Reaching health facilities in situations of emergency: qualitative study capturing experiences of pregnant women in Africa’s largest megacity

Abstract Background The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities. Methods This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes. Results Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women. Conclusion If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.

Download Full-text

Reaching health facilities in situations of emergency: Experiences of pregnant women in Africa’s largest megacity

10.1101/2020.03.18.20036830 ◽

2020 ◽

Author(s):

Aduragbemi Banke-Thomas ◽

Mobolanle Balogun ◽

Ololade Wright ◽

Babatunde Ajayi ◽

Ibukun-Oluwa Abejirinde ◽

...

Keyword(s):

Pregnant Women ◽

Public Transportation ◽

Traffic Congestion ◽

Health Workers ◽

Economic Status ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Health Facilities ◽

Health Systems Strengthening ◽

Night Time

AbstractTravel of pregnant women requiring emergency obstetric care (EmOC) to health facilities remains a ‘black box’ of many unknowns to the health system, more so in megacities which are fraught with wide inequalities. This in-depth study on travel of pregnant women in Africa’s largest megacity is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choice-options vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time ranged from 5-240 minutes in daytime and 5-40 minutes at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had their personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women. If the goal to leave no one behind remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved, advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.

Download Full-text

Perceptions of health workers on the referral of women with obstetric complications: a qualitative study in rural Sierra Leone

10.21203/rs.2.23166/v1 ◽

2020 ◽

Author(s):

R. Proos ◽

H. Mathéron ◽

J. Vas Nunes ◽

A. Falama ◽

P. Serry-Kamal ◽

...

Keyword(s):

Health Care ◽

Decision Making ◽

Maternal Mortality ◽

Sierra Leone ◽

Health Care Workers ◽

Health Workers ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Obstetric Complications ◽

Care Workers

Abstract BackgroundSierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric complications. This study describes the perspectives of health workers in rural facilities in Sierra Leone concerning the referral of women with obstetric complications.MethodsWe conducted semi-structured group interviews with health care workers in nine peripheral health units in rural Sierra Leone regarding the referral of women with obstetric complications. Themes discussed were based on an interview guide. The data was analysed by systematic text condensation.ResultsPerspectives were grouped according to the following themes identified: 1) communication between health care workers; 2) underlying influences on decision-making; 3) women’s compliance to referral; 4) logistic constraints.ConclusionSeveral factors in rural Sierra Leone are perceived to complicate timely and adequate referral of women in need of emergency obstetric care. Notable among these factors are fear among women for being referred and fear among health care workers for having maternal deaths or severe obstetric complications at their own facilities. Furthermore, the decision-making of health care workers concerning referral is negatively influenced by an atmosphere of hierarchy between health care workers. Such factors must be considered in efforts to reduce maternal mortality.

Download Full-text

Review of obstetric fistulas in a rural hospital in South-South Nigeria

Urogynaecologia ◽

10.4081/uij.2011.e7 ◽

2011 ◽

Vol 25 (1) ◽

pp. 7

Author(s):

Aniefiok J. Umoiyoho ◽

Aniekan M. Abasiattai ◽

Okon E. Akaiso

Keyword(s):

Antenatal Care ◽

Rural Areas ◽

Formal Education ◽

Health Workers ◽

Medical Condition ◽

Obstetric Fistula ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Medical Personnel ◽

Health Facilities

Background. Obstetric fistula is a devastating medical condition associated with adverse social, psychological and reproductive health consequences. This study was carried out to review the pattern of presentation and outcome of patients with obstetric fistulas in a rural health facility in South-South Nigeria. Design and Method. A retrospective review of case notes of 51 patients with obstetric fistula that were managed at the Family Life Center, Mbribit Itam, in Itu, Local Government Area of Akwa Ibom State. Results. During the study period, 51 obstetric fistulas were repaired in the hospital. The ages of the patients ranged from 15 to 50 years with median age of 25.8 years and modal age group of 21-30 years (45.1%). The majority of the patients were of low parity (72.5%), 56.9% had no formal education and 27.5% were traders. Thirty four patients (66.7%) had their fistulas for between 1 and 6 years, 19.6% of the patients had juxta-cervical fistulas, while eight (15.7%) had circumferential loss of the urethra. Thirty-seven (72.5%) of them where unbooked and thus had no antenatal care, while 4 (7.8%) booked and had antenatal care in conventional health facilities. Thirty-four patients (66.7%) remained dry twenty-one days after surgery, thirteen (23.5%) were still wet, while 4 patients (7.8%) had stress incontinence despite repair. Conclusion. Obstetric fistulas are found most commonly among young, poorly educated women of low parity who do not avail themselves of orthodox ANC in our environment. Government, community and religious leaders must make concerted efforts to ensure women obtain formal education and when pregnant, have access to emergency obstetric care even if resident in the rural areas. Government, relevant non-Governmental organisations, community leaders and health workers should through relevant health messages enlighten women in the community about obstetric fistulas and the dangers of delivering in unorthodox health facilities. More medical personnel should be trained as the first attempt at repair is the one that is most likely to succeed.

Download Full-text

Perspectives of health workers on the referral of women with obstetric complications: a qualitative study in rural Sierra Leone

BMJ Open ◽

10.1136/bmjopen-2020-041746 ◽

2020 ◽

Vol 10 (12) ◽

pp. e041746

Author(s):

Ryan Proos ◽

Hanna Mathéron ◽

Jonathan Vas Nunes ◽

Abdul Falama ◽

Patricia Sery Kamal ◽

...

Keyword(s):

Decision Making ◽

Maternal Mortality ◽

Sierra Leone ◽

Rural Areas ◽

Healthcare Workers ◽

Health Workers ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Obstetric Complications ◽

Structured Interviews

ObjectivesSierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric complications. This study describes factors affecting timely and adequate referral of women with obstetric complications in rural areas of Sierra Leone as viewed by health workers in rural health facilities.DesignQualitative research with semi-structured interviews using open-ended questions. Data were analysed by systematic text condensation.SettingInterviews were held in nine peripheral health units in rural Sierra Leone.Participants19 health workers including nurses, midwives and clinical health officers participated in nine interviews.ResultsFrom the interviews, four major themes describing possible factors of delay in referral of women in need of emergency obstetric care emerged: (1) communication between healthcare workers; (2) underlying influences on decision-making; (3) women’s compliance to referral and (4) logistic constraints.Several factors in rural Sierra Leone are perceived to complicate timely and adequate referral of women in need of emergency obstetric care. Notable among these factors are fear among women for being referred and fear among healthcare workers for having maternal deaths or severe obstetric complications occurring at their own facilities. Furthermore, decision-making of healthcare workers whether to refer a woman or not is negatively influenced by a hierarchical culture with high power distance between healthcare workers.ConclusionFactors identified that complicate timely and adequate referral of women in need of emergency obstetric care must be considered in efforts to reduce maternal mortality. Possible interventions that may reduce delay in referral include increased communication by mobile phones between health workers for advice and feedback regarding referrals, involvement of influential stakeholders to increase women’s compliance to referral, and consistent use of standardised management protocols.

Download Full-text

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district

PLoS ONE ◽

10.1371/journal.pone.0194576 ◽

2018 ◽

Vol 13 (3) ◽

pp. e0194576 ◽

Cited By ~ 1

Author(s):

Siphiwe Bridget Pearl Thwala ◽

Duane Blaauw ◽

Freddie Ssengooba

Keyword(s):

South African ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Health Facilities

Download Full-text

Prevalence, Indications, and Community Perceptions of Caesarean Section Delivery in Ngora District, Eastern Uganda: Mixed Method Study

Obstetrics and Gynecology International ◽

10.1155/2020/5036260 ◽

2020 ◽

Vol 2020 ◽

pp. 1-11

Author(s):

Isaac Waniala ◽

Sandra Nakiseka ◽

Winnie Nambi ◽

Isaac Naminya ◽

Margret Osuban Ajeni ◽

...

Keyword(s):

Caesarean Section ◽

Qualitative Data ◽

Health Workers ◽

Maternal Mortality Ratio ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Male Involvement ◽

Community Perceptions ◽

Caesarean Section Delivery ◽

Eastern Uganda

Background. Uganda has a high maternal mortality ratio (MMR) of 336/100,000 live births. Caesarean section is fundamental in achieving equity and equality in emergency obstetric care services. Despite it being a lifesaving intervention, it is associated with risks. There has been a surge in caesarean section rates in some areas, yet others remain underserved. Studies have shown that rates exceeding 15% do not improve maternal and neonatal morbidity and mortality. Our study aimed at determining the prevalence, indications, and community perceptions of caesarean section delivery in Eastern Uganda. Methods and Materials. It was both health facility and commuity based cross-sectional descriptive study in Ngora district, Eastern Uganda. Mixed methods of data collection were employed in which quantitative data were collected by retrospectively reviewing all charts of all the mothers that had delivered at the two comprehensive emergency obstetric care service facilities between April 2018 and March 2019. Qualitative data were collected by focus group discussions till point of saturation. Data were entered into EpiData (version 3.1) and analyzed using SPSS software (version 24). Qualitative data analysis was done by transcribing and translating into English verbatim and then analyzed into themes and subthemes with the help of NVIVO 12. Results. Of the total 2573 deliveries, 14% (357/2573) were by CS. The major single indications were obstructed labour 17.9%, fetal distress 15.3%, big baby 11.6%, and cephalopelvic disproportion (CPD) 11%. Although appreciated as lifesaving for young mothers, those with diseases and recurrent intrauterine fetal demise, others considered CS a curse, marriage-breaker, misfortune, money-maker and a sign of incompetent health workers, and being for the lazy women and the rich civil servants. The rise was also attributed to intramuscular injections and contraceptive use. Overall, vaginal delivery was the preferred route. Conclusion. Several misconceptions that could hinder access to CS were found which calls for more counseling and male involvement. Although facility based, the rate is higher than the desired 5–15%. It is higher than the projected increase of 36% by 2021. It highlights the need for male involvement during counseling and consent for CS and concerted efforts to demystify community misconceptions about women that undergo CS. These misconceptions may be a hindrance to access to CS.

Download Full-text

Public provision of emergency obstetric care: a case study in two districts of Pakistan

BMJ Open ◽

10.1136/bmjopen-2018-027187 ◽

2019 ◽

Vol 9 (5) ◽

pp. e027187

Author(s):

Peter Brückmann ◽

Ashfa Hashmi ◽

Marina Kuch ◽

Jana Kuhnt ◽

Ida Monfared ◽

...

Keyword(s):

Public Health ◽

Health Sector ◽

Emergency Obstetric Care ◽

Obstetric Care ◽

Health Facilities ◽

Public Provision ◽

Signal Functions ◽

The Public ◽

Public Health Sector ◽

Service Provisions

ObjectivesPakistan is one out of five countries where together half of the global neonatal deaths occur. As the provision of services and facilities is one of the key elements vital to reducing this rate as well as the maternal mortality rate, this study investigates the status of the delivery of essential obstetric care provided by the public health sector in two districts in Khyber Pakhtunkhwa in 2015 aiming to highlight areas where critical improvements are needed.SettingWe analysed data from a survey of 22 primary and secondary healthcare facilities as well as 85 community midwives (CMWs) in Haripur and Nowshera districts.ParticipantsUsing a structured questionnaire we evaluated the performance of emergency obstetric care (EmOC) signal functions and patient statistics in public health facilities. Also, 102 CMWs were interviewed about working hours, basic and specialised delivery service provision, referral system and patient statistics.Primary outcome measuresWe investigate the public provision of emergency obstetric care using seven key medical services identified by the United Nations (UN).ResultsDeliveries by public health cadres account for about 30% of the total number of births in these districts. According to the UN benchmark, only a small fraction of basic EmOC (2/18) and half of the comprehensive EmOC (2/4) facilities of the recommended minimum number were available to the population in both districts. Only a minority of health facilities and CMWs carry out several signal functions. Only 8% of the total births in one of the study districts are performed in public EmOC health facilities.ConclusionsBoth districts show a significant shortage of available public EmOC service provisions. Development priorities need to be realigned to improve the availability, accessibility and quality of EmOC service provisions by the public health sector alongside with existing activities to increase institutional births.

Download Full-text