provision. The study was approved by the National Ethics and Scientific Review Committee of the Ministry of Health and Sanitation. Pregnant women who participated gave individual informed consent. The outbreak of Ebola in May 2014 made it difficult to collect qualitative data. Focus group discussions were not convened as planned because of the Health Emergency Regulation limiting the movement of people. The study did not collect data on the structural and intermediary determinants of heath inequities that affect maternal outcomes.

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Based on the information provided, here are some potential innovations that could improve access to maternal health in Sierra Leone:

1. Mobile clinics: Implementing mobile clinics that can travel to remote areas and provide antenatal and delivery services to women who do not have easy access to healthcare facilities.

2. Telemedicine: Utilizing telemedicine technology to connect pregnant women in remote areas with healthcare professionals who can provide virtual consultations and guidance throughout their pregnancy.

3. Training and capacity building: Investing in training and capacity building programs for healthcare providers to improve their skills and knowledge in providing quality antenatal and delivery services.

4. Infrastructure improvement: Upgrading and improving the infrastructure of healthcare facilities to ensure they have the necessary equipment, supplies, and facilities for safe deliveries.

5. Community health workers: Expanding the role of community health workers to provide basic antenatal and delivery services, as well as education and support to pregnant women in their communities.

6. Public-private partnerships: Collaborating with private healthcare providers to increase the availability and accessibility of antenatal and delivery services, particularly in underserved areas.

7. Transportation support: Providing transportation support for pregnant women to access healthcare facilities, especially in areas where the distance to comprehensive emergency obstetric care facilities is a barrier.

8. Health information systems: Implementing robust health information systems to collect and analyze data on maternal health outcomes, which can help identify areas for improvement and inform decision-making.

9. Financial incentives: Introducing financial incentives for pregnant women to encourage them to seek antenatal and delivery services, such as cash transfers or vouchers for free or discounted healthcare services.

10. Community engagement and awareness campaigns: Conducting community engagement and awareness campaigns to educate pregnant women and their families about the importance of antenatal and delivery care, and to address cultural and social barriers that may prevent women from seeking these services.

These are just a few potential innovations that could be considered to improve access to maternal health in Sierra Leone. It is important to assess the feasibility, effectiveness, and sustainability of these innovations before implementing them on a larger scale.
AI Innovations Description
Based on the description provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Improve the quality of antenatal and delivery services: Based on the findings of the survey, it is crucial to address the poor quality of services provided. This can be achieved by implementing training programs for healthcare providers to ensure they adhere to national standards and guidelines for antenatal and delivery care. Additionally, facilities should be equipped with necessary infrastructure, delivery rooms, delivery kits, and portable water to enhance the quality of care.

2. Increase the availability of skilled attendants: The survey revealed that only 35% of deliveries were supervised by skilled attendants. To improve access to quality maternal health services, efforts should be made to increase the number of skilled healthcare providers, particularly in areas with limited access to comprehensive emergency obstetric care (CEOC) facilities. This can be achieved by offering incentives to healthcare professionals to work in underserved areas and implementing training programs to enhance their skills.

3. Address stock-outs of consumables: The survey identified stock-outs of consumables as a challenge in delivering quality maternal health services. To address this issue, a robust supply chain management system should be established to ensure a consistent supply of essential drugs, equipment, and supplies. Regular monitoring and evaluation should be conducted to identify and address any gaps in the supply chain.

4. Improve access to comprehensive emergency obstetric care (CEOC) facilities: The survey highlighted geographic inequities in access to CEOC facilities. To address this, efforts should be made to establish CEOC facilities in areas with limited access. Additionally, transportation systems should be improved to ensure timely and efficient referral of pregnant women in need of emergency obstetric care.

5. Explore sustainable funding mechanisms: The survey findings suggest the need for sustainable funding mechanisms to support maternal health services. This can be achieved by exploring partnerships with international organizations, NGOs, and private sector entities. Additionally, advocating for increased government funding for maternal health programs can help ensure long-term sustainability.

By implementing these recommendations, it is possible to develop innovative solutions that improve access to maternal health services and reduce maternal mortality in Sierra Leone.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthen infrastructure: Improve the physical infrastructure of health facilities by ensuring the availability of delivery rooms, delivery kits, and portable water. This will create a conducive environment for safe deliveries and enhance the quality of maternal health services.

2. Increase skilled staff: Address the shortage of skilled healthcare providers by recruiting and training more midwives and other healthcare professionals. This will ensure that deliveries are attended by skilled personnel, leading to better maternal outcomes.

3. Improve stock management: Implement effective stock management systems to prevent stock-outs of essential drugs and supplies. This will ensure that pregnant women receive the necessary interventions and treatments during antenatal care and delivery.

4. Enhance emergency obstetric care: Strengthen the provision of comprehensive emergency obstetric care (CEOC) facilities. This can be done by improving the infrastructure, equipment, and staffing of existing CEOC facilities and establishing new ones in areas with limited access.

5. Address geographic inequities: Develop strategies to address geographic inequities in access to CEOC facilities. This may involve establishing mobile clinics or outreach programs to reach remote areas and providing transportation support for pregnant women in need of emergency obstetric care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current state of maternal health services, including the availability of infrastructure, skilled staff, and essential supplies. Collect information on the distance between health facilities providing delivery services and the nearest CEOC facility.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of facilities with adequate infrastructure, the proportion of deliveries attended by skilled personnel, and the percentage of facilities within a certain distance of a CEOC facility.

3. Baseline assessment: Calculate the baseline values for the selected indicators based on the collected data.

4. Intervention implementation: Implement the recommended interventions, such as improving infrastructure, increasing skilled staff, and addressing stock management issues.

5. Post-intervention assessment: Measure the indicators again after the interventions have been implemented to assess the changes in access to maternal health services.

6. Data analysis: Analyze the data to determine the impact of the interventions on improving access to maternal health. Compare the post-intervention values with the baseline values to quantify the improvements.

7. Interpretation and reporting: Interpret the findings and report on the simulated impact of the recommendations. Highlight the areas of improvement and identify any remaining challenges or gaps that need to be addressed.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of specific recommendations on improving access to maternal health and make informed decisions to prioritize and implement the most effective interventions.

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