What’s in the way of quality antenatal care for women in West and Central Africa

By Comfort Z. Olorunsaiye: Assistant Professor of Public Health, Arcadia University

Globally, nearly 300,000 women die from pregnancy-related causes each year. Most of these deaths are in the low-income countries of sub-Saharan Africa and South Asia.

The leading causes of maternal mortality include severe bleeding, hypertensive disorders, infection, unsafe abortion and embolism. There are also indirect causes such as HIV, malaria and anaemia. About three in four maternal deaths could be prevented if women had adequate access to quality care before, during and after pregnancy.

Quality antenatal care can save lives by identifying and addressing health problems that can cause pregnancy complications and poor birth outcomes. But the women most at risk tend to be the ones who do not access life-saving health services. Barriers to quality antenatal care include lack of information, cultural practices, poverty and distance to health services. Others are inadequate and poor health services.

There is already global evidence of social and economic differences in access to maternal health care and the quality of that care. We sought to understand the quality of antenatal care in sub-Saharan Africa. Countries in the West and Central African sub-region have notably poor reproductive health indicators, as well as high levels of poverty and civil unrest or political fragility.

Yet, the region has been largely underrepresented in empirical research. Research findings can help inform policy and programme interventions for improving the reach and quality of antenatal care. They can also contribute to reducing the unacceptable rates of maternal and newborn deaths in the region.

At the time of our study, household survey data from the same source were available for seven countries in the United Nations region of West and Central Africa: Central African Republic (CAR), Chad, the Democratic Republic of Congo (DRC), Ghana, Nigeria, Sierra Leone and Togo. We analysed the data on 32,718 women whose pregnancies resulted in a live birth, considering the levels of poverty in the households and communities where these women resided.

What we found

Our findings indicated that one in four pregnant women did not receive antenatal care. The majority of these women were in Chad (37%) and Nigeria (38%). Among women who had antenatal care, the majority received low-quality care. This means receiving fewer than five of six possible antenatal care services. The proportion of women who received high quality antenatal care ranged from 3% in Chad to 33% in Nigeria.

Among women who received antenatal care, the most common services provided across all seven countries were blood pressure monitoring and tetanus vaccination. The figures ranged from 79% in Chad to 99% in Ghana for blood pressure monitoring. For tetanus vaccination they ranged from 87% in the DRC to 97% in Sierra Leone.

Less frequently provided services included HIV testing, malaria treatment and blood tests. We also found that higher levels of household wealth increased the likelihood of women reporting high-quality antenatal care. Poorer households are in the top 20% of the household wealth index. This measures the living standard of a family, based on the possession of certain household goods and infrastructure. The relationship of household wealth with quality of antenatal care was more noticeable in the DRC, Ghana, Nigeria, Sierra Leone and Togo.

Similarly, women who had secondary or higher levels of education were between two and three times as likely to receive high-quality antenatal care as women without formal education. With the exception of Chad, women who had more antenatal care visits reported high quality care.

Our results indicate that the quality of antenatal care varied according to the level of poverty in communities. Women who lived in poor communities were between 15% and 52% less likely to report high-quality antenatal care. Poor communities are clusters of households headed by someone with no formal education, and in the lowest 20% of the wealth index. The poorest household wealth quantile is the lowest 20%.

The findings indicate that living in a poor household and in close proximity to poor households is a risk factor for low quality antenatal care. Poor women and their families are already vulnerable and may have underlying conditions that can increase their risks for experiencing pregnancy complications and poor birth outcomes. But these women may miss out on the benefits of antenatal care altogether because they face financial and social barriers to healthcare.

What should be done

In countries with low coverage of antenatal care, for instance Chad and Nigeria, policies should focus on expanding access to maternal health services. Educational policies that support the enrolment and retention of women in school can contribute to raising awareness on health and well-being. They also empower women to demand quality care. Although some countries provide free or subsidised health services for pregnant women and young children, it is evident that these policies do not adequately bridge the gap between need and access to services.

Therefore, additional economic policies that empower women financially to afford direct and indirect costs of services are needed.

Across all the countries in our study, there is a dire need to improve the quality of services. The health systems are clearly missing an important opportunity to intervene early in pregnancy to address behaviours and health problems that could cause serious complications or pregnancy-related deaths among the poorest women.

Targeted support for health systems should also be provided. These include ensuring adequate supplies of medicines and equipment, enhanced pre-service and in-service training and supervision of healthcare providers. Equitable distribution of healthcare resources, including providers, would also contribute to improved access and quality of antenatal care services in West and Central Africa.

These recommendations, if implemented, would significantly reduce maternal and newborn deaths and increase wellbeing and social capital in the region.

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The article was first publshed by THE CONVERSATION

NIH to test one-dose antibiotic for the prevention of maternal and infant sepsis

Researchers supported by the National Institutes of Health and the Bill & Melinda Gates Foundation will assess whether a single oral dose of the antibiotic azithromycin during labor reduces the risk of maternal and infant bacterial infection and death in seven low- and middle-income countries.

“We urgently need effective interventions to reduce the death toll of pregnancy-related infections worldwide,” said Diana W. Bianchi, M.D., NICHD Director. “This study allows us to test a low-cost intervention that has shown promise in a smaller study.”

The clinical trial is funded by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Gates Foundation. The trial will be conducted by researchers in NICHD’s Global Network for Women’s and Children’s Health Research, or NICHD Global Network.

Maternal death from sepsis — a system-wide reaction to bacterial and other infections — is higher in many low- and middle-income countries, compared to wealthy countries. This higher death rate results from a combination of factors, including a longer time to diagnosis, lack of access to timely drug treatment and chronic malnourishment. Infection during pregnancy and in the weeks after birth account for roughly 10% of maternal deaths worldwide, according to the World Health Organization. Infection accounts for 16% of newborn deaths worldwide.

Azithromycin, an antibiotic effective against a broad range of bacteria, has been shown(link is external) to protect against infection resulting from cesarean delivery. The drug is low-cost and can be kept at room temperature, which makes it suitable for parts of the world where refrigeration isn’t always available. An earlier study of more than 800 women in The Gambia found that administering azithromycin to pregnant women at the beginning of labor reduced maternal and infant infections, compared to a group that received a placebo. Azithromycin and other antibiotics are not effective against COVID-19 and other diseases caused by viruses.

The current study plans to enroll up to 34,000 women at NICHD Global Network sites in Bangladesh, the Democratic Republic of the Congo, Guatemala, India, Kenya, Pakistan and Zambia. Half of the women will receive a single 2-gram dose of oral azithromycin, and the other half will receive a placebo. The women and their infants will be monitored for fever and other signs of infection during their hospital stay and again at one week and six weeks after giving birth. The study will also include records of unscheduled visits to health facilities outside of the network sites.

“The NICHD Global Network provides the expertise and infrastructure needed to carry out this essential clinical trial,” said lead investigator Waldemar Carlo, M.D., of the Neonatology Division of the University of Alabama at Birmingham. “We anticipate that this study will provide important data to help us improve the standard of maternal care in low- and middle-income countries.”

The Foundation for the National Institutes of Health, a not-for-profit organization that manages alliances with public and private institutions in support of the NIH mission, provided funding for the study with a grant from the Gates Foundation.

WHO releases first guideline on digital health interventions

WHO on Wednesday released new recommendations on 10 ways that countries can use digital health technology, accessible via mobile phones, tablets and computers, to improve people’s health and essential services.

“Harnessing the power of digital technologies is essential for achieving universal health coverage,” says WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Ultimately, digital technologies are not ends in themselves; they are vital tools to promote health, keep the world safe, and serve the vulnerable.”

Over the past two years, WHO systematically reviewed evidence on digital technologies and consulted with experts from around the world to produce recommendations on some key ways such tools may be used for maximum impact on health systems and people’s health.

One digital intervention already having positive effects in some areas is sending reminders to pregnant women to attend antenatal care appointments and having children return for vaccinations. Other digital approaches reviewed include decision-support tools to guide health workers as they provide care; and enabling individuals and health workers to communicate and consult on health issues from across different locations.

“The use of digital technologies offers new opportunities to improve people’s health,” says Dr Soumya Swaminathan, Chief Scientist at WHO. “But the evidence also highlights challenges in the impact of some interventions.”

She adds: “If digital technologies are to be sustained and integrated into health systems, they must be able to demonstrate long-term improvements over the traditional ways of delivering health services.”

For example, the guideline points to the potential to improve stock management. Digital technologies enable health workers to communicate more efficiently on the status of commodity stocks and gaps. However, notification alone is not enough to improve commodity management; health systems also must respond and take action in a timely manner for replenishing needed commodities. 

“Digital interventions, depend heavily on the context and ensuring appropriate design,” warns Dr Garrett Mehl, WHO scientist in digital innovations and research. “This includes structural issues in the settings where they are being used, available infrastructure, the health needs they are trying to address, and the ease of use of the technology itself.”

The guideline demonstrates that health systems need to respond to the increased visibility and availability of information. People also must be assured that their own data is safe and that they are not being put at risk because they have accessed information on sensitive health topics, such as sexual and reproductive health issues.

Health workers need adequate training to boost their motivation to transition to this new way of working and need to use the technology easily. The guideline stresses the importance of providing supportive environments for training, dealing with unstable infrastructure, as well as policies to protect privacy of individuals, and governance and coordination to ensure these tools are not fragmented across the health system.

The guideline encourages policy-makers and implementers to review and adapt to these conditions if they want digital tools to drive tangible changes and provides guidance on taking privacy considerations on access to patient data.

“Digital health is not a silver bullet,” says Bernardo Mariano, WHO’s Chief Information Officer. “WHO is working to make sure it’s used as effectively as possible. This means ensuring that it adds value to the health workers and individuals using these technologies, takes into account the infrastructural limitations, and that there is proper coordination.”

The guideline also makes recommendations about telemedicine, which allows people living in remote locations to obtain health services by using mobile phones, web portals, or other digital tools. WHO points out that this is a valuable complement to face-to-face-interactions, but it cannot replace them entirely. It is also important that consultations are conducted by qualified health workers and that the privacy of individuals’ health information is maintained.

The guideline emphasizes the importance of reaching vulnerable populations, and ensuring that digital health does not endanger them in any way.

‘Development starts with healthy people’ -UNDP Sierra Leone Country Director

By Ahmed Sahid Nasralla (De Monk)

Country Director UNDP Sierra Leone, Samuel Doe, on inspection of the MCHPs

Country Director UNDP Sierra Leone, Samuel Doe, has urged rural communities in the small West African country to stay healthy by accessing and helping in maintaining health facilities in their localities.

“Like all developing countries, Sierra Leone is faced with so many challenges and health is a major one. Health is important because development starts with healthy people. There would be no development if the people who should do the work are not healthy,” he said.

Doe was speaking during a tour of the Southern and Eastern regions of Sierra Leone officially handing over Maternal Child Health Posts (MCHP) to communities through the Kailahun District Council and District Health Medical Team (DHMT). UNDP Sierra Leone supported the rehabilitation and construction of these health facilities with funds from the Government of Japan.

Six of the MCHPs are in Kailahun District, Eastern Sierra Leone: Talia, Bandajuma Sinneh and Sengema in Luawa Chiefdom; Mendekele main Upper Bambara Chiefdom; and Sandia and Gbandiwulo in Kissi Tongi Chiefdom. During the Ebola outbreak (2014-2016) these border communities were among the hardest hit by the killer disease. The first Ebola case in Sierra Leone was reported in Kailahun district and at the peak of the outbreak the district was recording more than 80 new Ebola cases per week and more than 50 bodies were buried in just 12 days in makeshift graveyards close to the Ebola treatment center, according to the World Health Organisation.

The facilities are equipped with observation rooms,outpatient wards, Expanded Program on Immunization ward, Ante-natal and post-natal wards, drug stores, consultation rooms, labour rooms, typical toilets, incinerators, placenta pits and health staff quarters.

The old healthpost at Talia donated by a community member

The MCHPs will render services to a catchment population in all six communities of about 22,500 in 56 villages.

Doe was particularly happy about the fact that the health posts have moved from small family homes donated by kind community members to bigger permanent structures.

Bintu Alhaji, and her colleagues, attended the handing over ceremony at Talia with her two-months old baby strapped to her back. She had delivered under difficult conditions at the makeshift health post donated by a community elder identified as Pa Sellu Bockarie. She looked in high spirit as they danced in celebration to accustomed rhythm from their native drums.

“Before now, it was difficult for us and the nurses.I am happy for this new hospital and I look forward to come regularly with my children for check-up,” said Bintu.

Equally, the nurses were in high spirit. “We are happy about the new structures. We never honestly imagined we could have such facilities in this town,” said Nurse-in-Charge at Talia MCHP, Jestina Alpha. Jestina has been an MCHP aide for six years at Talia.

However, challenges of water supply, electricity, refrigerator and mobility cut across the facilities.

In Talia, digging of bore holes or water wells doesn’t seem feasible as there are no traces of water underneath within a reasonable distance from the new health post. The only possible location for a well or hand pump is at a swamp down a steep hill about 100 meters from the MCHP.

In Bandajuma Sinneh, the previous health post has gone three months without water due to a faulty hand pump. The drugs and vaccine refrigerator is also not functioning due to a faulty part.

The nurses said they use ‘Chinese lamps’ or torch lights to see their way in the rooms during the day and night. Before now the nurses lived in rooms within the MCHPs, and they claim to pay motorbike fares from their personal pockets to do outreach and to travel to and from the district headquarter town to fetch drug supplies.

The project, titled ‘Building a resilient community health system to prevent infectious diseases in post-Ebola country Sierra Leone’ implemented by SEND Sierra Leone, has three components: governance, livelihood and health. Under the governance component, according to UNDP Sierra Leone Project Officer Isata Mariam Bangura, there are Village Development Committees (VDCs)and Facility Management Committees (FMCs) which support the project monitoring and reporting to the  Kailahun district council through the councilors and other community stakeholders..

The livelihood component supports gender sensitive trainings to involve women in governance and business in Kailahun district and the health aspect of the project supports the rehabilitation and construction of health facilities in six towns in three chiefdoms of Luawa, Kissi Tongi and Upper Bambara as a support in addressing the issue of Infant and Maternal mortality in Sierra Leone.

“We hope these facilities will reduce the number of women and children who lose their lives during pregnancy and birth,” said Doe.

Sierra Leone is among countries with high incidences of maternal and infant mortality.

“Our responsibility now as DHMT, District Council and community is to take ownership of these new structures and ensure we maintain them. Let these facilities render the intended services to the people of Kailahun District,” said Francis Lansana, Acting DMO Kailahun District.

He added: “We want to jubilate next year when we come to visit and find out no woman or child has died in the hospital.”

In addition, the Kailahun District Council Chairman Sahr A. K. Lamin expressed gratitude to UNDP Sierra Leone and the Japanese government but particularly praised the contribution of the communities to the construction of the MCHPs.

In Talia for example, the community actually started the construction of their own health building before the intervention of UNDP Sierra Leone.

However, in Bandajuma Sinneh the initial community response was one of denial. The Project Manager for SEND Sierra Leone, Mohamed Jalloh, explained how attempts were made to beat him and drove him away from the community.

“When we started the project here there was a lot of denial and lack of cooperation from the community. At some point the people attempted to beat me and they drove me away. I am happy that we have reached this far, and everybody is happy,” said Jalloh.

In fact, during the handing over ceremony the Councilor Jacob Yankuba Amara pledged a bag of rice and assured he would mobilize the youth to help fence the health post.

Meanwhile, Country Director for SEND Sierra Leone, Joseph Ayamga, said the challenge now is to ensure the MCHPs are well equipped with the requisite materials, drugs and qualified and committed health nurses in charge.

Sierra Leone: President Bio warns healthcare workers to report on time for work

Sierra Leone president, Rtd. Brig. Julius Maada Bio, on Monday surprised healthcare workers at the Princess Christian Maternity Hospital (PCMH-Cottage) with an unannounced visit to check on the condition of the facility.

The president arrived at the hospital at 8:30am, the official report time for work, to monitor compliance by workers to report for work on time.

During his tour of the facilities, which is housing the Ola During Children’s Hospital at Fourah Bay Road in the east of Freetown, the President noticed that one of the matrons was not on her seat long after the clock-in time for all public workers. He interrogated the Doctor-in-Charge on the possible reason for her absence and asked that she be reprimanded and urgent actions be taken to enforce the recent measures for all government workers.

President Bio expressed his dissatisfaction over conditions at the hospital, saying that the facility was overcrowded and hygiene situation needed urgent attention. He commended  workers who showed for work early.

“In terms of turnout for personnel, we must be happy because I met the Doctor and most of the other senior staff on time. With the exception of very few that I did not meet for which I have left warnings, we must congratulate them for their hard work. We will challenge them that everyone is in their office by 8:30am because if we want to bring change we must start it with how we manage time,” he said.

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On the deplorable state of the health facilities, President Bio added that: “What I am not pleased with is that this place, where people give birth to children is not conducive. I have heard a lot about it and that is why I have decided to come and see for myself and definitely, this facility is not enough for the women who come here to deliver.  I have seen it and it is now the business of government to see where we can improve and help save the lives of our compatriots,” he said.

Doctor-in-Charge, A.V Koroma said the PCMH is a national referral centre that receives over two thousand patients on a monthly basis.

He thanked the Ministry of Health and Sanitation for their support in terms of drugs to the centre. He cited challenges such as lack of beds to accommodate more patients and called on the government to assist with more beds to accommodate the growing rate of patients at the hospital.