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The challenges of improving emergency obstetric care in two rural districts in Mali
International Journal of Gynecology and Obstetrics (2007) 99, 173–182
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
AVERTING MATERNAL DEATH AND DISABILITY
The challenges of improving emergency obstetric care in two rural districts in Mali S.A. Otchere a,⁎, A. Kayo b a b
Save the Children/US, Washington DC, USA Mali Field Office, Save the Children/US, Mali
Received 31 July 2006; accepted 18 July 2007
KEYWORDS Mali-West Africa; Emergency obstetric care; Quality of care; Maternal mortality
Abstract Objective: We describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali. Methods: Project planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts. Results: By the end of 2004, despite many health systems’ challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively. Discussion: Although useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed. Conclusion: Save the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
⁎ Corresponding author. Fax: +1 202 637 9362. E-mail address: [email protected] (S.A. Otchere). 0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.07.004
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1. Introduction The average maternal mortality ratio (MMR) in sub-Saharan Africa is estimated to have risen from 870 deaths per 100,000 live births in 1990 to 1000 deaths per 100,000 live births in 2001 [1]. The West African nation of Mali, with an estimated population of 12 million, has a high MMR of 1200 per 100,000 live births. The lifetime risk of maternal death is 1 in 10 compared to 1 in 16 for the whole of Africa and 1 in 2500 in the USA [2]. According to the 2000 State of the World's Mothers (SOWM) [3] report, a document that includes an index reflecting how individual countries compare in meeting the needs of mothers, Mali is ranked 105 out of the 106 countries studied and is described as one of the countries with the “longest road ahead” in meeting mothers’ needs. Health records show the major causes of maternal deaths in Mali to be from hemorrhage, sepsis, obstructed labor and pre-eclampsia, consistent with global causes of maternal death; yet many women still have no access to major life saving obstetric interventions due to poor quality and sub-standard care and inadequate resources [4,5]. Inadequate knowledge of symptoms of complications during childbirth, costs, and the distance to care are but a few of the many factors influencing utilization of services [3,6,7]. Emergency obstetric care (EmOC) is considered to be life saving and an essential ingredient to reducing maternal mortality and morbidity [8]. To improve the chances of survival for women in Mali, Save the Children/ USA (SCUS) received support from the Averting Maternal Death and Disability (AMDD) program and in collaboration with the Ministry of Health of the Government of Mali (MOH), implemented a safe motherhood/EmOC project in Sikasso region with the goal of improving the availability, access to and quality of emergency obstetric services in Yanfolila and Bougouni districts. This paper describes the impact of project interventions amidst health system challenges in the two rural districts in the Sikasso region from January 2001 to December 2004, in addition to SCUS continued collaboration with the MOH on policy issues through 2005.
1.1. Previous activities to reduce maternal mortality Save the Children/USA and the MOH have worked in partnership in Mali since 1995 to improve maternal health and survival through creating community awareness of health issues, improving prenatal care and clean delivery practices, recognition of danger signs during pregnancy, labor and childbirth, family planning and prompt careseeking for complications. In the late 1990s, SCUS partnered with UNICEF, and together with the MOH, established a referral and evacuation system in Bougouni district to facilitate the referral of patients and women with obstetric complications to the district hospital. The referral system consists of an ambulance and radio installation at each community clinic and district hospital to provide communication links between health facilities. This activity however, was not accompanied by improving case management of obstetric complications at the district hospital to enable them to receive and manage referred
S.A. Otchere, A. Kayo patients effectively — a missed opportunity. The AMDD program, which highlights the need for EmOC, was a timely addition to expand this previous effort. It helped focus on improving care for women in Bougouni district and extended programming into the neighboring deprived district of Yanfolila. The project approach was based on the 3-delay model, which asserts that because most obstetric complications cannot be predicted, prompt access to EmOC once a complication occurs, followed promptly by adequate treatment, can significantly reduce the number of maternal deaths and disabilities [6].
2. Methods 2.1. Profile of project area The project was carried out in 2 (of 7) districts in Sikasso region with a combined population of about 500,000. Yanfolila and Bougouni district each have one district hospital and 13 and 23 community clinics, respectively. Ideally, a community clinic covers a population of 10,000 residents, and the farthest point from one clinic to families should be 15 km. However, distances from the latter to the next level of care – the district hospital – can be as much as 150 km. District hospitals serve as the referral center for community clinics and receive and manage all types of cases from the district, including patients referred with obstetric complications. They are the only health facilities in the district to provide basic laboratory services and have general doctors on staff. Obstetricians/gynecologists work only in regional capitals and Bamako. Table 1 gives a summary of the project area and staff capacity in the hospitals at baseline. The health infrastructure in Sikasso region is typical of the whole of Mali [9].
2.2. Baseline assessment Baseline assessments were carried out from July through August 2000 to determine the capacity of the two hospitals, 10 community clinics and their staff, to provide quality EmOC. Community interviews were also carried out to find out the level of awareness and response of families and women to obstetric complications. Results in the two districts were similar. To summarize, none of the community clinics studied functioned as basic EmOC facilities [8] because – by policy – they offer only normal delivery care and other primary health care provided by an auxiliary midwife with 6–9 months training. All recognized complications are referred for further management at district hospitals. Women reported that care seeking for obstetric complications at the district hospital was hindered by poor quality of care, poor attitudes of staff, long distances to travel and bad roads — all increasing the cost of care. Variable availability of the ambulance for referral to Bougouni hospital and the lack of any referral system in Yanfolila were also mentioned. Hospital findings showed: ■ ■
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staff lacked skills to effectively manage obstetric complications; absence of clinical protocols to guide management of complications; inadequate quantities of essential obstetric drugs, supplies and equipment;
The challenges of improving emergency obstetric care in two rural districts in Mali Table 1
Summary of project areas at baseline, 2000
Bougouni district Bougouni hospital staff capacity
Yanfolila district Yanfolila hospital staff capacity
a b c d
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Crude birth rate (CBR) b Expected births c Expected complications d Total population a 304,646 46 14,014 2102 4 general doctors (only 1 had received formal training in surgical procedures), 4 midwives, 1 auxiliary midwife (none of the midwives had skills to carry out any life saving interventions), 1 nurse surgical assistant, 2 nurse–anesthetists, 3 laboratory technicians, 63 patient beds (13 in the maternity) Crude birth rate (CBR)b Expected birthsc Expected complicationsd Total populationa 130,330 46 5995 899 2 general doctors (only 1 had received formal training in surgical procedures),3 midwives, 1 auxiliary midwife (none of the midwives had skills to carry out any life saving interventions), 1 nurse surgical assistant, 2 nurse–anesthetists, 2 laboratory technicians, 52 patient beds (11 in the maternity)
National Statistics and Information Division, Bamako Mali (in French). Crude birth rate (number of births per 1000 population, 2001 (MDHS). Expected births is the crude birth rate multiplied by the total population. Expected number of complications is calculated using the UN estimation that 15% of births will develop complications.
dilapidated buildings with intermittent electricity and water supply; poor record keeping and thus no use of data for improving care; high staff turnover.
In addition, the two hospitals functioned as only basic EmOC facilities because they were missing the 2 signal functions needed to achieve comprehensive EmOC status. This is in spite of the fact that, according to MOH standards, district hospitals were expected to provide comprehensive EmOC as they serve as the referral center for the entire district and community clinics are expected to provide only primary care. Based on the assessment findings, the MOH recommended targeting the hospitals for improvements and hence most project inputs were made at the district hospitals with modest interventions targeted at auxiliary midwives in community clinics and community sensitization.
Figure 1
2.3. Planning of project activities We began project planning in early 2001 using the results framework approach [10] and AMDD's implementation stages of EmOC as a guide for project implementation. The latter is a step-by-step process, divided into preparatory and service delivery stages, each with several building blocks that focus on the key elements for strengthening EmOC [11]. The results framework approach targets issues affecting quality, access, availability, utilization of services and the existing social and political environment. To this end, as Fig. 1 shows, we added 4 additional blocks, namely: EmOC needs assessment; establishing an EmOC team in each hospital; community demand creation to sensitize the community to improved services; and advocacy for policy changes with regards to making motherhood safer. Project activities and strategies were developed to improve the functional capacity of the hospitals and staff to provide quality care (addressing the 3rd delay), improve referrals between
Building blocks (implementation stages).
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S.A. Otchere, A. Kayo trained providers (bearing in mind that staff transfers occurred without warning).
community clinics and hospitals (2nd delay) and improve care seeking through community sensitization (1st delay) [6].
3. Project implementation Project implementation ran from 2001 to 2004 and included: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Renovation, equipment, and supplies Training of staff Supportive supervision Establishing 24-hour availability of EmOC services Data collection and record keeping Introduction of quality improvement methods Development of treatment guidelines for EmOC Community sensitization Forming partnerships Taking EmOC to scale.
3.1. Renovation, equipment, and supplies Renovations in Bougouni hospital included transforming a one-room maternity ward with a leaking roof, cracked walls and no door into a building with several rooms for antenatal care, labor and delivery, and postpartum care, an office for midwives, a room for the radio-referral-evacuation unit and toilet facilities. These changes made the maternity department more functional and accessible, and provided a better environment for patients and providers. Yanfolila hospital needed a new operation theater and, fortunately for the project, the Belgian government was building one for Yanfolila. This meant that the designated project funds could be used to support other activities. Repairs were made to both hospitals’ water systems and power supplies. Essential equipment was also provided based on need and two ambulances were provided to improve referral and evacuation from communities to the hospital.
Competency-based training was completed by December 2002; during the first year after training, the project lost 2 doctors, one laboratory technician and one midwife from Yanfolila hospital, and another midwife from Bougouni hospital to transfers. New staff posted to the hospitals received on the job training and coaching from the pool of trained providers.
3.3. Establishing 24/7 availability of EmOC services To save the lives of women experiencing a life-threatening obstetric complication, EmOC services should be available 24 h a day, 7 days a week (24/7) and a team of trained health professionals should be always available to provide care. The current practice in Mali makes providing timely and 24/7 care a great challenge. Mali does not operate the typical “oncall” night duty where the emergency response team (ERT — doctor, nurse–anesthetist, surgical assistant, midwife, laboratory technician and ambulance driver) are available and reachable if called. In Mali the situation is that the midwife is the only staff member who stays at the hospital throughout the night and she sends a message to the other members of the team at their homes when needed. This often leads to delays in treatment because the staff on-call have no transport to get to the hospital at night and occasionally they are neither at home nor reachable. Early in the project, therefore, the SCUS team discussed with the hospital management the need to have the ERT on-site to ensure prompt and efficient care for women with complications, particularly if surgical intervention (such as cesarean delivery) is needed. The hospital management and project teams grappled with where to house the ERT during the night as the hospital had no rooms for rest and recovery. As an interim measure, the project team did the following to reduce the response time to obstetric emergencies at night:
3.2. Staff training ■
The project team, in collaboration with the MOH, specialists from Gabriel Touré and Commune V teaching hospitals, the national blood transfusion center and a team from JHPIEGO-Burkina Faso, organized a competency-based training for key hospital staff. Existing curricula were adapted from key international resources and used for the training [12–14]. ■
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5 general doctors received technical updates and training in EmOC and obstetric surgery to appropriately recognize and manage obstetric complications; 4 laboratory technicians received training in blood safety and transfusion; 4 nurse–anesthetists and 2 nurse–surgical assistants received training in their specialty and the latter passed on skills to 2 other nurses working in the surgical wards; 7 midwives, 3 auxiliary midwives and 3 doctors (out of the 5 above) received technical updates and training in basic emergency obstetric care procedures. The objective of training the doctors was to enable them to supervise midwives effectively and to increase the critical mass of
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Established a rotation schedule for ambulance drivers to ensure 24/7 coverage; Refurnished an abandoned storage room for rest and recovery during the night for ambulance drivers; Provided 3 walkie-talkies and 2 motorbikes to each hospital to be used by staff to reduce time needed to get to the hospital; and even this was threatened by the danger of riding alone at night.
Establishing 24-hour availability of EmOC to provide timely care to women proved to be one of the greatest challenges of the project. Despite this we continued to encourage and remind the management teams of the 2 hospitals to initiate a phased approach to having on-call staff at the hospital at night and on weekends. By mid-2003, the surgical assistant and ambulance drivers had started night duty and by the beginning of 2004, the nurse–anesthetists had joined the team on the hospital premises. They were temporarily accommodated in the consulting rooms. With 4 out of 6 members of the ERT on site the project team developed a tracking system to determine whether the presence of the staff reduced response time in providing treatment and improved maternal and
The challenges of improving emergency obstetric care in two rural districts in Mali newborn outcomes. Unfortunately, the change in staffing was not in place long enough to register substantial change and if the patient required surgery, the doctor was not immediately available. This delay in treatment (the 3rd delay) jeopardizes maternal and newborn outcomes.
3.4. Recording of patient information and data collection The baseline study revealed midwives were key recorders of obstetric information and had to complete up to 9 registers for each patient and incomplete recordings of patient information were common. SCUS discussed with MOH officials at the regional and national levels the duplication of data and inaccuracies observed in the registers and suggested pulling together all 9 registers into one or two to reflect the key variables relevant to maternal and newborn outcomes. However, they informed us that the registers served their purpose at the time and that many copies were still in stock. Nevertheless, they agreed to revisit our recommendations at the appropriate time. Although we knew that a consolidation of registers would have been worthwhile, we recognized the challenges presented (time, resources and the coordination of an array of national departments) in reviewing the national health information system. To facilitate our project monitoring and evaluation, we developed weekly and monthly summary forms that captured key variables and combined information from these with patient notes. The pulling of patient information onto one form improved midwives’ ability to compile, understand and review the data and use them to improve the care they provided. We believe the forms we developed will serve as an example for the MOH when they decide to review the existing record keeping system. We also introduced the UN Process Indicators to hospital staff as a means of tracking and monitoring availability of obstetric services [8]. The EmOC Core teams also convened monthly meetings where the UN Process Indicators were calculated and discussed, which contributed to understanding what improvements were needed within the hospitals.
3.5. Quality and performance improvement An adaptation of COPE [15] for EmOC [16] was introduced to the hospitals in April 2003 as one strategy to facilitate continuous quality improvement in the hospitals. The AMDD technical team provided on-the-job training workshops and mentoring to the majority of staff in each hospital. Over the next year, COPE exercises resulted in placement of sign posts in written and pictorial forms to help patients identify different departments within the hospital and weekly maternal health review meetings to help staff understand the circumstances for deaths and near misses within the hospital and how to avoid them. The AMDD technical team also strengthened the skills of the regional health monitoring team in clinical supervision. While the establishment of weekly meetings was an important step to improving patient care, the fact that part of the ERT did not sleep on the hospital premises and were not always reachable continued to contribute to the 3rd delay in providing treatment.
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3.6. Development of EmOC clinical protocols For the first time ever, obstetric clinical protocols were developed by the project in collaboration with hospital partners, the Division of Reproductive Health (DRH) of the Ministry of Health, obstetricians/gynecologists from medical schools in Bamako, and technical advisors from AMDD. International standards and examples from other countries were used as a guide during development. The activity began in September 2002 and ended in April 2004 when the MOH adopted it for use. Twenty-six staff from the two hospitals received training on the clinical protocols; provider performance and adherence to the protocols were audited by reviewing patient notes at weekly maternal health review meetings in each hospital.
3.7. Community sensitization for service utilization Save the Children/USA considers helping communities understand when, where, and how to seek care [17]. The referral and evacuation system in Mali plays a key role in transferring women with obstetric complications and other patients with other emergencies from the rural community clinics to the district hospital. We established the referral network in Yanfolila at the end of 2002, in collaboration with district government representatives, the regional MOH and community representatives, using the national resource “Cadre conceptuel de l'organization du systeme de reference/ evacuation au Mali” [18]. Early in 2003, after major interventions were in place, the project team in collaboration with SCUS Saving Newborn Lives Initiative (also operating in Bougouni district) developed behavior change and communication (BCC) messages (Box 1) that were aired weekly on local radio to help families prepare for delivery. Radio was used because 64% of rural dwellers had access to radio [19].
Box 1 Components of behavior change and communication (BCC) messages ■ ■
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Preparation for delivery Recognition of danger signs during pregnancy, labor and delivery, and postpartum care Preparation for emergency situations (obstetric and newborn complications) Initiation and functioning referral and evacuation systems in Yanfolila Bougouni has a new ambulance to strengthen its referral system Importance of timely care-seeking improves chances of survival Encouragement for voluntary blood donation Hospital improvement in treating obstetric complications through SC/US and MOH partners Encouraging deliveries at the community clinics to increase facility births with trained health staff but also to reduce overcrowding at the district hospital so that the latter can better respond to obstetric complications and other emergencies
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4. Partnership paves the way for collaboration, advocacy, policy change and replication Save the Children/USA established lasting partnerships with district, regional and national MOH representatives, policy makers and in-country bilateral agencies. The involvement of partners gave credibility to the project and to the promotion of international standards of care. While SCUS/ AMDD funded the project interventions, the MOH staff in Bougouni and Yanfolila hospitals implemented the project activities. Their salaries and time spent on project activities were never quantified, however, it was a significant contribution to project resources. The SCUS/AMDD strategy and experiences in Bougouni and Yanfolila were instrumental in clarifying the specific steps needed to strengthen Mali's health system to improve EmOC — a critical component in making motherhood safer. At a workshop to disseminate the experiences of this project in August 2005, the Director of the Division of Reproductive Health announced that Bougouni and Yanfolila would be used as pilot sites to replicate the improvement in EmOC throughout Mali.
5. Taking EmOC to scale Several important actions for promoting EmOC at scale started or were completed during the course of project implementation mostly as a result of advocacy efforts by the SCUS team and AMDD global collaboration. These are listed below: ■
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A national EmOC needs assessment was completed in 2003 and revealed a critical need for availability of good quality EmOC services; EmOC treatment guidelines were developed and adopted by the MOH in April 2004; A revision of the national reproductive health norms and procedures included EmOC treatment guidelines; Advocacy to adopt and adapt the UN Process Indicators led to their acceptance and inclusion as national indicators for monitoring the availability, quality and utilization of obstetric services at all levels of care;
Figure 2
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The MOH adopted a national strategy to implement EmOC in June 2004 collaborating closely with UNICEF to upgrade and improve the quality of EmOC in 65 health facilities throughout the country; An unprecedented policy change by the MOH in June 2005 made all cesarean deliveries in public facilities free of charge to encourage utilization of specialized services for obstetric complications; New midwifery skills were acquired through competencybased training such as active management of third stage of labor, manual removal of placenta and midwives were given greater responsibility so that they could administer oxytocin without a doctor's order; International standards of care were promoted through the national maternal and newborn taskforce of which SCUS is a member; and Advocacy to enhance the functional capacity of community clinics and staff to provide selected life saving services.
6. Results Project planning and implementation began in 2001 and by the end of 2002, major project inputs had been completed. Project data were compiled weekly and quarterly and used for monitoring with the UN Process Indicators. In February 2005 a qualitative evaluation was undertaken to determine the value added of community sensitization in using obstetric referral services.
6.1. Availability of EmOC The project sites Yanfolila and Bougouni districts are located in Sikasso region in southern Mali and have an estimated population of 150,000 and 350,000 respectively. The UN Process Indicators recommend as a minimum 1 comprehensive EmOC and 4 basic EmOC facilities for a 500,000 population. Where geographical access is a challenge we believe it is reasonable to deviate from the recommended number of facilities as is the case with Yanfolila and Bougouni. Therefore, we suggest at a minimum, the population of Bougouni must have access to 1 health facility offering the full range of comprehensive
UN Process Indicators — trend data over 4 years, Bougouni district hospital.
The challenges of improving emergency obstetric care in two rural districts in Mali
Figure 3
UN Process Indicators — trend data over 4 years, Yanfolila district hospital.
EmOC services and 3 facilities providing basic EmOC. The people of Yanfolila district must have access to at least 1 comprehensive EmOC facility and 2 basic EmOC facilities. At the start of the project, Bougouni and Yanfolila hospitals were not providing the full range of comprehensive EmOC services but through project inputs they did by the end of 2002. Community clinics by national policy provide only normal delivery and primary care services. SC/Mali continues to advocate for the functional capacity of community clinics and staff to provide selected life saving services.
6.2. Changes in clinical competence and practice of midwives Significant changes in clinical practice for midwives following competency-based training included: ■
routine application of active management of third stage of labor (AMTSL) for all deliveries;
Table 2
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the authority to administer oxytocin as treatment where indicated without a doctor's order; skills to perform vacuum extraction; skills to perform manual removal of placenta.
Removal of retained products of conception continued to be a service provided by the general doctors.
6.3. Utilization and quality of EmOC in Bougouni and Yanfolila district hospitals Figs. 2 and 3 show the changes observed in the 4 other UN Process Indicators reflecting utilization and quality of EmOC services in Bougouni and Yanfolila. Data from Bougouni hospital showed no change in the proportion of births and in the cesarean delivery rate over the project period. There was, however, a notable increase in the number of recorded complications from 197 in 2001 to 364 in 2004 (Table 2) and a corresponding increase in met need for EmOC from 9% in 2001 to 15% in 2004. We believe that
UN Process Indicators: the availability, utilization, and quality of EmOC, Bougouni district, Mali, 2001 to 2004 2001 Year 1
2002 Year 2
2003 Year 3
2004 Year 4
Population served Crude birth rate Expected births Expected complications
322,572 46 14,838 2226
331,926 46 15,269 2290
341,552 46 15,711 2357
351,457 46 16,167 2425
Service data Births in EmOC facilities Women with complications delivering in EmOC facilities Cesarean deliveries Maternal deaths (direct obstetric causes)
566 197 131 14
757 311 146 13
756 299 153 16
766 364 202 8
UN Process Indicators Proportion of births in EmOC facilities (UN recommendation — 15%) Met need for EmOC a (UN recommendation — 100%) Cesarean deliveries as a proportion of all births (UN recommendation — 5–15%) Case fatality rate (UN recommendation — b 1%)
3.8% 8.8% 0.8% 7.1%
5.0% 13.6% 1.0% 4.2%
4.8% 12.7% 1.05 5.4%
4.7% 15.0% 1.2% 2.2%
a
Women with complications delivering in EmOC facilities divided by the number of expected complications × 100.
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Table 3
UN Process Indicators: the availability, utilization, and quality of EmOC, Yanfolila district, Mali, 2001 to 2004 2001 Year 1
2002 Year 2
2003 Year 3
2004 Year 4
Population served Crude birth rate Expected births Expected complications
137,463 46 6323 948
141,174 46 6494 974
144,986 46 6669 1000
148,901 46 6849 1027
Service data Births in EmOC facilities Women with complications delivering in EmOC facilities Cesarean deliveries Maternal deaths (direct obstetric causes)
631 61 41 5
538 97 35 3
396 97 38 1
591 158 56 8
UN Process Indicators Proportion of births in EmOC facilities (UN recommendation — 15%) Met need for EmOC a (UN recommendation — 100%) Cesarean deliveries as a proportion of all births (UN recommendation — 5–15%) Case fatality rate (UN recommendation — b 1%)
9.9% 6.4% 0.6% 8.2%
8.2% 9.9% 0.5% 3.1%
6.0% 9.7% 0.5% 1.1%
8.6% 15.3% 0.8% 5.1%
a
Women with complications delivering in EmOC facilities divided by the number of expected complications × 100.
these results imply the availability of other treatment options provided by midwives and perhaps better reporting of complications (Table 2). In Yanfolila, on the other hand, data between 2001 and 2003 showed a decrease in the proportion of births in EmOC facilities, no change in the cesarean delivery rate and, as expected, a decrease in case fatality rate [CFR] (Table 3, Fig. 3). In 2004, however, an interesting turn of events occurred. There was an increase in the proportion of births in EmOC facilities from 6% to 9%, the population-based cesarean rate increased from 0.5% to 0.8%, and met need increased from 6% in 2001 to 10% in 2003 and to 15% in 2004 (Fig. 3).
6.4. The additional value of community mobilization and sensitization After a year of BCC messaging, data suggest that the messages had the desired effect of encouraging utilization of maternity and EmOC services. Data from Yanfolila hospital are particularly encouraging in spite of the increase in CFR. As described earlier, Fig. 3 shows modest but steady increases in all indicators. The effect of the policy and programmatic decision to sensitize the community to attend community clinics for the majority of normal deliveries also appears to have had the desired outcome. Between 2002 and 2004, deliveries in community clinics increased by 94% in Bougouni (6990 to 13,559) and by 61% (1259 to 2023) in Yanfolila. This suggests that community mobilization does contribute to utilization of services. Nevertheless, despite these modest gains, community interviews carried out in February 2005 highlighted the following: ■
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women and families still faced delays when they arrived at the hospital, especially at night, due to the absence of key staff; women and families continue to face long distances and bad roads when emergencies occur even when transport was readily available;
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the critical need to decentralize selected life-saving functions to community clinics.
7. Continuing challenges Throughout the project period we faced a number of challenges related to the health system that we believe will also affect the utilization, availability, and quality of delivering EmOC services nationwide. These are listed below: ■
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Staff transfers: Transfer of staff is a major problem in Mali and within a year of implementation, staff trained with project funds were transferred and new staff needed to be trained on-the job by existing staff. Maintenance of equipment: All hospital equipment including ambulances needing maintenance had to be sent to Bamako. Transportation, labor costs, distance, and bad roads made it difficult for hospitals to adhere to a regular maintenance schedule. Malian system of on-call night duty: The current system makes it difficult to provide timely EmOC 24/7; it also affects other patients with life-threatening injuries and illnesses. Requested focus on district hospitals: Lack of key life-saving EmOC functions in community clinics is a missed opportunity to save women's lives closer to home since community clinics are the first contact with the health system. Record keeping: We had to develop a one-page data collection sheet to capture the variables needed for monitoring the project indicators. Midwives also still had to complete up to 9 additional government registers for each patient making incomplete recording of patient information a common occurrence.
8. Sustainability One of the main goals of the SCUS and AMDD collaboration in Mali was to pave the way for sustainability and
The challenges of improving emergency obstetric care in two rural districts in Mali institutionalization of project inputs and lessons learned at national level. This has been achieved in part as noted earlier by policy changes and the several other important actions taken by the MOH for promoting EmOC at scale. There is, however, still a long road ahead and the greatest challenges Mali will continue to face given the lessons learned from our project are in human resource capacity, logistical supplies capacity, and the decentralization of certain functions to community clinics.
9. Discussion Even in the face of many challenges, SCUS's project in Mali showed that it is possible to achieve modest improvements in the quality and use of EmOC in hospitals. The management and staff of Yanfolila and Bougouni hospitals agreed that the onus falls on them to continue using the skills acquired over the project period with support from the regional authorities, and to reach and maintain the highest level of quality care. In spite of the low figures for “Met Need” (use of obstetric services by women with complications), 9% in 2001 and 15% in 2004 in Bougouni and 6% in 2001 and 15% in 2001 in Yanfolila, and while still far below the goal of 100% [8], they are still impressive increases — 66% and 116% respectively. While cesarean rates remain very low (1.2% and 0.8, Bougouni and Yanfolila, respectively) the availability of this lifesaving treatment did increase. Clearly much more needs to be done to make the treatment available at all times and to reach many women with life-saving care. Changes in the case fatality rate need care in interpretation. In Bougouni this decreased from 7% in 2001 to 2.2% in 2004, suggesting an improvement in the overall quality of services provided. While in Yanfolila the increase in utilization was disturbingly accompanied by an increase in the case fatality rate, from 1% to 5%, although it was based on only 1 and 8 maternal deaths respectively. The increase shows that at least women were arriving at the hospital, but possibly too late. Death reviews would help interpret this increase in CFR. The project emphasized improving EmOC at district hospitals. This, in combination with Mali's policy not to mandate community clinics to provide basic EmOC, meant less emphasis was put on upgrading community clinics to provide basic EmOC. SCUS, however, continues to advocate and is actively involved in raising awareness at the policy level to improve the functional capacity of strategically placed community clinics and staff to manage selected complications, particularly as women continue to face difficulties in reaching district referral hospitals. While decentralizing basic EmOC will require major policy changes, staff deployment and training, logistical implications and a different kind of monitoring and supervision, we believe it is a move that could potentially contribute to improving maternal health and survival for women in Mali. Save the Children/USA's efforts on improving the quality and availability of EmOC were an important step for Mali in going to scale with EmOC services nationwide. EmOC is now incorporated as an essential component of maternity services in saving women's lives.
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10. Lessons learned Key lessons learned include: ■
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Advocacy efforts and engaging policy and decision makers from the onset of project planning is key to embracing change and going to scale. Partnership and teamwork are essential for achieving and sustaining results and can only be achieved by the will to do something about a problem. The availability of a pool of trained providers is necessary to achieve and sustain quality of care. Community sensitization is a strategy that has the potential to mobilize communities to use improved services. Supportive and regular supervision by the regional team is an important activity for sustaining and institutionalizing project innovations. The importance of continuing challenges to project implementation.
11. Conclusions Save the Children/USA's work in Mali demonstrated that investments in the existing health system are needed to improve EmOC — a critical requirement for improving maternal survival. As we found, implementing interventions that we know can save women's lives, in the midst of health systems’ challenges, requires commitment, persistence, determination, encouragement, and collaboration with partners. In spite of the importance of access to quality EmOC, in Mali, geographical access to district hospitals providing EmOC services continues to be a considerable hurdle that is encountered by many women every day. Even when women do get to the district hospital, key staff may not always be readily available to provide timely care. Much additional work is needed to help Mali meet the needs of its mothers. Priority should be given in future programming to reviewing existing policies on maternity services at community clinics to decentralize specific functions of basic EmOC and to ensuring 24-hour availability of key staff at rural hospitals. This can be achieved when donors, partners, and the ministry of health coordinate efforts to strengthen health systems.
Acknowledgments We would like to convey our sincere thanks to our partners for financial and technical support: all levels of the Ministry of Health in Mali (especially Dr Maiga Zeinab Mint Youba (Minister of Health), Dr Keita Binta (Director of DRH, MOH) and staff at Yanfolila and Bougouni hospitals), the AMDD Global Program (especially Dr Sourou Gbangbade, Dr Grace Kodindo, Ms Samantha Lobis). AMDD's financial support was provided through the Bill and Melinda Gates Foundation.
References [1] Road map for the accelerating the attainment of the Millennium Development Goals related to maternal and Newborn Health in Africa. WHO/Afro; 2004.
182 [2] World Health Organization. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: WHO; 2005. [3] Save the Children/USA. State of the world's mothers report; 2000. [4] Dian S, An assessment of the availability of emergency obstetric care in Mali (in French) Ministry of Health Mali; June 2003. [5] World Health Organization. The World Health Report: make every mother and child count; 2005. [6] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med Apr 1994;38(8):1091–110. [7] Maine D. Safe motherhood programs: options and issues. Columbia University: Center for population and family health; 1993. [8] UNICEF, WHO, UNFPA. Guidelines for monitoring the availability and use of obstetric services. New York: UNICEF; 1997. [9] Ministry of Health Mali. Division of public health. National reproductive health norms and procedures (in French). March; 2000 [10] USAID. Performance, monitoring and evaluation. TIPS: Building a results framework. USAID center for development, information and evaluation; 2000. [11] Gill Z, Bailey P, Waxman R, Smith JB. A tool for assessing ‘readiness’ in emergency obstetric care: the room by room ‘walk-through’. Int J Gynecol Obstet 2005;89:191–9.
S.A. Otchere, A. Kayo [12] World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, WHO/ RHR/00.7. Integrated management of pregnancy and childbirth. Geneva: WHO; 2000. [13] Marshall MA, Buffington ST. Life saving skills manual for midwives. Third Edition. American College of Nurse Midwives; 1998. [14] Kinzie B, Gomez P. Basic maternal and newborn care: A guide for skilled providers. MNH/JHPIEGO; 2004. [15] EngenderHealth. Quality improvement services: COPE® for maternal health services: a process and tools for improving the quality of maternal health services; 2002 [16] EngenderHealth, AMDD. Quality improvement for emergency obstetric care leadership manual and toolbook: an adaptation of COPE. New York: EngenderHealth; 2003. [17] Grabman-Howard L, Snetro G. How to mobilize communities for health and social change: a field guide; June 2003. [18] Ministry of Health Mali, Division of public health. Guidelines for establishing and organizing a referral and evacuation system in Mali; August 2000 [in French]. [19] Demographic and Health Survey (DHS). Mali demographic and health survey 2001. Calverton Maryland USA: ORC Macro; 2002.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
AVERTING MATERNAL DEATH AND DISABILITY
The challenges of improving emergency obstetric care in two rural districts in Mali S.A. Otchere a,⁎, A. Kayo b a b
Save the Children/US, Washington DC, USA Mali Field Office, Save the Children/US, Mali
Received 31 July 2006; accepted 18 July 2007
KEYWORDS Mali-West Africa; Emergency obstetric care; Quality of care; Maternal mortality
Abstract Objective: We describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali. Methods: Project planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts. Results: By the end of 2004, despite many health systems’ challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively. Discussion: Although useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed. Conclusion: Save the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
⁎ Corresponding author. Fax: +1 202 637 9362. E-mail address: [email protected] (S.A. Otchere). 0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.07.004
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1. Introduction The average maternal mortality ratio (MMR) in sub-Saharan Africa is estimated to have risen from 870 deaths per 100,000 live births in 1990 to 1000 deaths per 100,000 live births in 2001 [1]. The West African nation of Mali, with an estimated population of 12 million, has a high MMR of 1200 per 100,000 live births. The lifetime risk of maternal death is 1 in 10 compared to 1 in 16 for the whole of Africa and 1 in 2500 in the USA [2]. According to the 2000 State of the World's Mothers (SOWM) [3] report, a document that includes an index reflecting how individual countries compare in meeting the needs of mothers, Mali is ranked 105 out of the 106 countries studied and is described as one of the countries with the “longest road ahead” in meeting mothers’ needs. Health records show the major causes of maternal deaths in Mali to be from hemorrhage, sepsis, obstructed labor and pre-eclampsia, consistent with global causes of maternal death; yet many women still have no access to major life saving obstetric interventions due to poor quality and sub-standard care and inadequate resources [4,5]. Inadequate knowledge of symptoms of complications during childbirth, costs, and the distance to care are but a few of the many factors influencing utilization of services [3,6,7]. Emergency obstetric care (EmOC) is considered to be life saving and an essential ingredient to reducing maternal mortality and morbidity [8]. To improve the chances of survival for women in Mali, Save the Children/ USA (SCUS) received support from the Averting Maternal Death and Disability (AMDD) program and in collaboration with the Ministry of Health of the Government of Mali (MOH), implemented a safe motherhood/EmOC project in Sikasso region with the goal of improving the availability, access to and quality of emergency obstetric services in Yanfolila and Bougouni districts. This paper describes the impact of project interventions amidst health system challenges in the two rural districts in the Sikasso region from January 2001 to December 2004, in addition to SCUS continued collaboration with the MOH on policy issues through 2005.
1.1. Previous activities to reduce maternal mortality Save the Children/USA and the MOH have worked in partnership in Mali since 1995 to improve maternal health and survival through creating community awareness of health issues, improving prenatal care and clean delivery practices, recognition of danger signs during pregnancy, labor and childbirth, family planning and prompt careseeking for complications. In the late 1990s, SCUS partnered with UNICEF, and together with the MOH, established a referral and evacuation system in Bougouni district to facilitate the referral of patients and women with obstetric complications to the district hospital. The referral system consists of an ambulance and radio installation at each community clinic and district hospital to provide communication links between health facilities. This activity however, was not accompanied by improving case management of obstetric complications at the district hospital to enable them to receive and manage referred
S.A. Otchere, A. Kayo patients effectively — a missed opportunity. The AMDD program, which highlights the need for EmOC, was a timely addition to expand this previous effort. It helped focus on improving care for women in Bougouni district and extended programming into the neighboring deprived district of Yanfolila. The project approach was based on the 3-delay model, which asserts that because most obstetric complications cannot be predicted, prompt access to EmOC once a complication occurs, followed promptly by adequate treatment, can significantly reduce the number of maternal deaths and disabilities [6].
2. Methods 2.1. Profile of project area The project was carried out in 2 (of 7) districts in Sikasso region with a combined population of about 500,000. Yanfolila and Bougouni district each have one district hospital and 13 and 23 community clinics, respectively. Ideally, a community clinic covers a population of 10,000 residents, and the farthest point from one clinic to families should be 15 km. However, distances from the latter to the next level of care – the district hospital – can be as much as 150 km. District hospitals serve as the referral center for community clinics and receive and manage all types of cases from the district, including patients referred with obstetric complications. They are the only health facilities in the district to provide basic laboratory services and have general doctors on staff. Obstetricians/gynecologists work only in regional capitals and Bamako. Table 1 gives a summary of the project area and staff capacity in the hospitals at baseline. The health infrastructure in Sikasso region is typical of the whole of Mali [9].
2.2. Baseline assessment Baseline assessments were carried out from July through August 2000 to determine the capacity of the two hospitals, 10 community clinics and their staff, to provide quality EmOC. Community interviews were also carried out to find out the level of awareness and response of families and women to obstetric complications. Results in the two districts were similar. To summarize, none of the community clinics studied functioned as basic EmOC facilities [8] because – by policy – they offer only normal delivery care and other primary health care provided by an auxiliary midwife with 6–9 months training. All recognized complications are referred for further management at district hospitals. Women reported that care seeking for obstetric complications at the district hospital was hindered by poor quality of care, poor attitudes of staff, long distances to travel and bad roads — all increasing the cost of care. Variable availability of the ambulance for referral to Bougouni hospital and the lack of any referral system in Yanfolila were also mentioned. Hospital findings showed: ■ ■
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staff lacked skills to effectively manage obstetric complications; absence of clinical protocols to guide management of complications; inadequate quantities of essential obstetric drugs, supplies and equipment;
The challenges of improving emergency obstetric care in two rural districts in Mali Table 1
Summary of project areas at baseline, 2000
Bougouni district Bougouni hospital staff capacity
Yanfolila district Yanfolila hospital staff capacity
a b c d
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Crude birth rate (CBR) b Expected births c Expected complications d Total population a 304,646 46 14,014 2102 4 general doctors (only 1 had received formal training in surgical procedures), 4 midwives, 1 auxiliary midwife (none of the midwives had skills to carry out any life saving interventions), 1 nurse surgical assistant, 2 nurse–anesthetists, 3 laboratory technicians, 63 patient beds (13 in the maternity) Crude birth rate (CBR)b Expected birthsc Expected complicationsd Total populationa 130,330 46 5995 899 2 general doctors (only 1 had received formal training in surgical procedures),3 midwives, 1 auxiliary midwife (none of the midwives had skills to carry out any life saving interventions), 1 nurse surgical assistant, 2 nurse–anesthetists, 2 laboratory technicians, 52 patient beds (11 in the maternity)
National Statistics and Information Division, Bamako Mali (in French). Crude birth rate (number of births per 1000 population, 2001 (MDHS). Expected births is the crude birth rate multiplied by the total population. Expected number of complications is calculated using the UN estimation that 15% of births will develop complications.
dilapidated buildings with intermittent electricity and water supply; poor record keeping and thus no use of data for improving care; high staff turnover.
In addition, the two hospitals functioned as only basic EmOC facilities because they were missing the 2 signal functions needed to achieve comprehensive EmOC status. This is in spite of the fact that, according to MOH standards, district hospitals were expected to provide comprehensive EmOC as they serve as the referral center for the entire district and community clinics are expected to provide only primary care. Based on the assessment findings, the MOH recommended targeting the hospitals for improvements and hence most project inputs were made at the district hospitals with modest interventions targeted at auxiliary midwives in community clinics and community sensitization.
Figure 1
2.3. Planning of project activities We began project planning in early 2001 using the results framework approach [10] and AMDD's implementation stages of EmOC as a guide for project implementation. The latter is a step-by-step process, divided into preparatory and service delivery stages, each with several building blocks that focus on the key elements for strengthening EmOC [11]. The results framework approach targets issues affecting quality, access, availability, utilization of services and the existing social and political environment. To this end, as Fig. 1 shows, we added 4 additional blocks, namely: EmOC needs assessment; establishing an EmOC team in each hospital; community demand creation to sensitize the community to improved services; and advocacy for policy changes with regards to making motherhood safer. Project activities and strategies were developed to improve the functional capacity of the hospitals and staff to provide quality care (addressing the 3rd delay), improve referrals between
Building blocks (implementation stages).
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S.A. Otchere, A. Kayo trained providers (bearing in mind that staff transfers occurred without warning).
community clinics and hospitals (2nd delay) and improve care seeking through community sensitization (1st delay) [6].
3. Project implementation Project implementation ran from 2001 to 2004 and included: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Renovation, equipment, and supplies Training of staff Supportive supervision Establishing 24-hour availability of EmOC services Data collection and record keeping Introduction of quality improvement methods Development of treatment guidelines for EmOC Community sensitization Forming partnerships Taking EmOC to scale.
3.1. Renovation, equipment, and supplies Renovations in Bougouni hospital included transforming a one-room maternity ward with a leaking roof, cracked walls and no door into a building with several rooms for antenatal care, labor and delivery, and postpartum care, an office for midwives, a room for the radio-referral-evacuation unit and toilet facilities. These changes made the maternity department more functional and accessible, and provided a better environment for patients and providers. Yanfolila hospital needed a new operation theater and, fortunately for the project, the Belgian government was building one for Yanfolila. This meant that the designated project funds could be used to support other activities. Repairs were made to both hospitals’ water systems and power supplies. Essential equipment was also provided based on need and two ambulances were provided to improve referral and evacuation from communities to the hospital.
Competency-based training was completed by December 2002; during the first year after training, the project lost 2 doctors, one laboratory technician and one midwife from Yanfolila hospital, and another midwife from Bougouni hospital to transfers. New staff posted to the hospitals received on the job training and coaching from the pool of trained providers.
3.3. Establishing 24/7 availability of EmOC services To save the lives of women experiencing a life-threatening obstetric complication, EmOC services should be available 24 h a day, 7 days a week (24/7) and a team of trained health professionals should be always available to provide care. The current practice in Mali makes providing timely and 24/7 care a great challenge. Mali does not operate the typical “oncall” night duty where the emergency response team (ERT — doctor, nurse–anesthetist, surgical assistant, midwife, laboratory technician and ambulance driver) are available and reachable if called. In Mali the situation is that the midwife is the only staff member who stays at the hospital throughout the night and she sends a message to the other members of the team at their homes when needed. This often leads to delays in treatment because the staff on-call have no transport to get to the hospital at night and occasionally they are neither at home nor reachable. Early in the project, therefore, the SCUS team discussed with the hospital management the need to have the ERT on-site to ensure prompt and efficient care for women with complications, particularly if surgical intervention (such as cesarean delivery) is needed. The hospital management and project teams grappled with where to house the ERT during the night as the hospital had no rooms for rest and recovery. As an interim measure, the project team did the following to reduce the response time to obstetric emergencies at night:
3.2. Staff training ■
The project team, in collaboration with the MOH, specialists from Gabriel Touré and Commune V teaching hospitals, the national blood transfusion center and a team from JHPIEGO-Burkina Faso, organized a competency-based training for key hospital staff. Existing curricula were adapted from key international resources and used for the training [12–14]. ■
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5 general doctors received technical updates and training in EmOC and obstetric surgery to appropriately recognize and manage obstetric complications; 4 laboratory technicians received training in blood safety and transfusion; 4 nurse–anesthetists and 2 nurse–surgical assistants received training in their specialty and the latter passed on skills to 2 other nurses working in the surgical wards; 7 midwives, 3 auxiliary midwives and 3 doctors (out of the 5 above) received technical updates and training in basic emergency obstetric care procedures. The objective of training the doctors was to enable them to supervise midwives effectively and to increase the critical mass of
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Established a rotation schedule for ambulance drivers to ensure 24/7 coverage; Refurnished an abandoned storage room for rest and recovery during the night for ambulance drivers; Provided 3 walkie-talkies and 2 motorbikes to each hospital to be used by staff to reduce time needed to get to the hospital; and even this was threatened by the danger of riding alone at night.
Establishing 24-hour availability of EmOC to provide timely care to women proved to be one of the greatest challenges of the project. Despite this we continued to encourage and remind the management teams of the 2 hospitals to initiate a phased approach to having on-call staff at the hospital at night and on weekends. By mid-2003, the surgical assistant and ambulance drivers had started night duty and by the beginning of 2004, the nurse–anesthetists had joined the team on the hospital premises. They were temporarily accommodated in the consulting rooms. With 4 out of 6 members of the ERT on site the project team developed a tracking system to determine whether the presence of the staff reduced response time in providing treatment and improved maternal and
The challenges of improving emergency obstetric care in two rural districts in Mali newborn outcomes. Unfortunately, the change in staffing was not in place long enough to register substantial change and if the patient required surgery, the doctor was not immediately available. This delay in treatment (the 3rd delay) jeopardizes maternal and newborn outcomes.
3.4. Recording of patient information and data collection The baseline study revealed midwives were key recorders of obstetric information and had to complete up to 9 registers for each patient and incomplete recordings of patient information were common. SCUS discussed with MOH officials at the regional and national levels the duplication of data and inaccuracies observed in the registers and suggested pulling together all 9 registers into one or two to reflect the key variables relevant to maternal and newborn outcomes. However, they informed us that the registers served their purpose at the time and that many copies were still in stock. Nevertheless, they agreed to revisit our recommendations at the appropriate time. Although we knew that a consolidation of registers would have been worthwhile, we recognized the challenges presented (time, resources and the coordination of an array of national departments) in reviewing the national health information system. To facilitate our project monitoring and evaluation, we developed weekly and monthly summary forms that captured key variables and combined information from these with patient notes. The pulling of patient information onto one form improved midwives’ ability to compile, understand and review the data and use them to improve the care they provided. We believe the forms we developed will serve as an example for the MOH when they decide to review the existing record keeping system. We also introduced the UN Process Indicators to hospital staff as a means of tracking and monitoring availability of obstetric services [8]. The EmOC Core teams also convened monthly meetings where the UN Process Indicators were calculated and discussed, which contributed to understanding what improvements were needed within the hospitals.
3.5. Quality and performance improvement An adaptation of COPE [15] for EmOC [16] was introduced to the hospitals in April 2003 as one strategy to facilitate continuous quality improvement in the hospitals. The AMDD technical team provided on-the-job training workshops and mentoring to the majority of staff in each hospital. Over the next year, COPE exercises resulted in placement of sign posts in written and pictorial forms to help patients identify different departments within the hospital and weekly maternal health review meetings to help staff understand the circumstances for deaths and near misses within the hospital and how to avoid them. The AMDD technical team also strengthened the skills of the regional health monitoring team in clinical supervision. While the establishment of weekly meetings was an important step to improving patient care, the fact that part of the ERT did not sleep on the hospital premises and were not always reachable continued to contribute to the 3rd delay in providing treatment.
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3.6. Development of EmOC clinical protocols For the first time ever, obstetric clinical protocols were developed by the project in collaboration with hospital partners, the Division of Reproductive Health (DRH) of the Ministry of Health, obstetricians/gynecologists from medical schools in Bamako, and technical advisors from AMDD. International standards and examples from other countries were used as a guide during development. The activity began in September 2002 and ended in April 2004 when the MOH adopted it for use. Twenty-six staff from the two hospitals received training on the clinical protocols; provider performance and adherence to the protocols were audited by reviewing patient notes at weekly maternal health review meetings in each hospital.
3.7. Community sensitization for service utilization Save the Children/USA considers helping communities understand when, where, and how to seek care [17]. The referral and evacuation system in Mali plays a key role in transferring women with obstetric complications and other patients with other emergencies from the rural community clinics to the district hospital. We established the referral network in Yanfolila at the end of 2002, in collaboration with district government representatives, the regional MOH and community representatives, using the national resource “Cadre conceptuel de l'organization du systeme de reference/ evacuation au Mali” [18]. Early in 2003, after major interventions were in place, the project team in collaboration with SCUS Saving Newborn Lives Initiative (also operating in Bougouni district) developed behavior change and communication (BCC) messages (Box 1) that were aired weekly on local radio to help families prepare for delivery. Radio was used because 64% of rural dwellers had access to radio [19].
Box 1 Components of behavior change and communication (BCC) messages ■ ■
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Preparation for delivery Recognition of danger signs during pregnancy, labor and delivery, and postpartum care Preparation for emergency situations (obstetric and newborn complications) Initiation and functioning referral and evacuation systems in Yanfolila Bougouni has a new ambulance to strengthen its referral system Importance of timely care-seeking improves chances of survival Encouragement for voluntary blood donation Hospital improvement in treating obstetric complications through SC/US and MOH partners Encouraging deliveries at the community clinics to increase facility births with trained health staff but also to reduce overcrowding at the district hospital so that the latter can better respond to obstetric complications and other emergencies
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4. Partnership paves the way for collaboration, advocacy, policy change and replication Save the Children/USA established lasting partnerships with district, regional and national MOH representatives, policy makers and in-country bilateral agencies. The involvement of partners gave credibility to the project and to the promotion of international standards of care. While SCUS/ AMDD funded the project interventions, the MOH staff in Bougouni and Yanfolila hospitals implemented the project activities. Their salaries and time spent on project activities were never quantified, however, it was a significant contribution to project resources. The SCUS/AMDD strategy and experiences in Bougouni and Yanfolila were instrumental in clarifying the specific steps needed to strengthen Mali's health system to improve EmOC — a critical component in making motherhood safer. At a workshop to disseminate the experiences of this project in August 2005, the Director of the Division of Reproductive Health announced that Bougouni and Yanfolila would be used as pilot sites to replicate the improvement in EmOC throughout Mali.
5. Taking EmOC to scale Several important actions for promoting EmOC at scale started or were completed during the course of project implementation mostly as a result of advocacy efforts by the SCUS team and AMDD global collaboration. These are listed below: ■
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A national EmOC needs assessment was completed in 2003 and revealed a critical need for availability of good quality EmOC services; EmOC treatment guidelines were developed and adopted by the MOH in April 2004; A revision of the national reproductive health norms and procedures included EmOC treatment guidelines; Advocacy to adopt and adapt the UN Process Indicators led to their acceptance and inclusion as national indicators for monitoring the availability, quality and utilization of obstetric services at all levels of care;
Figure 2
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The MOH adopted a national strategy to implement EmOC in June 2004 collaborating closely with UNICEF to upgrade and improve the quality of EmOC in 65 health facilities throughout the country; An unprecedented policy change by the MOH in June 2005 made all cesarean deliveries in public facilities free of charge to encourage utilization of specialized services for obstetric complications; New midwifery skills were acquired through competencybased training such as active management of third stage of labor, manual removal of placenta and midwives were given greater responsibility so that they could administer oxytocin without a doctor's order; International standards of care were promoted through the national maternal and newborn taskforce of which SCUS is a member; and Advocacy to enhance the functional capacity of community clinics and staff to provide selected life saving services.
6. Results Project planning and implementation began in 2001 and by the end of 2002, major project inputs had been completed. Project data were compiled weekly and quarterly and used for monitoring with the UN Process Indicators. In February 2005 a qualitative evaluation was undertaken to determine the value added of community sensitization in using obstetric referral services.
6.1. Availability of EmOC The project sites Yanfolila and Bougouni districts are located in Sikasso region in southern Mali and have an estimated population of 150,000 and 350,000 respectively. The UN Process Indicators recommend as a minimum 1 comprehensive EmOC and 4 basic EmOC facilities for a 500,000 population. Where geographical access is a challenge we believe it is reasonable to deviate from the recommended number of facilities as is the case with Yanfolila and Bougouni. Therefore, we suggest at a minimum, the population of Bougouni must have access to 1 health facility offering the full range of comprehensive
UN Process Indicators — trend data over 4 years, Bougouni district hospital.
The challenges of improving emergency obstetric care in two rural districts in Mali
Figure 3
UN Process Indicators — trend data over 4 years, Yanfolila district hospital.
EmOC services and 3 facilities providing basic EmOC. The people of Yanfolila district must have access to at least 1 comprehensive EmOC facility and 2 basic EmOC facilities. At the start of the project, Bougouni and Yanfolila hospitals were not providing the full range of comprehensive EmOC services but through project inputs they did by the end of 2002. Community clinics by national policy provide only normal delivery and primary care services. SC/Mali continues to advocate for the functional capacity of community clinics and staff to provide selected life saving services.
6.2. Changes in clinical competence and practice of midwives Significant changes in clinical practice for midwives following competency-based training included: ■
routine application of active management of third stage of labor (AMTSL) for all deliveries;
Table 2
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the authority to administer oxytocin as treatment where indicated without a doctor's order; skills to perform vacuum extraction; skills to perform manual removal of placenta.
Removal of retained products of conception continued to be a service provided by the general doctors.
6.3. Utilization and quality of EmOC in Bougouni and Yanfolila district hospitals Figs. 2 and 3 show the changes observed in the 4 other UN Process Indicators reflecting utilization and quality of EmOC services in Bougouni and Yanfolila. Data from Bougouni hospital showed no change in the proportion of births and in the cesarean delivery rate over the project period. There was, however, a notable increase in the number of recorded complications from 197 in 2001 to 364 in 2004 (Table 2) and a corresponding increase in met need for EmOC from 9% in 2001 to 15% in 2004. We believe that
UN Process Indicators: the availability, utilization, and quality of EmOC, Bougouni district, Mali, 2001 to 2004 2001 Year 1
2002 Year 2
2003 Year 3
2004 Year 4
Population served Crude birth rate Expected births Expected complications
322,572 46 14,838 2226
331,926 46 15,269 2290
341,552 46 15,711 2357
351,457 46 16,167 2425
Service data Births in EmOC facilities Women with complications delivering in EmOC facilities Cesarean deliveries Maternal deaths (direct obstetric causes)
566 197 131 14
757 311 146 13
756 299 153 16
766 364 202 8
UN Process Indicators Proportion of births in EmOC facilities (UN recommendation — 15%) Met need for EmOC a (UN recommendation — 100%) Cesarean deliveries as a proportion of all births (UN recommendation — 5–15%) Case fatality rate (UN recommendation — b 1%)
3.8% 8.8% 0.8% 7.1%
5.0% 13.6% 1.0% 4.2%
4.8% 12.7% 1.05 5.4%
4.7% 15.0% 1.2% 2.2%
a
Women with complications delivering in EmOC facilities divided by the number of expected complications × 100.
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Table 3
UN Process Indicators: the availability, utilization, and quality of EmOC, Yanfolila district, Mali, 2001 to 2004 2001 Year 1
2002 Year 2
2003 Year 3
2004 Year 4
Population served Crude birth rate Expected births Expected complications
137,463 46 6323 948
141,174 46 6494 974
144,986 46 6669 1000
148,901 46 6849 1027
Service data Births in EmOC facilities Women with complications delivering in EmOC facilities Cesarean deliveries Maternal deaths (direct obstetric causes)
631 61 41 5
538 97 35 3
396 97 38 1
591 158 56 8
UN Process Indicators Proportion of births in EmOC facilities (UN recommendation — 15%) Met need for EmOC a (UN recommendation — 100%) Cesarean deliveries as a proportion of all births (UN recommendation — 5–15%) Case fatality rate (UN recommendation — b 1%)
9.9% 6.4% 0.6% 8.2%
8.2% 9.9% 0.5% 3.1%
6.0% 9.7% 0.5% 1.1%
8.6% 15.3% 0.8% 5.1%
a
Women with complications delivering in EmOC facilities divided by the number of expected complications × 100.
these results imply the availability of other treatment options provided by midwives and perhaps better reporting of complications (Table 2). In Yanfolila, on the other hand, data between 2001 and 2003 showed a decrease in the proportion of births in EmOC facilities, no change in the cesarean delivery rate and, as expected, a decrease in case fatality rate [CFR] (Table 3, Fig. 3). In 2004, however, an interesting turn of events occurred. There was an increase in the proportion of births in EmOC facilities from 6% to 9%, the population-based cesarean rate increased from 0.5% to 0.8%, and met need increased from 6% in 2001 to 10% in 2003 and to 15% in 2004 (Fig. 3).
6.4. The additional value of community mobilization and sensitization After a year of BCC messaging, data suggest that the messages had the desired effect of encouraging utilization of maternity and EmOC services. Data from Yanfolila hospital are particularly encouraging in spite of the increase in CFR. As described earlier, Fig. 3 shows modest but steady increases in all indicators. The effect of the policy and programmatic decision to sensitize the community to attend community clinics for the majority of normal deliveries also appears to have had the desired outcome. Between 2002 and 2004, deliveries in community clinics increased by 94% in Bougouni (6990 to 13,559) and by 61% (1259 to 2023) in Yanfolila. This suggests that community mobilization does contribute to utilization of services. Nevertheless, despite these modest gains, community interviews carried out in February 2005 highlighted the following: ■
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women and families still faced delays when they arrived at the hospital, especially at night, due to the absence of key staff; women and families continue to face long distances and bad roads when emergencies occur even when transport was readily available;
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the critical need to decentralize selected life-saving functions to community clinics.
7. Continuing challenges Throughout the project period we faced a number of challenges related to the health system that we believe will also affect the utilization, availability, and quality of delivering EmOC services nationwide. These are listed below: ■
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Staff transfers: Transfer of staff is a major problem in Mali and within a year of implementation, staff trained with project funds were transferred and new staff needed to be trained on-the job by existing staff. Maintenance of equipment: All hospital equipment including ambulances needing maintenance had to be sent to Bamako. Transportation, labor costs, distance, and bad roads made it difficult for hospitals to adhere to a regular maintenance schedule. Malian system of on-call night duty: The current system makes it difficult to provide timely EmOC 24/7; it also affects other patients with life-threatening injuries and illnesses. Requested focus on district hospitals: Lack of key life-saving EmOC functions in community clinics is a missed opportunity to save women's lives closer to home since community clinics are the first contact with the health system. Record keeping: We had to develop a one-page data collection sheet to capture the variables needed for monitoring the project indicators. Midwives also still had to complete up to 9 additional government registers for each patient making incomplete recording of patient information a common occurrence.
8. Sustainability One of the main goals of the SCUS and AMDD collaboration in Mali was to pave the way for sustainability and
The challenges of improving emergency obstetric care in two rural districts in Mali institutionalization of project inputs and lessons learned at national level. This has been achieved in part as noted earlier by policy changes and the several other important actions taken by the MOH for promoting EmOC at scale. There is, however, still a long road ahead and the greatest challenges Mali will continue to face given the lessons learned from our project are in human resource capacity, logistical supplies capacity, and the decentralization of certain functions to community clinics.
9. Discussion Even in the face of many challenges, SCUS's project in Mali showed that it is possible to achieve modest improvements in the quality and use of EmOC in hospitals. The management and staff of Yanfolila and Bougouni hospitals agreed that the onus falls on them to continue using the skills acquired over the project period with support from the regional authorities, and to reach and maintain the highest level of quality care. In spite of the low figures for “Met Need” (use of obstetric services by women with complications), 9% in 2001 and 15% in 2004 in Bougouni and 6% in 2001 and 15% in 2001 in Yanfolila, and while still far below the goal of 100% [8], they are still impressive increases — 66% and 116% respectively. While cesarean rates remain very low (1.2% and 0.8, Bougouni and Yanfolila, respectively) the availability of this lifesaving treatment did increase. Clearly much more needs to be done to make the treatment available at all times and to reach many women with life-saving care. Changes in the case fatality rate need care in interpretation. In Bougouni this decreased from 7% in 2001 to 2.2% in 2004, suggesting an improvement in the overall quality of services provided. While in Yanfolila the increase in utilization was disturbingly accompanied by an increase in the case fatality rate, from 1% to 5%, although it was based on only 1 and 8 maternal deaths respectively. The increase shows that at least women were arriving at the hospital, but possibly too late. Death reviews would help interpret this increase in CFR. The project emphasized improving EmOC at district hospitals. This, in combination with Mali's policy not to mandate community clinics to provide basic EmOC, meant less emphasis was put on upgrading community clinics to provide basic EmOC. SCUS, however, continues to advocate and is actively involved in raising awareness at the policy level to improve the functional capacity of strategically placed community clinics and staff to manage selected complications, particularly as women continue to face difficulties in reaching district referral hospitals. While decentralizing basic EmOC will require major policy changes, staff deployment and training, logistical implications and a different kind of monitoring and supervision, we believe it is a move that could potentially contribute to improving maternal health and survival for women in Mali. Save the Children/USA's efforts on improving the quality and availability of EmOC were an important step for Mali in going to scale with EmOC services nationwide. EmOC is now incorporated as an essential component of maternity services in saving women's lives.
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10. Lessons learned Key lessons learned include: ■
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Advocacy efforts and engaging policy and decision makers from the onset of project planning is key to embracing change and going to scale. Partnership and teamwork are essential for achieving and sustaining results and can only be achieved by the will to do something about a problem. The availability of a pool of trained providers is necessary to achieve and sustain quality of care. Community sensitization is a strategy that has the potential to mobilize communities to use improved services. Supportive and regular supervision by the regional team is an important activity for sustaining and institutionalizing project innovations. The importance of continuing challenges to project implementation.
11. Conclusions Save the Children/USA's work in Mali demonstrated that investments in the existing health system are needed to improve EmOC — a critical requirement for improving maternal survival. As we found, implementing interventions that we know can save women's lives, in the midst of health systems’ challenges, requires commitment, persistence, determination, encouragement, and collaboration with partners. In spite of the importance of access to quality EmOC, in Mali, geographical access to district hospitals providing EmOC services continues to be a considerable hurdle that is encountered by many women every day. Even when women do get to the district hospital, key staff may not always be readily available to provide timely care. Much additional work is needed to help Mali meet the needs of its mothers. Priority should be given in future programming to reviewing existing policies on maternity services at community clinics to decentralize specific functions of basic EmOC and to ensuring 24-hour availability of key staff at rural hospitals. This can be achieved when donors, partners, and the ministry of health coordinate efforts to strengthen health systems.
Acknowledgments We would like to convey our sincere thanks to our partners for financial and technical support: all levels of the Ministry of Health in Mali (especially Dr Maiga Zeinab Mint Youba (Minister of Health), Dr Keita Binta (Director of DRH, MOH) and staff at Yanfolila and Bougouni hospitals), the AMDD Global Program (especially Dr Sourou Gbangbade, Dr Grace Kodindo, Ms Samantha Lobis). AMDD's financial support was provided through the Bill and Melinda Gates Foundation.
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