Dataset Information

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

ABSTRACT:

Objectives

Pakistan 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.

Setting

We analysed data from a survey of 22 primary and secondary healthcare facilities as well as 85 community midwives (CMWs) in Haripur and Nowshera districts.

Participants

Using 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 measures

We investigate the public provision of emergency obstetric care using seven key medical services identified by the United Nations (UN).

Results

Deliveries 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.

Conclusions

Both 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.

SUBMITTER: Bruckmann P

PROVIDER: S-EPMC6538091 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Although safe motherhood strategies recommend that women seek timely care from health facilities for obstetric complications, few studies have described facility availability of emergency obstetric care (EmOC). We sought to describe and compare availability and readiness to provide EmOC among public and private health facilities commonly visited for pregnancy-related complications in two districts of northwest Bangladesh. We also described aspects of financial and geographic access to healthcare and key constraints to EmOC provision.Using data from a large population-based community trial, we identified and surveyed the 14 health facilities (7 public, 7 private) most frequently visited for obstetric complications and near misses as reported by women. Availability of EmOC was based on provision of medical services, assessed through clinician interviews and record review. Levels of EmOC availability were defined as basic or comprehensive. Readiness for EmOC provision was based on scores in four categories: staffing, equipment, laboratory capacity, and medicines. Readiness scores were calculated using unweighted averages. Costs of C-section procedures and geographic locations of facilities were described. Textual analysis was used to identify key constraints.The seven surveyed private facilities offered comprehensive EmOC compared to four of the seven public facilities. With 100% representing full readiness, mean EmOC readiness was 81% (range: 63%-91%) among surveyed private facilities compared to 67% (range: 48%-91%) in public facilities (p = 0.040). Surveyed public clinics had low scores on staffing and laboratory capacity (69%; 50%). The mean cost of the C-section procedure in private clinics was $77 (standard deviation: $16) and free in public facilities. The public sub-district facilities were the only facilities located in rural areas, with none providing comprehensive EmOC. Shortages in specialized staff were listed as the main barrier to EmOC provision in public facilities.Although EmOC availability and readiness was higher among the surveyed seven most commonly visited private clinics, public facilities appeared to be more affordable for C-section and more geographically accessible. Strategies to retain anesthesiologists and surgeons, such as non-financial incentives, are needed to improve EmOC provision in the public sector. Centralized blood banks are recommended to streamline safe blood acquisition for obstetric surgeries.

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Project description:Training healthcare providers in Emergency Obstetric Care (EmOC) has been shown to be effective in improving their capacity to provide this critical care package for mothers and babies. However, little is known about the costs and cost-effectiveness of such training. Understanding costs and cost-effectiveness is essential in guaranteeing value-for-money in healthcare spending. This study systematically reviewed the available literature on cost and cost-effectiveness of EmOC trainings.Peer-reviewed and grey literature was searched for relevant papers published after 1990. Studies were included if they described an economic evaluation of EmOC training and the training cost data were available. Two reviewers independently searched, screened, and selected studies that met the inclusion criteria, with disagreements resolved by a third reviewer. Quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. For comparability, all costs in local currency were converted to International dollar (I$) equivalents using purchasing power parity conversion factors. The cost per training per participant was calculated. Narrative synthesis was used to summarise the available evidence on cost effectiveness.Fourteen studies (five full and nine partial economic evaluations) met the inclusion criteria. All five and two of the nine partial economic evaluations were of high quality. The majority of studies (13/14) were from low- and middle-income countries. Training equipment, per diems and resource person allowance were the most expensive components. Cost of training per person per day ranged from I$33 to I$90 when accommodation was required and from I$5 to I$21 when training was facility-based. Cost-effectiveness of training was assessed in 5 studies with differing measures of effectiveness (knowledge, skills, procedure cost and lives saved) making comparison difficult.Economic evaluations of EmOC training are limited. There is a need to scale-up and standardise processes that capture both cost and effectiveness of training and to agree on suitable economic evaluation models that allow for comparability across settings.PROSPERO_CRD42016041911 .