Background: In Madagascar, where more than half of women give birth without skilled attendants, quality improvement of health services may ameliorate community perception of facility-based delivery care, thereby increasing the skilled birth attendance rate. For women who do deliver in a facility, a higher quality of services will lead to better outcomes, moving the country closer to reaching Millennium Development Goals 4 and 5. To guide the quality improvement processes at health facilities in Madagascar, this study assessed the quality of care at facilities with respect to interventions addressing the main causes of maternal and newborn complications with a focus on postpartum hemorrhage (PPH) and pre-eclampia/eclampsia (PE/E).
Methods: The study targeted all health facilities with a high volume of deliveries through inventories of medications and material, interviews with health providers, and observations of routine care and complicated cases. A total of 36 health facilities were included in the study, and interviews were carried out with 139 providers. Observations were made of 323 antenatal consultations and 347 labor and delivery clients, including 255 observations of the first stage of labor and 288 at the second or third stages.
Results: The main challenges to providing high-quality services as revealed by the inventory are the low availability of clinical protocols and guidelines for providers, and syringes, needles, and IV infusion sets to give uterotonics. Also, communication equipment and emergency transport were available in half of facilities, and a safe water source within 500 meters was available in only 67%. Regarding provider knowledge as measured by the interviews, the strongest areas of knowledge were detection of lacerations and conducting a physical examination; the weakest were on management of uterine atony or of retained placenta, stabilizing the mother with magnesium sulphate and anti-hypertensives, initial steps in management of severe PE, management of convulsions, and essential equipment and supplies needed. Technical support or supervision of providers was often nonexistent or inadequate. Some aspects of the observed care were of moderately high quality, such as infection prevention and provision of prophylactic oxytocin. However, compliance with all elements of the active management of the third stage of labor (i.e., oxytocin within one minute of delivery, controlled cord traction, and uterine massage after delivery of the placenta) occurred in only 13% of observed deliveries. In only 48% of observed antenatal care consultations was blood pressure measured using correct technique, and in only 29% did the provider perform or refer the pregnant woman for proteinuria screening. During cases of postpartum hemorrhage management, manual removal of placenta (MRP) was attempted in five cases but in none was it carried out according to the guidelines. In several cases of severe pre-eclampsia and one case of eclampsia, magnesium sulphate, the drug of choice, was not given.
Discussion: Overall, quality improvement is urgently needed to provide prophylactic oxytocin to all women within one minute of delivery, and to supply magnesium sulphate to all maternities for treatment of severe PE/E, among other interventions. To build on existing favorable policies to improve maternal and newborn health care in Madagascar, quality improvement efforts should target provider and facility readiness. In addition, national guidelines and protocols need to be updated and operationalized according to an appropriate national strategy that includes a budgeted action plan, follow-up, and performance-based recognition of providers and facilities. A national strategy is critical to ensure that all partners in the health system support it. An increase in the government's participation in funding for health (more than 12%, per the Abuja recommendation) would facilitate this program. Provider competencies can be maintained through regular practice with low-cost anatomical simulators and through use of regular updates and reminders to providers on clinical protocols via cell phones. In addition, accountability can be promoted by an adequate health management information system that collects data on the main causes of maternal and neonatal deaths, adequate supply at facilities of oxytocin, magnesium sulphate and other lifesaving drugs, and routine presentation of this information in regional and national fora.
Keywords: Madagascar; postpartum hemorrhage; pre-eclampsia/eclampsia; quality of care.