22 March 2012

International evidence suggests that improving the quality of obstetric care and reducing maternal and neonatal deaths necessitates having accurate and reliable data on the quality of related health services. With support from USAID, MCHIP partnered with Ethiopia’s Federal Ministry of Health to gather such information in March and April of 2010.

A final report—entitled Quality of Care for Prevention and Management of Common Maternal and Newborn Complications: A Study of Ethiopia’s Hospitals—reveals the results of examining the quality of care (QoC) of maternal and newborn health services during antenatal and delivery care in Ethiopia. The survey was fielded in the 19 Ethiopian hospitals with the heaviest volume of deliveries, and is one of a series of MCHIP maternal and newborn QoC reports to be released in a multi-country study.

The primary objective of the survey in Ethiopia was to determine the frequency and quality of interventions that address the direct causes of maternal and neonatal deaths, and to guide the need for and content of QoC improvement activities for maternal and newborn care at hospitals. The results are itended to be used to inform and guide the national program and policies responsible for quality improvement in antenatal care, labor and delivery, and immediate newborn care.

Findings

The study involved observations of 126 antenatal care consultations and 192 deliveries, and interviews with 79 health workers (antenatal care providers and labor and delivery providers), plus an inventory of supplies, equipment and infrastructure at each facility.

Key findings include:

Postpartum hemorrhage (PPH)
 

• About 29% of women giving birth received the full components of active management of the third stage of labor, including a uterotonic within one minute of birth; this finding suggests that little has changed overall since the 2005 Prevention of Postpartum Hemorrhage Initiative (POPPHI)/FMOH study. However, oxytocin use has improved markedly, reaching nearly 100%.
• Low knowledge of PPH management among health workers, which indicates a need for improved training.

Pre-eclampsia/eclampsia (PE/E)
 

• Blood pressure was commonly checked during clients’ antenatal care visits and when they were admitted to the labor and delivery ward, but providers rarely asked about symptoms and signs of pre-eclampsia/eclampsia (in current or previous pregnancies) or counseled clients to return if they developed signs and symptoms. Urine was not routinely tested for protein in either service area. 
• Magnesium sulfate was rarely available in labor and delivery wards (only three of 19 facilities had it available).
• Knowledge of PE/E among health workers was low overall; scores for treatment were higher than those for examination and ongoing management.

Obstructed labor
 

• Partograph use was very low (despite available supplies), and in the few cases in which partographs were used, they were not always filled out correctly and completely.
• Cesarean section appeared to be underused: 7 out of 19 facilities reported performing no cesarean sections in the previous three months.
• Knowledge of the signs of obstructed labor was low among health workers, but management knowledge was a bit higher.

Postpartum sepsis in mother and newborn
 

• With the exception of hand washing and use of protective clothing, infection prevention practices were generally good.
• An unacceptable level of manual exploration of the uterus was found.
• Knowledge of newborn sepsis was better than knowledge of postpartum sepsis.

Newborn care
 

• There is room for improvement in newborn care practices, especially skin-to-skin care.
• Knowledge of routine care was found to be moderate, while diagnoses and management of asphyxia was low.
• Some practices do have a high level of adherence, including immediate drying of newborns as a component of essential neonatal care.

Conclusions and Recommendations

Overall, the QoC observed during the study was often below internationally accepted standards for antenatal care, labor and delivery practices, and essential newborn care. The study findings reveal a need to further integrate evidence-based practices and quality assurance processes at all hospital levels.

Furthermore, a concerted countrywide drive to improve the quality of maternal and newborn care is needed, and it should include implementing routine clinical and quality audits with attendant feedback mechanisms, retraining and supportive supervision, and making the FMOH’s Management Protocol on Selected Obstetrics Topics widely available. Such an effort will enhance the the capacity of health workers to provide the signal functions for basic and comprehensive emergency obstetric care and, consequently, to help to reduce maternal and newborn mortality and achieve Ethiopia’s targets for Millennium Development Goals 4 and 5.