Emergency care for mothers and babies in Zambia: Challenges and opportunities for improvement

Each year 2.4 million newborn babies die globally, with the leading causes of mortality being preterm birth, asphyxia and infections. In Zambia, the number of newborn deaths is 23 per 1000 livebirths – the Sustainable Development Goals’ target for newborn mortality is fewer than 12 per 1000 livebirths.

Funded by the James Percy Foundation, King’s Global Health Partnerships is working with Zambian health partners to tackle these challenges and improve the quality of emergency care for mothers and babies at primary health care clinics, and reduce the number of late referrals to specialised hospitals, in Ndola District.

A recent report, Emergency care for mothers and babies in the Copperbelt province, Zambia: challenges and opportunities summarises the key findings of a baseline assessment carried out by KGHP staff, registrar doctors from Ndola Teaching Hospital (NTH) and postgraduate students from King’s College London. The assessment identifies the current state of maternal and neonatal care at 11 Primary healthcare clinics (PHCs) and two tertiary facilities in Ndola District.

The report identifies five key findings which will continue to inform the activities of the project, as well as highlighting the gaps that need addressing, outside of the scope of this project:

1) Average time from referral to admission at a tertiary facility

If a woman in labour requires emergency care, PHC staff will call an ambulance to take her to one of the two tertiary facilities where she can access specialist care. The average time from referral to admission at a tertiary facility is 2 hours 37 minutes, but many patients face longer delays.

2) Blood pressure disorders are a major cause of obstetric emergencies

The most common reason for referral, resulting in a “near miss case” was hypertensive disorders of pregnancy (55%) and obstetric haemorrhage (33%).

3) There is a need to develop the skills of midwives to manage the key causes of maternal and neonatal mortality

Ninety percent of staff from the selected PHCs reported feeling fully confident to handle obstetric emergencies. However, in practice, only 17 percent were assessed as having the appropriate skills to handle post-partum haemorrhage and only 8% of midwives could appropriately recognise and handle sepsis cases. Nearly 50% of midwives lack the knowledge and skills to handle asphyxiation and pre-eclampsia cases.

4) The critical shortage of staff, equipment and supplies at PHC facilities significantly hampers effective referrals

Staff and equipment shortages drive unnecessary referrals to tertiary facilities, outside of clinical guidelines, as PHC midwives cannot perform simple procedures without the right consumables and equipment.

5) More collaboration between primary and tertiary healthcare staff can have a positive effect on referrals

Interviews with staff at primary and tertiary facilities demonstrated that mistrust and perceived lack of skill, motivation and mutual understanding of working conditions inhibits positive working relations between primary and tertiary facilities. Healthcare workers (HCWs) at all levels valued inter-facility collaboration and mutual understanding increased where HCWs collaborated more frequently and were able to focus on ensuring positive patient outcomes collaboratively.

Key learning points

The report identifies key areas of focus to improve the quality of emergency obstetric and neonatal care in Ndola district. These include:

• Providing further training and mentoring to HCWs in recognising and managing patients with sepsis, postpartum haemorrhage, preeclampsia and hypertension, and neonatal asphyxiation.

   

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  Increasing dialogue and collaboration between primary and tertiary HCWs to improve teamwork and communication in the referral process.

   

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  Undertaking research into health-seeking behaviour, antenatal care and appropriateness of referrals to understand women’s pathways from their first antenatal visit to delivery.

   

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  Addressing the bottlenecks caused by pre-hospital transport, ensuring that patients can be referred quickly to tertiary centres.

   

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  Addressing supply chain issues that threaten the sustainable resourcing of PHCs.

   

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  Addressing staff shortages and low retention in primary health care.

   

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  Engaging with the Ministry of Health through national, provincial and district offices to ensure that continuous professional development of HCWs is sustainably resourced and managed.

To address some of these recommendations, KGHP and our partners in Zambia are working together to train PHC staff to manage obstetric and neonatal emergencies; strengthen communications and working relationships between PHC staff and tertiary facility staff; and address the lack of basic equipment and training materials at the primary level.

Read the full report here.