Improving the quality of obstetric care at the teaching hospital, Zaria, Nigeria.

PRELIMINARY STUDIES: Research at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria, showed delay in treating women with obstetric complications and highlighted multiple contributing factors. INTERVENTIONS: In response, a surgical theater was restored to working order, the maternity ward renovated, resident physicians trained in obstetrics and an emergency drug pack system instituted. A system of blood donation from families of women attending antenatal clinics was introduced. Later, community interventions focused on improving access and reducing delay in seeking care. RESULTS: Mean admission-to-treatment interval was reduced by 57%, from 3.7 h in 1990 to 1.6 h in 1995. The proportion of women treated in less than 30 min increased from 39% in mid-1993 to 87% in late 1995. Case fatality rate (CFR) among women with major obstetric complications fell from 14% in 1990 to 11% in 1995. The annual number of women with complications seen, however, declined from 326 in 1990 to 65 in 1995. COSTS: Cost of material improvements was approximately US$135,000, of which 65% was provided by government. An additional $8000 per year in new staff salaries was paid by the government. CONCLUSIONS: Hospital obstetric services can be improved and government can be mobilized to contribute. Treatment delay and obstetric CFR can be reduced. Deteriorating economic conditions, however, may diminish utilization of services despite improvements.

The effect of improving maternity services in a secondary facility, Zaria, Nigeria. The Zaria PMM Team.

PRELIMINARY STUDIES: Facility review at the secondary hospital in Makarfi revealed a lack of drugs and skilled personnel and delays in treating and referring women with obstetric complications. INTERVENTIONS: In 1994, maternity facilities were renovated, a revolving drug fund was introduced, midwives were trained and an ambulance was restored to service. Attempts to secure a physician with skills in treating obstetric emergencies were unsuccessful. Prior to these activities, obstetric services at the referral hospital were improved. Community interventions focused on improving utilization by women with complications. RESULTS: Between 1990 and 1995, substantial increases occurred in antenatal attendance (2517 to 5565 per year) and deliveries (325 to 1952 per year). The number of women with complications seeking care at this facility, however, dropped from 85 in 1990 to 28 in 1995. Referrals to higher level facilities increased from four in 1990 to 17 in 1995. COSTS: The cost of the interventions was approximately US $32,000. Ninety-eight percent was paid by the government and 2% by PMM. CONCLUSIONS: Improving the quality of maternity services can increase utilization by women with uncomplicated pregnancies. However, utilization of emergency services appears to be influenced by other factors, such as the ability to treat obstetric complications and prevailing economic conditions.

Community loan funds and transport services for obstetric emergencies in northern Nigeria.

PRELIMINARY STUDIES: Focus group discussions and a community survey indicated that inadequate funds and transport caused delays in deciding to seek emergency obstetric care and in reaching facilities. INTERVENTIONS: Following improvements in the quality of obstetric services, a community loan program was established in early 1995. Community members determined its features: compulsory contributions; community administration; loans for obstetric complications only; no interest; a 6-month grace period; and 24-month repayment. A transport system was also established, in which private vehicle drivers agreed to respond to calls for emergency transport and charge a set fee. RESULTS: The equivalent of US $20,500 was collected from 81 annual and 2273 one-time contributors. Eighteen loans were approved in 9 months. Repayment data are not yet available. For the transport system, 23 drivers pledged permanent participation and 58 pledged to take part in 6-month rotations. They transported 18 women. COSTS: The cost of these interventions was $3409 for the loan fund and $2272 for the transport system. Sixty percent of the cost was paid by the community and the rest by the PMM project. CONCLUSIONS: Community-managed loan and transport systems for women with obstetric emergencies can be established and may contribute to reducing delay in obtaining emergency obstetric care.