0020-7292/$ -All rights resedoi:10.1016/j.

* CorrespondE-mail add

KEYWORDEmergencycare;Maternal mMozambiquHealth facil

www.elsevier.com/locate/ijgo

AVERTING MATERNAL DEATH AND DISABILITY

Improving emergency obstetric care inMozambique: The story of Sofala

C. Santos a, D. Diante Jr.b, A. Baptista b, E. Matediane c,C. Bique d, P. Bailey e,*

a International Center for AIDS Care and Treatment Program, Maputo, Mozambiqueb Provincial Health Directorate, Beira, Sofala, Mozambiquec Central Hospital in Beira, Sofala, Mozambiqued Ministry of Health, Family Health Division, Maputo, Mozambiquee Family Health International, Research Triangle Park, NC, USA

Received 29 August 2005; accepted 20 May 2006

see front matter D 200rved.ijgo.2006.05.024

ing author. Fax: +1 919ress: pbailey@fhi.org (P.

Sobstetric

ortality;e;ities

Abstract

Objective: The 5-year project in the province of Sofala was designed to improveaccess, quality and utilization of emergency obstetric care (EmOC) by strengtheningrural hospitals and health centers and ultimately the health system’s capacity torespond to emergencies more quickly and effectively. Methods: Implementationconsisted of attention to infrastructure, human resource development, transporta-tion and communication systems, and management. Specific management aspectsthat were targeted for improvement included: supportive supervision, logistics forsupplies, equipment and drugs, record keeping, monitoring and evaluation, andquality improvement techniques such as maternal death audits. Results: Access toEmOC improved with an increase in the number of fully functional EmOC facilitiesfrom 4 to 18. The number of women with obstetric complications who were admittedfor treatment in participating facilities tripled, and the proportion of those women

International Journal of Gynecology and Obstetrics (2006) 94, 190—201

6 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.

544 7261.Bailey).

Improving emergency obstetric care in Mozambique: the story of Sofala 191

dying declined by half. Conclusions: Close collaboration and partnership with theprovincial health directorate make the sustainability of many results likely while thereplication of much of the Sofala model to other provinces is promising for thenational strategy to reduce maternal mortality.D 2006 International Federation of Gynecology and Obstetrics. Published byElsevier Ireland Ltd. All rights reserved.

1. Introduction and background

Since the end of civil war in 1992, Mozambique hasseen improvements in health indicators, increases inliteracy rates, and high economic growth rates.Nevertheless, in 2003 it ranked 170 on the HumanDevelopment Index and had a GDP per capita of US$210 [1,2]. The health infrastructure has improvedbut remains deficient for the current and futuredemand of the population of almost 19 millionresidents, 75% of whom live in rural areas. Malariais endemic in much of the country and HIV/AIDS hasbecome an increasing burden. Although the preva-lence of 13.8% is not as high as that of someneighboring countries, its impact exacerbates theintertwined problems of scarce human resourcesand a weak health system [2]. Approximately two-thirds of the health budget is provided by externaldonors.

In 2000 the Ministry of Health approved anational maternal mortality reduction strategyshortly after a Safe Motherhood Needs Assess-ment and the publication of an in-depth study ofhospital maternal deaths. This study found thatpuerperal sepsis, hemorrhage and uterine rup-ture were the three leading causes of death [3].The needs assessment revealed significant short-comings in hospitals: service availability lessthan 24 h a day, shortages in trained humanresources, equipment, blood supplies, and drugs[4]. The national reduction strategy prioritizeddecreasing the number of institutional deaths inthe belief that in the short term this approach waspotentially more effective than other approaches.Increasing the availability and utilization of emer-gency obstetric care (EmOC) were key componentsto the strategy [5]. Details of the strategy andthese studies can be found elsewhere [6].

The most recent estimate of maternal mortalityfor Mozambique is 408/100,000 live births for thetime period 1994—2003 [7]. It was calculated fromthe 2003 Demographic and Health Survey using thedirect sisterhood method. The 2000 WHO estimate,on the other hand, is 1000/100,000, based on quite adifferentmethodology that involved computer mod-eling that takes into account HIV related mortality,demographic, economic, social and health system

factors [8]. In addition to this range of maternalmortality ratios, process indicators reinforce apicture of the vulnerability of pregnant Mozambicanwomen. Only about half (48%) of births are attendedby skilled personnel (virtually all births delivered byskilled attendants take place institutionally), rang-ing from 34% in rural areas to 81% in urban areas.Prenatal care coverage is higher at 85% [7].

The 1997 FIGO Conference, influenced by theUNICEF Guidelines first published in 1992 [9], wasthe inspiration for the Ministry of Health toaddress its problem of maternal mortality byimproving access and utilization of EmOC. Since1999 several significant initiatives to reducematernal mortality have been implemented, in-cluding the FIGO Save the Mothers Project [6].These early efforts targeted two hospitals in thecapital Maputo (Jose Macamo and Mavalane Hos-pitals) and several feeder health centers, as wellas a rural hospital in the district of Manhica (inMaputo Province) and five smaller health units.The intervention at Jose Macamo (supported byUNFPA with NORAD funds) stands out as highlysuccessful. Once the interventions (renovations tothe operating theatre, arranging 24 h staff cover-age, assuring the availability of equipment, drugs,and supplies, and improving the referral system)were concluded, within 6 months Jose Macamohad doubled the number of births attended. Bymaking fewer referrals and providing cesareandeliveries, the burden at the Central Hospital inMaputo was reduced substantially. Obstacles atboth Mavalene and Manhica Hospitals did not allowthe same level of success but more modestincreases in utilization did occur [6].

The UNFPA/AMDD initiative in the province ofSofala was the first to target the services and healthsystem of an entire province. Sofala is one of 10provinces and has a population of about 1.5 million.It is strategically important economically for itslocation on the corridor between landlocked Malawiand Zimbabwe and their access to the Indian Oceanat the port city of Beira, the second largest urbancenter in Mozambique. Sofala is poor and about 70%of residents living in and around Beira are unem-ployed [10]. Sofala has been a high priority for theMinistry of Health due to the destruction of the

C. Santos et al.192

health system infrastructure during the civil warand more recently due to the devastation caused byflooding in 2000.

Maternal health care is free, which is anincentive for women to use the system, althoughreports of under-the-counter payments may deterutilization [11]. In 1997 only 35% of births in Sofalawere institutional, but by 2003 this percentage hadincreased to 52% [7,12]. Sofala is also one of theprovinces with a higher than average HIV infectionrate (19%) among adults. Among pregnant womenattending antenatal clinics the Ministry reports ahigher rate (35%) [13]. Malaria is responsible for15% of the disease burden and is the primary causeof death.

This paper describes the Averting Maternal Deathand Disability (AMDD) project in Sofala that aimedto increase access and availability of EmOC, and toincrease the utilization and quality of this care. Itreports on project activities that occurred betweenJanuary 2000 and December 2005.

2. Project activities and accomplishments

To provide a baseline for subsequent monitoring ofthe project and to guide the type and scale ofproject interventions, in August and September of2000 an EmOC needs assessment was carried out.This needs assessment was similar to the one thatpreceded the national strategy that was per-formed in 43 facilities in 5 provinces, assessinginfrastructure, equipment, emergency drugs,supplies, and staff training [4]. The Sofala assess-ment included 27 facilities (4 hospitals and 23health centers) in the 13 health districts. Approx-imately 95% of the institutional births took placein these facilities. Ultimately, the project targeted23 facilities: 3 rural hospitals, the Central Hospitalin Beira and 19 health centers with maternities.The selection of project facilities was guided apriori by the desire that each rural hospital andthe Central Hospital in Beira provide comprehen-sive EmOC and that all 13 districts have basicEmOC services. The facility that acted as thedistrict headquarters was always selected as wereother strategically located health centers with arelatively large patient volume.

Implementation was phased: during the firstyear (2001) the project targeted 8 health facilities,another 8 facilities were added in 2002, and theremaining 7 in 2003. The rural hospitals and largeperipheral urban maternities were targeted firstwhile the second and third wave of facilitiesconsisted of facilities increasingly distant fromthe hospitals. Thus, a number of activities were

repeated each year such as the training of humanresources and the procurement of medical equip-ment and supplies.

2.1. Improvements in infrastructure

Capital improvements to buildings can be time-consuming and fraught with problems such asletting bids and evaluating them, frequent delays,and concerns about graft or theft. Mozambiquewas no exception and resistance to investing ininfrastructure was encountered at multiple levels.Ideally renovations should be planned and initiat-ed as soon as possible so that by the time staffhave been trained and equipment and supplieshave been distributed, both staff and patientswill benefit from these visible and functionalimprovements [14]. Renovations were slow tostart but by early 2004 all renovations werecomplete. Perseverance resulted in much neededrehabilitation.

Five health centers (Metuchira, Gorongosa,Sena, Mafambisse and Caia) were targeted formajor renovations and the Central Hospital in Beirareceived more limited attention. The electricalsystems and water and sanitation systems wereassessed and whatever was needed to assure aconstant supply of water and functioning showersand toilets was done. Roofs and ceilings wererepaired; the walls and floors of the labor anddelivery rooms were tiled. Doors and windows wererepaired or replaced as needed and maternity areaswere newly painted. Only Sena required significantmasonry to repair a badly cracked wall. The CentralHospital improvements took place only in labor anddelivery and in the main maternity corridor; theyincluded tiled walls, ceramic flooring, repairedwindows and doors and paint. The large labor anddelivery room also incorporated partial walls toprovide some privacy between beds.

Improvements in the infrastructure also meantassuring that adequate equipment, emergencydrugs and supplies were available; until thenvacuum extractors, manual vacuum aspirationequipment, and magnesium sulfate had not beenroutinely available.

2.2. Human resource development

Despite intense efforts on the part of the trainingdivision of the Ministry of Health, the countrysuffers from a scarcity of trained health personnel.In 2000 there were 435 medical doctors and onlyabout 250 were Mozambican [6,11]. The ratio ofnurses to population is 1 to 5000 [1]. There are

Improving emergency obstetric care in Mozambique: the story of Sofala 193

fewer than 25 national obstetricians/gynecologistsand some of these no longer live in Mozambique orpractice their profession. Approximately every 2years another 2 complete their specialized training.

Three obstetricians/gynecologists are on staff atthe Central Hospital in Beira. The rural hospitalsare staffed by general physicians and technicians(surgical, medical or maternal and child health(MCH)).1 Three categories of nurses are supportedby the Ministry of Health: the medium level MCHnurse, basic MCH nurse and elementary midwife, allof whom have some midwifery training.2 Healthcenters that also function as district headquartersgenerally have a physician on staff, but otherhealth centers depend almost entirely on nursesand technicians.

The Central Hospital in Beira attends approxi-mately 5500 deliveries a year and is one of only 3bcentralQ hospitals in the country that respondsdirectly to the national Ministry of Health. It is theprimary referral center for the province and inaddition to the specialists on staff, it employsseveral surgical technicians. The Central Hospitalserved as the training center and its MedicalDirector (coauthor EM) coordinated the EmOC in-service training. The 4-week training session forbasic EmOC consisted of one week of theory and 3weeks of practical bhands onQ experience. The 3-month comprehensive course had 1 month of theoryand 2 months devoted to honing practical skills. Noone entered the comprehensive course withoutsome experience in surgery.

The initial sessions were designed for 11 indi-viduals to learn the basic EmOC skills. After 4sessions, the coordinator reduced the number of

2 Some controversy surrounds the basic EmOC training of theelementary midwife who has only 18 months of pre-servicetraining after a minimum of 7 years of formal schooling (thebasic SMI nurse has 2 years of training and the medium 3 withincreasing requirements of prior schooling). Policy makers havediscussed dropping completely the pre-service curriculum of thisprofessional. Others defend the category pointing out thatelementary midwives are often more highly skilled and moremotivated than the MCH nurses. One point of contention iswhether an elementary midwife should perform vacuum extrac-tion. According to pre-service training, they are trainedexclusively to attend normal births. In this project someelementary midwives were trained to use vacuum extraction.

1 The first graduating class of the professional category ofsurgical technicians was 1987 and was a governmental responseto the departure of about 85% of the physicians who left eitherafter independence from Portugal (1975) or during the civil war.Surgical technicians were trained to provide surgery for preg-nancy- and trauma-related complications, and emergency in-flammatory conditions in rural hospitals [15,16]. Technicianscontinue to be trained and today 55 of the 61 ever trained arestill practicing, primarily in rural areas as planned.

trainees to 7 to allow for more hands on experi-ence. In 4 years 137 professionals participated in 17basic training sessions (11 physicians, 4 surgicaltechnicians, 15 medical and MCH technicians, 16mid-level nurses, 63 basic nurses and 28 elemen-tary midwives). Five individuals participated incomprehensive EmOC training and 132 in basic.

In addition to the training in the clinicalmanagement of obstetric complications, trainingwas given in infection prevention with an emphasison HIV prevention for health workers and thecleaning and sterilization of new equipment.

Human resource development meant trainingprovincial health directorate staff in the mainte-nance and repair of radios and solar panels, criticalelements to the emergency transport and referralsystem. It also meant strengthening the manage-ment capacity at the provincial level for super-visors, regular reporting, the use of indicators,procurement and distribution of equipment anddrugs, and planning.

2.3. Quality improvement activities

The UNFPA/AMDD project together with otheragencies and donors was instrumental in promotingthe development of clinical and training guide-lines.3 At the central level of the Ministry of Health,guidelines to manage obstetric complications weredeveloped (Manual de Cuidados Obstetricos Essen-ciais) as were trainer and trainee manuals forclinical management (Currıculo para Formacao emCuidados Obstetricos Essenciais). These documentswere distributed throughout Sofala and the otherprovinces of the country.

The project reactivated the provincial levelmeetings of the maternal mortality committee,which were started in 1998. These meetingsevolved into regional meetings to include a wideraudience. The one day meetings included a frankdiscussion of the maternal deaths that had takenplace over the past 8—12 months—why they oc-curred and what could have been done to avertthem. Often the UN process indicator data (seebelow) were discussed as well as the performanceof the 8 signal functions. On one occasion 2003 and2004 data were compared and it was clear that onefacility had largely replaced sharp curettage withmanual vacuum aspiration (MVA). It gave them anopportunity to describe how they had changed theirpractices.

This was also a forum to discuss problems withdiagnosis and treatment, problems with the refer-

3 The other agencies and donors included the Ministry ofHealth, NORAD, and USAID/JSI.

C. Santos et al.194

ral system and many aspects related to care. Themeetings were held in a climate of healthy self-criticism and were coordinated by the MedicalDirector of Central Hospital in Beira or projectstaff. The non-punitive climate in which patienttreatment was discussed led to a more accuratereporting of maternal deaths, which provided amore realistic appraisal of the situation, albeit asobering one, as the reported number of maternaldeaths rose during the course of the project. Earlysite visits revealed the under reporting of deathsdue to political pressure to show a reduction inmaternal deaths.

The bwalk-throughQ tool was introduced andmodeled by AMDD staff as a method of assessingreadiness in the facility [14]. This tool wasdesigned to be used for frequent if not dailyassessments by an external supervisor or internallyby senior staff. In the form of a simple checklist,it focuses on critical equipment that should be inevery room through which an emergency patientmight pass.

A quality improvement workshop introduced keyhospital staff to a set of tools that provide the basisfor carrying out COPE for emergency obstetric care[17], a methodology designed for local staff toassess readiness, response and patient and providerrights, to identify problems and solve them using tothe extent possible existing resources.4 Partici-pants included project coordinators from otherprovinces supported by UNFPA who planned toreturn to Zambezia and Gaza, for example, toreplicate the training in COPE for EmOC.

Supportive supervision was considered a keycomponent to improving the quality of services.Originally, to promote sustainability and ownershipof the project, the Medical Director of the Provin-cial Health Directorate (Direcao Provincial deSaude) and the Chief Nurse were given theresponsibility to coordinate all activities of theproject, which included frequent supervisory visitsto the facilities. After about a year it was clear thatthe visits could not be prioritized and a fulltimeproject coordinator was needed to oversee dailyactivities and to make frequent visits to projectfacilities to assist, encourage and motivate. Theproject never hired more than this one fulltimeposition. At best, the coordinator was accompaniedby the Chief Nurse, and they visited most of thesites monthly.

4 COPE stands for Client-Oriented, Provider Efficient servicesand was created originally by EngenderHealth for familyplanning services. New editions include COPE for reproductiveservices, for the community, for EmOC and other maternityservices. See website www.engenderhealth.org for additionalinformation and materials.

Mozambique was one of 6 AMDD projectcountries to have an external expert visit theproject to provide clinical support. This visitenabled the coming together of a team of interna-tional, national and local experts to model andpractice supervision that was part coaching andmentoring with an emphasis on clinical casemanagement.

2.4. Project monitoring

The project used the UN process indicators forobstetric services as its monitoring tools [18]. A onepage data collection form was designed for monthlysummaries containing the number of deliveries,complications (by type), medical interventionsperformed (the 8 EmOC signal functions5), andthe number of direct and indirect maternal deathsby cause. Participating facilities sent monthlyreports first to the district headquarters and fromthere a district level report was sent to thestatistical department of the Provincial HealthDirectorate in Beira. Prior to the project, the onlymaternal mortality data that the province collect-ed was the number of deaths, which was known tobe inaccurate and underreported [19]. The regis-tration of complications was routinely included inmaternity logbooks, taking advantage of columnsthat were not utilized. Six-month reports wereproduced to calculate the indicators and assessprogress and these reports were shared with AMDD.

At midpoint the project had developed its mon-itoring and evaluation capability to use the results toquestion why outcomes had not evolved asexpected. Although training and equipment hadbeen provided, staff at certain high volume facilitieswas not performing the 6 basic EmOC functions. Welearned that the early training sessions occurredbefore essential equipment had arrived and thus,given the delay between training and using the newskills in situ, trainees were understandably uncom-fortable. This was addressed by providing traineesmore hands-on experience, greater clinical supportand follow-up to ensure they were proficient andconfident to perform medical procedures.

Data collection was an integral part of supervi-sion, when registries were reviewed and keyelements were cross-checked with other registries,or omissions were discussed and training of newstaff members took place.

5 The 6 basic functions include parenteral antibiotics, anti-convulsants, oxytocics, manual removal of placenta, removal ofretained products, and assisted vaginal delivery. Comprehensivefunctions include the six basic functions plus cesarean deliveryand blood transfusion.

Improving emergency obstetric care in Mozambique: the story of Sofala 195

The data collection and monitoring system thatthe Provincial Health Directorate established inSofala acted as a pilot for changes made at thecentral level and expanded to other provinces.The Ministry of Health is reformulating the na-tional indicators and data collection tools (hospitaland health center registries). The number andtype of obstetric complications and cesareandeliveries will be collected, EmOC status (basic,comprehensive, or non-EmOC—not fully function-ing as an EmOC facility but providing some of theservices) will be monitored, and cause-specificcase fatality rates will become available amongother indicators.

2.5. Referral system

A functioning and reliable referral and transportsystem to transfer emergencies to facilities thatprovide surgery is critical to saving lives. Facilitieswere grouped into naturally occurring referralnetworks, each of which had a hospital at itscenter. With the project’s support for the purchaseof two vehicles, each hospital had an ambulance,but the centers could not directly communicatetheir need for transport to the hospital. Public orprivate transportation is scarce and unreliable andtelephones nonexistent. Nineteen Motorola radioswere purchased and 1 installed in each hospital,center and ambulance. For 5 locations where aconstant supply of electricity did not exist, solarpanels were purchased and installed. WHO, ProjectHope, NORAD, the Italian and Finnish aid agenciesalso contributed to the system in Sofala withtraining, buying additional equipment, or buildingrapid response systems in other regions of thecountry.

The first 4 networks (14 facilities in 4 districts)to receive equipment were assessed to determineif referrals increased and who was using thesystem. By the end of 2003 most of the systemwas installed and referrals had increased by 18%since 2002. By 2004, obstetric referrals hadincreased by 53% (from 330 to 504), with adoubling or more of referrals in the 2 mostremote networks. About half (49%) of the casesto benefit from the radio system were obstetricemergencies while the others were generalmedical, pediatric and trauma cases. In neigh-boring Zambezia Province, within 2 months ofinstalling an emergency response system theyobserved a 30% increase in obstetric emergencyreferrals [20]. The radios also serve to providedtelemedicineT—technical advice on how a patientshould be managed—and to a lesser degree foradministrative purposes. To keep administrative

or personal use to a minimum, the radios werelocated next to labor and delivery.

The installation of the radios and solar panelswas not problem-free. Besides technical problemswith the solar panels that function poorly duringthe rainy season, 2 were stolen but laterrecovered. Two facilities that did not receivepanels lost access to the electrical grid, andcould not function until panels could be secured.The radio system in yet another site neverfunctioned for more than 2 consecutive daysdue to a defective panel or poor installation.The time between procurement and installationwas long— about 11 months.

2.6. Policy, advocacy and human rights

The AMDD project in Mozambique was developed ina policy environment that clearly endorsed EmOCas a key strategy to reducing maternal mortality.The project was purposely implemented at theprovincial level to strengthen the decentralizationefforts of the government. At the national level,the project began supporting a national advisor(coauthor CB) in the Ministry in 2003 whose role itwas to coordinate activities of the national strategyto reduce maternal mortality in the 6 provincesthat UNFPA supported. At the central (Ministry)level, a working group composed of Ministrypersonnel and donors was formed to avoid duplica-tion of efforts, discuss strategies, donor agencystrengths and mandates, and delegate responsibil-ities. They worked together to cover the 10provinces.

UNFPA and the project supported meetings andworkshops in Maputo, which had advocacy as anobjective. A national maternal and perinatal mor-tality meeting was held in 2002. The same year aworkshop with central level involvement wasconvened to discuss how gender and human rightswere part of the maternal mortality reductionstrategy. The latter led to a training of trainers’workshop at the Center for Continuing Education inMassinga in the province of Inhambane in 2003. Thetraining of trainers workshop was facilitated byWILSA, an NGO working for women’s rights inMozambique, and directed at provincial programhealth professionals who would later replicate theworkshop that emphasized the methodology ofbHealth Workers for Change,Q a participatory ap-proach modeled by the Women’s Health Project inSouth Africa to promote organizational change toimprove the quality of care. The methodology wasto be tested in 2 health centers in Sofala, butproject funding was exhausted before this couldhappen.

C. Santos et al.196

2.7. Community activities

The project did not directly promote activities inthe community, but some occurred spontaneouslyand others are described in Section 3.4 as theywere supported by NGOs. At the rural hospital inBuzi, in reaction to a maternal death in 2001 thatcould have been avoided had a stock of blood beenavailable, the hospital director led a campaign torecruit blood donation from students in the com-munity, a strategy that had proved successfulelsewhere. By 2004 Buzi’s dependable blood supplyenabled them to occasionally supply the CentralHospital with blood.

3. Resources

3.1. Partner organizational support

AMDD’s partner in Mozambique was UNFPA whosecountry office is located in Maputo. Throughoutmost of the project one or more persons at thiscentral level followed the activities of the project,but central level involvement in the Sofala activ-ities was minimal. When a full-time project coor-dinator was hired at the end of 2002, he (coauthorDD) resided in Sofala.

In 2002 UNFPA hired a technical advisor to workat the Ministry of Health in Maputo (coauthor CB)to coordinate activities related to the nationalstrategy to reduce maternal mortality. In addition

Figure 1 Map of the provinces of Mo

to Sofala, UNFPA also supported maternal mortal-ity reduction activities in the provinces ofMaputo, Gaza, Inhambane, Zambezia, and Nam-pula. Other donors also supported some of theseas well as the remaining provinces (except forTete). See Fig. 1. Since the health sector hasmore recently moved towards a common basket offunding, the identification of donor and geograph-ical location of where funds are directed is lessimportant.

At least once a year UNFPA representatives fromGeneva or New York visited the project in Mozam-bique. In 2002, Maputo was the site for a UNFPA/AMDD meeting attended by project staff fromMorocco, Nicaragua, and Rajasthan, India.

3.2. Government support

Given the clear policymandate to improve EmOC, thegovernment at both the national and provincial levelhas been supportive; theMinistry of Health covers thesalaries of facility personnel and the recurrent costsof drugs, supplies, and facility maintenance.

The Provincial Health Directorate has assumedcomplete responsibility for the maintenance andsupport for the ambulance and the pickup truckthat were provided for 2 facilities. Their mainte-nance department also maintains the solar panelsand radio system. During the renovations, theDirectorate and the government’s Public Workssector oversaw the renovations as required bylaw.

zambique and donor collaboration.

Table 1 Project expenditures by category in Sofala,Mozambique (2000—2004)

Expenditure category Amount spent byproject in US$

Needs assessmentRenovation $137,676Medical equipment and drugs $212,234Drugs $77,320Data systems $4,718Technical training $144,083Radio system $134,794Quality improvements $39,789Project support (salaries and travel) $144,808Travel $46,891Vehicle purchases and maintenance $74,575Other $57,579Total $1,074,466

Improving emergency obstetric care in Mozambique: the story of Sofala 197

3.3. AMDD support

AMDD was supported by the Bill and Melinda GatesFoundation. AMDD staff visited Mozambique twice ayear and facilitated several workshops on topicsimportant to project maturation such as use ofprocess indicators, human rights, and qualityimprovement methodologies. Their role was toprovide technical support either directly or indi-rectly, and to keep project staff informed aboutoverall activities, priorities, and thinking of theAMDD program as a whole. Three internationalmeetings served to bring staff from all projectstogether that forged the identity of a participatorynetwork and to share ideas and experiences.

3.4. Other support

During the course of the project in Sofala, severalnon-project activities took place that affectedmaternity care. Although not planned as such, theycomplemented the more facility-based work of theproject. The rural hospitals of Nhamatanda and Buzibenefited from improvements in infrastructure(namely the hospital water systems) that the ItalianCooperation Agency supported. Dondo health centerwas rebuilt in 2004 after years of neglect, withgovernmental loans from the African DevelopmentBank. A new rural hospital in the southwest region ofSofala was constructed in Muxungue with loans fromWorld Bank and began functioning in 2004.

The International Federation Terre des Hommesworked in several districts of Sofala at the commu-nity level to address community needs for obstetricemergencies. They financed maternal waitinghomes (casas de espera) in Buzi, Dondo and Nhama-tanda and promoted the safety and advantages ofdelivery at health centers. They assisted communi-ties in the implementation of a community referralsystem based on bicycles with wagons and in thecase of Buzi, they facilitated the use of boats tocarry pregnant women across the river to reach theRural Hospital in Buzi.

The NGO Health Alliance International devel-oped information, education and communication(IEC) materials and activities at the communitylevel to increase awareness among traditional birthattendants and the general population of thedanger signs during pregnancy, and to promotewhere to go should an emergency arise.

3.5. Project expenditures

UNFPA received US$1 million for project activities inMozambique from AMDD for the period 2000—2004.

Table 1 shows an estimate of how those funds wereallocated plus about $74,000 added to the projectby the UNFPA country office and NORAD. UNFPAspent an additional sum of about $75,000 for theinitial project needs assessment and 2005 expenses.

4. Results and discussion

4.1. Availability of EmOC services

For a province with a population of 1.5 million,the minimum recommended ratio of comprehen-sive and basic EmOC facilities is 3 comprehensiveand 12 basic facilities. At the time of the baselineneeds assessment 4 facilities were found function-ing at the comprehensive level and none at thebasic level (Table 2). Through the process ofupgrading facilities or baccreditationQ that wasbased on training, supplying facilities with neededequipment and drugs, and performance, by theend of the 2005, 4 project facilities consistentlyprovided comprehensive care and 13 providedbasic EmOC services. A new rural hospital inMuxungue opened its doors in 2004 and its staffwas included in training sessions and meetings,and one of the vehicles purchased by the projectwas redirected to the new hospital. The inputs tothe other 23 facilities are likely to have enabledthe government to establish this hospital. Thus, bythe end of 2005 Sofala had 5 comprehensive and13 basic facilities for a total of 18 facilities, 3more than the minimum of 15 EmOC facilitiesrecommended by the UN guidelines.

4.2. Utilization

The proportion of births attended in facilitiesthat provide EmOC steadily increased as facilities

Table 2 Emergency obstetric care availability, utilization and quality in Sofala, Mozambique

Baseline d99/2000 2002 2003 2004 2005

Population information 1,453,926 1,516,165 1,548,751 1,583,255 1,616,722Number of expected births(CBR=45/1000 population)

65,427 68,227 69,694 71,246 72,752

Number of expected complications 9814 10,234 10,454 10,687 10,913Total project facilities=23Comprehensive EmOC 4 5 4 4 4Basic EmOC 0 1 9 12 13Non-EmOC 18 17 10 7 6

Data from project EmOC facilitiesNumber of births 8262 12,896 21,757 25,578 26,257Number of complications treated4 662 1253 2166 2958 3294Number of cesareans 664 899 870 968 1,277Number of direct maternal deaths 23 42 61 47 56Proportion of births in EmOC facilities (%) 12.6 18.9 31.2 35.2 36.1Met need (%) 6.7 12.2 20.7 27.7 30.2Cesarean deliveries as a proportion ofall births (%)

1.0 1.3 1.2 1.4 1.8

Case fatality rate (%) 3.5 3.4 2.8 1.6 1.7

Data from all project facilitiesNumber of births 24,766 27,490 25,800 28,210 28,671Number of complications treated 1108 1850 2487 3187 3586Number of cesareans 703 899 870 968 1,277Number of direct maternal deaths 32 44 63 49 57Proportion of births in facilities (%) 37.9 40.3 37.0 39.6 39.4Met need (%) 11.3 18.1 23.8 29.8 32.8Cesarean deliveries as a proportion ofall births (%)

1.1 1.3 1.2 1.4 1.8

Case fatality rate (%) 2.9 2.4 2.5 1.5 1.6

C. Santos et al.198

were upgraded and began to provide thoseservices, from 12.6% in 1999/2000 to 36.1% in2005 (panel 2 of Table 2). Overall, however, thepercent of institutional births did not increasedramatically (panel 3). By 2005 the non-EmOCproject facilities only contributed 3 additionalpercentage points.

More importantly, utilization among women withcomplications (met need or the proportion ofwomen expected to have complications who areadmitted for treatment) increased threefold, from11.3% to 32.8% in all facilities.

Table 3 Complication-specific case fatality rates (CFR)

1999/2000—2003* 20

Complication CFR (%) CFHemorrhage## 3.5 1.Prolonged/Obstructed labor## 0.7 0.Postpartum sepsis# 10.2 5.Complications of abortion 1.6 1.Severe pre-eclampsia/Eclampsia 1.3 2.Ectopic pregnancy 1.1 0.Uterine rupture 9.6 11

Analysis conducted using PEPI software bRATES1Q program [21].* No maternal deaths from 2001 were included.

## p V0.01.# p V0.05.

The proportion of births delivered by cesareansalso increased, but continues far below the lowerrange of 5% that the UN recommends.

4.3. Quality of care

The aggregate case fatality rate (CFR) was re-duced by almost half (2.9% to 1.6%), with anoticeable decline occurring between 2003 and2004. Thus, we looked at complication specificfatality rates comparing the two periods of 1999/2000—2003 and 2004—2005 (see Table 3). The

04—2005 Rate decrease 95% CI for Rate decrease

R (%) Per 1007 1.74 0.35%—2.92%2 0.51 0.07%—0.95%4 4.84 0.31%—9.37%4 0.24 �1.3%—1.8%3 �1.0 �2.3%—0.3%6 0.48 �2.1%—3.0%.4 �1.8 �8.0%—4.4%

Improving emergency obstetric care in Mozambique: the story of Sofala 199

specific CFRs show significant declines in thedeaths from hemorrhage, obstructed labor andpostpartum sepsis.

4.4. Discussion of indicators

The 2001 data are not included because informa-tion was collected for 6 months only and from thefirst 8 facilities targeted by the interventions. Thesubsequent 4 years show steady improvements inall the indicators except for the proportion of birthsin all facilities, which remained stable. AMDDproject sites in countries as diverse as Peru andRwanda [22,23] also failed to show increases in thisindicator. Service improvements have not translat-ed into higher rates of institutional delivery as weexpected. By including 2 new high volume facilities(the Muxungue Hospital and an urban maternityHospital), the overall proportion of births reachesonly 41% in 2005. Met need is a more informativeindicator for maternal mortality reduction than theproportion of births delivered in facilities, and metneed did increase. Among other factors, improvedreporting of complications and increases in refer-rals are likely to have contributed to the almosttripling of this indicator.

Several explanations have been proposed for thecesarean delivery rate remaining low: not allclinicians use protocols to determine who needs acesarean, partographs are not routinely completed,and breakdowns in communication take place atnight between the surgeon on call and attendingstaff.

Case fatality rates are difficult to interpret whenwe know that as data quality improved the numberof complications and maternal deaths increased.However, the overall trend is downward and thecomplication specific rates suggest that someimprovements in the management of hemorrhage,obstructed labor and sepsis have taken place, butrates are still unacceptably high. Clinical audits ofall these cases are likely to reveal some misman-agement and the extent to which access barriersare responsible for these women’s deaths.

Overall low met need suggests that women inrural Sofala still experience difficulty accessinghealth facilities and further work is critical togenerate greater demand, improve the quality ofcare, strengthen the health system, and to make itmore accountable to underserved women.

4.5. Policy change

At the provincial level the Sofala project helpedsensitize the leadership to the disadvantages of the

high rate of rotation of staff. When newly trainednurses moved elsewhere they took their new skillswith them to the benefit of their next post, but thetraining failed to benefit the site for which it wasplanned. After witnessing this phenomenon, dis-trict medical directors decided that they wouldbegin to select the candidates as opportunitiesarose and candidates would be obliged to spend atleast 2 years in their current post. Although someimprovements have been observed, the problemhas not disappeared.

Prior to the project many maternal deaths werenot reported by health providers for fear ofreprisal. During the life of the project, discussionsabout deaths became more open and were used asan educational opportunity. Supportive supervisionencouraged reporting. Today reports are less likelyto be hidden. This behavior change in response to achange in the political environment is likely to haveincreased the reporting of deaths during theproject. However, the quality of hospital officialdeath reports still needs improving as cause ofdeath is sometimes missing.

The purchase of drugs was a dilemma for theproject because of a concern for sustainability. Acase in point was magnesium sulfate which was noton the country’s essential drug list at the beginningof the project. Since it is the drug of choice forwomen with eclampsia and severe pre-eclampsia,project sites needed it among its supplies ofemergency drugs, but changing a government’sessential drug list takes a long time [24]. Thoseinvolved with efforts to reduce maternal mortalitylobbied with the Ministry of Health PharmaceuticalCenter to have it included and shipments ofmagnesium sulfate are now arriving directly fromgovernment stocks.

4.6. Replication and leveraging

With some variations, the Ministry of Health hasimplemented much of the Sofala model in the other9 provinces. Today 9 out of 10 provinces havereceived donor support for EmOC and some prov-inces benefit from multiple donors. The largestdonors have been UNFPA (with funding fromNORAD, and DFID in addition to AMDD), WHO,UNICEF, and USAID. The Mozambican governmenthas clearly set forth what its maternal mortalityreduction strategy is and donors have respondedaccordingly. However, coordination of so manyinputs is increasingly important to make the mosteffective and efficient use of support. The coordi-nating committee worked to avoid duplication ofactivities at the provincial level. Thus, donors tookthe lead, for example, in training in infection

C. Santos et al.200

prevention, others in pre-service training (in themidwifery school) and others led with in-servicetraining, equipment and supplies, and strengthen-ing the referral system. Donors came forward atdifferent times and thus, progress across theprovinces may have been uneven.

The Ministry of Health is now engaged in a SectorWide Approach (SWAp) for financing health sectoractivities. Rather than underwriting specific devel-opment projects, under the SWAp, donors contrib-ute to a common fund from which the Ministryfinances health activities. The SWAp mechanismmeans less control by donors to target specific areasof interest, but it may lead to a more productivework environment for the government as a result ofreduced donor fragmentation. The SWAp processbegan in February of 2004 and currently 26% of thehealth budget comes from Common Funds. A Na-tional Coordinating Committee meets twice yearlyand decides on the allocation of funds.

5. Conclusions

Many programs to reduce maternal mortality arepackages of interventions and are of short duration,and do not try to measure program impact withestimates of maternal mortality ratios [25]. Deter-mining causality or attributing a quantifiable con-tribution of each intervention is an on-goingchallenge for maternal mortality reduction pro-grams. Upgrading facilities with better trainedhuman resources and improved infrastructure (phys-ical plant, drugs, equipment and supplies) is aprerequisite to saving many women’s lives, andwas a high priority for the project. Strengthening theresponse system for medical emergencies improvedcommunication and probably increased the numberof referrals. Introducing a monitoring system withindicators improved the completion of maternityregisters and together with the reactivation of thematernal mortality committee to audit maternaldeaths, facility staff had opportunities to discusscase management of complications and their ownindicators. Introducing the concept of supportivesupervision and enabling frequent supervisory visitsis a strategy to promote on-going training, support tomanagement, and continuous quality improvement.As newly accredited EmOC facilities are added to thehealth system, women travel shorter distances andarrive in better condition. An added benefit to amore highly functional system is the decongestion ofCentral Hospitals such as those in Beira and Maputothat are better able to focus on providing higherquality care for women at the far end of themorbidity continuum.

This project reaped the benefits of policydecisions made more than 20 years ago to addressthe scarcity of trained human resources after mostmedical doctors fled the country. Without the localsolution of training mid-level providers the mater-nity services would be less well staffed than theyare today. The mid-level health professional or non-specialist assumes a significant degree of clinicalresponsibility in Sofala (and Mozambique in gener-al), where surgical technicians or general practi-tioners performed more than 3 of every 5 cesareansand SMI nurses performed most of the vacuumextractions and manual vacuum aspirations.

Sustainability is every successful project’s de-sired outcome and although minimal support isstill being provided, there are signs that manyactivities are sustainable. The project strategy ofworking at the provincial level with the provincialhealth directorate bpermitted the progressivedinstitutionalizationT of the changes introducedinto the system of maternal care. . ..Interventionswere not seen as transient but as change in thehealth system’s approach to normal delivery andthe management of obstetric emergenciesQ [6].

In retrospect this project addressed specificdeficiencies at facilities that resulted in a strongerprovincial health system. Because Sofala served asan evolving model for other provinces, evidencefrom the other provinces is now needed to tell ushow well the scaling up process is unfolding.

Acknowledgements

We would like to thank Chief Nurse Isabel Massangofor her facilitative work as a supervisor throughoutthe project, Dra. Lılia Jamisse who initially provid-ed direct support from the Ministry of Health inMaputo, Dr. George Georgi who at the time ofproject initiation was the UNFPA representative inMozambique, Dr. Mark Derveeuw for his role in theneeds assessment and elaboration of the project,and Dr. Vincent Fauveau, also of UNFPA, for hiscontributions to the project and the paper.

References

[1] CHGA (Commission on HIV/AIDS and Governance in Africa).Mozambique: the challenge of HIV/AIDS treatment andcare. Economic Commission for Africa; 2004. 14 pp.

[2] World Bank. Country Brief. http://web.worldbank.org, Lastviewed Jan. 5, 2006.

[3] Ministerio da Saude. Revisao de Mortes Maternas emMocambique 1998/99. Departamento de Saude da Comuni-dade. Maputo, 1999.

[4] Ministerio da Saude. Avaliacao das Necessidades para umaMaternidade Segura em Mocambique — 1999. Resumo doRelatorio. Maputo, 1999.

Improving emergency obstetric care in Mozambique: the story of Sofala 201

[5] Ministerio da Saude. Estrategia para a Reducao da Morbi-mortalidade Materna e Perinatal Ano 2000. Maputo, FNUAP2001.

[6] Jamisse L, Songane F, Libombo A, Bique C, Faundes A.Reducing maternal mortality in Mozambique: challenges,failures, successes and lessons learned. Int J GynecolObstet 2004;85:203–12.

[7] INE. Inquerito Demografico e de Saude 2003. Demographicand Health Surveys, Macro International Inc. 2005.

[8] WHO. Maternal Mortality in 2000: Estimates Developed byWHO, UNICEF and UNFPA. Geneva, 2004.

[9] Maine D, McCarthy J, Ward VM. Guidelines for monitoringprogress in the reduction of maternal mortality: a work inprogress. New York7 UNICEF; 1992.

[10] UN System VM. Mozambique United Nations System Com-mon Country Assessment, CCA. Maputo7 Office of the UNResident Coordinator; 2000.

[11] Becher H. Childbirth Practices in Beira City, Mozambique:Where women deliver and why. Master’s thesis, HumboldtUniversity in Berlin, Medical Faculty Charite, 2001.

[12] INE. Inquerito Demografico e de Saude 1997. Demographicand Health Surveys, Macro International Inc. 1998.

[13] Ministerio da Saude. Relatorio do Programa de DTS/SIDA.Unpublished report. 2004.

[14] Gill Z, Bailey P, Waxman R, Smith JB. A tool for assessingdreadinessT in emergency obstetric care: the room by roomdwalk-throughT. Int J Gynecol Obstet 2005;89:191–9.

[15] Vaz F, Bergstrfm S, da Luz Vaz M, Langa J, Bugalho J.Training medical assistants for surgery. Bull WHO 1999;77(8):688–91.

[16] Pereira C, Bugalho A, Bergstrfm S, Vaz F, Cotiro M. Acomparative study of caesarean deliveries by assistantmedical officers and obstetricians in Mozambique. Br JObstet Gynecol 1996;103:508–12.

[17] EngenderHealth and AMDD. Emergency obstetric care: amanual for improving the quality of services and toolbookfor improving the quality of services. New York 2003.http://www.engenderhealth.org/res/offc/mac/emoc.

[18] UNICEF, WHO, UNFPA. Guidelines for monitoring theavailability and use of obstetric services. NY7 UNICEF; 1997.

[19] Songane FF, Bergstrfm S. Quality of registration of maternaldeaths in Mozambique: a community-based study in ruraland urban areas. Soc Sci Med 2002;54:23–31.

[20] Hagemann K, Benech I. Rapid Response System for NaturalDisasters and Health Emergencies in Ile, Namarroi andMilange District, Zambezia Province. Final Narrative Re-port: October 2001—September 2002. Project Hope. 2002.

[21] Abramson JH, Gahlinger PM. Computer Programs forEpidemiologists: PEPI Version 4.0. Salt Lake City7 SagebrushPress; 2001.

[22] Kayongo M, Rubardt M, Butera J, Abdullah M, MboninyibukaD, Madili M. Making EmOC a reality — CARE’s experience inareas of high maternal mortality in Africa. Int J GynecolObstet 2006;92:91–298.

[23] Kayongo M, Esquiche E, Luna MR, Frias G, Centano LV, BaileyP. Strengthening emergency obstetric care in Ayacucho,Peru — experiences from an international PVO—CARE USA.Int J Gynecol Obstet 2006;92:299–307.

[24] Sevene E, Lewin S, Mariano A, Woelk G, Oxman AD,Matinhure S, et al. System and market failures: theunavailability of magnesium sulphate for the treatment ofeclampsia and pre-eclampsia in Mozambique and Zim-babwe. BMJ 2005;331:765–9.

[25] Campbell O. Lessons learnt: a decade of measuring theimpact of safe motherhood programmes. DFID researchwork programme on population and reproductive healthand maternal and child epidemiology unit; 1997.