| Table of contents |
Table of Contents
List of Tables and Figures
List of Acronyms
Foreword
Acknowledgments
Executive Summary
Chapter 1: Introduction
1.01 Geography and administration
1.02 Social economic situation
1.03 Health system, goals and priorities
1.04 Maternal health situation
1.05 Specific context and rationale of the study
1.06 Objectives
Chapter 2: Methodolog
2.01 Survey overview
2.02 Selection of facilities
2.03 Data collection modules and pre-testin
2.04 Recruitment and training of data collectors and supervisors
2.05 Research ethics
2.06 Organisation of data collection
2.07 Data entry and analysis
2.08 Quality assurance
2.09 Limitations of the survey
2.10 Organisation of the repor
Chapter 3: Emergency Obstetric and Newborn Care Indicators
3.01 Indicator 1: Availability of EmONC Services
3.02 Indicator 2: Geographic distribution of EmONC facilities
3.03 Indicator 3: Proportion of all births in health facilitie
3.04 Indicator 4: Met need for EmONC services
3.05 Indicator 5: Caesarean section as a proportion of all births
3.06 Indicator 6: Direct obstetric case fatality rate (DOCFR)
3.07 Indicator 7: Intrapartum and very early neonatal death rates
3.08 Indicator 8: Proportion of maternal deaths due to indirect causes
Chapter 4: Performance of Other MNH Services and Procedures
4.01 Overview of maternal and newborn services in all facilities
4.02 Length of stay for women following a normal delivery7
4.03 Provision of other essential services
Chapter 5: Facility Infrastructure and referral for maternal and newborn emergencies
5.01 Bed complement of health facilities
5.02 Availability of electricity
5.03 Availability of wate
5.04 Availability of services 24 hours a day 7 days a week
5.05 Communication and transportation
5.06 Protocols for referral and feedbac
5.07 Health information system and in-referra
5.08 Conclusio
Chapter 6: Human Resources
6.01 Meeting targets for human resources
6.02 Health worker cadre and recent posting
6.03 Distribution pattern of health worker cadre
6.04 Availability of health worker cadres 24/7
6.05 Facilities that provide EmONC signal functions by health worker cadre
6.06 Ratio of midwives to 1,000 deliveries
Chapter 7: Provider knowledge and comptetency for maternal and newborn care
7.01 Pregnancy and delivery care
7.02 Unsafe abortion and care for victims of rape
7.03 Newborn care and morbidity
7.04 Training and recent delivery of services
7.05 Competency in newborn resuscitation
Chapter 8: Availability of Drugs, Equipment and Supplies
8.01 Management and stock outs of drugs and supplies
8.02 Availability of essential medicines
8.03 Infrastructure, supplies and medical equipment in labour, delivery and maternit
8.04 Availability of operating theatre and equipment
8.05 Availability of laboratory equipment and supplies for blood transfusion
8.06 Universal precautions and infection prevention
Chapter 9: Case Reviews
9.01 Partograph review
9.02 Caesarean delivery review
9.03 Maternal death review
9.04 Neonatal death review
Chapter 10: Recommendations
10.01 EmONC Indicators
10.02 Performance of Other MNH Services and Procedures
10.03 Facility Infrastructure and referral for maternal and newborn emergencies
10.04 Human resources
10.05 Provider knowledge and comptetency for maternal and newborn care
10.06 Availability of Drugs, Equipment and Supplies
10.07 Case reviews
Appendix (Tables
List of Tables and Figures
Chapter 1: Introduction and Background
Fig. 1.01: Map of Ghana showing administrative Regions/Capitals
Fig. 1.02: Ghana population pyramid by age and sex
Fig. 1.03: Levels of service delivery
Chapter 2: Methodology
Table 2.01: Inclusion criteria and percent of included facilities with few monthly deliveries, by region
Table 2.02: Distribution of surveyed facilities according to facility type, by region and type of operating agency
Chapter 3: Emergency Obstetric and Newborn Care Indicators
Table 3.01: Signal functions used to identify basic and comprehensive EmONC
services
Fig. 3.01: Distribution of EmONC facilities using national standards
Fig. 3.02: Distribution of EmONC facilities using UN standards
Table 3.02: Distribution of EmONC facilities by region, facility type and designation
Fig. 3.03: National coverage of signal functions
Table 3.03: Percent of facilities that performed each signal functions in last 3
months
Table 3.04: Percentage of facilities that administered uterotonic drugs in
the last 3 Months
Table 3.05: Percentage of facilities that administered parenteral anticonvulsants
in the last 3 months
Table 3.06: Percent of facilities that removed retained products
Table 3.07: Percent of facilities that performed assisted vaginal delivery in last 3
months
Table 3.08: Percent of facilities that provided signal functions and reasons for not
Providing signal functions
Fig. 3.04: Distribution of basic and comprehensive EmONC facilities by district
Fig. 3.05: Distribution of partially functioning EmONC facilities by district 33
Table 3.09: Percentage of expected births attended in all facilities and EmONC
facilities, by Region
Table 3.10: Percentage of women with major direct obstetric complications treated in all
facilities and EmONC facilities, by Region
Table 3.11: Percentage of all births by caesarean section in all facilities by district
Table 3.12: Percentage of institutional deliveries by caesarean section by sector
Table 3.13: Direct obstetric case fatality rate in all facilities and EmONC facilities
Table 3.14: Numeric and percent distribution of all maternal deaths, by type of facility
Table 3.15: Cause specific case fatality rates of direct obstetric complications
Table 3.16: Intrapartum and very early neonatal deaths in all facilities
Table 3.17: Intrapartum and very early neonatal deaths in EmONC facilities
Table 3.18: Percent distribution of maternal deaths by indirect causes
Chapter 4: Performance of Specific Procedures and other MNH Services
Table 4.01: Percentage of surveyed facilities providing selected services, by Region
Table 4.02: Percentage of facilities providing selected services, by facility
Type and designation
Table 4.03: Percentage of facilities that performed procedure other essential services in
the last 3 months, by service and type of facility
Table 4.04: Percentage of facilities that responded service was not provided in
the last 3 months, by service and type of facility
Chapter 5: Facility Infrastructure and referral for maternal and newborn emergencies
Table 5.01: Ratio of maternity beds to 1000 deliveries, by facility type/sector
and region
Table 5.02: Percent distribution of surveyed facilities according to primary source of
3: Percent distribution of surveyed facilities according to primary source of
water
Table 5.04: Percent of facilities with services available 24 hours a day, 7 days a week…….61
Table 5.05: Percent distribution of surveyed facilities with functional mode of
communication
Fig. 5.01: Frequency with which facility staff call ahead to inform receiving facility………….65
Table 5.06: Percent of facilities using various strategies for emergency referral……………….66
Table 5.07: Percent distribution of surveyed facilities with functional mode of
Motorized transpor
Equipment
Table 5.09: Number of facilities that received referred patients
Table 5.10: Percent of facilities with explicit written guidelines for emergency referral.... 75
Chapter 6: Human Resources
Fig. 6.01: National level targets for selected health worker cadre in surveyed facilities
Fig. 6.02: No. of selected health worker cadre currently working in facilities
Per 200,000 population
Fig. 6.03: Percent distribution of midwives in health centres, health clinics,
Maternity homes and CHPS Compounds
And Maternity homes
Fig. 6.05: Percent distribution of obstetrician/gynaecologists in hospitals by facility type
Fig. 6.06: Percent distribution of obstetrician/gynaecologists in hospitals by facility typei
And operating agency
facilities
Table 6.01: Number of midwives per 1,000 institutional deliveries by Region
Table 6.02: Number of midwives per 1,000 institutional deliveries by facility type and
operating agency
Chapter 7: Interviews with Service Providers
Table 7.01: Knowledge scores related to select maternity care, by health worker cadre
Table 7.02: Knowledge scores related to abortion care and care for victims of rape
Table 7.03: Knowledge scores related to newborn care and morbidity
Table 7.04: Knowledge scores related to diagnosis and management of birth asphyxia
among midwives and nurses with either training or experience in neonatal resuscitation
Chapter 8: Availability of Drugs, Equipment and Supplies
Table 8.01: Percent of facilities with a supply of medicines with registers and sorce of drugs
Fig. 8.01: Percent of facilities reporting on stock-outs of ergometrine, ketamine,
Atropine, oxytocin and magnesium sulphate
Table 8.02: Percentage of facilities that had contraceptives and other drugs, by type of
facility (among facilities with a pharmacy/supply of medicine),,Table 8.03: Percentage of facilities that had the indicated guidelines in maternity
ward by type of facility
Table 8.04: Percentage of facilities that had the indicated materials for infection
prevention in maternity area by type of facility
Chapter 9: Case Reviews
Table 9.01: Use of the partograph among all facilities, by type of facility
Table 9.02: Partograph assessment by progress of labour and augmentation
Table 9.03: Number of women with partographs and times those key measurements
were taken and recorded, by hours between first exam and delivery
Table 9.04: Percent distribution of facilities where caesarean delivery reviews were
performed according to number of cases reviewed, type of facility, sector and EmONC
status
Table 9.05: Percent distribution of women whose caesarean deliveries were reviewed
according to age, parity, residence and referral status
Table 9.06: Percent distribution of women whose caesarean deliveries were reviewed
according to the indication for surgery, type of caesarean, and use of partograph among
emergency caesareans, by secto
Table 9.07: Number of facilities where maternal deaths were reviewed
Table 9.08: Percent distribution of women whose deaths were reviewed according
to primary cause of death, by facility type
Fig. 9.01: Timing of death in maternal death cases reviewed
Table 9.09: Percent distribution of women whose deaths were reviewed according to
age, location of delivery, type of delivery and condition of newborn
Table 9.10: Percent distribution of women whose deaths were reviewed according to
EmONC classification, referral status, day of week death occurred
Table 9.11: Percent distribution of facilities where neonatal death reviews were
Performed according to number of cases reviewed
Table 9.12: Percent distribution of facilities where neonatal death reviews were
Performed according to maternal and delivery characteristics
Table 9.13: Percent distribution of facilities where neonatal death reviews were
Performed according to age at death, gestational age at birth, birth weight,
Table 9.14: Percent distribution of cause of death by age at death and facility type130
Table 9.15: Percent of reviewed neonatal deaths with newborn complication by age
At death
Table 9.16: Number of neonatal deaths reviewed where a maternal or foetal
Complication was reported132
Tables in Appendix
Chapter 2: Methodology
Table 2.1A: Names of data collectors by Region
Table 2.2A: Names of Supervisors and Facilitators
Chapter 3: Emergency Obstetric and Newborn Care Indicators
Table 3.01A: Availability of EmONC facilities according to national standards,
by Region (EmONC Indicator 1)
Table 3.02A: Availability of EmONC facilities according to UN standards,
by Region (EmONC Indicator 1
Table 3.03A List of facilities surveyed, EmONC classification and signal functions
performed in the last 3 months
Table 3.04A: Number of facilities that reported 'no indication' as a reason for not
performing the signal function with no drugs, Equipment or health worker who
could perform the signal function, by signal function in the last three months
Chapter 5: Facility Infrastructure, Transport and Communication and User Fees
Table 5.01A: Percentage of facilities with cell phone signal at facility and use and reimbursement of cell phone costs, by facility type and region (among facilities that
performed deliveries in last 12 months)
Table 5.02A: Frequency with which facility staff call ahead to inform receiving
facility that a patient is coming, by facility type (among facilities that performed
deliveries in last 12 months)
Table 5.03A: Total number of each type of vehicle available and functional at each
facility type and in each region (among facilities that performed deliveries in last
12 months)
Table 5.04A: Among facilities with each type of transport, percentage that use
transport for emergencies and for other purposes, by facility type and region
Table 5.05A: Percent distribution of facilities according to person responsible for
managing or organizing emergency transport at facility, by facility type (among facilities
that performed deliveries in last 12 months)
Table 5.06A: Percent distribution of facilities according to person responsible for
supervising the driver(s), by facility type (among facilities that use own vehicles for
emergency transport)
Table 5.07A: Percent distribution of facilities according to person responsible for ensuring vehicles are in working order, by facility type (among facilities that use own vehicles for emergency transport)
Table 5.08A: Percentage of facilities that use guidelines by facility type and region (among facilities that use their own vehicles for emergency transport)
Table 5.09A: Percentage of facilities that use guidelines by facility type and region (among facilities that use their own vehicles for emergency transport)
Table 5.10A: Percentage of facilities where drivers are always available, average number of drivers employed and trained, and percentage of facilities including various topics in driver training, by facility type and region (among facilities that use their own vehicles for emergency transport)
Table 5.11A: Percentage of facilities with access to local garage, fuel and funds, by facility
type and region (among facilities that use their own vehicles for emergency transport)…….208
Table 5.12A: Number of facilities by distance (Km) to nearest facility with surgical care,
by type of facility, and region
Table 5.13A: Number of facilities by distance (Km) to nearest facility with surgical care,
by type of facility, and region
Table 5.14A: Number of facilities by time (minutes) to nearest facility with surgical care,
by type of facility, and region
Table 5.15A: Number of facilities by time (minutes) to nearest facility with surgical care,
by type of facility, and region
Table 5.16A Percentage of facilities that refer to or receive patients from a private
facility, by facility type and region (among facilities that performed deliveries in
previous 12 months
Table 5.17A: Percent of facilities that waive or require certain fees for patients
referred out or in, by facility type and region
Table 5.18A: Percent of facilities that provide food, lodging and fuel to families of women referred in, by facility type and region
Table 5.19A: Percentage of facilities that receive feedback on referred patients and
that send a medical person to escort a referred patient, by facility type and
region (among facilities that refer patients out)
Table 5.20A: Number of direct obstetric complications admitted and number and percent referred out, by type of complication and type of facility (among facilities that perform deliveries) - 12 month period between April 2009 and June 2010
Table 5.21A: Number of indirect obstetric complications admitted and number and
percent referred out, by type of complication and type of facility (among facilities that
perform deliveries) - 12 month period between April 2009 and June 2010
Table 5.22A: Percentage of facilities with various components of an HMIS system
for referrals
Table 5.23A: Percentage of facilities that provide feedback on referred patients and that record and report on patients referred in, by facility type and region (among facilities that refer patients in)
Chapter 6: Human Resources
Table 6.01A: National targets of required staff for selected health worker cadres
by region
Table 6.02A: Number of selected health worker cadres currently working in facilities
by region
Table 6.03A: Ratio of required staff per per 200,000 population for selected
health worker cadres by Region
Table 6.04A: Ration of current staff per 200,000 population for selected health
worker cadres by region
Table 6.05A: Total number of selected health worker cadres who are currently
working, who left and who were posted in the 12 months, by type of facility and
cadre of health worker
Table 6.06A: Total number of selected health worker cadres who are currently
working, who left and who were posted in the 12 months, by type of facility
and cadre of health worker
Table 6.07A: Total number of selected health worker cadres who are currently
working, who left and who were posted in the 12 months, by type of facility and
cadre of health worker
Table 6.08A Distribution of midwives in health centres and health clinics
Table 6.09A Distribution of midwives in Maternity Homes and CHPS Compounds
Table 6.10A: Distribution of currently working General Practitioners in All
facilities and in District Hospitals by operating agency
Table 6.11A: Distribution of currently working General Practitioners in All
facilities and in maternity homes and CHPS compound
Table 6.12A: Number of Obstetrician/Gynaecologist in Hospitals by Operating
Agency
Table 6.13A: Percentage of Hospitals with health workers present on duty and
on call during the week, by health worker cadre
Table 6.14A: Percentage of Hospitals with health workers present on duty and
on call during during weekends, by health worker cadre
Table 6.15A: Percentage of hospitals and health centers/clinics that provide EmONC
signal functions, by health worker cadre
Table 6.16A: Percentage of health centers/clinics that provide EmONC signal
functions, by health worker cadre
Table 6.17A: Percentage of hospitals and health centres/clinics that provide other
essential services or procedures, by health worker cadre
Chapter 7: Interviews with Service Providers
Table 7.01A: Percent distribution of health providers interviewed and mean
number of deliveries, by health worker cadre
Table 7.02A: Percent distribution of health workers according to time worked
in facility, by health worker cadre
Table 7.03A: Percentage of providers who know focused antenatal care practices
and which pregnant women are at risk, by health worker cadre
Table 7.04A: Percentage of providers who recognize complications of
abortion, how to intervene, and what to do for victims of rape, by health worker
cadre
Table 7.05A: Percentage of providers who know steps of immediate newborn
care, signs of newborn complications and the appropriate responses, by health
worker cadre
Table 7.06A: Percentage and number of providers who reported training in
various services, and percentage of those trained and untrained who
provided the service in the past 3 months, by health worker cadre
Table 7.07A: Percentage and number of providers who reported training in
various services, and percentage of those trained and untrained who provided
the service in the past 3 months, by health worker cadre
Table 7.08A: Place of training, diagnosis and management of birth asphyxia,
among those with either training or experience with neonatal resuscitation, by
health worker cadre
Chapter 8: Availability of Drugs, Equipment and Supplies
Table 8.01A: Percentage of facilities according to mechanisms for ordering
drugs, among facilities with a pharmacy
Table 8.02A: Percentage of reporting most common cause of delay in the
delivery of supplies in hospitals and health centres, by operating agency
(among facilities with a pharmacy/supply of drugs)
Table 8.03A: Percentage of reporting most common cause of delay in the
delivery of supplies health clinics, maternity homes and CHPS compounds by
operating agency (among facilities with a pharmacy/supply of drugs)
Table 8.04A: Percentage of facilities reporting on pharmacy-related items, xii
by type of facility (among facilities with a pharmacy/supply of drugs)
Table 8.05A: Percentage of facilities reporting on stock-outs of ergometrine,
ketamine and atropine, oxytocin and magnesium sulphate, by type of facility
(among facilities with pharmacy/supply of drugs)
Table 8.06A: Percentage of facilities with drugs related to the signal functions
and emergencies, by type of facility (among facilities with pharmacy/supply of
drugs)
Table 8.07A: Percentage of facilities with basic and emergency
newborn supplies and equipment in the maternity area, by type of facility
Table 8.08A: Percentage of facilities with basic diagnostic and resuscitation
equipment and equipment and supplies for other procedures in the maternity
area, by type of facility (among facilities that do deliveries)
Table 8.09A: Percentage of facilities with an operating theatre (OT) and,
among those with an OT, percent with select equipment and supplies
Table 8.10A: Percentage of facilities with an operating theatre (OT) that
have anaesthesia equipment and supplies
Table 8.11A: Percentage of facilities with laboratory supplies, by type of
facility (among facilities with a laboratory)
Table 8.12A: Percentage of facilities with a laboratory and, among those with a
lab, the percent with equipment and supplies for blood transfusion, by type of
facility
Table 8.13A: Percentage of facilities with autoclave, sterilization and
incineration items in the maternity area1, by type of facility (among facilities
that do deliveries)
Chapter 9: Case Reviews
Table 9.01A: Percent distribution of time between diagnosis for caesarean
and surgery, and reasons for delay, by sector
Table 9.02A: Percent distribution of time spent in facility following caesarean
delivery and mean duration of stay according to type of cesarean, infection
status and indication, by secto
Table 9.03A: Percent distribution of women whose caesarean
deliveries were reviewed according to wound infections status, antibiotic
treatment, permanent contraception and condition after surgery, by sector…..277 xiii
List of Acronyms
AMDD Averting Maternal Death and Disability
APH Antepartum Haemorrhage
BEmONC Basic Emergency Obstetric and Newborn Care
BMC Budget management centre
CEmONC Comprehensive Emergency Obstetric and Newborn Care
CHPS Community-based Health Planning Services
CPD Cephalo-pelvic disproportion
C/S Caeserean section
D&C Dilatation and Curettage
D&E Dilatation and Evacuation
DFID Department for International Development Of The United Kingdom
DOCFR Direct obstetric case fatality rate
EHP Essential Health Package
EmONC Emergency Obstetric and Newborn Care
FANC Focussed antenatal care
FP Family planning
GHS Ghana Health Service
GNI Gross National Income
GNP Gross National Product
GRMA
GSS Ghana Statistical Services xiv
HIRDA
ICPD International Conference on Population and Development
IV Intravenous
MAF Millennium accelerated framework
MDG Millennium Development Goal
MMR Maternal mortality ratio
MOH Ministry of Health
MVA Manual Vacuum Aspiration
NGO Non-Governmental Organisation
PMTCT Prevention of mother to child transmission
PNC Postnatal care
PPH Postpartum Haemorrhage
STI Sexually transmitted infection
TBA Traditional Birth Attendant
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
USAID United States Agency for International Development
VCT Voluntary Counselling and Testing
WHO World Health Organization |
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