Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-Saharan Africa: An integrated approach

Background: Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries. Methods: Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care. Results: All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level. Conclusion: Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning. Doctors with Africa CUAMM (hereafter referred to as CUAMM) is an Italian NGO which has been supporting health service delivery in Africa for over 60 years. The organisation has adopted the continuum of care approach as the main health service delivery strategy in its interventions [14]. In 2012, CUAMM started to implement a five-year project focusing on equitable and effective access to safe childbirth and neonatal health services (dubbed “mothers and children first”) in three SSA countries: Ethiopia, Tanzania and Uganda. The project aims at achieving improved coverage and quality of essential maternal and neonatal health services and reduced inequity in access to the services. Three countries are involved in the project: Ethiopia, Tanzania and Uganda. All three countries belong to the high mortality (both maternal and under 5), high priority group of countries and are included in internationally driven strategies and initiatives such as the United Nations Secretary General’s Strategy [15] and the countdown to 2015 initiative [16], being among the five countries that account for half of Africa’s newborn deaths [17]. The project is being conducted in Wolisso, Goro and Wonchi (WGW) districts in Ethiopia, Oyam district in Uganda and Iringa district in Tanzania. All the districts and related health facilities covered by the project in the countries were included in the study. In order to accelerate reduction in maternal and neonatal mortality, government guidelines in the study countries require all health centres (HCs) and hospitals to provide basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care (CEmOC), respectively [18–20]. Table 1 presents the main demographic and health system indicators of the three countries and five districts included in the study. All three district hospitals are private-not-for-profit, belong to national health systems, and are supported by CUAMM through provision of expatriate health professionals and variable amounts of financial support. a Source: latest demographic and health survey b Source: WHO data on country stillbirth rates per 1000 total births for 2009. d Doctors, nurses and midwives; the recommended number is 23. C Source: 2014 WHO African Region country statistics summary (2002—present). e Based on data from the health management information system f District household survey A summary of tools and methods of data collection is presented in Table 2. Three types of tools were used to collect cross-sectional baseline data on coverage, equity and quality. With respect to coverage, both availability and actual use of services were assessed using the “needs assessment of emergency obstetric and newborn care” (EmONC) tools developed by the Averting Maternal Death and Disability (AMDD) program of Columbia University [21]. The AMDD’s EmONC needs assessment toolkit consists of 10 modules that cover various aspects of the health system including health facility infrastructure, human resources, drugs; equipment and supplies, facility statistics, availability of emergency obstetrics care (EmOC) signal functions, provider knowledge and competency in maternal and newborn care and the referral system. The findings in this paper are based on modules 4 (facility case summary) and 5 (EmOC signal functions). The facility case summary module was completed by reviewing hospital registers and monthly summary sheets. Data on EmOC signal functions were collected at each health facility by interviewing the maternity ward in-charge using the EmOC signal functions module. To improve the accuracy of the data, data collectors, after specific ad hoc training, reviewed several records to double-check the data. Data from these two modules were used to calculate EmOC indicators according to the standard United Nations guidelines [22] as summarised in S1 Table. EmOC indicators were used to measure the availability, use and, to a limited extent, the quality of maternal and neonatal health services. The EmOC status of a health facility is defined based on whether the facility performed certain signal functions in a three-month period prior to the survey. A BEmOC facility is one that performed all of the following 7 signal functions: i) administration of parenteral antibiotics; ii) administration of oxytocic drugs; iii) administration of anticonvulsants; iv) manual removal of placenta; v) removal of retained products; vi) assisted vaginal delivery; and vii) neonatal resuscitation with bag and mask. A CEmOC facility is one which performed all BEmOC signal functions as well as caesarean sections and blood transfusions [22]. In calculating the proportion of births in EmOC facilities, the met need for EmOC and the caesarean section coverage, we excluded 35.6% and 11% women from the neighbouring districts who sought treatment in the study hospital in Ethiopia and Uganda, respectively. However, we did not exclude women resident in the study districts who might have been treated in neighbouring districts because their number, due to long distances, was negligible. Data from Tanzania were not detailed enough to allow this kind of adjustment. We collected data on coverage between August and November 2012 from one hospital and seven HCs in Ethiopia, and from one hospital and six HCs in each of Uganda and Tanzania. We assessed equity using proxy wealth indices developed according to the methodology proposed by Pitchforth et al. [23] and previously applied to one of the participating hospitals [24]. In brief, the methodology consists of three steps: 1) using household survey data to select a small set of proxy wealth variables; 2) developing a questionnaire using the selected wealth variables; and 3) using the questionnaire to compare the wealth status of women utilising delivery services with that of women in the general population and thereby identifying inequity in the former group. A detailed description can be found in the original papers [23, 24]. The main features of the equity surveys are as summarised in S2 Table. We developed the equity assessment questionnaires based on Demographic and Health Survey (DHS) data of the respective countries. For each country, we selected 6 out of about 40 variables from the DHS; we attributed scores to these variables and assessed the validity and reliability of the scores using Pearson’s correlation coefficient (rho) and a measure of agreement (kappa), respectively, with reference to the DHS wealth index. Details regarding the scoring system are available in S3 Table. The selection of only 6 variables was driven by the need to have a simple and easy to administer tool that will cause minimal inconvenience to respondents, yet valid and reliable enough to measure the socio-economic status of the service users. The selected variables were then included in a one-page questionnaire and pretested. Two midwives/nurses were recruited at each health facility and trained on data collection. The data collectors invited all women who had delivered at the health facility to participate in the interview. Equity assessment was conducted between December 2011 and February 2013. In Uganda and Ethiopia, we collected data at both the hospital and HCs whilst in Tanzania we collected data only at the hospital. This was because a previous household survey in the Iringa District in Tanzania had shown that coverage for institutional delivery was very high (90%) and equitable, but there was some concern that utilisation of the highest level of care, i.e. at hospital, was inequitable. Data were analysed using Stata version 11. Scores from proxy wealth variables for each woman were summed up and were used to categorize women into wealth groups using the cut-off points for wealth quintiles of women in the household survey data. In the household survey data women are equally distributed in the wealth quintiles (about 20% in each quintile) and any significant shift from this distribution among users of service implies inequity. We compared the household survey data with our collected data using F tests (chi squared tests adjusted for survey design) [25]. In doing so, we used Stata commands that account for the complex sampling design and weighting used in DHS. Quality was assessed using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool [26]. The tool is standard-based and action-oriented and assesses the whole range of obstetric and neonatal care across 17 areas from support services to case management, focusing primarily on safety and effectiveness but also on women’s rights to respect, confidentiality and information. More than 400 items were assessed. Four sources of information were utilised: hospital statistics, medical records, direct observation of cases, and semi-structured interviews with staff and mothers. Interviews with staff were mainly aimed at exploring knowledge and use of guidelines, organizational procedures and team work. Interviews with mothers explored obstacles to access and patients’ satisfaction with the care and information received. A minimum of ten staff members and ten mothers was interviewed in each hospital. The sample included a variety of women who had experienced either vaginal deliveries or caesarean sections. Mothers with premature babies admitted to the neonatal ward and mothers with babies readmitted to hospital were also represented in the sample. By combining the information from the various sources, scores ranging from 3 to 0 were attributed to each item based on the following criteria: 3 = care corresponding to international standards (no need for improvement or need for marginal improvement); 2 = substandard care but no serious hazard to health or violation of human rights; 1 = inadequate care with consequent serious health hazards or violation of women’s rights to information, privacy or confidentiality and/or to children’s rights; 0 = very poor care with consequent systematic and severe hazards to the health of mothers and/or newborns, e.g. systematic omission of potentially life-saving interventions or lack of essential safety requisites for key procedures such as caesarean section, blood transfusion, neonatal resuscitation, etc. By summing up all scores, an overall average score for each main area of care was obtained. The assessments were conducted by an external multidisciplinary team (an obstetrician, a midwife, and a paediatrician/neonatologist) and involved hospital managers and health professionals. The assessments led to identification of main gaps in quality of care and to a draft plan of actions which included all issues amenable to change based on hospital resources. To ensure consistency of the assessment process, the assessment teams followed the standardized methods described for the tool [26], and one team member participated in all three assessments. Moreover, most team members had previously conducted such assessments jointly in other countries [27]. Quality assessments were conducted between August and October 2012 in all three participating hospitals. Ethical approvals to conduct the studies were obtained from the Oromiya Regional Institutional Review Committee in Ethiopia, the National Council for Science and Technology in Uganda and the National Institute of Medicine in Tanzania. The studies were also approved by the respective district health management teams in each participating district. Participants in the equity and quality studies provided signed informed consent after the objectives and methods of the study had been explained to them. Those who could not write provided verbal consent in the presence of a witness. Coverage and quality assessments relied mainly on observation and review of routine health data and medical records hence did not require informed consent. Verbal consent in the presence of a witness was obtained from interviewed mothers. All collected data were anonymous and did not contain any information that might be used to identify individual patients.