The status of maternal and newborn health care services in Zanzibar

Background: It is estimated that 287,000 women worldwide die annually from pregnancy and childbirth-related conditions, and 6.9 million under-five children die each year, of which about 3 million are newborns. Most of these deaths occur in sub-Saharan Africa. The maternal health situation in Tanzania mainland and Zanzibar is similar to other sub-Saharan countries. This study assessed the availability, accessibility and quality of emergency obstetric care services and essential resources available for maternal and child health services in Zanzibar. Methods: From October and November 2012, a cross-sectional health facility survey was conducted in 79 health facilities in Zanzibar. The health facility tools developed by the Averting Maternal Death and Disability program were adapted for local use. Results: Only 7.6% of the health facilities qualified as functioning basic EmONC (Emergency Obstetric and Neonatal Care) facilities and 9% were comprehensive EmONC facilities. Twenty-eight percent were partially performing basic EmONC and the remaining 55.7% were not providing EmONC. Neonatal resuscitation was performed in 80% of the hospitals and only 17.4% of the other health facilities that were surveyed. Based on World Health Organisation (WHO) criteria, the study revealed a gap of 20% for minimum provision of EmONC facilities per 500,000 population. The met need at national level (proportion of women with major direct obstetric complications treated in a health facility providing EmONC) was only 33.1% in the 12months preceding the survey. The study found that there was limited availability of human resources in all visited health facilities, particularly for the higher cadres, as per Zanzibar minimum staff requirements. Conclusion: There is a need to strengthen human resource capacity at primary health facilities through training of health care providers to improve EmONC services, as well as provision of necessary equipment and supplies to reduce workload at the higher referral health facilities and increase geographic access.

A cross-sectional health facility survey was conducted in Unguja and Pemba Islands of Zanzibar between October and November, 2012. The study involved public, private for profit, and non-governmental organization health facilities providing maternal and child health (MCH) services. There were 224 health facilities in Zanzibar at the time of the survey. Sixty four percent of these facilities were government owned; 34 % were privately owned, while 2 % were parastatal. The health sector in Zanzibar includes three levels of care and corresponding facilities as follows: a) Primary level: Health Care Units and Centres (PHCUs, PHCU+ and Primary Health Care Centres-PHCCs) b) Secondary level: District Hospitals c) Tertiary level: Mnazi Mmoja National Hospital. PHCUs provide Primary health care services, PHCU+ are selected to provide additional services such as delivery, dental, laboratory and pharmacy services. PHCCs provide the same services as PHCU+ with the addition of inpatient and X-ray services. District hospitals provide second line referral services, including basic surgery and the tertiary hospital (Mnazi Mmoja Hospital) provides referral services. A measure of relative variance was applied to determine the sample number of health facilities required [20]. All secondary and tertiary health facilities (43 facilities) offer maternity services and thus were included in the sample. A stratified random sampling procedure was applied to sample first line PHCUs. The targeted health facilities were divided into two strata. The first stratum was comprised of first line Primary Health Care Units (PHCUs) and the second stratum of PHCU+ and PHCC facilities. All higher secondary and tertiary health facilities (43 facilities) were included in the sample as they offer maternity health services. The random sampling procedure was applied to get the remaining sample of the first line PHCUs. The sampling frame included 100 PHCUs in all districts. STATA 12.0 software was used to conduct random sampling required sample size (38 of 100 PHCUs). Our initial sample was 80 health facilities; however, one health facility was dropped due to unavailability of staff to participate in the study. The assessment methods and modules developed by the Averting Maternal Death and Disability (AMDD) program (www.mailman.columbia.edu/research/averting-maternal-death-and-disability-amdd) at Columbia University, New York, USA, and United Nations (UN) Partners were adapted for local use. Methods included key informant interviews, observations, and data extraction. A workshop with the Zanzibar Ministry of Health (ZMOH) and other stakeholders was held to make the relevant adaptations to the Zanzibar context [21]. In order to ensure that the wording of the questions was correct and understood by both, interviewer and interviewee, study instruments were translated into Swahili and pilot-tested in Kivunge, Chukwani, Kitope, Jambiani and Mwera health facilities. A total of 5 teams, each of which included a supervisor, data entry clerk and three research assistants (RAs), were recruited, ensuring at least one midwife per team. All interviewers had completed at least secondary school education. Research assistants and supervisors were trained for three days to ensure that they understood the objectives of the survey, the study methods and the content of the modules. During the training, roles of supervisors, research assistants and other study team members were also explained. A training manual was prepared to enhance the effectiveness of training and was also used as a reference for data collectors during the survey. Teams were assigned to move around the districts ensuring data collection from all sampled facilities. With exception of hospitals, data collection required approximately one day per health facility. Supervisors contacted the health facility in-charge, assigned work to RAs, maintained continuous progress in data collection and reviewed the completed questionnaires for errors and omissions on a daily basis. Interviews were conducted with health facility in-charges or midwives at the PHCUs and PHCUs + and in-charges of the maternity wards, pharmacy, laboratory and human resource for PHCC and hospital levels. Data cleaning and consistency checks were conducted after the survey. Data were analyzed using STATA (version 12.0, College Station, Texas, USA). Analyses were conducted in accordance with UN guidelines for monitoring obstetric services [22], including performance of signal functions and the calculation of the EmONC indicators. The World Health Organisation (WHO) handbook on monitoring emergency obstetric and neonatal care EmONC defines the signal functions as 1) administration of parenteral antibiotics, 2) administration of parenteral uterotonics, 3) administration of parenteral anticonvulsants; 4) manual removal of the placenta (MRP); 5) removal of retained products; 6) Assisted Vaginal Delivery (AVD); 7) neonatal resuscitation; 8) blood transfusion; and 9) obstetric surgery. The handbook classifies health facilities that have performed the first seven signal functions in the last three months as basic EmONC (BEmONC) facilities and those providing all nine signal functions are classified as comprehensive EmONC (CEmONC) facilities [22]. Furthermore, any facility providing at least one of the first seven signal functions was considered as partially functioning. A non-EmONC facility was defined as a facility which never provided any of the seven basic signal functions in the three-month period before the assessment.

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• Dima Health