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Innovating beyond traditional measurements- Health system preparedness for emergency obstetric care service delivery in a South African district

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Innovating beyond traditional measurements - health system preparedness for emergency obstetric care service delivery in a South African district 

Background:

-Improving the delivery of emergency obstetric care (EmOC) is critical to addressing the high maternal mortality ratio (MMR) in South Africa.

-The United Nations (UN) signal functions are widely used to measure the availability of EmOC services.
-Although useful they do not capture all important aspects related to the availability of EmOC services in some settings.
-In this study, traditional UN process indicators were combined with additional audits to in an effort to provide a more comprehensive assessment of the availability of public sector EmOC services in one health district.
 
Methods:
-multiple audit methods were used to measure the preparedness of the 8 community health centres (CHCs) and 7 hospitals in the district to provide EmOC services
-UN signal functions used to classify health facilities as basic EmOC (BEmOC) or comprehensive EmOC (CEmOC) facilities.
-Checklists were used to determine the availability of: skilled human resources (doctors and midwives); essential EmOC drugs (max 24); resuscitation equipment (max 24); critical EmOC management protocols (max 10); and the performance of adult and neonate resuscitation drills.
 
Results:
-All 7 hospitals were classified as CEmOC facilities, while none of the 8 CHCs performed all of the 7 signal functions required to be classified as BEmOC facilities.
-The density of EmOC facilities fell short of the prescribed UN benchmarks, when adjusted for the non-medically insured population in the district (Figure 1).
-All CHCs provided some of the signal functions. Only 25% (N=2) CHCs provided manual removal of placenta and removal of retained products. None had done an assisted delivery (Figure 2).
-Blood availability was at a 100% of facilities across the district. However, none of the hospitals or CHCs obtained the maximum desired scores for drugs, fluids, and management protocols (Figure 3).
-Doctors were available 24hours a day, 7 days a week in all hospitals, but not in CHCs (Figure 4).
-Midwives skilled in EmOC were not available 24 hours day, 7 days a week in all CHCs.
-Midwives in hospitals had a much higher workload than those in CHCs.
-Only 6.7% (N=1) facility had performed adult resuscitation drills regularly while 73.3% had performed neonatal resuscitation drills across the district.
 
Conclusions:
-Preparedness of public health facilities for the provision of EmOC care in the district is suboptimal.
-BEmOC facilities are considerably fewer than required. This will result in the existing facilities, especially hospitals, being overwhelmed by the demand.
-All CHCs did provide some BEmOC services, but this was not reflected in the UN analysis. The UN indicator suggested the absence of any BEmOC  facilities, which is incorrect.
-All CHCs had fulltime midwives and doctors present some days of the week. However, this did not translate into the continuous availability of EmOC services in CHCs.
-Hospitals have to provide both CEmOC and BEmOC services for the entire population of over 2.4 million public sector users. Some of this burden could be shared with lower levels of care (CHCs), provided resources are made available up to allow them to provide such services safely.
 
Implications:
-More facilities are required in the district to cater for the current non-medically insured population in the district
-EmOC skilled providers are not always available to offer EmOC services in CHCs.
-There is a need to reinforce the use of adult resuscitation drills and the availability of protocols for managing common obstetric. emergencies to assure adequate EmOC  skills.
-This study has shown the benefit of a more comprehensive assessment of the availability of EmOC services using standard UN methods combined with additional checklists to capture important dimensions such as human resource availability, not reflected in the UN indicators.
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