Improving obstetric care at the district hospital, Ekpoma, Nigeria. The Benin PMM Team.

PRELIMINARY STUDIES: Facility reviews and focus group discussions revealed several factors at the district hospital contributing to maternal deaths in Ekpoma District, Nigeria. INTERVENTIONS: In response, the necessary equipment for the operating theater, labor suite and laboratory were repaired or purchased. A blood bank and standby generator were repaired. Drugs and consumable material were purchased and a revolving fund established. Refresher courses were held for medical officers, nursing staff and laboratory technicians. At a later stage, community interventions focused on improving access and reducing delay in seeking care. RESULTS: The number of cesarean sections performed increased from zero in 1990-1991 to between seven and 13/year in the period 1992-1995. The number of women with major obstetric complications seen at the hospital increased from seven in 1990 (5% of obstetric admissions) to a high of 29 (20% of obstetric admissions) in 1993. These gains were not sustained, however. In 1995, only 12 women with complications (9% of obstetric admissions) were seen. COSTS: The cost of improvements was approximately US $12,800, of which 41% was paid by the government and the rest by the project. CONCLUSIONS: Improving obstetric care at the district hospital can increase use by women with complications. However, sociopolitical and economic problems can hamper success.

Emergency loan funds to improve access to obstetric care in Ekpoma, Nigeria. The Benin PMM Team.

PRELIMINARY STUDIES: Focus group discussions in the community identified difficulties in paying for transport as a major barrier to seeking and reaching emergency care for obstetric complications. INTERVENTIONS: After emergency obstetric services in local health facilities had been upgraded, the clans in Ekpoma were mobilized in 1995 to set up emergency loan funds for women with complications. Funds were managed entirely by the clans, with ongoing monitoring and supervision by project staff. Two percent simple interest was charged. RESULTS: Of the 13 clans contacted, 12 successfully launched loan funds. Total donations amounted to US$793, of which four-fifths were contributed by the community. In the 1st year of the operation, 456 women/families requested loans (ranging from US$7 to US$15), and 380 (83%) were granted. Three-hundred and fifty-four (93%) loans were repaid in full. In addition to being used for transport, loans were used to help pay for drugs, blood and hospital fees. COSTS: The cost of establishing the loan fund was US$1360, including initial donations to the loan funds. The PMM project paid 55% of the total. CONCLUSIONS: With relatively little outside financial input, communities can set up and administer loan funds for emergency obstetric transport and care. However, sustaining the funds over the long term requires continuing effort and involvement with the communities.

Sociocultural aspects of haemorrhage in pregnancy.

The knowledge, attitudes and practices of rural women in southern Nigeria are at least as important as the availability of modern obstetric care in the fight against haemorrhage in pregnancy. Community-based interventions taking this into account are necessary if the considerable mortality associated with the condition is to be significantly reduced.

PIP: Recent observations in southern Nigeria revealed that there was a lack of knowledge of the warning signs and risk factors associated with hemorrhage during pregnancy, delivery, and the postnatal period; certain food taboos were disadvantageous to pregnant women; there was a belief that supernatural forces caused some cases of maternal hemorrhage and precluded effective modern treatment; and women suffering from hemorrhage continued to seek care from traditional sources. Therefore, focus groups were convened with women, men, and traditional birth attendants in the Ekpoma group of 13 villages from March 1989 to June 1990 to discuss local ideas about hemorrhage and the situations when a pregnant woman may bleed, use and accessibility of interventions, and strategies for community health education. After analyzing the findings, the following actions were taken by the end of 1992: facilities in the first referral hospital were upgraded; a revolving drug fund was established; an emergency transport loan scheme was established; medical officers, nursing staff, medical records officers, and laboratory technicians were given retraining and refresher courses; and the hospital staff was mobilized and reoriented. In addition, and community education and mobilization efforts were continued until 1995. Additional focus group discussions were held between 1993 and 1995. Comparison of the results of the first and second series of focus groups revealed that age, sex, and education had no effect on knowledge, attitudes, and practices. A marginal decline in traditional beliefs had occurred, but postpartum bleeding continued to be induced. The use of modern obstetric care facilities increased threefold from 1993 to 1995. In addition, midwives began referring patients for hemorrhage more readily. Sustained community educational efforts could build on these modest results.