MOH A National Assessment of Emergency Obstetric Care Services in Zambia

Publication date: 2005

[image: image15.png] Republic of Zambia Ministry of Health A NATIONAL ASSESSMENT OF EMERGENCY OBSTETRIC CARE SERVICES IN ZAMBIA Prepared in collaboration with the Central Board of Health by: Dr. Gricelia Mkumba Mr. Kwibisa Liywalii Mr. Chipoya Chipoya Ms Ethel Mangani Lyuba Mr. Crispin Sapele Mrs. Batista C. Mwale Funded by: USAID (through the Health Services and Systems Program) and UNICEF TABLE OF CONTENTS PAGE Table of Contents i List of Tables and Figures iii Acronyms iv Acknowledgements v Glossary vi Executive Summary 1 CHAPTER ONE 1.0 Background and Introduction 4 1.1 Rationale 6 1.2 Literature Review 7 CHAPTER TWO 2.0 Methodology 9 2.1 Study Design 9 2.2 Sampling 9 2.3 Research Tools 10 2.4 Pretest Training and Fieldwork 10 2.5 Data Processing and Analysis 10 2.6 Study Limitations 11 CHAPTER THREE 3.0 Findings 12 3.1 Antenatal 12 3.2 Labour Ward 13 3.3 Theatre 14 3.4 Postnatal Care 14 3.5 Equipment and Supplies 15 3.6 Availability of EmOC 15 3.7 Infrastructure 16 3.8 Birth in EmOC Facilities 17 3.9 Distribution of EmOC Facilities 17 3.10 Met Needs For EmOC 18 3.11 Staffing 19 3.12 Caesarean Section Rate 20 3.13 Case Fatality Rate 21 3.14 Referral System 23 CHAPTER FOUR 4.0 Discussion and Conclusion 25 4.1 Infrastructure 25 4.2 Equipment and Supplies 25 4.3 Infection Prevention Practices 25 4.4 Staffing 25 4.5 Availability of EmOC Services 26 4.6 Utilisation of EmOC 26 4.7 Quality of EmOC Services 26 Recommendations 27 References 28 Appendices I Survey Personnel 29 II Study Cases 31 III Sample Design 32 IV Profiles of Health Institutions in Zambia 37 V Teams for Field Work 38 VI Work Plan For EmOC 39 VII Drugs and Surgical Supplies 40 VIII Caesarean Section Rates by District 44 List of Tables Page Table 1 Process indicators defined and their acceptable levels by vii WHO UNICEF UNFPA Table 1.1 Potential EmOC facilities per 500 000 5 Table 2.1 Distribution of hospitals surveyed by province 9 Table 2.2 Distribution of health centres surveyed by province 9 Table 3.1 Antenatal / Postnatal clinic equipment and supplies 12 Table 3.2a Number of surveyed facilities with basic equipment and supplies in the labour ward 13 Table 3.2b Some basic equipment in theaters of surveyed hospitals by province 14 Table 3.3 Percentage availability of selected drugs 15 Table 3.4 Potential EmOC facility in Zambia, in surveyed facilities 16 Table 3.5 Number of surveyed facilities without maternity wings by province 17 Table 3.6 Percentage of births in EmOC facilities 17 Table 3.7 Percentage of women who have obstetric complications and are treated at EmOC facilities 19 Table 3.8 Availability of midwives in the surveyed facilities by province 20 Table 3.9 Caesarean Section Rates for six months 2005 per province 21 Table 3.10 Case Fatality Rates in surveyed facilities by complication 21 Table 3.11a Availability of some signal functions in surveyed facilities 22 Table 3.11b Availability of signal functions in some districts 23 Table 3.12 Number of referred complicated cases from all facilities to higher levels 24 List of Figures Figure 1.1 Potential Basic and Comprehensive EmOC per 500,000 population 5 Figure 3.1 Distribution of hospitals in Zambia 18 Figure 3.2 Percent met needs for EmOC 19 Figure 3.3 Maternal Deaths in the last 6 months (2005) by province 22 Acronyms AIDS - Acquired Immunodeficiency Syndrome ANC - Antenatal Care AMDD - Averting Maternal Deaths and Disabilities ARV - Antiretroviral Drugs CBOH - Central Board of Health CDE - Classified Daily Employee CSO - Central Statistics Office C/S - Caesarean Section D & C - Dilatation and Curettage EmOC - Emergency Obstetric care ECG - Electro cardiograph EDD - Expected date of delivery EHT - Environmental Health Technician HIV - Human Immunodeficiency Virus HLD - High Level Disinfections HMIS - Health Management Information Systems HSSP - Health Services and Systems Programme IPP - Infection Prevention & Practice IM - Intra Muscular IV - Intravenous IUD - Intrauterine Contraceptive Device LMP - Last Menstrual Period MVA - Manual Vacuum Aspiration MDG - Millennium Development Goals PMMZ Prevention of Maternal Mortality Zambia PMTCT - Prevention of Maternal to Child Transmission PNC - Post Natal Care RPR - Rapid Plasma Reagin SVD - Spontaneous Vaginal Delivery TBA - Trained traditional birth attendant UTH - University Teaching Hospital UNFPA - United National Fund for Population Activities UNICEF - United National Children Fund VE - Vaginal Examination VIP - Ventilated Improved Pit latrine VCT - Voluntary Counseling and Testing WHO - World Health Organization ZDHS - Zambia Demographic Health Survey Acknowledgement The Ministry of Health wishes to thank the Health Services and Systems Prgoramme (HSSP) for providing most of the financial and technical support for this assessment. We would also like to thank UNICEF for financial and technical support and WHO for technical support. We gratefully acknowledge that the forms used in the Needs Assessment were adapted from the Emergency Obstetric Care Site Assessment Tools prepared by the JHPIEGO/MNH program. This made our task manageable. Many thanks also go to all Provincial Health Directors who worked very well with the research team to enable them collect the data. We would like to recognize the support of the Districts Health Directors who provided the research teams with staff to guide them. In addition, our appreciation goes to the Managers, Midwives, Doctors, and anaesthetists, Clinical officers, Environmental Health Technicians and Classified Daily Employees for the information provided to us at short notice. We thank the research team who went into the field to collect this information. They responded promptly to the call to go out as data collectors. Amidst the joy of doing the work there were hard times, which they endured. We thank Dr. Reuben Mbewe, Ms Christine Mutungwa, Dr. A. Girma, Dr Miriam Chipimo, Mrs. Patricia Kamanga and Dr. Christine Kaseba for their valuable technical contribution to this work. We also thank our colleagues from Central Statistics Office Mr Crispin Sapele and Mrs Batista Mwale for assistance in the area of survey design, methodology, and compilation and processing of data. Lastly we thank Mrs. Muriel Syacumpi who coordinated the needs assessment activities. Glossary DEFINITIONS: Maternal Death This is the death of a woman during pregnancy, childbirth or in the 42 days of puerperium irrespective of duration or site of pregnancy from any cause related to or aggravated by the pregnancy or its management. Maternal Mortality Ratio This is the proportion of deaths per 100, 000 live birth of same period. The denominator leaves out still births, ectopic pregnancies and abortions. Maternal Mortality Rate This refers to maternal deaths per 100, 000 women of reproductive age 15 – 49 years per year. The denominator leaves out early teenage group and above 49 years who become pregnant and dies. Case Fatality Rates Proportion of women with obstetric complications admitted to a facility who die. Skilled Birth Attendant Refers to a health professional such as a doctor midwife, nurse who is trained and competent in the skills needed to manage normal childbirth and postnatal period, and who can identify complication and provide emergency management and / or refer to a higher level of health care. Emergency Obstetric Care This is defined as the care given to pregnant women with complications to prevent maternal deaths. It includes services that can save the lives of the majority of women with obstetric complications. Basic Emergency Obstetric care (Basic EmOC) A facility is said to have Basic EmOC when it can perform the following six functions: Administer parenteral antibiotics, parenteral oxytocics, parenteral anticonvulsants, manual removal of the placenta, removal of retained products of conception and assisted vaginal delivery (instrumental delivery). All these six elements are called SIGNAL FUNCTIONS. Comprehensive Emergency Obstetric Care (comprehensive EmOC) A facility is said to have comprehensive EmOC when all the Basic EmOC signal functions plus Caesarean Section and blood transfusion services are offered in that facility. Potential EmOC A Facility that already exists and is expected to offer EmOC but does not offer the service because of one or several missing signal functions e.g. a hospital without an operating theatre is a potential comprehensive EmOC. Process Indicators Process indicators are a measure of the changes in steps leading to the desired outcome. They are used in the monitoring of the availability, utilisation and the quality of emergency obstetric services (WHO, UNICEF, UNFPA, 1997). The process indicators that measure utilisation of EmOC are; the proportion of births in EmOC facilities, the proportion of complicated cases in EmOC facilities and the percentage of births delivered by caesarean section. To some extent these indicators reflect the availability and accessibility of EmOC facilities. Process indicators that measure the quality of EmOC are case fatality rate among women with complications admitted to the facility and life saving procedures performed at the facility. The indicators provide answers to questions such as:- Are there sufficient facilities providing EmOC? Are they well distributed? Are enough women using them? Are the women with complication using them? Are enough critical services being provided? Is the quality of services adequate? There are two levels of facilities i.e. Basic and comprehensive EmOC. It is assumed that EmOC is made up of certain medical services and procedures that are critical to save lives of women with obstetrics complications. For a facility to be designated as Basic EmOC facility procedures such as parenteral antibiotics, parenteral oxytocics drugs, parenteral anticonvulsants, manual removal of placenta, removal of retained products of conception and assisted vaginal delivery must be available. As for Comprehensive EmOC, Basic EmOC, blood transfusion and caesarean section must be available. Table 1: Process Indicators Defined and their Acceptable Levels According to WHO, UNICEF, UNFPA Process Indicators Definition Acceptable level Availability of EmOC Number of facilities that at least provide EmOC per 500, 000 population At least 4 B EmOC 1 C EmOC Percentage of all births in EmOC facilities Percentage of all expected births in EmOC facilities Minimum = 15% Met Need for EmOC services Percentage of women estimated to have complication who are treated in EmOC facilities Minimum = 100% Caesarean Section as a percentage of all births Caesarean Section as a percentage of all expected births Minimum = 5% Maximum 15% Case Fatality Rate Proportion of women with obstetric complications admitted to a facility who die. Maximum 1% Geographical distribution of EmOC facilities Minimum level for amount of EmOC services is met in sub-national areas Minimum 100% Source: Maine, D. et al (1997) The Design and Evaluation of Maternal Mortality Programs. Unmet Need for EmOC The percentage of women estimated to have developed complications who are not treated in EmOC facilities. Obstetrics Complications The major obstetric complications that cause maternal mortality and morbidity are:- Obstetric haemorrhage Hypertensive disorder of pregnancy Puerperal sepsis Complication of abortion Ectopic pregnancy Ruptured uterus Retained placenta Obstructed labour. These complications are used to calculate the Met need for EmOC. EXECUTIVE SUMMARY Zambia is a land locked, developing country which covers an area of 752,612 square kilometres. It has nine provinces. The population is 10.4million although the projected one for 2006 is 11,959,943 .Out of this population 23% are in the child bearing age (15-49 years). The fertility rate is 5.9 births per woman. Antenatal attendance is 97% but institutional deliveries isstill below 50%. The maternal mortality ratio is 729/100 000 live births (DHS 2001 – 2002). Despite some efforts, such as development of the family planning policy and decentralisation of health services to address the problem of maternal mortality the latter continues to rise as evidenced by comparison of DHS 1996 and DHS2001-2002 reports. Maternal mortality ratio in 1996 was estimated at 649/100 000 live births. From other studies, more emphasis is being put on improving emergency obstetric care (Uganda 2003 MOH). All aspects of EmOC i.e. accessibility, availability of equipment, supplies and human resource, utilization and effective and efficient management of obstetric complications need to be at play for any impact to occur. Africa constitutes 12% of the world population and 17% of annual births (WHO, 2002). In industrialized countries the frequency of maternal deaths is estimated to be 1 in 4000 while in Africa it is 1 in 14.The causes of maternal mortality are treatable and to some extent preventable. Most of obstetric complications cannot be predicted or prevented the survival of the woman depends on the treatment her receives. It is important then that those who develop a complication have the means to access and receive prompt treatment at a facility with basic or comprehensive emergency obstetric care (EmOC). The survey of EmOC took place between 9th July 2005 and 6th September 2005 in all 9 provinces. Eleven questionnaires used for data collection were adapted from JHPIEGO & AMDD to suit the local conditions and were pre-tested. Data collection was preceded by orientation and training of researchers and research assistants. The team was lead by a Consultant obstetrician and comprised a social scientist, midwives, anaesthetist, theatre nurse and medical students. The tools were administered according to facility level by 4 teams of data collectors in all sampled facilities. The respondents were various health workers at a facility working in maternity units. All provincial and general hospitals, selected district hospitals and health centers were surveyed (a total of 277). Data was entered and was analysed using a computer soft ware, Census and Survey Processing (CSPro). There was loss of few survey days due to national shortage of diesel. Some centers had no health personnel working there or had only an Environmental Technicians or Classified Daily Employee running the facility. The questionnaire was still administered to them. It was found that some sampled Mine and private clinics did not conduct any maternity services. Therefore these 47 health facilities were excluded from the analysis. There were some other health centers which were only providing antenatal care. Some health centers on the list did not exist any more. A total of 230 health facilities(with at least 5 tools )were used for the final analysis. OBJECTIVES The main objective of the needs assessment was: To assess the level of Emergency Obstetric Care in Zambia based upon UN process indicators. Specific Objectives of the study were:- To provide CBoH with information on availability of emergency obstetric care services. To provide information on the use of emergency obstetric care services by women with life threatening complications. To provide CBoH with information on the quality of the services for emergency obstetric care. To assess the number of facilities that provides EmOC per 500,000 people. To determine the geographical distribution of facilities providing EmOC at district/ provincial level. To determine the proportion of all births in the population taking place in EmOC facilities. To determine the proportion of women with obstetric complications delivering at EmOC facilities. To determine the proportion of all births in the population delivered by caesarean section. To determine the proportion of women admitted at EmOC facilities who die from obstetric complication. FINDINGS Generally the findings showed that due to critical shortage of the midwives(53%) and other health staff, the quality of care was substandard. Retension schemes for staff are underway .In all these areas only 23% of facilities that conduct deliveries and manage 3rd stage of labour followed the guidelines. In antenatal/postnatal clinics, only 35, that is 16% of facilities have carried out the infection prevention practices according to the guidelines. The main procedures not usually performed are decontamination and sterilization of instruments for the accepted duration. Only 25 to 40 % of the facilities visited had the records and forms available in antenatal, labour ward, theatres and postnatal areas. In some hospitals, the theatre had no recovery rooms and there was a mixing of clean and dirty cases in the same theatre. However some theatres were undergoing renovations. Only 16% of the facilities had most of the required equipment in the antenatal clinic, labour ward, postnatal ward and nursery. The basic theatre equipment was available in most hospitals with a functioning theatre. Some of the equipment is stored in the storeroom because staff do not know how to operate it. Other equipment were non functional. Thirty two percent of general hospitals had all operation sets available i.e. caesarean section set, laparotomy set, hysterectomy and D&C Sets. However all other hospitals had only one or two sets that are used for all procedures such as laparotomy, caesarean section and hysterectomy. Basic antenatal drugs such as iron, folic acid, fansidar and mebendazole are readily available in the facilities. However anticonvulsants and oxytocics are in short supply. Ergometrine comes in the drug kits. Available antibiotics are mainly the penicillins. The levels of both comprehensive and basic EmOC services in Zambia in most cases were below acceptable levels. There was no health centre that had basic EmOC defined as presence of the six signal functions. These eight signal functions are: Administer Parenteral antibiotics Parenteral oxytocics Parenteral anticonvulsants Instrumental delivery, Evacuation of retained products Manual removal of placenta Comprehensive EmOC , that is availability of the above signal functions and Caesarian section and blood transfusion services was only available in 77.2% (44 of the 57) hospitals. This means that 22.8% of the hospitals lacked theatre, surgeon or operative equipment and therefore were not able to carry out Caesarean Sections or blood transfusion e.g. Mpanshya, Kapiri-Mposhi and Itezhi-Tezhi. In addition 18% of the districts in Zambia do not have hospitals.Sixty one percent (170)of facilities had no maternity wing. However there were maternity wings built by partners in Lusaka, Copperbelt & Northern provinces. The distribution of EmOC facilities was below acceptable minimum levels of 100% as EmOC was only available in some hospitals. As indicated earlier, Health centers did not offer any EmOC at all. The overall Caesarean Section rate was 1.67% with the highest rates in Luapula and Lusaka provinces. The acceptable minimum is 5% and maximum is 15%. This means that many women still do not have access to this intervention. Case fatality rate was 2.41% and the deaths were mainly due to postpartum hemorrhage, infection and pre- eclampsia & eclampsia. Met needs for EmOC was 8.5%, which is below acceptable levels of 100%. In all districts other than Mwense almost all clinics and hospitals had radio communication. However some radios were not functioning and the districts had failed to have them repaired (e.g. Mkushi district). The radios in some districts were congested with irrelevant conversations. All the districts had an ambulance each. In nearly all cases however, the ambulance serviced a whole district regardless of distances from the district office, thereby causing delays in picking up the patients referred to the next level. There was a critical shortage of midwives in all districts. Casual Daily Employees (CDEs) and Traditional Birth Attendants (TBAs) had been delivering pregnant women in the health facility. Environmental health technicians were also carrying out these obstetric services. In some of the hospitals the only doctor available lacked knowledge and skills for surgical intervention and emergency management of complicated cases e.g. Kapiri-Mposhi. Some midwives had training in life saving skills&PMTCT. There is a deficiency in the delivery of EmOC just as in most developing countries. Zambia can learn from other countries about the strategies they used in Zambia to reduce maternal mortality. Staff and equipping the heath centers and hospitals is critical. Recommendations Arising from the findings, a number of recommendations have been given in the main text. However, it is strongly felt that the following require urgent attention: Government must improve staffing levels and enhance the skills of the skilled attendants in the health facilities through recruitment of midwives, accelerating the training midwives and provision of training in Life Saving Skills. In order to improve the quality of service in antenatal, delivery and postnatal clinics, maternity wings should be built at all health facilities that can accommodate different clinics or sections. All health facilities must be equipped with all the necessary equipment required in ANC, delivery room and Post natal clinics in the right quantities and develop mechanisms for repair and service back up. Immediate steps should be taken to promote infection prevention practices through among other things, provision and dissemination of national infection prevention guidelines and conducting refresher courses in infection prevention and control. Support supervision to health facilities should have an emphasis on maternal health issues, especially to monitor the quality of ANC, management of labour and postnatal services. There is need for increasing the number of ambulances in the districts to ensue that women that develop complications can reach facilities where these complications can be managed without unnecessary delays. CHAPTER ONE INTRODUCTION AND BACKGROUND The 2001 – 2002 Zambia Demographic Health survey (ZDHS) reveals that in Zambia almost 60% to 70% of women in all age groups give birth by age of 18 years. The current total fertility rate is 5.9 and one of the highest in Sub Sahara Africa. Although the optimal interval between births is at least 36 months, the median birth interval is 33 months – 3 months shorter than the “safe” birth period. The proportion of deliveries in health facilities declined from 51% in 1992 to 44% in 2004. The maternal mortality however is on the increase. Currently it is estimated to be 729 per 100, 000 live births (DHS 2001 – 2002) increasing from 649/100,000 in 1996. Emergency Obstetric Care (EmOC) refers to care given to women experiencing complications occurring during pregnancy, labour and immediately after childbirth that will threaten the life of the mother and newborn unless timely and effective intervention (s) is/are instituted. This therefore entails that skilled professionals with obstetric care knowledge and skills should attend to every pregnancy and delivery. In Zambia this is not the case: 56% are home deliveries but even in the facilities there is a critical shortage of midwives meaning that not every delivery is assisted by a skilled attendant. We will define basic EmOC as a facility which will provide all the following signal functions: parenteral antibiotics, parenteral Oxytocics, parenteral anticonvulsant, manual removal of placenta, manual vacuum aspiration of retained products e.g. incomplete abortion and instrumental delivery (Forceps and Vacuum). Comprehensive EmOC includes all the above components plus the availability of blood transfusion and caesarean section services. Globally, there is now increasing evidence that provision of quality EmOC in addition to other maternal health care services has led to the reduction of maternal deaths. It has been proven that successful management of obstetric complications can be achieved if a committed skilled attendant is available to attend to a woman in pregnancy and labour, there is prompt access to emergency obstetric care through provision of reliable and efficient referral system i.e. appropriate transport and communication modalities; and there is availability of essential drugs and supplies, basic equipment and blood transfusion and operative delivery procedures. In Zambia, several interventions on Safe Motherhood are supported by partners working with the Ministry of Health since its inception. Unfortunately, these interventions have not comprehensively covered EmOC and therefore implementation of EmOC services is poor. This to some extent may be attributed to failure to pay more attention and focus on emergency obstetric care in addition to ongoing maternal health services. In Zambia the antenatal coverage is above 90% suggesting that most women are in contact with some health care (Nsemukila et al, 1998; CSO, 1997). A more comprehensive approach and a carefully managed and coordinated partnership of Government and donors are required. Further, an explicit goal to establish EmOC services in every district is needed. The challenge now for Zambia and other countries with high maternal mortality rates is to shift focus and concentrate on improving efficient delivery of care for emergency obstetric complications in addition to ongoing maternal health care services. It is imperative that the Government of the Republic of Zambia and development partners refocus their efforts and support Emergency Obstetrics Care in an effort to reduce maternal and perinatal deaths and disabilities thereby improving survival of women and babies during childbirth. Monitoring of progress towards the reduction of maternal mortality requires reliable, timely and internationally comparable data. Such data is needed to form a basis for policy and program development, implementation, monitoring and evaluation. In Zambia, this data is only made available through Demographic and Health surveys. The UN Process Indicators on Emergency Obstetric Care Services measure activities that lead to the desired goal of reduction of maternal deaths. The indicators are based on the understanding that, to prevent maternal death, certain types of obstetric services must be available and used. They further indicate whether the services are available to women in sufficient quantity and acceptable quality, and whether women who need these services i.e. those experiencing an obstetric emergency are in fact using them. The table and figure below show the potential and expected distribution of facilities that are EmOC centers in the whole of Zambia according to WHO UNICEF UNFPA definition of Basic and Comprehensive EmOC. Table 1.1: Potential and expected EmOC facilities per 500,000 populations Province Population Potential Comprehensive Expected Number of Comp/500,000 Potential Basic Expected Number of Basic/500,000 Total 11,564,031 94 23 1,214 52 Central 1,194,749 9 3 110 46 Copperbelt 1,837,761 17 4 192 52 Eastern 1,530,118 9 3 145 47 Luapula 913,248 7 4 113 62 Lusaka 1,607,596 8 2 91 28 Northern 1,487,391 8 3 145 49 North Western 687,895 9 2 113 82 Southern 1,432,076 16 6 192 67 Western 873,197 11 6 113 65 Source: Health Institution in Zambia (CBOH 2002): Projections Report 2000 - 2005 Calculations of expected EmOC facilities per 500 000 population is based on: Total Basic EmOC facilities X 500 000 = Number of Basic EmOC facilities Total population per 500 000 population Figure 1.1: Potential Basic and Comprehensive EmOC per 500,000 population [image: image1.wmf] Each province has at least one general hospital, six or more district/ mission/ private hospitals and over a hundred health centers to serve less than 2 million populations. Hospitals must be comprehensive EmOC when their theatres are functional, and staff with required knowledge and skills is available. Health centers must be basic EmOC and supplies and equipment is provided and skilled staff available. In the 1996 Safemotherhood needs assessment the findings were that there was no legal framework for midwives to carry out certain procedures on complicated cases, no standards, skeleton essential components of care, lack of midwives and supervision, poor drug availability, poor referral systems and communications. Among the recommendation was for legal authorisation of life saving interventions by midwives. This has since been passed. 1.1 RATIONALE Maternal mortality is recognized in the world as a serious problem. Several conferences have addressed the issue .The third world continues to have high maternal deaths. Several efforts have been put forward especially the 1987 Safe motherhood Conference in Nairobi, 1990 World Summit for Children Declaration, 1994 International Conference on Population & Development in Cairo, 1995 World Conference on Women in Beijing had maternal mortality as an agenda item .The maternal mortality for industrialized countries used to be as high as what is found in the third world .However, the figures dropped steeply over several years to single figures currently prevailing. What brought about the decline has been attributed to improvement of economic status of the country, presence of midwives and later availability of blood transfusion services and antibiotics. In other words, the decline came from availability of EmOC services. Sri Lanka, Comoros, Cape Verde, Mauritius and Seychelles although in the third world have much lower maternal deaths (World Bank, 2003). Some of the major strategies undertaken by these countries included establishing EmOC facilities in underserved areas, investing in training of skilled attendants, professionalization of midwives and emphasizing on improvements in quality. Other countries with high maternal death like Zambia can learn from these countries what brought about the change. Africa constitutes 12% of the world population and 17% of annual births (WHO, 2002). In industrialized countries the frequency of maternal deaths is estimated to be 1 in 4000 while in Africa it is 1 in 14.The causes of maternal mortality are treatable and to some extent preventable. Most of obstetric complications cannot be predicted or prevented the survival of the woman depends on the treatment her receives. However, when these complications occur, death can be prevented. It is important then that those who develop a complication have the means to access and receive prompt treatment at a facility with basic or comprehensive emergency obstetric care (EmOC). In Zambia, policy makers and health providers are aware that maternal mortality is a serious national problem. Zambia has therefore taken steps to implement some strategies such as the Road map accelerating the attainment of Millennium Development Goals such as; Reproductive health policy is being finalised, family planning guidelines are being updated, maternal death review advocacy at community level. Furthermore, the AIDS pandemic and Malaria continue to be a drawback to these efforts. Maternal Mortality ratio in Zambia is 729 per 100,000 live births (DHS2001-2002). Over several years, there have been efforts to reduce maternal mortality and morbidity. A number of initiatives namely Safe Motherhood (SM), making pregnancy safer (MPS), averting maternal death and disability (AMDD), beyond the numbers, confidential enquires into maternal deaths have been working towards achieving a reduction in maternal mortality. Zambia is signatory to some of these and is making an effort to implement measures that will help achieve the millennium development goals (MDGS). The Millennium Summit in 2000 endorsed the Millennium Development Goals, which calls all to action to reduce maternal mortality by 75 % of 1990 maternal deaths by 2015. Maternal mortality however is a complex problem because it involves all citizens of a country. Community, transport & communication, education, finance, health, agriculture and Gender Departments have a role to play. Their involvement can be seen in the 3-delay model – delay in deciding to seek care, delay to reaching care, delay in receiving appropriate treatment. These are the factors that need to be appreciated and factored in interventions aimed at reducing maternal mortality. Maternal mortality is also difficult to measure and evaluate as some cases are not reported. It is estimated that 56% of the deliveries in Zambia take place at home. The rural areas account for 72% of these deliveries. In a study of factors associated with maternal mortality in Zambia, Nsemukila (1998) found that 85 percent of deaths were in women below 35 years and of the postnatal deaths 78 percent occurred in the first week. Currently the number of facilities offering emergency obstetric care is not known. The last needs assessment was conducted in 1996 and only covered a few districts. Before starting new activities or modifying existing ones there is need to find out what EmOC services are available, how they are being utilized and what factors may be affecting their utilization. A needs assessment was therefore carried out to try and answer these questions. LITERATURE REVIEW Maternal mortality has been a subject of discussion in many countries and world bodies. The World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) estimate that each year 585 000 women die from causes related to pregnancy and child birth (WHO & UNICEF, 1996). Worldwide, it is estimated and generally believed that between 10 – 20% of all pregnancies will develop a complication (Mc Cord et al 2001). UNICEF/WHO/UNFPA (1997) estimated that 15% of pregnant women will develop a complication either at antenatal, during labour or postpartum periods. Pregnancy complications are therefore among the leading causes of death and disability for women, especially in the age range of 15 – 49 years. The problem of maternal mortality and morbidity however, is more pronounced in developing countries. According to Maine et al (1997), maternal mortality rate in developing countries is higher than in industrialized countries. World Bank (2003) has reported that of all the maternal deaths that occur every year, 99 percent take place in the developing countries; women in the developing world have a 1 in 48 chance of dying from pregnancy-related causes whereas the ratio in the developed countries is 1 in 1,800. Furthermore, it is stated that for every women who dies, another 30 – 50 women suffer injury, infection, or disease. Maine et al (1997) has observed that while obstetric complications do occur even in developed countries and in every population, women in developing countries are much less likely to get prompt and adequate treatment and are therefore likely to die, making maternal mortality the greatest discrepancy of all human development indicators between developed and developing countries. The direct causes of maternal mortality are known: Haemorrhage 25%, sepsis 15%, abortion related 13%, hypertensive disorders 12%, obstructed labour, 8%. The indirect causes are malaria and HIV and AIDS, which account for approximately 20% (WHO/AFRO, 2002). In Zambia, both medical and patient factors that contribute to maternal mortality have been identified (UNICEF 1994). Medical factors include inadequate supplies and equipment for antenatal, delivery and postnatal facilities; human resources constraints, low numbers of supervised deliveries; and a poor referral system. Patient factors comprise the following: age at first pregnancy; poorly spaced pregnancies; lack of knowledge about risk factors, complications and their symptoms, and healthy behaviors; poor socio-economic status; lack of money for fees and transport; distance to and from facilities; and harmful traditional practices during pregnancy and labour. The report has further noted that for specific medical causes, 70% of deaths during the antenatal period are due to pre-eclampsia, abortion, anemia and parasite infection and that deaths during post-partum period are attributed to hemorrhage, obstructed labour, ruptured uterus and puerperal infection. It was however also observed that the relative contribution of these identified causes varies with geographic location and socio-economic environment. Currently, awareness of and responses to the problem of maternal mortality has been raised among policy makers, health professionals and the general public. This has been so especially since the launch of the safe motherhood initiative. The safe motherhood program has emphasized the importance of and access to emergency obstetric care to manage the common causes of obstetric deaths. The 50th session of the WHO Regional Committee’s discussions centered on access to efficient antenatal care, provision of hospital based treatment of pregnant women with life threatening complications, improvements in transport and strengthening of the health care system. The conference also concluded that investing adequately in education and health may reduce maternal deaths. However, developing countries continue to have high maternal mortality because of insufficient national commitment and financial support, weak and under funded health systems, lack of functional referral system, lack of drugs, inadequate supplies and equipment, critical shortage of skilled attendants and lack of coordination among stakeholders (Indra Panthmanathan et al 2003). However, this is not necessarily the case through out the developing world as is the case of Malaysia, Sri Lanka, Mauritius and Seychelles. According to World Bank (2003), Malaysia and Sri Lanka have been a success story. These are among the developing countries that have successfully reduced maternal mortality during the past few decades to levels comparable with those of many industrialized countries. The strategies of Malaysia and Sri Lanka changed overtime, from initial emphasis on expanding the provision of services, especially in underserved areas, to increasing utilization and finally to emphasizing improvement in quality. Among the activities was professionalization of midwifery, increased birth with skilled attendant and improved emergency obstetric care services. These strategies have been employed in the developed countries before. In the 19th century, Sweden reduced maternal mortality because of availability of midwives and registration of births and deaths (De Brouwere et al 2001). Similarly, the United Kingdom experienced a steep decline in maternal mortality with the introduction of antibiotics, Caesarean Sections, blood transfusion and improved economic status (De Brouwere et al 2001). This needs assessment seeks to ascertain the extent to which both basic and comprehensive EmOC is available in facilities in Zambia. An attempt is also made to examine and explore factors that contribute to availability or non-availability of EmOC services in these institutions. Similar studies have been conducted elsewhere in Africa using more or less the same approaches. Chad, Benin and Uganda have used UN process indicators to assess EmOC in their respective countries (AMDD, 2004). CHAPTER TWO 2.0 METHODOLOGY 2.1 Study Design This was a descriptive study.The methodsof extracting information were by interview of staff , observation of procedures,desk review and records review using questionaires from 11 tools. 2.2 Sampling: All general, Central and provincial hospitals were selected whereas District Hospitals and Health Centers, whether private, mission or government were randomly sampled. All provinces were selected and almost all districts in each province were included in the sample. Two hundred and eighty eight facilities in total were selected (58 hospitals and 230 health centers). Table 2.1: Distribution of hospitals surveyed by province Province General/Central District Mission Mine Private Total Central 1 4 0 0 0 5 Copperbelt 4 2 0 2 0 8 Eastern 1 2 1 0 0 4 Luapula 1 1 1 0 0 3 Lusaka 1 0 2 0 1 4 Northern 2 2 1 0 0 5 North Western 1 3 7 0 0 7 Southern 1 6 5 0 0 12 Western 1 4 2 0 0 7 TOTAL 13 24 14 2 1 55 There were 55 hospitals representing 56.7% of total hospitals in the country. St Francis, Katondwe and Roan hospitals were also added either because they are general hospitals or were not on the original list or as a replacement of a facility. Yuka, Namwala, Itezhi-Tezhi, Roan, Petauke, Mufumbwe and Mpanshya, had no functional theatre at time of the visit. Chavuma district hospital and Chavuma mission hospital though in the selected sample were not visited as these were not reflected in the field schedule. Forty-seven health centers either did not exist anymore, or did not have any antenatal, postnatal deliveries, theatre or nursery. Therefore, they were not included in the computations. A total of 230 (with at least 5 tools used) facilities were available for analysis of all or some tools depending on the facility. Some facilities like Hospital Affiliated Health Centres (formerly OPDs) only provide Antenatal and Postnatal services while other services like delivery conducted in the hospitals. Other hospitals did not conduct ANC and had no theatres. Table 2.2: Distribution of health centers surveyed by category and province Province Urban H/C Rural H/C Private/ Mine Total Central 6 13 1 20 Copperbelt 30 5 5 40 Eastern 4 20 1 25 Luapula 1 20 0 21 Lusaka 12 8 8 28 Northern 3 19 1 23 North Western 0 14 0 14 Southern 7 25 1 33 Western 2 16 0 18 TOTAL 65 140 17 222 2.3 Research Tools Eleven-survey instruments were adapted from JHPIEGO and AMDD survey tools to suit the local conditions. The information required was equipment and supplies, and service being provided antenatally during labour/ delivery and postnatally and newborn care, drug availability and availability of surgery. The following survey tools were used in specific areas of the facility as applicable: Equipment and supplies for antenatal and postpartum clinics. Care and documentation in antenatal and postpartum clinics. Equipment and supplies for labour and birth areas. Care, documentation and clinical decision making during labour and birth. Equipment and supplies for the operating theatre. Care and documentation in the operating theatre. Equipment and supplies for inpatient post partum care. Care and documentation for inpatient postpartum clients. Equipment and supplies for the nursery. Care and equipment for new born. Drugs and medical supplies 2.4 Pretest, training and Field work Data collection was preceded by orientation and training of researchers and research assistants. Tools were first pre-tested for comprehension and approximation of the time it would take to administer each instrument so that the amount of time required to cover the 277 facilities could be estimated. The pre-test was conducted at Kafue district hospital and Chongwe health centre. Instruments were administered to respondents who were working in maternity department. The corrections and comments from research assistants were incorporated into the instruments. Team leaders and /Research assistants underwent training on use of the instruments for four days. Then the instruments were pre tested again at Kanyama, Chelstone, Chawama and Matero clinics in Lusaka. Additional recruitment of research assistants was necessitated by the need to cover 277 (see above) facilities in 30 days. Facilities that could not be reached or offered services not related to maternity were replaced by other additional sampled facilities. Data collection took place from 18th July and was completed on 6th September 2005 lasting for 42 days. There were four (4) survey teams; each team surveyed two provinces except for one team that had three. Prior arrangements for the field visits were made with the Provincial Directors of Health by the Ministry of Health. Data collection methods included interviewing of health care providers (trained and non trained health workers who where found attending to clients), observation of service delivery and records/desk review of documents. 2.5 Data Processing and Analysis Two data entry clerks underwent training for 3 days to familiarise themselves with the eleven data entry screens developed for the 11 data collection tools. The completed tools were deposited with HSSP by teams before proceeding to the next province and checked for completeness. Data entry was carried out simultaneously as the questionnaires were brought back from the field by the data entry clerks. A member of staff from the Central Statistical Office (CSO) developed the data capturing system and supervised the process. The data entry team communicated with team leaders for any clarification. The entire data processing system was developed and implemented using the Census and Survey Processing (CSPro) system version 2.6 . The data entered was subjected to data edits including the generation of derived analysis variables. Production of analytical tables and frequencies commenced soon after the compilation of the 11 analysis data sets, one for each tool. A total of 230 facilities were available for analysis of all or some tools depending on the facility and the nature of maternal health services offered. The care of patients was observed or the staff was interviewed on how they would perform a procedure. All information was then computed to give the overall performance. Each ward was assessed separately. However some facilities had only one room for all activities. 2.6 Study Limitations Relatively longer travel time to some sites and the shortage of diesel at the time resulted in loss of workdays. In some areas, private clinics refused the teams permission to carry out the survey. In addition, some Military Health facilities could not be accessed as permission could only be obtained at the Ministry of Defence headquarters. Interviews in some facilities had to be carried out with the untrained personnel running the health centers and conducting deliveries. In some operating theatres surgical instruments are prepared and packed by staff not trained in theatre nursing. Hence instrument identification was difficult. Anaesthetic information was also difficult to collect because data was not being aggregated or recorded in relevant documents. This was more serious in situations where anaesthesia was administered by none anaesthetists, e.g. nurses and CDEs. Chilubi Island could not be visited because of the persistent bad weather. Some of the sampled health centers on the list were none existent. These were however replaced with other centers sampled in consultation with the Statistician. In some cases direct observation of service providers prompted them to follow guidelines which they would otherwise not do whereas in other cases staff would be overly positive especially in private institutions. CHAPTER THREE FINDINGS 3.1 Antenatal In antenatal care the initial assessment of the client scored poorly. Despite having a check list on antenatal cards past obstetric and medical history was omitted in some cases. The examination was deficient in that the blood pressure sometimes was not taken because the blood pressure machine was shared with the rest of the clinic. Only 60 (26.1%) of all the facilities had the means to perform haemoglobin estimation. The staff did not discuss the danger signs or birth preparedness with each client. The infection prevention practices in antenatal clinic were substandard; only 16.1% of the facilities visited observed the recommended infection prevention guidelines despite having the buckets and some chlorine for decontamination process. The postnatal clinic was carried out hurriedly because it was the same midwife to see the antenatal client as well as the postnatal. In most cases the general and sometimes obstetric examination was omitted. Few basic equipment and basic antenatal drugs were available in the antenatal / postnatal clinic e.g. blood pressure machine 198(86.1%), stethoscope 194(84.3%), examination gloves 196(85.6%) iron 220 (95.2%) Folic acid 220(95.2%) Sulfadoxine-pyrimethamine 218 (94.4%). These drugs come in the health center kits. Table 3.1 below shows availability of the basic equipment and some supplies in facilities. Table 3.1: Antenatal/Postnatal Clinic Basic Equipment /Supplies (N = 209) Item No. of Facilities Percent Adult Stethoscope 194 84.3 BP Machine 198 86.1 Exam Couch 108 47.0 Fetal Stethoscope 198 94.8 Lab Equipment for: HB 60 26.1 Syphilis 118 51.3 HIV 80 34.8 Thermometer 140 60.9 Speculum Cuscos 113 49.1 Ringers Lactate 62 27.2 Needles 108 47.2 Syringes 108 47.2 Adult ambu Bag 36 15.7 Chlorine for decontamination 147 64.2 Examination Gloves 196 85.6 Sterile Gloves 155 67.7 Autoclave 35 15.3 Boiling Steriliser 68 29.7 Iron 199 95.2 Folate 199 95.2 Benzathine Penicillin 134 50.6 Mebendazole 180 77.9 Sulfadoxine – Primethamine 197 94.4 Tetanus toxoid 187 81.0 As shown in Table 3.1, examination couch, lab equipment, ambu bag, autoclave or boiling sterilizer were lacking in most of the facilities. 3.2 Labour Ward In Labour ward, the client assessment was inadequate. In most cases the staff did not know how to use the partograph during labour. Both observation and review of documented partographs revealed lack of knowledge of plotting. There is no privacy in most cases as all activities took place in the only room available for maternity. Fifty one percent of the facilities followed the guidelines for management of 3rd stage of labour. There were no job aids in the labour wards. A few guidelines were on walls but the staff had neither read them nor applied them to their work. Just as in the antenatal clinics, it was also found that infection prevention practices were poor in labor wards. Washing of hands after each patient, wearing of protective gear and vulval swabbing were not routinely performed. In the immediate postpartum period patients are not re-examined because of shortage of staff. Repair of perineal tears was done with any suture material from silk to chromic catgut. Only documentation in the safe motherhood register was carried out adequately in many facilities. The basic equipment and supplies in the labour wards such as cord clamps, ambu bag, suction for neonate, oxytocin, were in short supply. Delivery beds were only in 61.8% of facilities. Some facilities used ordinary beds or the floor mattress for deliveries. Table 3.2a below shows some equipment and supplies in the labour wards. Table 3.2a: Percentage of Surveyed Facilities with Basic Equipment and Some Supplies in the Labour Wards per Province (N = 209) Item Central Cbelt East Luap Lsk North N/Wes South West Total/% Number of Facilities 19 25 26 20 18 23 15 41 22 209 Adult Stethoscope 13.6 76 61.5 85 72 78.3 93.3 58.5 86.4 74.4 BP. Machine 84.2 88 65.4 90 72 82.6 100 58.5 81.8 77.3 Delivery Bed 57.9 60 53.8 45 61 65.2 100 46.3 86.4 61.8 Ambu Bag 10.2 64 15 50 33.3 13 66.6 29.3 31.8 33.8 Obstetric Forceps 15.8 44 19.2 15 27.8 43.5 40 48.8 27.3 33.3 Neonatal ambu bag 26.3 80 30.8 15 55.5 21.7 73.3 46.3 54.5 44.9 Oxygen 26.3 80 7.7 10 27.8 13 6.7 7.3 4.5 19.8 Vacuum Extractor 26.3 20 15 5 16.7 21.7 26.7 14.6 45.4 20.8 Cuscos Speculum 52.6 68 61.5 40 61 56.5 93.3 58.5 68.1 61.8 Cord Clamp 73.6 88 84.6 15 72 39 80 78 72.7 70 Episiotomy scissors 47.4 100 80.8 35 50 65 80 70.7 31.8 67.1 Kelly Clamps 78.9 12 100 55 83.3 73.9 0 70.7 100 66.7 Oxytocin 10 units 26.3 52 19.2 5 44.4 21.7 80 48 59 37.7 Bulb Suction 2 4 57.7 25 44.4 4.3 20 48.8 31.3 33.3 Lignocaine 94.7 96 84.6 60 72 82.6 86.7 90 54.5 82 Needle Holder 57.9 100 88.5 40 77.8 91 60 87.8 72.7 79.5 3.3 Theatre Only 44 hospitals out of 58 had functional theatres. All procedures of receiving a patient, assessing the patient’s condition, evaluation by the anaesthetist, and care during procedure until the patient left the theater were observed. Interviews were conducted if there was no procedure to observe. It was found that in 72.7% of facilities patients were prepared adequately for theatre. However patients were transferred from theatre to the ward before full recovery because of either no recovery room, or there was no nurse to help the patient recover. A number of concerns were identified with respect to infection prevention. Observations were made in nearly all the facilities that: Sterility was in some cases not observed Some providers did not know the strength of Jik to be used for decontamination or disinfection. In some areas, staff passed through a dirty theatre, en route to a clean theatre. On the whole, it was observed that to a great extent infection prevention practices were not observed on account of many factors including; low knowledge levels, lack of supplies and sheer carelessness on the part of staff. Functioning theatres had better equipment than other wards. Equipment such as anesthetic machine, blood pressure machine and trolleys were available in 41(93.3%) out of 44 hospitals. Instrument sets in most hospitals were for all types of operations. The table below shows some equipment available in the theatres. Table 3.2b: Some Basic Equipment in Theatre’s of Surveyed Hospitals by Province (N = 44) Equipment Cent Cbelt East Luap Lsk North N/West South West Total % Total Hospitals 3 7 4 3 2 5 4 8 8 44 Anaesthesia. Machine 100 100 100 100 100 80 75 100 6 88.6 Anaesthetic Trolley 100 71.4 100 66.7 100 60 75 75 75 75 BP Machine 100 85.6 100 100 100 100 100 100 100 97.7 Laryngoscope 100 100 75 100 100 80 100 87.8 87.8 90.9 Adult Ambu bag 100 100 75 100 100 80 100 100 87.8 93.2 Operating Table 100 100 100 100 100 100 75 100 100 93.2 Oxygen source 100 85.6 100 100 100 100 100 100 100 97.7 Stethoscope 100 14.3 100 100 100 100 50 87.8 62.5 72.7 Central Suction 100 55 75 66.7 100 2 100 66.7 0 81.8 Caesarean Section Set 66.6 55 50 66.7 100 40 50 50 62 56.7 3.4 Postnatal care Most of the rural health centers did not have a separate postnatal ward. Deliveries and other services are conducted in the same room. Postpartum evaluation was hardly carried out in the labour ward or in postnatal ward. However, equipment and supplies and documentation was 73-99.4%. The patients were kept in the facility for 2-6 hours. In addition, patients were not under observation of a skilled attendant during the first 6 hours. 3.5 Equipment and Supplies Ambu bag (adult and neonatal), Obstetrics forceps, oxygen, vacuum extractor, bulb suction, oxytocin were lacking in most facilities. Where these were available, the numbers were inadequate or the equipment was not functional. In other cases, equipment like stethoscopes and blood pressure machines were shared between the different clinics: ANC, labour and birth areas and general OPD. In such instances, it was reported that providers would not use these, if they were being used in other areas of the facility. In other areas, the lack of examination beds was reported, and observed to the extent that in some situations, one bed was used for all cases, that is, medical, surgical, labour and delivery with a profound bearing on infection prevention and control. In other areas, screens were not just available and so privacy even during delivery was not observed. In one or two facilities, clients sat on the floor when they went for ANC. In a number of facilities, lack of ANC cards forced staff to photocopy or at worst simply used exercise books as ANC cards. On the part of emergency drugs, these were simply not there in a number of facilities. Where they were stocked or available at times, supply was erratic. In a few cases, expired drugs were found in some facilities. In a number of areas, it was reported that even supplies such as Jik (chlorine solution) often run out. Lignocaine, amoxyl, Benzathine Penicillin, Metronidazole (oral), iron/folate, Albendazole, Paracetamol, Antimalarias, Diazepam, and IV fluids are readily available in the facilities. Some critical drugs such as anti hypertensives, anticonvulsants mainly Magnesium Sulphate, oxytocics are either not available, or in short supply or not used because the staff feels the patients do not need it despite the policy, or the staff would order but would be told that it is out of stock. Table 3.3 below shows the percentage of availability of some drugs found in the facilities. In most cases, staff in public health facilities did not know what should be on the emergency tray. In mine health facilities, emergency tray contents are standardized. The table below shows percentage of facilities that have the selected drugs. Table 3.3: Percentage Availability of Selected Drugs per Province (N=247)( Drugs Cent Cbelt East Luap Lsk North N/West South West Total % Benzylpen 95.5 88.4 88.5 95.7 100 100 100 93 91.3 93.8 Magnesium Sulphate 13.6 9.3 18.5 12.5 16.7 14.3 11.1 20.5 13.0 14.6 Diazepam 100 97.7 100 95.8 94.4 75.0 94.4 95.5 100 94.7 Ergometrine 81.8 88.4 88.9 91.7 94.4 78.6 100 90.9 82.6 88.3 oxytocin 18.2 41.9 34.8 13.0 61.5 35.7 27.8 38.1 30.4 30.4 Hydralazine 22.7 27.9 25.9 12.5 22.2 25.0 27.8 27.3 39.1 25.9 ( Sources tool number 11 3.6 Availability of EmOC Services All hospitals are potential comprehensive EmOC, that is, they are ideally supposed to offer all the functions of a comprehensive EmOC package .a number of hospitals cannot be categorized as comprehensive EmOC facilities due to missing of one or two signal functions. Therefore this means that comprehensive EmOC is not available in such hospitals and so these may only offer Basic EmOC or none. None of the surveyed health centres-rural or urban offered basic EmOC. Availability of EmOC was 80% (44 of 55 surveyed hospitals). Six (10.9%) of 55 surveyed hospitals were only offering basic EmOC services while 3 out of the 55 (5.5%) did not have any EmOC at all. Some hospitals were undergoing renovations (Roan General hospital) others did not have a doctor to perform caesarean section (Mpanshya) others had no theatre e.g.(Kalomo, Kapiri-Mposhi) or no blood transfusion. The table below compares the potential, expected and actual EmOC facilities. Table 3.4: Potential, Expected and Actual EmOC Facilities in Zambia Province Population Potential Comprehensive EmOC (Present) Hospitals Potential Basic EmOC (Present) Health centers Recommended EmOC facility for provinces (Expected) Surveyed EmOC facilities (Actual) hospitals Comp Basic Comp Basic Central 1,194,742 9 110 3 12 4 1 Copperbelt 1,837,761 16 192 4 16 7 - Eastern 1,530,118 10 149 3 12 3 - Luapula 913, 248 7 114 2 8 3 - Lusaka 1,607,596 11 91 4 16 2 1 Northern 1,487,891 8 145 3 12 5 - North Western 687,895 9 113 2 8 7 2 Southern 1,432,076 19 191 3 12 10 2 Western 873,197 11 113 2 8 7 - The Copperbelt province has highest number of urban Health Centers (143) with Northern Province having the least. Southern Province has the highest number of Rural Health Centers (173) and Lusaka Province has the lowest, 45, (CBoH 2002).All the surveyed health centres did not have either one or more of the signal functions especially manual removal of placenta, evacuation of retained products and instrumental deliveries. All general hospitals had comprehensive EmOC. However even in some district hospitals Caesarean section, instrumental deliveries were not performed either because there was no doctor or theatre or theatre was undergoing renovations. They all had one to three signal functions missing. The main components missing were manual removal of the placenta, evacuation of retained products and instrumental deliveries. Minimum acceptable basic EmOC is 4 facilities per 500, 000 populations Mpanshya, Yuka and Itezhi-Tezhi despite being classified as hospitals are not EmOC facilities because they lack capacity for surgical intervention and cannot perform manual removal of placenta and instrumental deliveries. All general hospital/central hospitals (13=23.6%) have all the signal functions required. However as evidenced by the care given in all wards, quality of care is substandard. The minimum acceptable level of comprehensive EmOC is 1 per 500,000 populations (Table 8). Despite the large number of health centers, none qualified as an EmOC facility. It means therefore that patients have to travel long distances to reach a hospital in the event of an obstetric emergency. 3.7 Infrastructure Poor infrastructure was observed as one of the major factors contributing to compromised quality of care in essential and obstetric care. In a number of facilities, maternal health services were not separated from other general care activities especially in terms of where these were conducted, principally due to lack of space. In some facilities, especially at health centre level, ANC services were conducted in staff offices or in general screening rooms, often times denying the client the privacy so much required. Due to the problem of inadequate space, in other areas, ANC services were conducted in labour wards. This often resulted in among other things, less attention given to clients, cancellation of some activities and examinations, and sharing of both equipment and supplies. Table below shows the numbers of facilities that did not have a maternity wing in the facilities visited. Table 3.5: Number of Surveyed Facilities without Maternity Wing by province Province Total facilities visited Facilities without maternity wing Total 277 170 Central 23 17 Copperbelt 49 18 Eastern 28 20 Luapula 24 20 Lusaka 31 22 Northern 28 17 North Western 21 15 Southern 47 30 Western 26 11 The lack of space was not only restricted to ANC services. In some centers, the labour ward was also used as inpatient, admission or and postpartum ward. It was also found that some facilities did not have delivery rooms. In worst scenarios, relatives’ shelters are used as delivery rooms. Due to the lack of space, it was not uncommon for most respondents to make the following observation “We cannot keep women in the facility for long after delivery because we simply do not have room”. In some facilities it was found that nurseries served as storerooms while in a few others, the pharmacy was also used for linen storage and/ or general storerooms. 3.8 Births in EmOC Facilities Table below shows the proportion of all births in both basic and comprehensive EmOC facility. Since only hospitals had EmOC, hospital deliveries were used to calculate percentage births in EmOC facilities. Only 9.2 % deliver in EmOC facilities. This means that 90.8% of deliveries do not take place in EmOC facilities. None of the provinces reached the minimum acceptable level of 15%. Table 3.6: Percentage of Births in EmOC Facilities (For the six months) Surveyed facilities Province Expected Deliveries Deliveries in Hospitals Percent Total 300,440 27,667 9.2 Central 31,063 1,142 3.7 Copperbelt 45,447 5,859 12.9 Eastern 40,766 995 2.4 Luapula 23,744 2,298 9.7 Lusaka 41,797 5,924 14.2 Northern 39,799 2,534 6.4 North Western 17,885 1,511 8.4 Southern 37,234 4,670 12.5 Western 22,703 2,734 12.0 3.9 Distribution of EmOC Facilities Copperbelt province with 9 districts has 143 urban health centers, 49 rural health centers (Health Institution in Zambia 2002) and 16 hospitals. These hospitals are concentrated within urban areas and no hospital is available in Lufwanyama and Masaiti districts. Figure 3.1 shows the districts and the number of hospitals in each district. Petauke, Kaoma, Mazabuka, Copperbelt, Lusaka have more than 2 hospitals because of the contribution from private sector and missions. There are 13 districts without a hospital. (Shangombo, Kazungula, Lufwanyama, Masaiti, Milenge, Mwense, Chiengi, Mungwi, Nakonde, Chilubi, Chadiza, Mpulungu and Chongwe). Figure 3.1: [image: image2.wmf] Minimum acceptable level = 100% Hospitals in some districts: Kitwe 3, Chingola 2, Kalulushi 1, Chililabombwe 1, Luanshya 3, Mufulira 3, Ndola 1 Sesheke 3, Kaoma 3, Mazabuka 3, Petauke 3, Mumbwa 2, Choma 2, Kalomo 2, Kalabo 2, Zambezi 2, Kabompo 2, Mwinilunga 2, Samfya 2, Mpika 2, Serenje 2, Chipata 2, Lusaka 8. 3.10 Met Needs for EmOC This indicator describes the proportion of women that develop complications and receive treatment. The total met need for EmOC in all surveyed facilities is 8.5% which is far below the minimum acceptable level of 100% as shown in Table 11. It is estimated that 15% of the pregnant women would develop complication. In this study therefore 91.5% of these women do not access the EmOC facility. Therefore, this indicator does not give much information on quality of the care given. Figure 3.2 shows the reported complications per province. These are the patients who must access an EmOC facility to survive. Copperbelt had the highest number of complications. This may be attributed to proper documentation or a high number of hospitals. Table 3.7: Percentage of Women Who Have Obstetric Complication and are Treated at EmOC Facilities Province Expected Births Complications Met Need Total 300,440 3,842 8.5 Central 31,063 185 4.0 Copperbelt 45,447 1,414 20.7 Eastern 40,766 435 7.1 Luapula 23,744 212 6.0 Lusaka 41,797 343 5.5 Northern 39,799 231 3.9 North Western 17,885 314 11.7 Southern 37,234 516 9.2 Western 22,703 192 5.6 Figure 3.2: Percent Met Needs per Province [image: image3.emf] In some cases there were no midwives in some facilities. Where these were available they lacked life saving skills. 3.11 Staffing Inadequate or low staffing levels were reported and observed in nearly all facilities. In most of these, certain areas or clinics in the facilities were badly affected. The worst affected areas were ANC, labour ward, theatres and pharmacies. It was observed that in a number of cases, especially at health centres, CDEs and TBAs in most cases, are the ones who conducted both ANC and delivery services. In other cases, this category of staff did the bulk of work, including conducting deliveries, even in facilities where qualified cadres were available. The absence of qualified staff was also found in pharmacy and theatres. Appropriate staff did not run a number of pharmacies. In some facilities, porters and scrubbers also took up the roles of anesthetists and theatre nurses. The perceptions and views on the impact of the absence of or inadequate staffing levels were highlighted. The most identified concerns or negative manifestations were: cancellation of outreach services, involvement of health centre committee officials in making follow up visits to postpartum clients, health centers being headed by CDEs, lack of certain required knowledge e.g. use of partographs and proficiency in resuscitation, student nurses escorting referred clients and increased workload for remaining trained staff, among others. The practice where one member of staff looked at everything per shift was reported widely, especially in rural areas. Providers, especially in ANC services observed that it was practically difficult to follow all the recommended steps, when one was conducting an ANC clinic because the numbers of clients and other competing demands, some of them administrative, often overwhelmed staff (see Case 3 appendix 2). It was observed in some areas that the introduction of PMTCT has further exacerbated this ‘so much has to be done per client and not all those trained for PMTCT, are available when they are needed.’ Apart from facilities that were run by CDEs, the other concern was for hospitals which did not have any doctor(s) at all. In other words there is a generally low availability of skilled attendants in the facilities. This therefore means that even when mothers reach a facility a skilled attendant does not attend to them. Table 3.8 shows availability of midwives in the surveyed facilities. Table 3.8: Availability of Midwives in the Surveyed Facilities by Province Province Availability of a midwife in a facility (percent) Average 53 Central 61 Copperbelt 92.5 Eastern 61 Luapula 29 Lusaka 42 Northern 50 North Western 47 Southern 54 Western 40 3.12 Caesarean Section Rate The caesarean section deliveries as a percentage of all expected births in surveyed facilities is called caesarean section rate. In this study the caesarean section rate was 1.67% which is below the acceptable range. Fifty seven percent of deliveries take place at home in Zambia. Other factors however must be taken into account especially morbidity because the operations in some hospitals are performed by staff with minimal skills. Some Caesarean sections are now carried out by Licentiates e.g. In Katete and Mkushi. Luapula, Lusaka and Eastern province had the largest number of caesarean section as shown in appendix 6 & table 3.9. It is not clear why Luapula has a high caesarean section rate. Table 3.9: Caesarean Section Rates For 6 Months 2005 Per Province Province Expected Deliveries Caesarean Deliveries Percent Caesarean Sections Total 300,440 5,014 1.6 Copperbelt 45447 950 2.09 Eastern 40766 449 1.10 Luapula 23744 1,000 4.21 Lusaka 41797 1,318 3.15 Northern 39799 415 1.01 North Western 17885 93 0.52 Southern 37234 307 0.82 Western 22703 161 0.71 Minimum acceptable level = 5% Maximum acceptable level = 15% The rate is below the accepted range. This means that most patients do not access this life saving intervention. 3.13 Case Fatality Rate Case fatality rate in the surveyed facilities was 2.41% which is above the acceptable maximum of 1%. This indirectly measures the quality of care. The largest number of deaths occurred due to postpartum haemorrhage (20) 5%, infections (17) 11% and eclampsia (12) 3%. Table 3.10: Case Fatality in Surveyed Facility by Complication Cause Number of complications Number of deaths Percent Deaths/Complication Total 3,823 92 2.41 Eclampsia/Severe Pre-Eclampsia 407 12 2.95 Antepartum hemorrhage 322 8 2.48 Ruptured uterus 97 11 11.14 Postpartum hemorrhage 371 20 5.32 Ectopic pregnancy 834 2 0.24 Complications of abortion 718 3 0.42 Infections 161 17 10.56 Complicated malaria 333 7 2.10 Other complications 580 12 2.07 Figure 3.3: Numbers of Maternal Deaths in last 6 months by province (Jan-June 2005) [image: image4.wmf] While respondents felt that the lack of or poor knowledge levels affected quality of service, they also observed that there were other compounding factors that translated into poor practices, such as poor staff motivation, lack of equipment, high workload and lack of or poor technical supervision, among others. The table below shows availability of basic EmOC services. Some of the services such as manual removal of placenta, instrumental deliveries and evacuations of retained products of conception have not been included since they are not available in most of the health centres. Table 3.11a: Availability of some Signal Functions in the Surveyed Health Facilities N = 247( Signal Function Percentage Parenteral Antibiotics Benzyl Penicillin 93.8 Cefotaxime 13.4 Gentamycin 59.9 Parenteral Oxytocics Oxytocin 33.6 Ergometrine 88.3 Parenteral Anticonvulsants Magnesium Sulphate 14.6 Diazepam 94.7 ( Source:- Tool number 11 All general, provincial and central hospitals were comprehensive EmOC facilities. There was a doctor and few midwives working in the labour ward. The table below shows selected district hospitals surveyed and the status of signal functions at the time of the visit. Table 3.11b: Availability of Signal Functions in Some Surveyed Districts Hospitals by Province Province District Hospital Status of Signal Functions 1 2 3 4 5 6 7 8 Central Mumbwa y y y y y y N y Mkushi y y y y y N y y Kapirimposhi y y y N N N N y Copperbelt Roan y y y N N N N y Kalulushi Mine y y y y y y y y Thompson y y y y y ? y y Eastern Petauke y y y y y y N y Lundazi y y y y N N y y Luapula Kawambwa y y y y y ? y y Kashikishi y y y y y y y y Lusaka Mpanshya y y y N N N N y Katondwe y y y y y y y y Northern Luwingu y y y y y y y y Mpolokoso y y y y y y y y Chilonga y y y y y y y y North Western Zambezi y y y y y y y y Chitokoloki y y y y y y y y Southern Choma y y y y y y y y Macha y y y y y y y y Gwembe y y y y y y y y Itezhitezhi y y y N y N N y Western Kalabo y y y y y y y y Yuka y y y N N N N y Kaoma y y y y y y y y Senanga y y y y y y y y Mwandi y y y y y y y y KEY y = Yes It is performed N = No not performed 1 = Have and administer Injectable antibiotics 2 = Have and administer Injectable Oxytocics 3 = Have and administer Injectable Anticonvulsants 4 = Perform Manual Removal of Placenta 5 = Perform Manual Vacuum Aspiration or Removal of Retained Products 6 = Perform Vacuum Extraction or Forceps Delivery 7 = Perform Caesarean Section 8 = Availability of Blood Transfusion Service 3.14 Referral system Referrals were often frustrated by long distances and lack of transport and bad roads (Chama, Chilubi and Samfya districts). However, in some cases, it was reported that where staff was required to accompany the client, lack of staff became a factor. In one centre in Luapula, the problem had a different dimension. It was reported that when staff accompanied a client to Mansa, the staff met the costs for upkeep and return journey to the center. Radios and ambulances were available in most facilities and hospitals respectively. However one ambulance serves up to 37 health centers in all direction. Mwense district had no radios communication. It was also observed that the radios were used to send irrelevant messages. Table 3.12 shows the complicated cases that were referred to next level of care. Copperbelt and Southern provinces had the highest numbers of referred cases. However the figures may reflect that some patients had multiple complications. Table 3.12: Referred Complicated Cases from all Facilities to Higher Levels by Province Complication Zambia Cent CBelt East Luap LSK North NWest South West All Complications 115 9 26 11 4 8 9 4 28 13 Eclampsia/Severe Pre-Eclampsia 52 2 20 9 1 5 8 3 4 - Antepartum hemorrhage 21 - 14 2 - 1 2 - 2 - Fetal distress 5 - - - - 2 2 1 - - Ruptured uterus 20 - 10 5 - 3 - 1 1 - Postpartum hemorrhage 19 - 10 - - - 9 - - - Ectopic pregnancy 10 - 1 - - 6 1 - 2 - Complications of abortion 54 4 19 3 - 1 18 - 9 - Infections 3 - 1 - - - 2 - - - Complicated malaria 6 - 3 - 1 - 2 - - - Other Complications 114 6 14 35 11 3 29 - 14 - CHAPTER FOUR 4 .0 DISCUSSION AND CONCLUSION Although not all hospitals were visited, these findings could be generalized for all health facilities in Zambia: Firstly, all general and provincial hospitals were surveyed; secondly, the sampling of hospitals and health centres involved stratification of all the facilities by type and systematic selection of these within the strata. The high maternal mortality ratio in Zambia can be interpreted in the context of the various aspects of maternal health care examined such as infrastructure, equipment and supplies, infection prevention practices, staffing and the process indicators used in this study. 4 .1 Infrastructure The findings suggest that whereas, infrastructure generally in terms of maternal health care needs is not a problem in hospitals, this was not the case with the majority of health centers. Infrastructure in most health centers is not supportive of or conducive to the totality of maternal health care needs. The lack of space is a critical problem; most health centers have no maternity wings and as the study has pointed out in some cases, ANC, PNC, and delivery are conducted in the same room or rooms that also serve as offices. ANC, delivery and PNC demand certain minimum infrastructural standards. For effective and meaningful care in ANC, for example, a covered waiting area with adequate seating and availability of an examination area that provides privacy is a primary requirement. Accordingly, quality of care in labour and birth areas requires certain minimum standards like privacy, and availability of clean water and toilets. If existing infrastructure does not exhibit this, in addition to the other factors, a facility may not be attractive to potential users. 4 .2 Equipment and supplies Certain types of equipment is required in the various clinics or sections of any given health facility. In ANC and PNC, certain equipment such as stethoscopes, blood pressure machines, fetal stethoscopes, equipment for various tests were available. While these were generally available (80%), the study also revealed that in most cases these were shared between and among different sections of the facilities. The study also revealed that other equipment and supplies such as instrument sets for birth, episiotomy/repair supplies, neonatal and adult ambu bags and delivery beds were lacking. Most centers only have a few artery forceps, kidney dishes and episiotomy scissors; full maternity department equipment was generally not available. On the other hand, theatres were generally better equipped. 4 .3 Infection Prevention Practices The findings have shown that only 16.1% of all facilities surveyed, practiced infection prevention according to standard requirements. Infection prevention was only better in nurseries, (98%) than in all other areas. The variations can be attributed to levels of knowledge and simply attitude factors or the erratic supply of chlorine, both of which can be addressed. 4 .4 Staffing The study also revealed that in addition to and in places of qualified staffs, the CDEs also carried out ANC, deliveries, postnatal care and general screening in the facilities. These findings point to an increasing pattern of more involvement of unskilled attendants in service delivery in the facilities. This has implications on the quality of care that mothers receive in these facilities. According to WHO standards, all deliveries are supposed to be attended to by trained staff to guarantee a good outcome. The findings further show that health providers available also delegate the duties to untrained cadres with minimum supervision. When staff leaves for meetings and workshops the facility is left to CDE/TBA to run it. Due to this critical shortage of staff MDGs will be difficult to achieve. This has contributed to the substandard quality of care. The general absence of skilled attendants in health facilities does pose a challenge in Zambia’s efforts to attain the MDG (5). 4 .5 Availability of EmOC Services The assessment identified that all the general and central hospitals (13) offer comprehensive EmOC. Eleven percent of the hospitals surveyed are basic EmOC; they have no capacity for surgical intervention and blood transfusion while 8.8% of the hospitals have no EmOC at all. No rural and urban health centers provide EmOC. These centers do not offer manual removal of placenta, instrumental deliveries and evacuation of the uterus for retained products of conception which are among the six signal functions required for basic EmOC. All this translates into extremely low availability of EmOC services in the country. The total met need for EmOC is only 8.5%. This means when faced with complications, most of our pregnant mothers are not guaranteed of any meaningful and effective management of these complications and are therefore likely to die. The distribution of EmOC facilities is concentrated on the copperbelt and Lusaka. 4 .6 Utilisation of EmOC The study has indicated that only 9.2% of complicated deliveries are taking place in EmOC facilities; that is facilities that are ready to manage the complication. This is well below the 15% minimum expected. However, this is not a good pointer of utilisation of EmOC on a national scale. This is because the calculation is based only on hospital deliveries since only these had EmOC. The study has also noted that in fact some districts have no hospitals while others have up to 3 hospitals. Met needs for EmOC was 8.5%. This means that 91.5% of women experiencing complication of pregnancy and childbirth are not treated in EmOC facilities. 4 .7 Quality of EmOC Services The Caesarean Section rate of 1.67% is below acceptable range of between 5% and 15%. There is need to improve on this indicator. The case fatality rate of 2.41% is in excess of the acceptable maximum of 1%. The findings suggest that the high cause of death was PPH which is preventable by routine active management of 3rd stage of labour. Further more the CDEs /TBAs are not legally covered to administer oxytocics even though they are delivering women in health facilities. Complications due to infection may result from, among other factors, unhygienic environment, poor infection prevention practices, prolonged labour and poor management of labour as evidenced from partograms inspected. The observed high number of ruptured uterus complications could be attributed to mothers going late to health facilities. This might also mean that mothers die in the community. On the other hand, the low numbers of abortion related complications raises questions as to whether such cases reach the health facilities. The numbers may not reflect what is on the ground because abortion is secretive and poor documentation. The high case fatality rate explains a lot about the quality of essential and obstetric care services provided in our institutions. It exposes, the highly compromised quality of care to which pregnant mothers are subjected to or encounter in the health facilities. E.g. no Magnesium sulphate for eclamptics, and poor infection practices. There are also a number of compounding factors; poor infrastructure; lack of equipment, unavailability of skilled personnel; increased workload; low motivation of staff; lack of focused technical and supervisory support in maternal health, lack of an effective referral system and poor infection prevention practices. Similarly, client assessment in either ANC or PNC should follow certain steps, which include, but not limited to taking a thorough history of the client, performance of certain examinations and tests and proper documentation of all actions, findings, treatment and offering of counseling services and observation of standard infection prevention practices. When this does not take place, as the findings suggest, quality of care is compromised. The gaps identified in the provision of quality obstetric care in Zambia can be addressed by more focused and coordinated interventions. This assessment has provided a picture of where the country is in terms of Maternal Health Care and can provide a new starting point in the delivery of essential and emergency obstetrics care in Zambia. RECOMMENDATIONS Government must improve staffing levels and enhance the skills of the skilled attendants in the health facilities through recruitment of midwives, accelerating the training midwives and provision of training in Life Saving Skills. In order to improve the quality of service in antenatal, delivery and postnatal clinics, maternity wings should be built at all health facilities that can accommodate different clinics or sections. All health facilities must be equipped with all the necessary equipment required in ANC, delivery room and Post natal clinics in the right quantities and develop mechanisms for repair and service back up. Health facilities should be allowed to use their grants to procure minor but essential equipment e.g. Blood Pressure machine, stethoscopes and thermometers. Immediate steps should be taken to promote infection prevention practices through among other things, provision and dissemination of national Infection prevention guidelines and conducting refresher courses in infection prevention and control. There should be deliberate efforts by Government to ensure that all facilities designated as hospitals offer comprehensive EmOC services. This should be in addition to establishing EmOC centres where these do not exist: districts with no hospitals. All health centres, whether urban or rural should offer Basic EmOC services. Government should train and deploy Anaesthetists and Theatre nurses to improve the quality of service delivery in the theatres. There is need to maintain adequate supplies of prescribed drugs in the facilities and standardise the contents of an emergency tray and revision of the essential drug kit so that oxytocin, ergometrine and magnesium sulphate are supplied in adequate quantities. There is need to define the role of TBAs and CDEs in health delivery especially that they are currently found in health facilities. Although this study did not look at the family and community perceptions, there should be programs that target families and communities to play a major role in decision making and identification of emergencies and complications. Capacity building and training: Anaesthetists in the use of regional anaesthesia in obstetrics. Protocols and job aids in management of obstetric emergencies should be formulated and made available to all facilities. Documentation of management of labour, obstetric complications, maternal deaths to improve on self-assessments, evaluation and planning for interventions. REFERENCES Alwar, J & Mtonga, V 2000, A report of the summative evaluation of Essential Obstetric care project in Mpongwe Masaiti and Lufwanyama, Lusaka, Zambia. AMDD working group on Indicators using UN process indicators to assess needs in emergency obstetric services: Benin of Chad, IJGO 86. 2004. pp 110 – 120. Brouwere De, V and W, Lerberghe V (eds.) 2001, ‘Safe motherhood Strategies: A review of Evidence’ Studies in Health Services Organisation and Policy, no. 17, pp. 1-448. Central Statistical Office (Zambia), Central Board of Health (Zambia), and ORC Macro 2003, Zambia Demographic and Health Survey 2001-2002, Calverton, Maryland, USA. Maine, D, Akalin, MZ, Ward, VM, Kamara, A 1997, The design and evaluation of maternal mortality programs, Centre for population and Family Health, Columbia University. Maimbolwa, M 1998, Evaluation study of the TBA program in Zambia, Lusaka, Zambia. McCord C, Premkumark, R, Arole S, Arole R. 2001, ‘Efficient and effective emergency obstetric care in a rural Indian community where most deliveries are at home,’ International Journal of Gynecology Obstetrics, no. 7, pp.297–307. Nsemukila, B, Phiri, D., Diallo, H, Banda S, Kalunde W, Kitahara, N 1998, A study of factors associated with maternal mortality in Zambia, MOH, UNFPA, CBoH, & UNZA, Lusaka. Uganda MoH 2003, A National needs assessment of EmOC process Uganda. UNICEF 1994, Safe Motherhood in Zambia- A situation analysis, UNICEF, Lusaka. WHO/UNICEF 1996, Revised 1990 estimates of maternal mortality, WHO/FRM/MSM/96.11 UNICEF/PLN/96.1. WHO/AFRO 2002, Reducing maternal and newborn mortality in Africa, WHO/AFRO, Geneva. WHO 1996, Safe Motherhood – Needs Assessment, WHO, Lusaka, Zambia. World Bank 2003, ‘Investing in maternal health. Learning from Malaysia and Sri Lanka’, Health, Nutrition and Population series, Human Development Network, World Bank, Washington D.C.: APPENDIX I SURVEY PERSONNEL CONTRIBUTORS Dr Victor Mukonka MOH/CBOH Dr Mirriam Chipimo MOH Dr Reuben Mbewe HSSP Dr Mubiana Macwan’gi HSSP Ms Christine Mutungwa UNICEF Dr Girma Alemayehu UNFPA Dr Sarai Malumo UNFPA Mr Kwibisa Liywalii PMMZ Mrs Patricia Kamanga WHO Mrs Siachumpi Muriel Coordinator Dr Gricelia Mkumba Consultant TEAM LEADERS Mrs Ethel Mangani Lyuba Mr Chipoya Chipoya Mr Kwibisa Liywali DATA COLLECTORS Mrs Lydia Jumbe Mrs Monde Luhanga Mr Deostidius Chipowe Mrs Siapuku Chibela Mrs Ray Chiko Mr Moses Sapezo Mrs Emely Chingambu Mrs Muyunda Mr Linos Mwiinga Mr Abidan Chansa Mrs Oscar Mwiinde Mr Teddy Sokesi DATA ENTRY CLERK Ms Gloria Jombo Ms Chibemba Kaoma DATA ANALYST Mr Crispin Masaku Sapele Mrs Batista Mwale REPORT Dr Gricelia Mkumba Mr Crispin Masaku Sapele Mrs Ethel Mangani Lyuba Mr Kwibisa Liywalii, Mr Chipoya Chipoya APPENDIX II STUDY CASES Case 1 Mrs. C.D. a 26 year old in her 3rd pregnancy at 36 weeks started having vaginal bleeding at 04.00 hours on 5th August 2005. She was carried on ox cart to health center in Mwanjabanthu area and arrived at 07.00 hours. The nurse at the health center did not examine her, nor start any emergency treatment. She only wrote a referral letter to Petauke hospital. Patient continued the journey in ox cart to hospital and arrived at 11.00hours while the EmOC survey team was in labour ward. Midwife on duties examined the patient and found to be in shock no pulse no Bp and called the administrator after she had already collected blood for cross matching and Hb and started the drip. The hospital theatre was undergoing renovations and therefore the patient was put on the ambulance and transferred to Katete hospital where she underwent caesarean section for major placenta praevia by a clinical officer Licentiate. She was delivered of FSB and patient recovered well. Case 2 Mrs. G.M. was a 41 Para 13 in her 14th pregnancy, having had three antenatal visits to the health centre. Family planning had been discussed but the husband refused. She was delivered at home and had a retained placenta. She bled at home and after some time of unsuccessfully trying to remove the placenta she was brought to Kwenje Health Centre in shock. She died in the clinic as the midwife was awaiting transport to take patient to the next level of health care. This was not recorded as clinic death but the only record available was a referral letter. The husband immediately took the body as EmOC team arrived. Case 3 As the EmOC survey team visited a busy Lusaka urban clinic one midwife asked whether the team had time to listen to her complaint on behalf of others. She had just finished conducting a postnatal clinic. She sees over fifty clients every day until Friday. She also has to examine their babies for neonatal diseases. Meanwhile clients for family planning were accumulating and waiting to be attended to by the same midwife. She is also on the duty Rota for labour ward and antenatal clinic, which are in different rooms. She has no time to take a cup of tea or lunch. By the time she finishes that day’s work she is so exhausted that she fails to cook for her family. She says, “Most of us are on medication of some kind or another. We are left to die on the Job. We teach clients to eat well but we cannot. This is not all, we are required to document these findings and fill in forms for several projects. Too much paper work as well”. She repeated her sentiments several times looking frustrated, angry and looking for help. Case 4 Ms C. Lungu 24 years old primigravida at 38 weeks was brought into a district hospital in Central province at 10.00 hours convulsing. She convulsed again as she was being examined by the midwife. The Bp was 170/110. Urinalysis was not done due to non availability of albustics. A Vagina Examination (VE) was done and the cervix was fully dilated with the fetal head at the level of ischial spines. The only doctor of the hospital was called and he just told the midwives to give hydralazine and valium and asked them to deliver her. Patient continued to convulse. Midwifes called other nurses to help her to hold the patient. The midwife asked the others to apply fundal pressure and she performed a generous episiotomy until the baby was delivered. There was no oxytocin only ergometrine was available. Therefore no oxytocic was given. Placenta was delivered and episiotomy suture with difficult. No lithotomy bed, no cot bed, and but vacuum extraction machine was available. Survey team just missed the drama. This was a near miss of maternal and fetal death. APPENDIX III SAMPLE DESIGN SAMPLING The primary objective of the Emergency Obstetric Care (EmOC) Needs Assessment survey was to provide EmOC service indicator data with acceptable precision for important characteristics of facilities providing EmOC services. The major domains for which separate tabulation of characteristics required included: The nation, Zambia as a whole Each of the hospital type in Zambia (Central, General and District, Other Hospital Levels) Each of the clinic types (Urban/Rural Health Centers and other clinics and health posts) All provincial hospitals were selected while a sample of facilities from the other categories was drawn. The sample was nationally representative to allow national level tabulation of important indicators and also allow representation by the following facility types: i) District hospitals Mission Private Other Levels ii) Rural health centers Urban health centers iv) Clinics Sample Size Determination There is generally no unique definition available for a good or desirable sample (Kish, 1995). The important issues in sample size determination are the required reliability or precision, variability of characteristics in the population, the size of the population, the method of sampling and the levels of non-response. Factors of cost, time and operational constraints are to be considered. A sample size that will ensure that the study results can be relied upon to make generalizations was therefore sought. Computation of Sample Size A step-by-step approach was followed to come up with a sample size as follows: Specify a level of precision Decide on a method of sampling Obtain estimate of design effect Assume response rate Level of Precision Precision or reliability is a measure of closeness of sample estimates to the results you could get from a census i.e.100% enumeration. The level of precision is specified in terms of the coefficient of variation (cv) which is derived by dividing the absolute measure of variability (standard error) by the estimate (mean, ratio or proportion). The cv is a relative measure of variability and is chosen because it allows comparison in the spread in variables under study for different groups. As a rule of thumb, we aim for a coefficient of variation less than 0.1, but cv less 0.2 is tolerable (Kish,1995). For this purpose a cv = 0.1 was chosen in order to allow reliable indicators for all important levels of tabulation within the funding available. Method of Sampling The sampling method involved stratification of the health facilities by type, and systematic selection of facilities within the strata. The survey objectives and the available sampling frame were the main determinants for the method. Design effect (deff) The formulars to calculate sample size are based on simple random sampling. It is therefore necessary to inflate the sample size determined using simple random sampling formulas to take the type of design into account. The multiplication factor is called the design effect (deff). The design effect (deff) is the ratio of the actual variance of a sample to the variance of a simple random sample of the same number of elements. This factor inflates the simple random sample size to take care of complexities of clustering and stratification in the sample design. This inflation factor is usually determined from other surveys of the same or similar design. The design effect is usually estimated subjectively by making use of whatever knowledge is available about the variability of Characteristics of interest in the population. A value of 1.1 for the design effect is chosen because no survey of similar nature conducted provides any estimates of deff. Response Rate It is extremely rare that a 100 percent response is achieved in surveys. Therefore if the effect of non-response is ignored, the number of units in the sample would be smaller than expected and consequently lower the precision of the produced estimates. This situation can be avoided by taking a larger initial sample size based on an expected response rate, which could be estimated from a pilot study or similar survey. For this design a response rate of 60 percent was chosen based on some establishment surveys conducted by the Central statistical Office. The sample size is then obtained by using estimated proportions, whose variance, under the assumption of simple random sampling, is given as s2=p (1-p), (1) where p is an estimate of the proportion of the population that has the characteristic of interest or the probability of success. Since the initial estimate of p is not available the estimate p=0.5 will be used-this is the case when maximum variability occurs. Generally the greater the variability among units in the population, the lager will be the sample size needed to achieve specific levels of precision. Unfortunately, the variability is usually not known in advance therefore the most conservative choice is p=0.5-the case of most variability (See table 1). The variance s2=p (1-p) increases as p moves towards 0.5 and reduces as p moves away from 0.5. Therefore the simple random sample size is computed as Step 1 [image: image5.wmf] EMBED Equation.3 [image: image6.wmf] (2) [image: image7.wmf] where cv(p) is the coefficient of variation for the proportion. The table below summarizes the simple random sample estimates for varying levels of the cv and p. Simple random sample sizes for varying levels of coefficients of variation and proportion Guesstimate of p variance Sample sizes at different levels of coefficient of variation CV=0.025 CV=0.05 CV=0.1 CV=0.2 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0.09 0.16 0.21 0.24 0.25 0.24 0.21 0.16 0.09 14,400 6,400 3,733 2,400 1,600 1,067 686 400 178 3,600 1,600 933 600 400 267 171 100 44 900 400 233 450 100 67 43 25 11 225 100 58 38 25 17 11 6 3 Step 2 Adjust the initial simple random sample with the design effect and the expected response rate. From table 1 the initial sample size at p=0.5 and cv=0.1 is 100. The adjusted sample size is obtained as follows: [image: image8.wmf] = [image: image9.wmf] where n = the overall sample size under this design is at least 250 health facilities. nsrs= the initial simple random sample size r = the expected response rate Deff=the design effect Sample Frame The sample frame for this survey was a list of all health facilities in Zambia compiled using different sources. These sources included Ministry of Health/Central Board of Health, Medical Council of Zambia and also from the Census of Health facilities conducted by JICA. All these records were obtained from the sources mentioned in June 2005. These records were considered updated at this time. Stratification The health facilities were listed by Province, District, Facility Type and Ownership. The list also indicated the number of Beds and Cots for each facility. The explicit stratification variable was the type of facility. For hospitals the separate types were Central, General, District, Mission and Other hospitals. For clinics, the separate types were, Urban Health Centers, Rural health Centers, Private clinics and health posts. Sampling was done separately within each of these institution types. The table below shows the distribution of the sample and the total number of institutions according to the frame. Sample distribution Type of Institution Number Sample Replacements Central Hospitals 3 3 0 General Hospitals 12 12 0 Districts Hospitals 51 26 3 Mission Hospitals 16 8 2 Other Hospitals 28 3 1 Total 110 52 6   Urban Health Centers 266 65 5 Rural Health Centers 996 140 12 Private Clinics 322 18 2 Health Posts 19 2 1 Total 1603 225 20   Overall Total 1713 277 26 Sample Selection Procedure All Health facilities with in a stratum were assigned serial numbers A sampling interval (SI) was calculated by dividing the total number of listed facilities by the number to be selected. For example if 10 facilities are listed in a stratum and 5 are to be selected the SI = 10/5=2. Generate a random start between 1 and the interval SI (from a table of random numbers) for the first selection (the health facility assigned a serial number that corresponds to the random number is selected) Add the interval to the random number to get the next selection Continue adding the interval until you get the required 5 facilities. Estimation Procedure Due to the non-proportional allocation of the sample to the different strata (types of facility) sampling weights will be required to ensure actual representative ness of the sample at national level. The sampling probabilities were used to calculate the weights. The weights of the sample are equal to the inverse of the probability of selection. The probability of selecting facility i was calculated as [image: image10.wmf] Where nh =the number of facilities selected from stratum h, Nh=the total number of facilities in stratum h. The weight or boosting factor is, thus, given as [image: image11.wmf] Let yhj be an observation on variable Y for the ith facility in hth stratum. Then the estimated Total for the h-th stratum is: [image: image12.wmf] [image: image13.wmf] Where, yh is the estimated total for the h-th stratum. whi is the weight for the ith household, i=1-nh is the number of selected facilities in the stratum, The national estimate is given by: [image: image14.wmf] Where, y is the national estimate, h=1, …, H is the total number of strata. For this purpose, H = 9 (The types of facilities). APPENDIX IV PROFILE OF HEALTH INSTITUTIONS IN ZAMBIA Profile of Health Institutions in Zambia Province 1st level 2nd level 3rd level RHC UBC Private Mission Total Central 7 2 0 86 24 0 0 119 Copperbelt 12 2 3 49 143 1 4 209 Eastern 7 2 0 143 2 2 9 158 Luapula 6 1 0 111 2 2 6 121 Lusaka 6 0 2 45 46 10 5 102 Northern 5 3 0 144 1 8 16 154 Northwestern 7 2 0 110 3 2 13 124 Southern 11 5 0 173 18 2 20 216 Western 10 1 0 110 3 1 9 124 TOTAL 71 18 5 971 242 28 82 1327 Summary of Health Institutions Facility type No. of Units No. of Beds Government Private Mission 3rd Level 5 3,802 5 0 0 2nd level 18 5,133 12 0 6 1st Level 74 6,795 36 17 21 Rural h/c 973 8,077 889 23 61 UrbanH/C 237 1,632 163 74 0 Health post 20 0 0 19 1 Total 1,327 25,439 1,124 115 88 Source: Health Institutions in Zambia (CBoH2002) RHC -Rural Health Centre UBC Urban Health Centre APPENDIX V TEAMS FOR FIELD WORK Team Names Occupation Province TEAM 1 Dr Mkumba Consultant Obstetrician Lusaka Linos Mwiinga Medical Student Eastern D Chipowe Anaesthetist Central Monde Luhanga Midwife TEAM 2 Kwibisa Liywalii Social Scientist Southern Muyunda Milupi Midwife Western Abidan Chansa Medical Student Siapuku Chibela Midwife TEAM 3 Chipoya Chipoya Anaesthetist Copperbelt Lydia Jumbe Midwife/Lecturer North Western Ray Chiko Midwife Oscar Mwiinde Medical Student TEAM 4 Ethel Mangani Midwife/Sister In Charge Northern Emely Chingambu Midwife Luapula Teddy Sokesi Medical Student Moses Sapezo Theatre Nurse APPENDIX VI WORK PLAN FOR EMOC NEEDS ASSESSMENT 2005 Dates Activity Responsible Person In Put Out Put 06 – 13.07.05 (7 days) Testing and Finalizing Tool / Training Research Ethics highlights Research Team and Dr. Mbewe Stationery Refined Survey Tools 18 07 05- 22 07 05 {5 days} Orientation of Research Assistants to the tools Original Research Team Stationary Tea/ Lunch 3 Teams 25.07.05 – 02.09.05 (30 days) Field Work Research Team Stationery, Transport + Logistics Data Collection Completed 01.08.05 – 09.09.05 (30 days) Data Entry Data Entry Clerk Stationery + Printing Data Entry Completed 05.09.05 – 30 09 05 (20 days) Data Analysis Report Writing Dissemination of preliminary report Research Team and Collaborators Stationery + Printing Draft Report to SMH Task Group (26 Sept 05) Feedback from SMH Task group (28 Sept 05) Dissemination meeting for Stakeholders (7 Oct. 05) 03-07.10.05 {5days} Report writing Research Team and Collaborators Stationery + Printing Final Report Dr. R. Mbewe - Reproductive Health Advisor - HSSP Dr. G. Mkumba - Consultant Obstetrician and Gynaecologist - UTH Ms Ethel Mangani Lyuba - Sister In Charge Midwife - UTH Mr. Chipoya - Anaethetist - UTH Mr. Kwibisa - Social Scientist – Prevention of Maternal Mortality Zambia Mr. C.M. Sapele - Central Statistics Office Mrs. B. Mwale - Central Statistics Office Mrs. P. Kamanga - WHO Ms. C. Mutungwa - UNICEF Dr. S. Malumo - UNFPA Dr. M. Chipimo - CBOH Dr. Girma - CBOH/UNFPA APPENDIX VII DRUGS & SURGICAL SUPPLIES Drug Yes (Percent) No (Percent) Analgesics Morphine 6 89.2 Paracetamol 97.6 0.4 Pethidine 17.3 75.5 Fentanyl 1.6 96.8 Anaesthetics Lignocaine 87.1 8.8 Bupivacaine 9.6 87.1 Ketamine 18.5 79.9 Thiopentone 11.8 87.8 Propofol 1.6 98.4 Etomidate 0.4 98.8 Suxamethonium 13.5 85.7 Pancuronium 7.3 91.8 Rocuronium 0.4 98.4 Neostigmine 10.6 87.8 Halothane 16.3 83.3 Haematinics Iron folate 97.2 1.6 Antibiotics Amoxicillin 82.5 8.9 Benzathine Penicillin 92.7 4.9 Cefotaxime 13.4 82.2 Gentamycin 59.9 27.1 Metronidazole 85.4 6.5 Tetracycline 1% eye ointment 85.4 10.5 Trimethoprim-sulfamethoxazole 74.1 17.8 Anticonvulsants Magnesium sulphate 14.6 83.0 Diazepam 94.7 2.8 Antihelminthes Albendazole 92.3 6.1 Antihypertensives Hydralazine 25.5 72.5 Nifedipine 21.5 71.7 Atenolol 27.9 68.4 Antimalarials Quinine 94.3 3.6 Fansidar 98.8 1.2 Adrenaline 74.1 19.0 Aminophylline 81.4 13.4 Atropine 30.8 66.8 Calcium gluconate 13.0 85.0 Digoxin 23.1 76.9 Diazepam inj 91.1 7.7 Ephedrine 5.3 90.3 Frusemide 41.3 53.4 Naloxone 2.4 95.1 Hydrocortisone 63.6 29.6 Promethazine 57.4 36.4 Sodium citrate 0.8 99.2 Drug Yes (Percent) No (Percent) Iv fluids Glucose 5%, 10% 83.8 10.1 Haemacel 13.4 83.8 Dextran 83.0 10.1 Ringer lactate 82.0 9.3 Normal saline 88.0 8.9 Oxytocics Ergometrine 2.0 96.8 Misoprostol 33.5 61.0 Oxytocin 30.1 68.2 Antiretrovirals Zidovidine 19.5 79.2 Vaccine Tetanus toxoid 72.9 20.8 Supplies Yes (Percent) No (Percent) Endo-tracheal tubes 13.9 85.3 Laryngeal mask 8.2 89.8 Oro-pharyngeal airways 55.5 83.3 Spinal set 5.3 93.9 Epidural set 4.1 94.7 CVP lines 2.0 97.2 SIGNAL FUNCTIONS: Drugs Availability of Benzyl penicillin by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 243 100 228 93.8 3 1.2 12 4.9 Central 22 100 21 95.5 - - 1 4.5 Copperbelt 43 100 38 88.4 - - 5 11.6 Eastern 26 100 23 88.5 1 3.8 2 7.7 Luapula 23 100 22 95.7 - - 1 4.3 Lusaka 18 100 18 100.0 - - - - Northern 27 100 27 100.0 - - - - North Western 18 100 18 100.0 - - - - Southern 43 100 40 93.0 - - 3 7.0 Western 23 100 21 91.3 2 8.7 - - Availability of Cefotaxine by province Province Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 33 13.4 11 4.5 203 82.2 Central 22 100 2 9.1 3 13.6 17 77.3 Copperbelt 43 100 8 18.6 - - 35 81.4 Eastern 27 100 2 7.4 1 3.7 24 88.9 Luapula 24 100 2 8.3 - - 22 91.7 Lusaka 18 100 3 16.7 1 5.6 14 77.8 Northern 28 100 1 3.6 4 14.3 23 82.1 North Western 18 100 4 22.2 - - 14 77.8 Southern 44 100 7 15.9 2 4.5 35 79.5 Western 23 100 4 17.4 - - 19 82.6 Availability of Magnesium Sulfate by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 36 14.6 6 2.4 205 83.0 Central 22 100 3 13.6 - - 19 86.4 Copperbelt 43 100 4 9.3 - - 39 90.7 Eastern 27 100 5 18.5 - - 22 81.5 Luapula 24 100 3 12.5 - - 21 87.5 Lusaka 18 100 3 16.7 - - 15 83.3 Northern 28 100 4 14.3 - - 24 85.7 North Western 18 100 2 11.1 - - 16 88.9 Southern 44 100 9 20.5 4 9.1 31 70.5 Western 23 100 3 13.0 2 8.7 18 78.3 Availability of Valium/Diazepam by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 234 94.7 6 2.4 7 2.8 Central 22 100 22 100.0 - - - - Copperbelt 43 100 42 97.7 1 2.3 - - Eastern 27 100 27 100.0 - - - - Luapula 24 100 23 95.8 - - 1 4.2 Lusaka 18 100 17 94.4 - - 1 5.6 Northern 28 100 21 75.0 3 10.7 4 14.3 North Western 18 100 17 94.4 - - 1 5.6 Southern 44 100 42 95.5 2 4.5 - - Western 23 100 23 100.0 - - - - Availability of Hydralazine by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 64 25.9 4 1.6 179 72.5 Central 22 100 5 22.7 - - 17 77.3 Copperbelt 43 100 12 27.9 - - 31 72.1 Eastern 27 100 7 25.9 - - 20 74.1 Luapula 24 100 3 12.5 - - 21 87.5 Lusaka 18 100 4 22.2 3 16.7 11 61.1 Northern 28 100 7 25.0 1 3.6 20 71.4 North Western 18 100 5 27.8 - - 13 72.2 Southern 44 100 12 27.3 - - 32 72.7 Western 23 100 9 39.1 - - 14 60.9 Availability of Atenolol by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 69 27.9 9 3.6 169 68.4 Central 22 100 7 31.8 - - 15 68.2 Copperbelt 43 100 13 30.2 - - 30 69.8 Eastern 27 100 7 25.9 1 3.7 19 70.4 Luapula 24 100 3 12.5 - - 21 87.5 Lusaka 18 100 9 50.0 2 11.1 7 38.9 Northern 28 100 5 17.9 4 14.3 19 67.9 North Western 18 100 5 27.8 1 5.6 12 66.7 Southern 44 100 15 34.1 - - 29 65.9 Western 23 100 5 21.7 1 4.3 17 73.9 Availability of Ergometrine by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 247 100 218 88.3 7 2.8 22 8.9 Central 22 100 18 81.8 - - 4 18.2 Copperbelt 43 100 38 88.4 1 2.3 4 9.3 Eastern 27 100 24 88.9 1 3.7 2 7.4 Luapula 24 100 22 91.7 1 4.2 1 4.2 Lusaka 18 100 17 94.4 - - 1 5.6 Northern 28 100 22 78.6 2 7.1 4 14.3 North Western 18 100 18 100.0 - - - - Southern 44 100 40 90.9 - - 4 9.1 Western 23 100 19 82.6 2 8.7 2 8.7 Availability of Oxytocin by province Provinces Total Always Sometimes No/Never Total % Total % Total % Total % Total 235 100 79 33.6 12 5.1 144 61.3 Central 22 100 4 18.2 - - 18 81.8 Copperbelt 43 100 18 41.9 - - 25 58.1 Eastern 23 100 8 34.8 1 4.3 14 60.9 Luapula 23 100 3 13.0 2 8.7 18 78.3 Lusaka 13 100 8 61.5 1 7.7 4 30.8 Northern 28 100 10 35.7 2 7.1 16 57.1 North Western 18 100 5 27.8 - - 13 72.2 Southern 42 100 16 38.1 4 9.5 22 52.4 Western 23 100 7 30.4 2 8.7 14 60.9 APPENDIX VIII CAESAREAN SECTION RATE BY DISTRICT Province/District C/S Number 2005 Population Expected Births C/S Rate Total 5,014 11,555,378 300,440 2 Central 321 1,194,742 31,063 1 Chibombo 0 285,468 7,422 0 Kabwe 274 201,961 5,251 5 Kapiri Mposhi 0 229,442 5,965 0 Mkushi 47 130,489 3,393 1 Mumbwa 0 188,155 4,892 0 Serenje 0 159,227 4,140 0 Copperbelt 950 1,747,957 45,447 2 Chililabombwe 33 82,365 2,141 2 Chingola 57 204,153 5,308 1 Kalulushi 17 44,892 1,167 1 Kitwe 343 437,519 11,375 3 Luanshya 37 164,868 4,287 1 Lufwanyama 0 73,862 1,920 0 Masaiti 0 56,813 1,477 0 Mpongwe 0 75,350 1,959 0 Mufulira 82 171,197 4,451 2 Ndola 381 436,938 11,360 3 Eastern 449 1,567,925 40,766 1 Chadiza 0 108,034 2,809 0 Chama 0 93,904 2,442 0 Chipata 188 403,302 10,486 2 Katete 261 223,947 5,823 4 Lundazi 0 297,411 7,733 0 Mambwe 0 55,799 1,451 0 Nyimba 0 83,612 2,174 0 Petauke 0 301,916 7,850 0 Luapula 1,000 913,249 23,744 4 Chiengi 0 98,042 2,549 0 Kawambwa 51 123,128 3,201 2 Mansa 126 216,780 5,636 2 Milengi 0 32,651 849 0 Mwense 0 125,155 3,254 0 Nchelenge 823 129,908 3,378 24 Samfya 0 187,585 4,877 0 Lusaka 1,318 1,607,596 41,797 3 Chongwe 0 161,783 4,206 0 Kafue 0 175,131 4,553 0 Luangwa 0 22,743 591 0 Lusaka 1,318 1,247,939 32,446 4 Province/District C/S Number 2005 Population Expected Births C/S Rate Northern 415 1,530,742 39,799 1 Chilubi 0 79,882 2,077 0 Chinsali 0 152,122 3,955 0 Isoka 0 115,734 3,009 0 Kaputa 0 101,673 2,643 0 Kasama 170 201,558 5,241 3 Luwingu 49 93,001 2,418 2 Mbala 123 177,538 4,616 3 Mpika 17 172,639 4,489 0 Mporokoso 56 90,150 2,344 2 Mpulungu 0 79,673 2,071 0 Mungwi 0 135,102 3,513 0 Nakonde 0 131,670 3,423 0 NorthWestern 93 687,895 17,885 1 Chavuma 0 34,765 904 0 Kabompo 2 85,078 2,212 0 Kasempa 0 61,815 1,607 0 Mufumbwe 0 52,877 1,375 0 Mwinilunga 0 139,751 3,634 0 Solwezi 78 237,953 6,187 1 Zambezi 13 75,656 1,967 1 Southern 307 1,432,075 37,234 1 Choma 170 230,329 5,989 3 Gwembe 0 41,049 1,067 0 Itezhi-tezhi 0 52,002 1,352 0 Kalomo 2 204,650 5,321 0 Kazungula 0 81,381 2,116 0 Livingstone 0 118,659 3,085 0 Mazabuka 39 241,314 6,274 1 Monze 0 194,429 5,055 0 Namwala 0 102,161 2,656 0 Siavonga 36 67,988 1,768 2 Sinazongwe 60 98,113 2,551 2 Western 161 873,197 22,703 1 Kalabo 17 129,161 3,358 1 Kaoma 62 187,954 4,887 1 Lukulu 0 79,389 2,064 0 Mongu 64 184,776 4,804 1 Senanga 0 122,836 3,194 0 Sesheke 18 88,833 2,310 1 Shan'gombo 0 80,248 2,086 0 Source: 2000 Census of Population and Housing, Population Projections Report, 2003 � CSPro is software developed by the United States Bureau of the Census. It is a derivative of IMPS and ISSA soft wares. It has capabilities of handling small to very large data processing requirements. PAGE 40 _1187984390.unknown _1198933224.xls _1199273926.xls Chart3 4 11 2 12 12 17 2 21 13 Province Deaths complications Table 1. Q10 1A: District Code District Code Frequency Cumulative Total Central Copperbelt Eastern Luapula Lusaka Northern North Western Southern Western Blank Total 415 0 415 20 114 43 13 125 26 8 48 18 0 Central 20 20 Copperbelt 114 134 Eastern 43 177 Luapula 13 190 Lusaka 125 315 Northern 26 341 North Western 8 349 Southern 48 397 Western 18 415 Blank 0 415 Table 2. Q10 2A: District Code District Code Frequency Cumulative Total 325 0 325 34 116 34 20 6 43 16 47 9 0 Central 34 34 Copperbelt 116 150 Eastern 34 184 Luapula 20 204 Lusaka 6 210 Northern 43 253 North Western 16 269 Southern 47 316 Western 9 325 Blank 0 325 Table 3. Q10 3A: District Code District Code Frequency Cumulative Total 362 0 362 35 143 86 6 1 19 34 36 2 0 Central 35 35 Copperbelt 143 178 Eastern 86 264 Luapula 6 270 Lusaka 1 271 Northern 19 290 North Western 34 324 Southern 36 360 Western 2 362 Blank 0 362 Table 4. Q10 4A: District Code District Code Frequency Cumulative Total 97 0 97 19 8 20 8 4 12 12 10 4 0 Central 19 19 Copperbelt 8 27 Eastern 20 47 Luapula 8 55 Lusaka 4 59 Northern 12 71 North Western 12 83 Southern 10 93 Western 4 97 Blank 0 97 Table 5. Q10 5A: District Code District Code Frequency Cumulative Total 380 0 380 12 161 34 39 9 21 26 51 27 0 Central 12 12 Copperbelt 161 173 Eastern 34 207 Luapula 39 246 Lusaka 9 255 Northern 21 276 North Western 26 302 Southern 51 353 Western 27 380 Blank 0 380 Table 6. Q10 6A: District Code District Code Frequency Cumulative Total 289 0 289 12 126 0 19 0 4 18 86 24 0 Central 12 12 Copperbelt 126 138 Eastern 0 138 Luapula 19 157 Lusaka 0 157 Northern 4 161 North Western 18 179 Southern 86 265 Western 24 289 Blank 0 289 Table 7. Q10 7A: District Code District Code Frequency Cumulative Total 834 0 834 0 637 12 16 109 17 36 3 4 0 Central 0 0 Copperbelt 637 637 Eastern 12 649 Luapula 16 665 Lusaka 109 774 Northern 17 791 North Western 36 827 Southern 3 830 Western 4 834 Blank 0 834 Table 8. Q10 8A: District Code District Code Frequency Cumulative Total 757 0 757 5 144 146 45 1 18 151 198 49 0 Central 5 5 Copperbelt 144 149 Eastern 146 295 Luapula 45 340 Lusaka 1 341 Northern 18 359 North Western 151 510 Southern 198 708 Western 49 757 Blank 0 757 Table 9. Q10 9A: District Code District Code Frequency Cumulative Total 161 0 161 0 27 18 10 42 6 22 28 8 0 Central 0 0 Copperbelt 27 27 Eastern 18 45 Luapula 10 55 Lusaka 42 97 Northern 6 103 North Western 22 125 Southern 28 153 Western 8 161 Blank 0 161 Table 10. Q10 10A: District Code District Code Frequency Cumulative Total 346 0 346 1 96 62 20 1 48 43 44 31 0 Central 1 1 Copperbelt 96 97 Eastern 62 159 Luapula 20 179 Lusaka 1 180 Northern 48 228 North Western 43 271 Southern 44 315 Western 31 346 Blank 0 346 Table 11. Q10 11A: District Code District Code Frequency Cumulative Total 420 0 420 91 104 61 36 27 22 0 40 39 0 Central 91 91 Copperbelt 104 195 Eastern 61 256 Luapula 36 292 Lusaka 27 319 Northern 22 341 North Western 0 341 Southern 40 381 Western 39 420 Blank 0 420 Table 12. Q10 12A: District Code District Code Frequency Cumulative Total 107 0 107 3 7 5 5 19 18 0 47 3 0 Central 3 3 Copperbelt 7 10 Eastern 5 15 Luapula 5 20 Lusaka 19 39 Northern 18 57 North Western 0 57 Southern 47 104 Western 3 107 Blank 0 107 ComplicationsByProvince Women estimated to have obstetric complication who are treated at EmOC Facilities Province Complications Total Central Copperbelt Eastern Luapula Lusaka Northern North Western Southern Western Total 3,842 185 1,414 435 212 343 231 314 516 192 Eclampsia/Severe Pre-Eclampsia 415 20 114 43 13 125 26 8 48 18 Antepartum haemorrhage 325 34 116 34 20 6 43 16 47 9 Ruptured uterus 97 19 8 20 8 4 12 12 10 4 Postpartum haemorrhage 380 12 161 34 39 9 21 26 51 27 Ectopic pregnancy 834 0 637 12 16 109 17 36 3 4 Complications of abortion 757 5 144 146 45 1 18 151 198 49 Infections 161 0 27 18 10 42 6 22 28 8 Complicated malaria 346 1 96 62 20 1 48 43 44 31 Other complications 527 94 111 66 41 46 40 0 87 42 Deaths of Women estimated to have obstetric complication who are treated at EmOC Facilities Province Complications Total Central Copperbelt Eastern Luapula Lusaka Northern North Western Southern Western Total 92 4 11 2 12 12 17 2 21 13 Eclampsia/Severe Pre-Eclampsia 12 1 3 0 1 2 1 0 4 0 Antepartum haemorrhage 8 1 1 0 1 0 0 0 5 0 Ruptured uterus 11 0 1 0 2 0 3 0 3 2 Postpartum haemorrhage 20 2 2 0 3 8 4 0 1 0 Ectopic pregnancy 2 0 1 0 0 0 0 0 1 0 Complications of abortion 3 0 1 0 0 0 1 0 1 0 Infections 17 0 0 0 4 2 2 0 1 8 Complicated malaria 7 0 2 2 0 0 1 0 1 1 Other complications 12 0 0 0 1 0 5 0 4 2 Percent Women estimated to have obstetric complication who are treated at EmOC Facilities Province Complications Total Central Copperbelt Eastern Luapula Lusaka Northern North Western Southern Western Total 2 2 1 0 6 3 7 1 4 7 Eclampsia/Severe Pre-Eclampsia 3 5 3 0 8 2 4 0 8 0 Antepartum haemorrhage 2 3 1 0 5 0 0 0 11 0 Ruptured uterus 11 0 13 0 25 0 25 0 30 50 Postpartum haemorrhage 5 17 1 0 8 89 19 0 2 0 Ectopic pregnancy 0 - 0 0 0 0 0 0 33 0 Complications of abortion 0 0 1 0 0 0 6 0 1 0 Infections 11 - 0 0 40 5 33 0 4 100 Complicated malaria 2 0 2 3 0 0 2 0 2 3 Other complications 2 0 0 0 2 0 13 - 5 5 Met Need for EmOC by Province Province Complications Births Met Need Total 3,842 39,068 66 Central 185 1,948 63 Copperbelt 1,414 9,870 96 Eastern 435 2,250 129 Luapula 212 3,126 45 Lusaka 343 6,103 37 Northern 231 3,881 40 North Western 314 1,704 123 Southern 516 7,283 47 Western 192 2,903 44 Complications Deaths Complications Percent deaths by complication Total 92 3,842 2 Eclampsia/Severe Pre-Eclampsia 12 415 3 Antepartum haemorrhage 8 325 2 Ruptured uterus 11 97 11 Postpartum haemorrhage 20 380 5 Ectopic pregnancy 2 834 0 Complications of abortion 3 757 0 Infections 17 161 11 Complicated malaria 7 346 2 Other complications 12 527 2 ComplicationsByProvince 4 11 2 12 12 17 0 21 13 Province Deaths Maternal Deaths in last 6 months by province 2.1621621622 0.7779349364 0.4597701149 5.6603773585 3.4985422741 7.3593073593 0 4.0697674419 6.7708333333 Province case fatality rate Case fatality rates by province 185 1414 435 212 343 231 314 516 192 Province Number of complications Obstetric complications in last 6 months _1188808285.unknown _1188808608.unknown _1187985236.unknown _1153721632.unknown _1154700298.unknown _1104411491.unknown _1153721617.unknown _1105170337.unknown _1103635524.unknown

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