Title Meeting the Millennium Development Goals 3 and 5: Do our labour wards meet standard level?

Solange Mianda, MSc (MPH), PhD student; School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal %mail& solange'(oe)*+gmail'com ,*-.,*,.-+stu'u/(n'ac'(a Phone n0& **,1 12.)*3-.2 Dr 4nna 5oce, senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal' %mail& voceas+u/(n'co'(a 6el& **,1 27,)*---2 8ord count& 7)7) 4uthor biographic Solange Mianda is a PhD student at the department of public health medicine at the Universit of !"a#ulu$Natal' Dr 4nna 5oce& is a senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal'

I declare there is no actual or potential conflict of interest in relation to this article

Abstract S/illed attendance has increased "orld"ide to address the challenge of maternal and perinatal mortalit ' 9ut the provision of s/illed attendance onl reflects the presence of the health care "or/er and not the environment "ithin "hich the "or/' 6o e:plore this dimension of s/illed attendance this stud "as designed' Methods ;ive labour "ards of five district hospitals in a rural health district of !"a#ulu$Natal "ere audited' 6he enabling environment "as assessed in terms of the availabilit of referral s stem, drug and supplies, e<uipment, supervision and "or/load' esults =esult sho" "ide ranges in scores bet"een hospitals in the referral subset (.*>$7**>), in the scores for drug and supplies (-*>$7**>), supervision and "or/load (*>$7**>)' Ho"ever, the range is narro"er for the e<uipment subset (),>$7**>), ho"ever three hospitals met the enabling environment mid"ives "or/load as recommended b the ro al ?ollege of @bstetricians and A naecologists' No hospital reported all the components of the enabling environment' Interpretation 6here is a need for <ualit improvement initiatives to address the availabilit of drugs, e<uipment maintenance and ineffective supervision in the health district' MaBor policies revie" are needed to ensure e<uitable distribution of health professionals bet"een urban versus rural areas'

!e" words: s#illed attendance$ enabling environment

Introduction %ver ear "omen and babies die as a result of child bearing, "ith most of these deaths

occurring in sub$Saharan 4frica (M=? ,*7,)' 6he millennium development goals (MDAs) called for a t"o$third reduction in under$five mortalit and three$<uarter in maternal mortalit b ,*7. "orld"ide; an increased s/illed attendance at birth is the main strateg to achieve these goals (N ango et al ,*7*)' S/illed attendance comprises both the s/illed attendant and the environment "ithin "hich the care is provided' 6he health care "or/ers providing care must possess ade<uate s/ills defined as core s/ills to provide effective care during labour and the environment of care is defined in terms of sufficient health care "or/ers, re<uired e<uipment, essential drugs, supervision, transport, manual of protocol for obstetric management and <ualit referral (4detoro et al ,*77) 6o provide <ualit care to "omen and babies the =o al ?ollege of @bstetricians and A naecologist (=?@A) recommend 7'7. mid"ives per "oman in labour (=?@A 7333, currentl , South 4frica is facing maBor challenges in terms of human resources shortage, s/ills imbalances, poor distribution across sectors and undesirable "or/ing conditions (=a"at, ,*7,& ,)' Not onl is there need for mid"ives conducting deliveries in re<uired <uantit , there is also need for other component of the enabling environment e'g' a labour "ard "ith all the re<uired e<uipment and supplies' Cn the effort to improve maternal and perinatal care in South 4frica the Perinatal Problem Cdentification (PPC) and the National ?onfidential %n<uiries into Maternal Deaths (N??%MD) "ere introduced to reflect on the causes of maternal and perinatal deaths and suggest appropriate measures to avoid maternal and perinatal deaths (M=? ,*7,)' 6hese reports have recommended in$service training to upgrade health care "or/ers competence and the need to e<uip maternit services "ith re<uired e<uipment and supplies (NaPeM?o, ,*77, N??%MD, ,*7,) 6he proportion of deliveries "ith s/illed attendance onl reflects on the presence of a health care provider but do not reflect the environment in "hich the "or/ (4dego/e et al ,*77)' 6his stud "as designed to investigate the provision of s/illed attendance in terms of the enabling environment in district hospitals "here the maBorit of deliveries occur, in one

health district of rural !"a#ulu$Natal; "ith the follo"ing obBectives& to assess the enabling environment in "hich care is provided' 6o achieve the above obBectives& labour "ards in . district hospitals "ere audited' Methods 6he stud "as conducted in one health district of rural !"a #ulu$Natal in ,**D' 4ll district hospitals ()) in the health district "ere selected for the stud e:cept for one hospital that did not consent to participate in the stud ' 4n e:plorator observational cross$sectional descriptive stud "as implemented; "hich audited labour "ards in district hospitals' 6o assess "hether the enabling environment "as enabling, labour "ards "ere audited using the 5oceE Philpott facilit revie" F esG$FNoG chec/list "hich measured the presence or absence of "ritten protocols for the management of obstetric complications, the availabilit of /e drugs, e<uipment and supplies, "hich are referred to as Fessential elementsG of obstetric care @ne point "as a"arded to H esI responses' 4 score "as obtained for each hospital b summing up the number of items that scored H esI divided b the number of items on the chec/list multiplied b one hundred to obtain a percentage score for the enabling environment; 1.> "as used as acceptable overall score for the enabling environment; mid"ives "or/load "as also assessed' Percentages and ranges "ere calculated for the enabling environment' Permission to underta/e the stud "as obtained from the Universit of !"a#ulu$Natal biomedical ethic committee, the provincial Department of Health, and hospital managers' Ct "as clearl stated to them that participation "as voluntar and "ithdra"al could happen at an stage of the stud "ithout an negative conse<uences' esults 6he overall enabling percentage score "as 1->, less than he set standard' ;igure 7 sho"s the overall enabling score per district hospital in ,**D'

100 80 60 40 20 0 H1 H2 H3 H4 H5 Overall en ab lin g en viron m en t %score

Figure 1 Overall enabling environment score per district hospital 1

6hree hospitals met the enabling environment standards "ith ranges bet"een 1D>$D->'

120 100 80 60 40 20 0 H 1 H 2 H 3 H 4 H 5 e!erra l " rug sa nd s upplies # $uipment % upervis ion &or' loa d

Figure 2 %ub(sets enabling environment % scores per district hospitals in 2008

;igure , sho"s "ide ranges in scores bet"een hospitals in the referral subset (.*>$7**>), in the scores for drug and supplies (-*>$7**>), supervision and "or/load (*>$7**>); ho"ever the range is narro"er for the e<uipment subset (),>$7**>)'

H is used to identify district hospitals

)id*ives *or'load

4 3+5 3 2+5 2 1+5 1 0+5 0 H1 H2 H3 H4 H5

)id *ives *orload

Figure 3 )id*ives *or'load b, district hospitals in -une 2008

6hree hospitals met the =?@A recommended 7'7."orload ratio per "oman in labour,' Discussion 6hree hospitals met the enabling environment standard, ho"ever "ith lo" score' 4ll hospitals but one scored poorl on referral, and the availabilit of supervision on both shifts' @ne hospital scored poorl on drugs and supplies, thus the need for <ualit improvement initiatives to address the availabilit of drugs, e<uipment maintenance and ineffective supervision' @verall no hospitals reported the presence of all the elements of the enabling environment' Studies b Abangdade et al (,**2) and Mc?a"$9inns et al (,**-) loo/ed at the enabling environment; ho"ever no details on their results "ere reported' 6hree hospitals had acceptable "or/loads but "ith ine<uitable distribution across sectors' 6his calls for a revie" of policies pertaining to the deplo ment of healthcare "or/ers in the countr to ensure an e<uitable distribution of health professionals bet"een urban versus rural areas' %onclusion 6he enabling environment refers to conditions in "hich s/illed attendants "or/ to provide "omen "ith care during childbirth' =esults from districts Hospitals this Health District suggest that the
2

To calculate midwives workload an average of deliveries per midwives per day was obtained by dividing the number of deliveries in June 2008 by the number of midwives in each district Hospital in the health District on both shifts day!night" divided by the number of days #0 days" in the month$ To obtain the acceptable workload the number of midwives was divided by the average number of deliveries per 2%&hour day$

environment is not full enabling and there are still gaps in the coverage of health professionals in rural areas' eference Medical =esearch ?ouncil (M=?) %ver death counts saving the lives of mothers, babies and children in South 4frica (,*7,)' ?ape 6o"n' N ango DD, Mutihir J6, Kaabes %P, !igbu JH, 9uba M'S/illed attendance& the /e challenges to progress in achieving MDA$. in north central Nigeria' 4fr J =eprod Health' (,*7*); 7-(,)&7,3$2D' 4dego/e 44 et al, Hofman =N, !ongn u %J' Monitoring and evaluation of s/illed birth attendance& 4 proposed ne" frame"or/' Mid"ifer (,*77) (,1) 2.*L2.3 National Perinatal Morbidit and Mortalit ?ommittee (NaPeMM?o)' National perinatal mortalit and morbidit committee triennial report (,**D$,*7*)' ,*77' Abangbade S, Harve S4, %dson 8N, 9ur/halter 9, 4ntona/os ?' Safe mother "ood studies results from 9enin' ?ompetenc of s/illed attendants, the enabling environment for s/illed attendance at deliver , in hospital dela s in obstetric care (documenting the 2rd dela ) <ualit assurance' Pattinson =? 9e Prepared& 6raining and on$going %ducational Cnitiatives' Cn 4 Monograph of the Management of Postpartum Haemorrhage' ,*7* 8H@EC?ME;CA@, ,**-, Ma/ing pregnanc safer& the critical role of s/illed attendants' 4 Boint statement b 8H@EC?ME;CA@, Aeneva ,**-'