The impact of a multi-level maternal health programme on facility delivery and capacity for emergency obstetric care in Zambia

Figures & data

Table 1. Intervention components and core activities of SMGL as implemented in Kalomo District, Zambia.

1. Educate and Mobilize Communities to Drive Demand for Facility Delivery

A. Support and train a cadre of community volunteers as part of Safe Motherhood Action Groups (SMAG) to identify pregnant women in the community and provide messages regarding safe delivery

B. Community sensitisation: deliver key messages about maternity care via radio and through social networks of trained local leaders within the community

2. Improve Transport and Referral Systems

A. Improve emergency response referrals via a functional radio system, using an emergency vehicle and community transport systems

B. Refurbish mothers’ shelters as an option for improving access to facilities for women in remote areas

3. Improve Availability and Quality of Care

A. Human Resources: hire new clinical staff, train staff in emergency obstetric care and provide ongoing clinical mentorship at facilities

B. Provide necessary equipment and supplies so that staff can provide higher quality care

Table 2. Indicators used to identify basic and comprehensive emergency obstetric and newborn care services.

Proposed obstetric and newborn care functions	Assessed in this study
Routine obstetric care
Monitoring/management of labour – partograph	X
Infection prevention measures for hands	X
Active management of third stage of labour	X
Basic Emergency Obstetric Care (BEmOC)
Parenteral magnesium sulphate for pre-eclampsia	X
Assisted vaginal delivery	X
Parenteral antibiotics for maternal infection	X
Parenteral oxytocic drugs for haemorrhage	X
Manual removal of placenta – retained placenta	X
Removal of retained products of conception	X
Comprehensive Emergency Obstetric Care (CEmOC)
Surgery (C-section)	X
Blood transfusion	X
Routine newborn care
Thermal protection^g	X
Immediate and exclusive breastfeeding	X
Infection prevention – hygienic cord care
Basic Emergency Newborn Care (BEmNC)
Resuscitation of non-breathing baby with bag & mask	X
Antibiotics to mother if preterm/prolonged PROM
Corticosteroids in preterm labour
KMC for premature/very small babies	X
Alternative feeding if baby unable to breastfeed
Injectable antibiotics for neonatal sepsis
(PMCTC if HIV-positive mother)
Comprehensive Emergency Newborn Care (CEmNC)
Intravenous fluids^h	X
Safe administration of oxygen^i	X

Notes: List adapted from proposed obstetric and newborn functions (Gabrysch et al., 2012). Existing EmOC signal functions are in italic bold (from the WHO/UN Handbook).

^aAt least one nurse, midwife, general doctor, or OBGYN at facility.

^bFunctioning communication equipment (landline, mobile, or radio). This does not include private cell phones unless the facility reimburses for cost of phone calls.

^cFacility has a functioning motorised vehicle with fuel that is routinely available and can be used for emergency transportation or access to a vehicle in near proximity that can be used for that purpose.

^dFacility routinely has electricity for lights and communication (at a minimum) from any power source during normal working hours; there has not been a break in power for more than two hours per day during the past seven days.

^eThe toilet/latrine is classified using criteria: Flush/pour flush to piped sewer system or septic tank or pit latrine; pit latrine (ventilated improved pit or other) with slab; composting toilet.

^fImproved water source include the following: Piped, public tap, standpipe, tubewell/borehole, protected dug well, protected spring, and rain water.

^gThermal protection: drying baby immediately after birth, skin-to-skin contact with mother, wrapping, no bath in first six hours (AMDD, n.d.).

^hNewborn intravenous fluid kit available in labour ward.

ⁱNewborn oxygen available in labour ward.

Figure 1. FBB in Kalomo versus Comparison April 2011–June 2013.

Table 3. Difference-in-differences analysis of FBB before and during SMGL between SMGL and non-SMGL areas.

Time period	Facility-based birth		Absolute difference (95% CI)
	Pre- SMGL	During SMGL
Kalomo N (%)	54.8 (1567/2859)	64.6** (2336/3618)	+9.8 (7.4, 12.2)
Comparison N (%)	64.6 (4881/7559)	64.7 (4949/7644)	+0.2 (−1.4, 1.7)
		Net difference	+9.6

**p < .01.

Table 4. FBB before and during the SMGL program implementation time period in Kalomo district and comparison districts.

	Adjusted OR (95% CI)^a
	Model 1^b	Model 2^c	Model 3^d
Intervention period × intervention area
Before, intervention versus comparison	1	1	1
During, intervention versus comparison	1.54 (1.25, 1.83)	1.53 (1.26, 1.82)	1.49 (1.21, 1.77)
Respondent's distance to facility
<2 h		1	1
≥2 h		0.51 (0.44, 0.60)	0.51 (0.44, 0.61)
Antenatal care
<4 visits			1
≥4 visits			1.54 (1.35, 1.75)

^aConsecutive adjustment of covariates in the model and changes of odds ratios of FBB before and during, intervention district versus comparison district.

^bAdjusted for household size, mother's age, mother's education (any), parity, marital status, and asset quartile.

^cAdjusted for covariates in model 1 + respondent's distance to facility.

^dAdjusted for covariates in model 2 + number of antenatal care visits.

Table 5. Proportion of non-hospital health facilities with select obstetric and newborn care indicators in Kalomo and comparison districts, before and during SMGL implementation.^a

	Kalomo		Comparison
	Before (n = 22) N(%)	During (n = 22) N(%)	Before (n = 52) N(%)	During (n = 53) N(%)
Routine obstetric care
Monitoring and management of labour with partograph	18 (81.8)	21 (95.5)	48 (92.3)	48 (90.6)
Infection prevention measures for hands	18 (81.8)	22 (100.0)	50 (96.1)	52 (98.1)
Active management of third stage of labour (AMSTL)	14 (63.7)	19 (90.5)	51 (98.1)	50 (94.3)
Basic emergency obstetric care (BEmOC)
Parenteral magnesium sulphate for pre-eclampsia	5 (22.7)	6 (27.3)	10 (19.2)	12 (22.6)
Assisted vaginal delivery	1 (4.6)	4 (19.1)	0 (0)	0 (0)
Parenteral antibiotics for maternal infection	20 (95.2)	19 (86.4)	42 (80.8)	29 (54.7)**
Parenteral oxytocic drugs for haemorrhage	20 (95.0)	21 (100.0)	49 (98.0)	50 (96.2)
Manual removal of placenta for retained placenta	6 (27.3)	7 (31.8)	10 (19.6)	12 (22.6)
Removal of retained products of conception	0 (0)	9 (40.9)**	4 (7.7)	2 (3.8)
Routine newborn care
Thermal protection^b	2 (9.1)	15 (68.2)**	24 (46.2)	27 (50.9)
Immediate and exclusive breastfeeding	20 (90.9)	20 (95.2)	48 (92.3)	51 (98.1)
Basic emergency newborn care (BEmNC)
Resuscitation with bag and mask	7 (31.8)	19 (86.4)**	15 (28.9)	17 (32.1)
KMC for premature/very small babies	3 (13.6)	20 (90.9)**	32 (61.5)	46 (86.8)**
Comprehensive emergency newborn care (CEmNC)
Intravenous fluids^c	1 (4.6)	10 (45.5)**	11 (21.1)	12 (22.6)
Safe administration of oxygen^d	1 (4.6)	1 (4.6)	4 (7.7)	3 (5.7)
Mean signal functions for BEmOC^e	2.68 (1.09)	3.86 (1.39)**	2.51 (1.00)	2.30 (1.39)

^aList adapted from proposed obstetric and newborn functions (Gabrysch et al., 2012).

^bDrying baby immediately after birth, skin-to-skin contact with mother, wrapping, no bath in first six hours (AMDD, n.d.).

^cNewborn intravenous fluid kit available in labour ward.

^dNewborn oxygen available in labour ward.

^eSeven BEmOC functions are listed in bold italic.

*p < .05.

**p < .01.

Gabrysch, S., Civitelli, G., Edmond, K. M., Mathai, M., Ali, M., Bhutta, Z. A., & Campbell, O. M. R. (2012). New signal functions to measure the ability of health facilities to provide routine and emergency newborn care. PLoS Medicine, 9(11), e1001340. doi: 10.1371/journal.pmed.1001340

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AMDD. (n.d.). Needs assessment of emergency obstetric and newborn care. Retrieved January 29, 2015, from http://www.amddprogram.org/content/emoc-needs-assessments

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