Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: It is time to improve regulatory mechanisms

  • Reproductive Health, Volume 16, No. 1, Year 2019

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Study Justification:
– The study aimed to assess the availability, quality, and equity of emergency obstetric care (EmOC) in the Democratic Republic of the Congo (DRC).
– The DRC has high maternal and neonatal mortality rates, indicating a need for improvement in EmOC services.
– The study aimed to identify the challenges and gaps in EmOC service delivery in order to inform policy and improve regulatory mechanisms.
Study Highlights:
– Out of the surveyed health facilities, only 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC.
– The distribution of EmOC services was unequal across provinces and urban vs. rural areas, with urban areas and certain provinces having better access.
– Some health centers and health posts were providing services, such as caesarean sections and blood transfusions, despite guidelines disallowing the practice.
– None of the facilities provided quality EmOC due to the lack of proper standards and guidelines.
Recommendations for Lay Reader and Policy Maker:
– The Ministry of Health should go beyond granting funds and ensure the establishment and monitoring of appropriate standard operating procedures for EmOC providers.
– Regulatory mechanisms should be strengthened to improve the distribution and quality of EmOC services.
– Efforts should be made to ensure equitable access to EmOC services across all provinces and urban vs. rural areas.
– Proper training and guidelines should be provided to health facilities to ensure the provision of quality EmOC services.
Key Role Players Needed to Address Recommendations:
– Ministry of Health: Responsible for implementing and monitoring regulatory mechanisms, establishing standard operating procedures, and providing training and guidelines.
– Health Facilities: Need to adhere to the established standards and guidelines, provide training to staff, and ensure the availability of necessary equipment and supplies.
– Provincial Health Authorities: Responsible for coordinating and supporting the implementation of regulatory mechanisms and ensuring equitable access to EmOC services.
– Research Institutions: Can provide technical support, conduct further studies, and evaluate the impact of interventions.
Cost Items to Include in Planning Recommendations:
– Training and Capacity Building: Budget for training healthcare providers in EmOC procedures and guidelines.
– Equipment and Supplies: Allocate funds for the procurement and maintenance of necessary equipment and supplies for EmOC services.
– Monitoring and Evaluation: Set aside resources for monitoring the implementation of regulatory mechanisms and evaluating the quality of EmOC services.
– Research and Technical Support: Allocate funds for research institutions to provide technical support, conduct studies, and evaluate interventions.
Please note that the above information is a summary of the study and its recommendations. For more detailed information, please refer to the publication “Reproductive Health, Volume 16, No. 1, Year 2019”.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a cross-sectional survey of 1,555 health facilities in the Democratic Republic of the Congo (DRC) to assess the availability, quality, and equity of emergency obstetric care (EmOC). The data collection methods included interviews, document reviews, and direct observation of service delivery. The study found that only 9.1% of facilities provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across provinces and urban vs. rural areas. The study also highlighted the lack of proper standards and guidelines as a major factor contributing to the lack of quality EmOC. To improve the strength of the evidence, future studies could consider using a longitudinal design to assess changes over time and include a larger sample size to increase generalizability.

Background: The Demographic and Health Survey 2013-14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC. Methods: A cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson’s chi-squared test using an alpha significance level of 0.05. Results: A total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines. Conclusions: The distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.

The DRC extends over a large land mass the size of Western Europe. The country faces several major challenges in the EmOC needs of its population due, at least in part, to poor supply chain management, which greatly hinders the delivery of any type of health service. Despite the persistence of these challenges, reproductive health services are well attended by women aged 15–49 years; an estimated 88% of pregnant women benefit from antenatal care (ANC) and 80% of deliveries occur in health facilities. However, modern contraceptive prevalence remains low, estimated at 8% and the fertility rate is still high at 6.6 children per woman [6]. The health system is organized at the national, provincial, and local level. All health facilities have to provide reproductive health services, such as ANC, deliveries, postnatal care (PNC), family planning, and post-abortion care. The Health District consists of two types of health facilities: first line health centers and a district referral hospital. Based on the DRC’s policy documents, the former provide primary health care, including basic EmOC, whereas the latter provides specialized care, which includes comprehensive EmOC, imagery, and laboratory services. Two other ‘non-compulsory’ types of facilities exist: health posts and referral health centers, which deliver services that are not clearly defined [29, 30]. The health sector is characterized by public underfunding, the uncontrolled production of doctors and nurses, in association with the under-production of qualified midwives. The health infrastructure is insufficient and outdated, and the functioning of health facilities is essentially ensured by patients’ payments. This is a cross-sectional study conducted in health facilities in the DRC from April 2014 to June 2014. Four types of facilities were included in the study: hospitals, referral health centers, health centers, and health posts [30]. To be eligible for the study, each facility had to be listed on the Ministry of Health’s roster of facilities and to have provided data to the National Health Information System (NHIS) in the 6 months prior to the study. Before selecting health facilities, the researchers and health officials reviewed the list from each province and updated the roster of facilities reporting to the NHIS. The sampling frame contained only functional facilities. For this study, we used 11 strata, equivalent to the 11 provinces of the DRC. Four substrata corresponded to each type of health facility. To calculate the sample size for each substratum, we used a proportion of 0.5 of facilities that were supposed to have the characteristic of interest, given that the proportion of facilities providing EmOC was unknown. Systematic random sampling, using a sampling interval, helped select the visited health facilities in each substratum. Of the 15,998 functioning health facilities, this procedure yielded a sample of 1,568 facilities. An index of availability of EmOC and an index of quality of EmOC were calculated by modifying WHO-proposed tools [31]. The index of availability of EmOC was based on four criteria a facility had to meet to be considered as offering EmOC: infrastructure, a specific room dedicated to assisted vaginal delivery (a delivery room); a staff member is assigned to reproductive health activities, such as assisted vaginal delivery, and family planning; at the time of the survey or over a period of 6 months before the study, the facility offers seven functions defined as basic EmOC (assisted vaginal delivery, removal of retained products of conception, manual removal of the placenta, basic neonatal resuscitation, and parenteral administration of oxytocin, antibiotics, and anticonvulsants) or nine functions defined for comprehensive EmOC (all basic care plus blood transfusion and caesarean section) [20]; and evidence of service utilization based on service statistics (e.g., at least one assisted delivery recorded during the 6 months preceding the survey). The quality index for basic EmOC was based on four elements: the presence of at least one staff member trained in EmOC during the 2 years preceding the survey; existence of basic EmOC delivery guideline documents; availability of material and equipment, including delivery kits, birthing bed, partograph, examination light, manual vacuum, sterilization equipment, ambulance for emergency transport, suction apparatus, manual vacuum extraction, ball and face mask; and availability of drugs and products, such as gloves, disinfectant, injectable uterotonics, injectable antibiotics, infusion solutions, ophthalmic antibiotic ointment, and magnesium sulfate. The quality index for comprehensive EmOC was based on the following five elements: availability of at least one staff member trained in each category of care (comprehensive EmOC, surgery, anesthesia) in the prior 2 years; existence of comprehensive EmOC delivery guideline documents; availability of material and equipment, including a baby incubator and anesthesia equipment; availability of drugs and products, such as sufficient blood supply, secure blood supply, lidocaine 5%, epinephrine (injection), halothane (inhalation), atropine (injection), thiopental (powder), suxamethonium bromide (powder), and ketamine (injection); and diagnostic capability, such as blood grouping test and cross-compatibility test. These elements focus mostly on Donabedian’s first dimension of quality care, concentrating on the structure of care. Donabedian’s second dimension, process of care, was captured in the researchers’ index by observing whether EmOC service delivery guidelines exist and are used. As the elements included in our index comprise a modest measure of quality, only facilities that met all of the above criteria were classified as having high quality; if one or more of the criteria were not met, the facility was assessed as having low quality EmOC. In order to determine the efforts needed to improve the quality, particularly when it was poor, we calculated the index ‘operational capacity of EmOC’, which indicates the proportion of quality elements available in health facilities and, indirectly, those to be provided. Independent variables included the administrative identity of health facilities, location, types of health facilities, and provinces. Before collecting the data, we contacted provincial health officials to determine how to access each selected facility and what resources were needed. At each facility, data were collected by two staff members (doctors and nurses) recruited from health facilities not selected for the study and trained as interviewers. They visited all facilities and collected data through structured interviews with managers and heads of reproductive health services, performed document reviews, and made direct observations. One interviewer asked the questions and recorded the answers on a paper form while another recorded the same information on a laptop computer. Before leaving the facility, the two interviewers resolved any discrepancies between the paper and electronic forms. Quality control was done by supervisors who revisited 10% of facilities selected randomly to validate the data. All data were weighted by stratum before analysis. Microsoft Excel 2010 was used to produce graphs and charts and WINPEPI version 11.54 for analysis and testing of associations. The indices of availability and quality of EmOC were calculated as a proportion of all facilities according to the independent variables mentioned above. Pearson’s chi-squared test was used to test the association of different variables. All hypotheses were tested using an alpha significance level of 0.05. This study was reviewed and approved by the Ethics (Human Subjects) National Committee (approbation number 07/CNES/BN/PMMF/2013). The research team obtained authorizations from national and provincial health authorities prior to the survey. Data were collected anonymously after obtaining informed consent from the facilities.

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Based on the provided description, here are some potential innovations that could improve access to maternal health in the Democratic Republic of the Congo:

1. Strengthening supply chain management: Implementing innovative supply chain management systems can help ensure the availability of essential maternal health supplies and medications in health facilities across the country. This could involve using technology such as mobile applications or blockchain to track and manage inventory, improve forecasting, and streamline distribution.

2. Telemedicine and teleconsultations: Introducing telemedicine services can help overcome geographical barriers and improve access to specialized maternal health care in remote areas. This could involve setting up teleconsultation centers where healthcare providers can remotely assess and provide guidance to pregnant women and healthcare workers in underserved areas.

3. Mobile health (mHealth) interventions: Utilizing mobile phones and text messaging services can be an effective way to disseminate important maternal health information and reminders to pregnant women and new mothers. This could include sending text messages with prenatal care tips, appointment reminders, and information about emergency obstetric care services.

4. Training and capacity building: Investing in training programs for healthcare providers, particularly midwives, can help improve the quality of maternal health services. This could involve innovative training methods such as simulation-based learning or e-learning platforms to enhance skills and knowledge.

5. Community-based interventions: Implementing community-based programs that focus on raising awareness about maternal health, promoting healthy behaviors, and providing support to pregnant women can help improve access to care. This could involve training community health workers to provide basic maternal health services, conducting community outreach programs, and establishing support groups for pregnant women.

6. Strengthening regulatory mechanisms: Improving regulation and monitoring of maternal health services can help ensure the provision of quality care. This could involve developing and enforcing standards and guidelines for emergency obstetric care, conducting regular facility assessments, and implementing mechanisms for accountability and quality improvement.

These are just a few potential innovations that could be considered to improve access to maternal health in the Democratic Republic of the Congo. It is important to assess the feasibility, acceptability, and effectiveness of these innovations in the local context before implementation.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health in the Democratic Republic of the Congo (DRC) is to establish and monitor appropriate standard operating procedures for providers. This recommendation is based on the findings that the distribution and quality of emergency obstetric care (EmOC) in the DRC are problematic, with only a small percentage of health facilities providing basic or comprehensive EmOC. The lack of regulation and monitoring is identified as a key contributing factor to this issue.

To address this, the Ministry of Health should go beyond simply granting funds and take steps to ensure the establishment and monitoring of appropriate standard operating procedures for providers. This would involve developing clear guidelines and standards for EmOC services, including infrastructure requirements, staffing levels, and service utilization criteria. These guidelines should be based on internationally recognized best practices and tailored to the specific context of the DRC.

Additionally, the Ministry of Health should implement a system for monitoring and evaluating the implementation of these standard operating procedures. This could involve regular inspections of health facilities to assess their compliance with the guidelines, as well as the collection and analysis of data on EmOC service delivery and outcomes. By monitoring the quality and availability of EmOC services, the Ministry of Health can identify gaps and take corrective actions to ensure that all women in the DRC have access to safe and effective maternal health care.

Overall, the recommendation is to improve regulatory mechanisms for EmOC in the DRC by establishing and monitoring appropriate standard operating procedures for providers. This will help to ensure that maternal health services are available, of high quality, and equitably distributed across the country.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health in the Democratic Republic of the Congo (DRC):

1. Strengthen supply chain management: Implementing effective supply chain management systems can help ensure the availability of essential maternal health commodities, such as drugs, equipment, and supplies, in health facilities across the country. This can be achieved through improved forecasting, procurement, storage, and distribution processes.

2. Enhance regulatory mechanisms: The Ministry of Health should establish and enforce proper standards and guidelines for maternal health service providers. This includes monitoring the quality of care provided, ensuring adherence to best practices, and taking appropriate actions against non-compliant facilities.

3. Increase investment in healthcare infrastructure: The DRC should invest in improving and expanding healthcare infrastructure, particularly in rural areas where access to maternal health services is limited. This includes constructing and equipping health facilities, as well as improving transportation networks to facilitate the timely referral of high-risk cases.

4. Strengthen the healthcare workforce: Addressing the shortage of qualified midwives and healthcare professionals is crucial for improving access to maternal health services. This can be achieved through increased training programs, incentives to attract and retain healthcare workers in underserved areas, and the deployment of community health workers to provide basic maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that reflect access to maternal health services, such as the number of facilities providing EmOC, the availability of essential maternal health commodities, the quality of care provided, and the proportion of pregnant women receiving ANC and delivering in health facilities.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, document reviews, and direct observations in a representative sample of health facilities across the DRC.

3. Implement interventions: Implement the recommended interventions, such as strengthening supply chain management, enhancing regulatory mechanisms, investing in healthcare infrastructure, and strengthening the healthcare workforce.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through regular surveys, facility assessments, and data collection from health information systems.

5. Analyze the data: Analyze the collected data to assess the impact of the interventions on the selected indicators. This can involve comparing the baseline data with the post-intervention data and conducting statistical tests, such as Pearson’s chi-squared test, to determine the significance of any observed changes.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the impact of the interventions on improving access to maternal health. Identify any gaps or areas that require further attention and make recommendations for future interventions or improvements.

By following this methodology, policymakers and stakeholders can gain insights into the effectiveness of the recommended interventions and make informed decisions to further improve access to maternal health in the DRC.


Statistics:
Citations: 14
Identifiers:
DOI: 10.1186/s12978-019-0772-z
Research Areas:
Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Congo
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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