Assessment of Newborn Baby

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					Assessment of

Maternal and Neonatal Health Services

in Zimbabwe




      (Final Working Draft June 7, 2005)
            MOHCW, UNFPA, UNICEF and WHO
                     June 2005




   MOHCW        UNFPA          UNICEF      WHO
Preface and Acknowledgements

During the post independence decade, Zimbabwe made commendable strides forward in the
social sectors. Substantial investments in health and education were correlated with a
considerable decline in Maternal, Infant and Child Mortality. By 1987, Antenatal Coverage had
reached 89%, efforts in family planning resulted in a universal awareness of modern
contraceptive methods (98% by 1985) and Contraceptive Prevalence for modern methods
increased from 27% in 1984 to 42% in 1992. The Total Fertility Rate was reduced from 6
children per woman of reproductive age in 1984 to 4.3% children in 1992. A massive expansion
of the education sector (in terms of the number of schools, teachers and enrolled children)
resulted in almost universal primary education and increased adult literacy.

At present however, many of these achievements are threatened due to the economic and HIV
challenges facing the country. Against this backdrop, and in order to develop a pragmatic
roadmap outlining the way forward, a Maternal and Neonatal Health Assessment was conducted
by the Government of Zimbabwe (GoZ), in collaboration with UNICEF, UNFPA and WHO.
This study includes an assessment of 265 primary, 31 secondary, 10 tertiary and 4 quartenary
health facilities. Additionally, 2,900 community members were surveyed to provide community
perceptions.

The resulting document, entitled “An Assessment of Maternal and Neonatal Health in
Zimbabwe”, aims at providing insights into each of the “Three Delays” that contribute to
Maternal and Neonatal Morbidity and Mortality. Each of the delays is examined in relation to
each of 4 levels of service delivery. Particular attention is given to community perceptions,
transport, communication and referral, human resource requirements, essential drugs, supplies
and equipment. Additional attention is also given to assessing the status of each of eight process
indicators, thus providing a baseline against which future efforts can be assessed. Ultimately, the
document outlines a clear roadmap of specific actions that can be taken in the short and medium
term in order to prevent each of the three delays.

The outcome of this analysis could not have been accomplished without the ongoing
collaboration of the Ministry of Health and Child Welfare (MoHCW), the United Nations
Children‟s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World
Health Organization (WHO). Greatest appreciation is therefore extended to all of those who have
contributed to this analysis, and in particular to Dr. T.L. Magwalie and Dr. M.T. Manase, who
provided their invaluable technical guidance throughout the study. Credit is also due to Elizabeth
Krijgh who assisted in the technical editing and layout. Additionally, gratitude can be offered to
Dr. Marc Derveeuw, and Dr. Florence Ebanyat of the UNFPA Country Support Team in Harare,
and Dr. Luwei Pearson of the UNICEF Regional Office in Nairobi for their comments on several
versions of this important document.

This truly collaborative effort has provided the evidence required to clearly map the way forward
and prioritize a series of interventions that need to be taken in the coming year as well as over the
next 1-5 years. By following the road map outlined in this document, we are now in a position to
substantially reduce the number of tragic and unnecessary Maternal and Neonatal deaths amongst
the people of Zimbabwe.


________________          _________________         _________________         _________________
Dr. Elizabeth Xaba        Dr. Bruce Campbell        Dr. Festo Kavishe         Dr. Evarist Njelesani
Permanent Secretary       Representative            Representative            Representative
MOHCW                     UNFPA                     UNICEF                    WHO
Table of Contents

EXECUTIVE SUMMARY ..................................................................................................... I

The context ................................................................................................................................ i

The three delays .......................................................................................................................ii

Monitoring the National Maternal and Neonatal Health programme ..............................iii

A Roadmap to address each of the delays, thus reducing Maternal and Neonatal
Morbidity and Mortality ........................................................................................................ iv

INTRODUCTION.................................................................................................................... 1

Context ...................................................................................................................................... 1

The 4 essential pillars of Maternal and Neonatal Health ..................................................... 2

Definitions of Essential Obstetric Care .................................................................................. 3

Four Levels of Institutional Health Care in Zimbabwe ....................................................... 4

Justification for the Assessment ............................................................................................. 5

Objectives of the Assessment .................................................................................................. 6

METHODOLOGY .................................................................................................................. 7

Interview/data collection tools used ....................................................................................... 7

Tools for Monitoring the National MNH Programme ......................................................... 8

PRESENTATION OF FINDINGS ....................................................................................... 12

First Delay: Deciding to seek care ....................................................................................... 12

Second Delay: Reaching care ............................................................................................... 19

Third Delay: Receiving care ................................................................................................ 22

Levels of Health Care and Catchment Populations ............................................................ 22

Maternal and Neonatal Health care services ....................................................................... 24

Human resource availability by level of care ...................................................................... 25

Essential Drugs, Supplies and Equipment ........................................................................... 32
MONITORING THE NATIONAL MATERNAL AND NEONATAL HEALTH
PROGRAMME ...................................................................................................................... 41

ROAD MAP TOWARD REDUCING MATERNAL AND NEONATAL MORTALITY
................................................................................................................................................ VII


ANNEX I: SOURCES OF INFORMATION ..................................................................... 57
Table 1:   Number of staff at primary health care facilities, by cadre, Zimbabwe, 2004 ....57
Table 2:   Days of the week during which different services are offered at the primary
           health care level, Zimbabwe, 2004 ......................................................................57
Table 3:   Hours during which delivery services are offered at primary care centres (n=197)
                 57
Table 4:   Non-availability of basic equipment at the primary health care centres,
           Zimbabwe, 2003/04 .............................................................................................57
Table 5:   Availability of ambulance transport at primary care centres (n=247) .................58
Table 6:   Availability of telephone and radio services at primary care centres ..................58
Table 7:   Primary centres where antibacterial and antimalarial drugs NOT available
           (n=265).................................................................................................................58
Table 8:   Number of health providers by category at secondary level health facilities.
           Zimbabwe, 2004 (n=30) ......................................................................................58
Table 9:   Number of supporting staff at secondary level health facilities, by cadre,
           Zimbabwe, 2004 (n=30) .....................................................................................59
Table 10: Deliveries, Maternal and Perinatal Mortality at secondary level institutions, June
           2003-July 2004.....................................................................................................59
Table 11: Deliveries at secondary level institutions ............................................................59
Table 12: Distribution of indirect obstetric complications at secondary institutions...........59
Table 13a: Secondary institutions where basic equipment NOT available (n=31) ...............60
Table 13b: Secondary institutions where equipment for neonatal resuscitation not available
           (n=31)...................................................................................................................60
Table 14: Secondary institutions where basic equipment for anaesthesia, blood transfusion
           and laparatomy NOT available (n=31) ................................................................60
Table 15: Secondary institutions where essential drugs NOT available (n=31) ..................61
Table 16: Catchment area populations and number of referring centres for tertiary level
           facilities ................................................................................................................61
Table 17: Distance from furthest referring centre and distance to referral centre for tertiary
           facilities ................................................................................................................61
Table 18: Number and category of medical staff working at the tertiary facilities .............62
Table 19: Deliveries and caesarean sections at tertiary facilities .........................................62
Table 20: Number of obstetric admissions and mean hospital stay (in days) ......................62
Table 21: Distribution of direct obstetric complications treated at the tertiary facilities.....63
Table 23: Maternal Mortality due to direct causes (tertiary facilities).................................63
Table 24: Perinatal Mortality (tertiary institutions) .............................................................63
Table 25a: Availability and state of basic equipment for EmOC at tertiary facilities ...........64
Table 25b: Tertiary institutions where equipment for neonatal resuscitation available ........64
Table 26: Availability of essential drugs at the tertiary health facilities..............................65
Table 27: Referring institutions for quartenary health facilities ..........................................65
Table 28: Number of staff currently working and occupancy of established posts at the
           quartenary health facilities ...................................................................................65
Table 29:      Deliveries at quartenary facilities by cadre of health staff ..................................65
Table 30:      Admissions, C/sections and mean hospital stay ..................................................66
Table 31:      Indirect obstetric complications admitted at quartenary facilities .......................66
Table 32:      Maternal Mortality due to direct causes (quartenary facilities) ...........................66
Table 33:      Perinatal Mortality (quartenary institutions) ........................................................66
Table 34:      Availability and state of basic equipment for MNH at quartenary facilities .......67
Table 35:      Availability of essential drugs at the national level health facilities ...................67
Table 36:      District and population sampled by province ......................................................68
Table 37:      Coverage of comprehensive EmOC for 500,000 population by district ..68
Table 38:      Coverage of comprehensive EmOC for 500,000 population by province ...........69
Table 39:      Proportion of births taking place in health facilities and % of all births byC-
               Section, by district and province ..........................................................................69
Table 40:      Proportion of births taking place in health facilities and by CS, by province,
               Zimbabwe, 2003/2004 .........................................................................................70
Table 41:      Proportion of obstetric complications treated by district and province ...............70
Table 42:      Met need by province, Zimbabwe, 2003/2004 ....................................................72
Table 43:      Complications of pregnancy mentioned by women (total responses=846) .........72
Table 44:      Places where help first sought (n=471) ................................................................72
Table 45:      Places approached by respondents for ANC (n=449) ..........................................72
Table 46:      Reasons for not being delivered by a health worker (n=89) ................................73
Table 47:      Complications of pregnancy mentioned by men (n=769) ...................................73
Table 48:      Complications endangering a baby‟s life as mentioned by the men (n=529) ......73
Table 49:      What men would do if their wife/partner experienced problems during pregnancy
               (n=544).................................................................................................................73
Table 50:      Ways of preventing pregnancy as mentioned by the youth (n=1284) .................73
Table 51:      Sources of information on family planning as mentioned by youth (n=889) ......74
Table 52:      Sources of contraceptives as mentioned by the youth (n=814) ...........................74
Table 53:      Factors which prevent young people from using contraceptives (n=668) ...........74
Table 54:      Places for HIV testing as mentioned by the youth (n=532) .................................74
Table 55:      District and population sampled by province ......................................................75

ANNEX II: SAMPLE QUESTIONAIRE ........................................................................... 76
Primary Health Centre Level Questionnaire ............................................................................76

ANNEX III: REFERENCES ............................................................................................... 98
EXECUTIVE SUMMARY

The context
In Zimbabwe, rural health centres and clinics can anticipate
                                                                                     In the average rural
approximately 320 deliveries per year in the average catchment
                                                                                            health facility
population. This translates to about one normal delivery per
                                                                                     catchment area, one
day in each sub-district health facility1.                                      woman per week is likely
                                                                                          to experience a
More importantly, in any rural health facility catchment area,                    pregnancy complication
one woman per week is likely to experience a complication                        and may lose her life if
during her pregnancy, and may lose her life if her birth is not                    a skilled and equipped
attended by a skilled and equipped service provider, or referred                    service provider does
to a facility with Basic or Comprehensive Emergency Obstetric                      not attend her birth.
Care services.

At the secondary level there will be approximately 5,900 births per year for the average
district population. Of these pregnancies, approximately 888 will develop complications
every year. If the referral system functions smoothly every district hospital may anticipate 2-
3 complicated pregnancies every day of the week, throughout
                                                                      Ultimately, district and
the year. If attended promptly by trained and equipped staff, at       mission hospitals might
the district or mission hospital, the vast majority of                         anticipate 2-3
complications can be managed successfully, and the lives of         complicated pregnancies,
thousands of women can be saved.                                      every day of the week,
                                                                                     throughout the year.
At the tertiary and quartenary level, provincial and national
hospitals continue to attend to large numbers of normal                         Similarly, every tertiary
deliveries due to their location in urban areas and their larger                    and national hospital
numbers of trained staff. Additionally, as these facilities are                   must be equipped with
                                                                                   blood transfusion and
able to provide Comprehensive Emergency Obstetric Care,
                                                                                     theatre capacity to
they also cater for a vast majority of C-Sections as well as
                                                                                  manage as many as 18
more complex surgical, septic, and hypertensive conditions.                            C-sections a day.


Methodology
The coverage and utilization of Maternal and Neonatal Health services was assessed through
a cross-sectional study, combining, staff interviews, a review of the availability of essential
drugs, supplies and equipment, and questionnaires presented to selected community
members. Information was gathered using 7 different survey tools, administered to 4
quartenary, 10 tertiary, 31 secondary and 265 primary care facilities distributed over 24
districts in 10 provinces (including Harare and Bulawayo). Additionally, 2,900 men, women
and youth were interviewed in the community.
1
    Based on 2002 Census data available from CSO, which suggest a Crude Birth Rate of 30.3 per thousand,
    the approximate number of pregnancies for the nation as a whole is 350,000 per year. It is estimated that
    slightly more than 15% of these pregnancies will have a complication
                                                     i
The three delays
FIRST DELAY
This study indicates that a majority of women, men and youth in Zimbabwe have some,
although limited knowledge regarding the health risks involved with pregnancy and
childbirth. Knowledge regarding danger signs of complications during labour and delivery is
particularly limited. This causes lack of any preparatory action designed to overcome the
“first delay”: the time that is lost in recognizing the seriousness of the situation and whether
or not to seek appropriate medical attention.

Lack of knowledge about complications of pregnancy and childbirth and lack of recognition
of the seriousness of the symptoms contribute to delay in recognizing the need for medical
care, whereas lack of confidence in the medical system, concern about the distance to be
travelled, cost of the services, traditional beliefs and poverty related to low socio-economic
status often contribute to delay in deciding when to seek medical care.


SECOND DELAY
Similarly, the study indicates that there is little evidence of
                                                                         For every single minute
structured or viable emergency transport and communication                 of unnecessary delay,
schemes, thus contributing to increases in the “second delay”, or         there is an increase in
the time needed for reaching a health facility or trained service           the possibility that a
provider, once a decision is taken to seek care. Similarly,                minor complication will
communication and transportation between the levels in the                        become a life-
health system is erratic, and thus referrals from one level to the        threatening emergency
other may create substantial additional delays.

THIRD DELAY
The “third delay”, that of receiving expeditious and effective care, is critical in order to
reduce Maternal and Neonatal Morbidity and Mortality.
    In order to address the third delay, the rural health facility must have sufficient equipment
and supplies as well as trained staff able to stabilize complications, and refer a woman to the
nearest district or mission hospital. Similarly, all district and mission hospitals must have
sufficient staff, equipment, and supplies to manage both normal and complicated pregnancies.
As mentioned, district and mission hospitals must be able to manage on average, 3
complications every day of the year. Provincial and national hospitals may be required to
manage on average 18 complications and perform 3 or more C-sections every day of the year.
Further details of these requirements are outlined in the body of the report.

The importance of the three delays can be summarized as follows: For every single minute of
unnecessary delay, there is an increase in the possibility that a minor complication will
become a life-threatening emergency.




                                               ii
Monitoring the National Maternal and Neonatal Health
programme
Given the findings of this study, it is clear that substantial
improvements can be made with only a few strategic and                                 It is only by carefully
                                                                                     monitoring each of the 8
nationwide interventions. In order to map progress toward
                                                                                      process indicators that
achieving the Millennium Development Goal (#4) of reducing
                                                                                          it will become clear
Maternal Mortality by 75% by the year 2015, eight specific
                                                                                      which interventions are
process indicators were charted and can now be utilized to guide                     most likely to contribute
annual programming as well as ongoing policy and strategy                                        to measurable
review.                                                                                reductions in Maternal
        Only by carefully monitoring each of these indicators, it                     and Neonatal morbidity
will become more clear which interventions, according to each of                                  and mortality
the three delays, and according to each of the 4 institutional levels,
are most likely to contribute to measurable reductions in Maternal
and Neonatal morbidity and mortality.

These indicators and their baseline status are shown in the following table.

Baseline Indicators for Monitoring the national Maternal and Neonatal Health Programme
    Indicator                   National           Primary       Secondary        Tertiary         Quartenary
1   Skilled Attendance at       53.6%2             8.3%          29.1%            6.4%             8.8%
    delivery
2   Number of facilities
    providing BEmOC per         During the fieldwork of the study, the BEmOC signal functions were not formally
    500,000 population          assessed, either by observation or by interviews. Therefore, it was not possible to
    (standard is 4 per          calculate coverage of Basic EmOC at the various levels.
    500,000)
3   Number of facilities        1.23               Not           1.2              1.2              1.2
    providing CEmOC per                            applicable    (average)        (average)        (average)
    500,000 population
    (standard is 1 per
    500,000)
4   Met Need: proportion of     38.1%              Not           14.7%            26.1%            23.3%
    total number of obstetric   population         available     Institution      Institution      Institution based
    complications treated in    based                            based            based            estimation
    EmOC facilities4            estimation                       estimation       estimation
5   C-section as a proportion   3.6%               Not           Population       Population       Population based
    of all births in the                           applicable    based <5%        based <5%        <5%
    catchment population5
                                                                 Institution      Institution      Institution based
                                                                 based 6.2%       based 22.6%      34.7%


2
    The percentage of skilled attendance at delivery reflected at the national level is the sum total of the
    coverage at each of the four institutional levels, as assessed from the study. This figure is likely to vary
    from the routine Health Management Information System data, and will also be different from the
    upcoming DHS data, as it only reflects the sites visited during the assessment.
3
    The average CEmOC sites per 500,000 population is calculated for the nation as a whole, by dividing total
    CEmOC sites by the total population and multiplying by 500.
4
    See Table 42 in Annex.
5
    See Table 40 in Annex.
                                                        iii
    Indicator                    National           Primary       Secondary         Tertiary         Quartenary
6   Case Fatality Rate: total    Range from 0.3     0.3% total    1.7% total        1.2% total       1.5% total
    number of maternal           at primary level
    deaths from direct           to 1.7 at                        0.98% for         0.6% for         1.2% for direct
    obstetric complications      secondary level                  direct causes     direct causes    causes
    among the number of
    women admitted with                                           8.7% for          6.5% for         13.7% for
    these conditions                                              indirect          indirect         indirect causes
                                                                  causes            causes
7   Maternal Mortality Ratio:    Institution        Data not      238/100,000       350/100,000      338/100,000
    number of maternal           based figures      available     (institution      (institution     (institution
    deaths per 100,000 live      ranged from                      based)            based)           based)
    births6                      238-338 per
                                 100,000 live
                                 births
8   Perinatal Mortality Ratio:                      Data not      32.5/1000         55.4/1000        Data not
    number of newborn                               available                                        available
    deaths in 1000 live births



Summary of recommendations according to each of the three
delays
Based on the analysis provided in this study, a number of
specific and immediate next steps are offered to address each of                          Several opportunities
                                                                                         exist for immediately
the three delays along the road to safe delivery and a healthy
                                                                                           addressing the first
mother and her newborn baby.
                                                                                                         delay:
                                                                                        Design and make
Some suggestions are more “emergency response” in nature, and                            widely available a
are designed to provide immediate and measurable results.                                simple brochure that
Additionally, a selection of longer-term development strategies                          introduces the
is proposed to approach issues of behavioural change at the                              concept of danger
community level, while simultaneously addressing more                                    sign recognition, and
sustainable capacity development at each of the four institutional                       household emergency
levels.                                                                                  preparedness
                                                                                        Introduce the
FIRST DELAY (RECOGNIZING)                                                                brochure within
Based on this study, it is clear that further effort must be put into                    training programmes
                                                                                         such as the planned
ensuring that Maternal and Neonatal health issues are part of
                                                                                         EmOC training, PCN,
every-day language in the whole community. Every woman,
                                                                                         and PCC training as
their husbands, their mother-in law, other relatives and
                                                                                         well as other related
community leaders must know the specific danger signs that                               training.
anticipate a tragic and unnecessary death. Every family must
have its‟ own “emergency preparedness” action plan which


6
    It is important to note, that this study could only provide a Maternal Mortality ratio for institution-based
    deliveries. This figure is often far less than a population-based maternal mortality figure. In order to
    calculate a population based Maternal Mortality Rate, a large and nationally representative sample of all
    births and maternal deaths is required.
                                                          iv
spells out who will do what, and with what resources, if specific maternal or neonatal
symptoms are observed.

Immediate steps that can be taken within the coming year to address the first delay include:
 Identify any planned or ongoing related community mobilization or behavioural change
   initiatives (e.g. HIV prevention activities, Primary Care Counsellor (PCC) training,
   Primary Care Nurse (PCN) Training, peer counsellor training, etc.), and negotiate to
   incorporate MNH danger signs and emergency preparedness messages within all related
   capacity building initiatives.
 Develop simple one page print materials outlining MNH danger sign recognition and
   household/community preparedness strategies for distribution through all available
   channels including MOHCW static and EPI outreach, ZNFPC static and community
   based distributions schemes, and all government and civil society VCT/PMTCT sites.
 As ANC coverage is high, immediate emphasis should be placed on birth and emergency
   preparedness counselling during every ANC visit.

In the medium term (1-5 years), strategies to consider might include:
 Develop mass media (e.g. radio) messages as part of a national communication strategy to
    ensure that MNH danger signs and the concept of emergency preparedness become
    “household language”. Incorporate similar messages in relevant school curriculum.

SECOND DELAY (REACHING)
The assessment makes clear that due to long distances between
communities and health facilities, financial constraints,            To address the second
transport and communication problems, women often do not                   delay of reaching
reach the heath care facility at all, or if they do, they are             appropriate health
                                                                     services within a short
seriously delayed and consequently, minor complications
                                                                             period of time,
become unnecessarily aggravated or even fatal.
                                                                     continued efforts must
                                                                      be given to supporting
Immediate steps that can be taken within the coming year to                 community based
address the second delay include:                                         transport schemes
 Continue structured and strategic support for all possible        including ox and donkey
   community referral and transport schemes including ox or        drawn ambulances, while
   donkey-drawn ambulances, and further development of             simultaneously mobilizing
   community and faith-based organization revolving fund               resources to procure
   schemes for reimbursement of emergency transport costs.           and maintain motorized
                                                                     ambulances which must
 Identify all potential resources for increasing the number of
                                                                     be located at places in
   motorized ambulances and drivers available at strategically                greatest need.
   selected health facilities which are in greatest need, making
   certain that recurrent costs for fuel, maintenance and
   drivers are available as well.
 Expand obstetric First Aid capacity to as many primary care facilities as possible in order
   to minimize delays in receiving care.



                                            v
In the medium term (1-5 years), strategies to consider may include:
 Utilize civil society organizations to establish and maintain
    MNH communication networks that link formal MOHCW                If attended promptly by
    and private ambulance transport systems with the                     trained and equipped
                                                                      staff at the district or
    community. For example, in areas where an ambulance is
                                                                         mission hospital, the
    functioning at primary or secondary levels (and cell phone
                                                                              vast majority of
    networks are available), community leaders could be                  complications can be
    advocated to provide cell phone access for families during           managed successfully
    an emergency. Such a service may be benevolent in                  and thousands of lives
    nature, or alternatively may be reimbursed by community                     can be saved.
    and faith-based revolving fund schemes.
 Undertake a nationwide “mapping exercise” of every
    health facility in the country to identify which facilities should be upgraded to BEmOC
    and which to CEmOC, based on the guiding principal that first aid should be available
    within 1-2 hours travel time, BEmOC within 2-4 hours travel, and CEmOC within 4-6
    hours travel.

THIRD DELAY (RECEIVING)
The study clarifies that incapacity due to lack of appropriately
trained staff, essential drugs and equipment often forces                A number of distinct
                                                                      opportunities have been
referral of patients to higher levels of health care than should
                                                                                 identified to
be needed, thus causing more delay before appropriate
                                                                     immediately address the
treatment is received.       Rural health clinics, district and                   third delay:
provincial hospitals do not function to the limits of their          Mobilize resources
assumed and expected capacity, thus creating avoidable strain           to procure the
on the highest level of health care.                                    drugs, supplies and
                                                                        equipment identified
Immediate steps that can be taken within the coming year to             as necessary by this
address the third delay include:                                        assessment
 Review of job descriptions and functional responsibilities         Undertake the
   of all staff cadres in order to decentralize as many first aid       reorientation of all
                                                                        Midwifery and
   and BEmOC functions to the periphery as possible.
                                                                        Nursing staff to the
 Organize a rapid nationwide 3-4 day reorientation on                  concept of EMoC,
   Obstetric First Aid for all nurses and midwifery personnel.          and decentralize
 Procure essential drugs, supplies and equipment, as                   several carefully
   outlined in this assessment, for distribution as appropriate         selected EmOC life-
   to all levels of care.                                               saving skills.


In the medium term (1-5 years), strategies to consider may
include:
 Structured review of staffing norms by institutional level, to ensure a pragmatic and
    sustainable level of staffing, based on an analysis of actual and potential MNH workload.
 Based on the above-mentioned staffing norms, establish a long-term human resource
    development strategy, which includes production of sufficient nursing/midwifery
    personnel to fill vacant posts.
                                               vi
                     As part of the new autonomous status of the MOHCW, develop remuneration packages
                      designed to retain health workers in Zimbabwe, while simultaneously providing specific
                      incentives for staff to work in the difficult peripheral areas at the district level and below.
                     Expand the concept of Reproductive Health Commodity Security (RHCS) to include a
                      careful selection of MNH life-saving drugs, supplies and equipment. Ensure that a
                      consortium of government, multi-lateral and bi-lateral partners engage in an annual
                      review of commodity requirements, and come to consensus on shortfalls. Host an annual
                      donor round-table to ensure sufficient internal and external resources are available to
                      provide RH commodity security.

Road Map Toward Reducing Maternal and Neonatal Mortality

The following Road Map outlines a series of specific interventions designed to minimize the
three delays, and thus contribute to a reduction in maternal and neonatal morbidity and
mortality in Zimbabwe.
                                                                                                                                  Tertiary/
                                                                                   Primary level health        Secondary level    Quartenary level
                                      Community                                    care                        health care        health care
                                                                        FIRST DELAY
                                      (1)
                                      Consider training or upgrading
                                      traditional midwives and community
                                      based health cadres on warning signs,
                                      timely referral and the need for skilled
                                      attendance at birth.

                                      (2)
                                      Develop 1-page educational materials
                                      for community members, on danger
                                      signs, emergency preparedness, and
Interventions that could be planned




                                      the need for skilled attendance at
                                      delivery (for distribution through all
     within the next 12 months




                                      available channels)

                                      (3)
                                      Involve community leaders through
                                      special training session on danger
                                      signs / advocate for their
                                      contribution/responsibility through
                                      emergency cell phone access.

                                                                                   (4)
                                                                                   Focus every ANC visit, at every facility, on danger signs, birth
                                                                                   preparedness and skilled attendance at birth

                                                                                   (5)
                                                                                   Training for primary health facility staff on promotion of
                                                                                   kangaroo mother care for pre-term infants, the importance of
                                                                                   breastfeeding, cord care and hygiene in general, as well as on
                                                                                   conducting 1-2 postpartum visits during the 1st and 6th week after
                                                                                   delivery.

                                                                                   (6)
                                                                                   Refresher training for referral protocols and clinical management
                                                                                   guidelines for all staff.




                                                                                 vii
                                                                                                                    Tertiary/
                                                                     Primary level health        Secondary level    Quartenary level
                           Community                                 care                        health care        health care
                           (7)
                           Develop and widely disseminate 1 page specific information sheet regarding Abortion and its
                           complications

                           (8)
                           Develop mass media messages (on
                           danger signs and household
                           emergency preparedness) for national
                           communication strategy, and for
                           schools.

                                                                     (9)
Medium Term intervention




                                                                     FP services: refresher
                                                                     training in
    within 1-5 years




                                                                     communication +
                                                                     counseling skills for all
                                                                     health staff.

                           (10)
                           Introduce the concept of community based “Maternal Mortality
                           Verbal Autopsies”, where a sub-committee of every district
                           health team (including district/mission hospital staff) visit the
                           home where a maternal death occurred and review the
                           surrounding context and factors which may have contributed to
                           the maternal death.

                                                                     (11)
                                                                     Train and motivate health staff in preparedness to go out on home
                                                                     visits in case of emergency.


                                                          SECOND DELAY
                           (12)
                           Continue structured support for all Community Emergency
                           transport schemes + further development of faith-based revolving
interventions
 Immediate




                           funds.

                           (13)
                           Advocate role of community leaders to provide emergency cell
                           phone access in order to organize transportation.

                           (14)
within 1-5 year




                           Utilize local administration and civil society organizations to establish and maintain MNH communication
 interventions
  Immediate




                           networks from community level to primary, secondary, tertiary and ultimately referral level facilities.

                                                                     (15)
                                                                     Identify non-functional vehicles per facility and organize repair.


                                                            THIRD DELAY
                                                                     (16)
within the next 12
Interventions that




                                                                     Decentralize as many
could be planned




                                                                     First Aid and BEmOC
                                                                     functions as possible to
     months




                                                                     the periphery.

                                                                     (17)
                                                                     Procure and distribute missing essential drugs, supplies and
                                                                     equipment where so required, as indicated by the study.




                                                                     viii
                                                                                        Tertiary/
                                        Primary level health       Secondary level Quartenary level
                           Community    care                       health care          health care
                                        (18)
                                        Develop/refresh specific drug, supply and equipment
                                        standards/guidelines for each level of care, and if possible, by
                                        complication.

                                        (19)
                                        Review and clarify existing stock-keeping records and drug
                                        ordering procedures with relevant staff.

                                        (20)
                                        Research/identify drug requirements by expected number of each
                                        major complication, by facility level, based on Mother-Baby
                                        package template.

                                        (21)
                                        Review job descriptions and functional responsibilities for all staff
                                        cadres.

                                        (22)
                                        Organize a rapid, nation wide 3-4 day reorientation on
                                        Emergency Obstetric First Aid for all Nurses and Midwives.

                                        (23)
                                        Introduce and support maternal mortality review committees in
                                        all secondary, tertiary and quartenary facilities in order to
                                        identify “avoidable factors” that may have contributed to
                                        maternal death.

                                        (24)
                                        Identify and service non-functional pieces of MNH equipment
                                        where possible.

                                        (25)
                                        Organize refresher training for referral protocols and clinical
                                        management guidelines, taking in account present staffing gaps.
Medium Term intervention




                                        (26)
    within 1-5 years




                                        Establish/increase collaboration between private or other facilities
                                        that are well staffed and facilities in need of personnel

                                        (27)
                                        Emphasize importance of correct use of Maternal and Neonatal
                                        death records and maternal death audits amongst all staff.

                                        (28)
                                        Develop a viable incentive system to encourage staff to remain at
                                        post, placing special emphasis on remuneration packages for rural
                                        and district postings.

                                        (29)
                                        Organize structured review of staffing norms by institutional
                                        level, based on analysis of actual and potential workload.




                                       ix
                                                              Tertiary/
            Primary level health          Secondary level Quartenary level
Community   care                          health care         health care
            (30)
            Undertake a nationwide “mapping exercise” of every health
            facility in the country to identify which facilities should be
            upgraded to BEmOC and which to CEmOC, based on the guiding
            principal that first aid should be available within 1-2 hours travel
            time, BEmOC within 2-4 hours travel, and CEmOC within 4-6
            hours travel.

            (31)
            Develop a long-term Human Resource strategy to produce
            sufficient midwives and nurses to fill vacant posts.




             x
List of Abbreviations

ANC          -      Antenatal Care
Anaes.       -      Anaesthetist
BEmOC        -      Basic Emergency Obstetric Care
CEmOC        -      Comprehensive Emergency Obstetric Care
D&C          -      Dilatation and Curettage
EmOC         -      Emergency Obstetric Care
FSB          -      Fresh Stillbirth
GMO          -      General Medical Officer
IUD          -      Intra-Uterine Contraceptive Device
IVI          -      Intravenous Infusion
LAM          -      Lactational Amenorrhoea Method
MNH          -      Maternal and Neonatal Health
MOHCW        -      Ministry of Health and Child Welfare
MVA          -      Manual Vacuum Aspiration
NA           -      Nurse Anesthetist
NBTS         -      National Blood Transfusion Services
NND          -      Neonatal Death
O&G          -      Obstetrician/Gynecologist
Paed.        -      Pediatrician
PCC          -      Primary Care Counselor
PCN          -      Primary Care Nurse
Pharm.       -      Pharmacist
PIH          -      Pregnancy Induced Hypertension
PMR          -      Perinatal Mortality Ratio
PMTCT        -      Prevention of Mother to Child Transmission
PNC          -      Post Natal Care
PSC          -      Public Service Commission
RGN          -      Registered General Nurse
RH           -      Reproductive Health
RHCS         -      Reproductive Health Commodity Security
RNM          -      Registered Nurse Midwife
RNT          -      Registered Nurse Anesthetist
SB           -      Stillbirth
SCNM         -      State Certified Nurse Midwife
TBA          -      Traditional Birth Attendant
UNFPA        -      United Nations Population Fund
UNICEF       -      United Nations Children Fund
VCT          -      Voluntary Counseling and Testing
WHO          -      World Health Organization
ZDHS         -      Zimbabwe Demographic and Health Survey




                                        xi
INTRODUCTION

Context
In Zimbabwe, national efforts to improve Reproductive Health gathered momentum during
the past decade, with the recognition of:
 The rapidly growing burden of RH-related illnesses
 The urgent need to respond to the threat posed by the AIDS
    pandemic, and thus, the increasing demands for health care     Complications during
    services, and                                              pregnancy and childbirth
 The ramifications for women and children‟s health of the       are the leading causes
    deteriorating socio-economic situation in the country.             of morbidity and
                                                                                                                                   mortality among women
                                                                                                                                    of reproductive age in
The first major component of Reproductive Health Care (as
                                                                                                                                           most developing
listed by the 1994 International Conference on Population and                                                                                    countries
Development ICPD programme of Action) was Safe
Motherhood. The ICPD programme of action emphasizes:
Complications related to pregnancy and childbirth are the leading causes of morbidity and
mortality among women of reproductive age in most developing countries.

Thus it is in Zimbabwe. Like most other countries in sub-Saharan Africa, Zimbabwe has a
high Maternal Mortality Ratio (MMR) when compared to countries in other regions in the
world. Moreover, it is suspected that the MMR continues to rise at an alarming rate: and
although more recent data are not available, the figure increased more than tenfold from an
estimated 63 per 100,000 live births in 1987 to 695 per 100,000 in 1999.

The Perinatal Mortality Ratio (PMR) increased as well: from 33 per 1000 births in 1995 to
41 per 1000 births in 1999.
                                                                                                                                              Every year,
According to the 2002 census, the population in Zimbabwe is                                                                        approximately 52,500
                                                                                                                                women in Zimbabwe may
currently estimated to be 11.6 million. Women of reproductive
                                                                                                                                  require specific clinical
age (15-45 yrs) comprise 25% of the population. With a birth
                                                                                                                                interventions in order to
rate of just over 30 per thousand, there are an estimated
                                                                                                                                        save their life or
350,000 births per year in Zimbabwe.                                                                                                     prevent life-long
                                                                                                                                                disability
According to international norms, approximately 15% of these
births are expected to be complicated. This translates to
approximately 52,500 women who may need specific clinical interventions in order to save
their life or prevent life long disability. This significant proportion of the population can only
illustrate the magnitude of work that needs to be done in the area of Maternal and Neonatal
Health in Zimbabwe.




Assessment of Maternal and Neonatal Health Services in Zimbabwe ....................................................................................................................... 1
The most common causes of maternal deaths are:
 Haemorrhage (Antepartum and postpartum),
 Prolonged/obstructed labour,
 Pre-eclampsia/eclampsia: pregnancy induced hypertensive disorders
 Complications of abortion
 Ectopic pregnancy
 Ruptured uterus, and
 Postpartum sepsis

The 4 essential pillars of Maternal and Neonatal Health
The following essential components are required in any effective national Maternal and
Neonatal Health programme:

ANTENATAL CARE (ANC)
ANC visits provide routine services as well as opportunities to identify women at risk of
developing obstetric complications.
In Zimbabwe, during the 1990‟s, ANC attendance rates have remained above 80%, despite
the deteriorating socio-economic situation.

However, it is almost impossible to predict which individual woman will develop a life-
threatening complication. Some women are more likely to develop complications than
others, but all pregnancies should be considered at risk. Since even if a woman has received
proper ANC and is correctly identified as being at risk, she may not reach or receive
appropriate care at a later stage during pregnancy or delivery.

ESSENTIAL EMERGENCY OBSTETRIC CARE
Hence, continuous access to quality Essential Obstetric Services by all pregnant women is of
crucial importance if current MMR trends are to be reversed.

CLEAN AND SAFE DELIVERY FOR THE MOTHER AND THE NEWBORN
Many studies have shown that there is a direct correlation between the percentage of
professionally attended births and Maternal Mortality Ratios, as
well as skilled attendance at birth and neonatal survival.            In Zimbabwe, the
Evidence from a number of studies in various countries shows      percentage of women
                                                                     who have a skilled
that most complications and deaths occur during childbirth
                                                                     attendant at their
(25%), or immediately thereafter (60%). The remaining 15%
                                                                 delivery has remained
occur before the onset of labour: Skilled attendance at birth     stagnant around 50%
accompanied by quality obstetric care, and the capacity of the    since the mid-1990’s
attendant to take care of the newborn becomes the key to the
reduction of Maternal and Perinatal mortality.

In Zimbabwe, the proportion of women delivering in institutions has remained stagnant at
around 50% since the mid 1990‟s.
    Every year more than 40% of all deliveries take place without the assistance of a skilled
birth attendant.


2 ................................................................................. Assessment of Maternal and Neonatal Health Services in Zimbabwe
ADOLESCENT SEXUAL HEALTH AND FAMILY PLANNING
The vulnerability of women to Maternal Morbidity and Mortality is greatly increased when
women who want to limit or space future pregnancies are unable to do so because family
planning services are unavailable, inaccessible, unaffordable, of poor quality, or because their
use is restricted. It is therefore of utmost importance to reach young women and men at the
onset of their reproductive age, as well as all other adults, and prepare them for their future
choices with appropriate access to information and services.

Definitions of Essential Obstetric Care
Three levels of Essential Obstetric Care can be distinguished:

OBSTETRIC CARE FIRST AID
First Aid services can be provided in various degrees at all levels of the health system. In
order for a woman with a complication to reach a Basic or Comprehensive Emergency
Obstetric Care facility, peripheral health facilities need to be staffed, trained and equipped to
stabilize the leading complications (bleeding, infection, hypertension), long enough to allow
the woman to safely reach the next level of referral. These first aid services can be provided
at the majority of all health facilities.

BASIC EMERGENCY OBSTETRIC CARE
BEmOC refers to an (abbreviated) list of services that can save the lives of women with
obstetric complications. A health facility qualifies as a BEmOC facility if it has performed
each of the following “signal functions” at least once over the preceding 3 months7:
1) Provision of parenteral antibiotics
2) Provision of parenteral oxytocics
3) Provision parenteral sedatives/anticonvulsants
4) Manual removal of placenta
5) Removal of retained products of conception (MVA or D&C)
6) Assisted vaginal delivery (Vacuum/Breech Extraction)

COMPREHENSIVE EMERGENCY OBSTETRIC CARE
To qualify as a CEmOC facility, all of the above services are offered, but in addition the
following 2 functions are performed:
7) Caesarean Section
8) Blood Transfusion

UNICEF, WHO, and UNFPA all recommend that there should be at least 1 facility that offers
CEmOC for every 500,000 people and 4 facilities that offer BEmOC for every 500,000
people.




7
       Data collected on the signal functions were not sufficient to calculate the coverage of BEmOC services in
       the country.
Assessment of Maternal and Neonatal Health Services in Zimbabwe ....................................................................................................................... 3
Four Levels of Institutional Health Care in Zimbabwe
The public health delivery system in Zimbabwe is designed around 4 referral levels
consisting of, in increasing levels of sophistication:
 Primary (rural health centre) level;
 Secondary (district) level;
 Tertiary (provincial hospital) level; and
 Quartenary (national or central hospital) level.

Table I:              An Overview of Maternal and Neonatal Health Services by Level
Maternal and Neonatal Health Services                                      Primary           Secondary          Tertiary        Quartenary
                                                                           level             level              level           level
Antenatal Care
Counsel on pregnancy, nutrition, breastfeeding, STI‟s
and Family Planning
Refer complications of pregnancy
Detect and treat women with STI‟s/RTI‟s
Prophylaxis for Tetanus, Malaria, Anaemia
Manage most complications of delivery
Refer selected cases to provincial hospital
Maintain and distribute a supply of drugs and
prophylactic agents to the clinics
Manage obstetric, medical and surgical complications of
pregnancy and give feedback about referred cases
Delivery Care
Normal deliveries
Detect complications, manage initially and refer for
hospital delivery
Upgrade selected facilities to provide Basic EmOC
Upgrade selected facilities to provide CEmOC
Arrangement of transport for obstetric emergencies
within the district and to the provincial hospital
Manage all complications and provide feedback about
referred cases
Postpartum Care
Provide early Postpartum care
Support breast feeding
Provide breast milk substitutes to HIV positive mothers
where applicable
Provide nutrition education and supplements
Identify and initially treat puerperal Sepsis
Manage mild to moderate asphyxia of the newborn and
neonatal hypothermia
Manage all post partum complications, including
retained placenta and puerperal Sepsis
Manage neonatal problems
Manage rare neonatal problems and provide feedback
about referred cases
Provide undergraduate and graduate training for nurses,
midwives and doctors



4 ................................................................................. Assessment of Maternal and Neonatal Health Services in Zimbabwe
Justification for the Assessment

      As part of their commitment to improve Reproductive Health status throughout the
       country, the MoHCW identified the provision of adequate and accessible Maternal and
       Neonatal Health services as a priority focus.
      Signs of economic deterioration are usually reflected in Maternal and Neonatal Health
       services by shortages of supplies; the loss of professional staff; and in the steady
       deterioration of infrastructure. The present MNH survey therefore focuses on these
       particular facets of the health system to gain insight in the current state of Maternal and
       Neonatal Health services in Zimbabwe.
      The MNH survey was further designed and completed to provide data based on which
       policy, planning and other managerial and clinical decisions can be guided, as well as
       necessary interventions planned. Availability of such baseline data will aid efforts to
       implement evidence-based and result oriented programming, and eventually measure
       impact of services.
      Current data regarding access and quality of MNH services will add to the high level of
       awareness and political will regarding the concept of Maternal and Neonatal Health: they
       can support advocacy for specific budgetary allocations to Reproductive Health, and
       specifically ensure that Maternal and Neonatal Health services are maintained as a
       priority investment focus by the government and all others concerned.
      Current data regarding MNH services will also help to monitor trends in the use of
       Maternal Health services as an indicator of deterioration/improvement in the quality of
       care, and of potential increases in the Maternal Mortality Ratio.
      The use of relevant process indicators to determine the current state of MNH in this study
       will facilitate comparability of data at international level.
      The last RH assessment was conducted in 1999 by the MOHCW. The present study aims
       at updating essential information for effective and focused interventions in the immediate
       future (within one year), as well as longer-term development initiatives that can take
       place over the next 1-5 years.




Assessment of Maternal and Neonatal Health Services in Zimbabwe ....................................................................................................................... 5
Objectives of the Assessment
BROAD OBJECTIVE:
 To assess the availability, the use and, where possible, the quality of MNH in Zimbabwe.
 To fill a gap in knowledge about the leading causes of maternal death, delays in deciding
  to seek, reach and receive care, as well other avoidable factors at the different levels of
  health care.

SPECIFIC OBJECTIVES:
 To assess, at the community level:
   1) The knowledge pertaining to Maternal and Neonatal Health issues amongst selected
      community members.

    To assess, at each of the 4 institutional levels:
     2) The accessibility of care
     3) The availability of staff
     4) The availability of essential drugs and supplies for MNH
     5) The availability of equipment

    To determine:
     Factors that prevent adequate provision and use of quality MNH services

    To make recommendations:
     For specific actions to be taken to address each of the three delays, according to each
     institutional le




6 ................................................................................. Assessment of Maternal and Neonatal Health Services in Zimbabwe
METHODOLOGY
The survey was conducted by the MOHCW in partnership with UNICEF, WHO and UNFPA.
The survey was to designed to solicit information from sub-district, district, provincial and
national level health personnel in relation to their MNH tasks and functions, and volunteer
informants from the community.

Interview/data collection tools used
Assessment of the coverage and utilization of MNH in Zimbabwe was a cross sectional
study, combining: staff interviews; the review of the availability of essential drugs, supplies
and equipment; and questionnaires presented to selected community members.

Generic, structured UN questionnaires and checklists developed by AMDD (Averting
Maternal Mortality and Morbidity, Columbia University) and UNICEF were used for the
survey, after these had been adapted to suit the Zimbabwean situation at a preliminary
meeting by all stakeholders.

Comprehensive checklists were adopted, listing the essential drugs and supplies, and
appropriate instruments and related equipment per level of health facility.
    A different questionnaire was used for each of the 4 institutional levels, each one tailored
to level-appropriate norms for staff cadres, equipment, essential drugs and supplies.
    The respondent selected for this questionnaire was the most senior person directly
involved in the provision of MNH services at the institution.

For the community element of the study, 3 different questionnaires were used: 1 for women
of reproductive age (15-45); 1 for men; and 1 for youth (female and male).
    Three community members from each of these 3 categories were interviewed for each
health facility visited. In total, 646 women, 769 men, and 1,615 youth were interviewed. The
average age of women was 27.6, and they had a mean number of pregnancies of 3.
    Female respondents were women who had been pregnant in the previous 2 years. Male
respondents were husbands or spouses of women who had been pregnant in the previous 2
years.
    The community level instrument was designed to assess the individual‟s knowledge about
possible complications during pregnancy and childbirth, and also to assess her/his health-
seeking behaviour in case of complications occurring during pregnancy.

In total, the study gained information through 7 different survey tools.

The staff interview was conducted by one of the enumerators of the survey team.

The review of the availability of essential drugs, supplies and equipment was done as part of
the staff interview, e.g. the inventory of selected essential drugs and equipment was
conducted by asking nurses in charge or medical personnel on duty, and by physically
checking for the availability and functionality of such supplies and equipment.

Assessment of Maternal and Neonatal Health Services in Zimbabwe ....................................................................................................................... 7
The assessment of the knowledge base in the community was attained by approaching
spontaneously selected community members identified at various distances from the health
facility under survey, at growth points and shopping centres, and requesting them for
cooperation with the study. Patients being attended to in the health institutions were not
included in the study. If cooperation was denied for any reason, another person would be
asked to provide their informant service.


Tools for Monitoring the National MNH Programme

A list of indicators for monitoring a Maternal and Neonatal Health program was jointly
developed by WHO, UNFPA and UNICEF.
    The UN process indicators are based on the understanding that, in order to prevent
maternal deaths, certain types of obstetric services must be available. These services must be
used in sufficient quantity, and the women who experience life-threatening obstetric
emergencies use them. The indicators give an indication as to whether women‟s lives are
being saved as a result of the programs put in place.

For this assessment the following process indicators for MNH were used:
1) Skilled Attendance at delivery
2) Number of facilities providing BEmOC per 500,000 population
3) Number of facilities providing CEmOC per 500,000 population
4) Met Need: proportion of total number of obstetric complications treated in MNH facilities
5) C-section as a proportion of all births in the catchment population
6) Case Fatality Rate: total number of maternal deaths from direct obstetric complications
   among the number of women admitted with these conditions
7) Maternal Mortality Ratio: number of maternal deaths per 100,000 live births
8) Perinatal Mortality Ratio: number of newborn deaths in 1000 live births

Geographic Sampling
All 10 provinces in the country were included in the survey: Mashonaland West;
Mashonaland East; Mashonaland Central; Matabeleland North; Matabeleland South;
Masvingo; Midlands; and Manicaland were considered the eight rural provinces. Harare and
Bulawayo were the two urban provinces.
   For the assessment, three districts from each province were selected on the base of their
higher MMR and bigger population size.

In total 24 districts were assessed, with a range from 33% district coverage in Mash East to
50% district coverage in Mat South. For analytic purposes, the population in the sampled
districts was contrasted with the population of the total provincial population, and the range
was from 32% in Mash East to 67% in Mash West. On average, 42% of all districts were
sampled with a percentage of population covered at approximate 47%. Details of this
sampling frame can be seen in Table 55 in the Annex.



8 ................................................................................. Assessment of Maternal and Neonatal Health Services in Zimbabwe
Preparation and Technical training
A workshop with all parties and experts concerned was held to adapt existing, generic UN
questionnaires for the specific context of Zimbabwe, and the four different levels of health
care.
    These adapted data collecting tools were pre-tested at one health facility at each of the
four levels.

Two consultants were hired to supervise and lead the training of the required data collection
teams, the training of data entry clerks, and to analyse and finalise the outcome of the study.

Selection and training of interviewers
After selection criteria were discussed and agreed upon by all partners, two groups of people
were identified as appropriate interviewers: senior health personnel were drawn from the
provinces to be trained as enumerators, while senior provincial managers were to serve as
supervisors.
    A three-day workshop was held to train 40 enumerators and 10 supervisors. The
workshop was facilitated by the two consultants mentioned above, the MoHCW RH
coordinator and partners from UNICEF, WHO and UNFPA.
    The objective of the training was to enhance knowledge and skills of the participants to
carry out the task of interviewing, and to review and practise the relevant tools and data
collection techniques.

Ten provincial teams comprising of four enumerators and one supervisor were set up. In
order to minimize bias, none of the enumerators were derived from the province in which
they worked. The supervisors however, were drawn from their home provinces in order to
retain someone in the team who could interpret the particularities of the health system and
relevant people in that province.

Four national level teams comprising of two members each were responsible for the overall
supervision of the fieldwork completed.

Fieldwork and monitoring of the study execution
Interviews of staff members were conducted by each of the four team members, and the
supervisor‟s role was to continuously check the quality of the data gathered in the field and to
collect the questionnaires once they had been completed. The supervisors were also
responsible for sending the completed questionnaires to the supervisory teams at MoHCW
headquarters.

Data management and quality control
Four data entry clerks were hired and trained by the consultants regarding the data entry
process. The programs Epi Info 2002 version 1.1. and MS Excel software were used in the
data entry and analysis process.




Assessment of Maternal and Neonatal Health Services in Zimbabwe ....................................................................................................................... 9
Good quality of the data was ensured by:
 Familiarization of the enumerators and supervisors with the tools during training and pre-
   testing
 Checking for completeness and consistency, and rectifying any detected errors during the
   fieldwork by the supervisors before they collected the completed questionnaires from the
   enumerators
 Supervision of the data entry process by the 2 consultants. The entered data were also
   checked for completeness and correctness by the consultants.

Limitations of the study design
As in any study design, there are always particular strengths as well as limitations. Several
specific limitations can be outlined as follows:

Sampling:
 The facilities selected for the survey included mission and private hospitals, which have
   different systems, e.g. for staffing. For particular sections of the study analysis these
   facilities had to be excluded in order to avoid skewing of the results.
 Some CEmOC facilities were likely to be left out of the survey because some districts
   were not sampled.

Data collection:
 While a large amount of data was collected, not all data could be used for the analysis.
 Analysis and presentation of the data were not always conducted in similar ways, thus
   limiting consistent comparison between levels of care. For example, staff levels were
   presented in percentages for the primary and secondary facilities, while for the tertiary
   level actual number of staff cadres and occupancy rates were calculated.
 The six signal functions of Basic Emergency Obstetric Care were not consistently
   assessed throughout all potential BEmOC sites, making it impossible to calculate
   coverage of this important indicator.
 The actual, average time required to travel from the community to the nearest health
   facility, and/or from one referral level to the next was not assessed, thus disallowing a
   more practical analysis of the actual hours lost in deciding, and reaching care.
 Women, men and youth were not divided by age, thus limiting insight in knowledge gaps
   by age level.
 There was a lack of clarity about staffing norms and actual posts which limited
   facility/level specific analysis of staffing patterns.
 There was a lack of clear standard lists for essential drugs and equipment, thus limiting
   the preciseness of the analysis for this part of the assessment.
 Incomplete records in some facilities caused information gaps for some aspects of the
   study.

Dissemination of the study findings
The findings and recommendations of the study are to be used by the Ministry of Health and
Child Welfare for policy review regarding the national Maternal and Neonatal Health care

10 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
programme, with special emphasis on the reduction of Morbidity and Mortality. The results
will also be disseminated through meetings at the facilities studied, through workshops and
meetings with partner agencies and donors in order to sensitise them regarding the health
system performance with respect to EmOC services.

Conceptual framework of the findings
Maternal Mortality is never caused by one isolated factor, or by one section of the health
system alone. Rather, the interaction of many different factors contributes to the illness, and
eventually the death of a woman anticipating or experiencing childbirth. The unavailability
of a skilled birth attendant at the first referral level, inaccessible health facilities, and
inadequate transport are just a few examples of a long list of those factors.
    In order to gain the most insight from the findings of the study, it is important to bear in
mind that the main elements of the study focus, i.e. staffing levels, availability of essential
drugs, equipment and supplies, and transport and communication. These elements are
embedded in a continuum of factors contributing to MMR and PMR, and can be seen as only
some of the, albeit extremely important, links in a chain of unfortunate events that may lead
to disability of death.

In recognition of this, the concept of “the three delays” provides a practical framework
through which factors relevant to the reduction of MMR can be unravelled and effectively
addressed. The 3 delays can be briefly outlined as follows:

First Delay:         Recognizing the need for medical care, and in deciding when to seek
                     medical care
      Lack of knowledge about complications of pregnancy and childbirth and lack of
       recognition of the seriousness of the symptoms contribute to delay in recognizing the
       need for medical care, whereas lack of confidence in the medical system, concern about
       the distance to be travelled, cost of the services, traditional beliefs and poverty related to
       low socio-economic status often contribute to delay in deciding when to seek medical
       care.

Second Delay: Reaching a medical facility that provides needed care.
 The unavailability and the inaccessibility of facilities and lack of transport and
   communication leads to delay in reaching needed care. Furthermore, even if
   transportation is available, financial constraints may prohibit women from utilizing these
   services.

Third Delay: Receiving adequate and appropriate treatment.
 Unavailability of staff, insufficiently trained staff, and lack of the proper drugs, supplies
   and equipment leads to low quality of care as well as delays in receiving treatment.
   These conditions are further exacerbated by out-migration of health workers, as well as
   illness and death amongst civil servants as a result of the HIV pandemic. Furthermore,
   many essential drugs, equipment and supplies require foreign exchange, which has
   become increasingly scarce.


Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 11
PRESENTATION OF FINDINGS

First Delay: Deciding to seek care
PERCEPTION OF PREGNANCY RELATED COMPLICATIONS AND BARRIERS
TO CARE

Women of reproductive age
In total, 846 women were interviewed. The mean age of the                                                                                          35 percent of all women
women was 27.6 years, and the mean number of pregnancies                                                                                                   who experienced
                                                                                                                                                      problems during their
per woman was 3.6.
                                                                                                                                                     most recent pregnancy
                                                                                                                                                      nevertheless chose to
Of all women, 86.7% responded positively when asked                                                                                                stay at home to deliver.
whether they knew any complications or problems related to
pregnancy and childbirth. The remaining 13.3% did not
know of any problems.

All the possible complications of pregnancy mentioned were, in order of frequency:

When asked whether they knew
                                                               Complications of pregnancy mentioned
any problems of delivery or the                             25.0
immediate post-delivery period                                                                                                             Women                        Men




                                                                                                                                                                                                                                     19.8
                                                                         19.3




                                                                                                                                                                                                                         18.9
                                                                                                                                                                                         16.9
                                                            20.0
that could put the life of the baby
                                                                                        15.0




                                                                                                                                                                              13.7
                                                                                                                                                 13.5




in danger, 84.2% of all women                               15.0
                                                                                                                                                            10.4




interviewed responded positively,
                                                                                                                                         9.5




                                                            10.0
                                                                                                                                                                                                             7.2
while 15.8% did not know of any
                                                                                                                             6.7




                                                                                                                                                                                                    4.4

problems thus associated.                                     5.0
                                                                                                    1.3
                                                                                                                0.3




                                                              0.0
The     three   most frequently                                                in
                                                                                 g
                                                                                                        fit
                                                                                                            s
                                                                                                                                  he
                                                                                                                                     s
                                                                                                                                                       m
                                                                                                                                                        a
                                                                                                                                                                                 ai
                                                                                                                                                                                     n
                                                                                                                                                                                                      m
                                                                                                                                                                                                       ia
                                                                                                                                                                                                                           es
                                                                                                                                                                                                                                s.
                                                                           d                       s/                         c                    e                            P
                                                                                                                                                                                                 ne                      pr
                                                                        ee                       on                        da                   ed                           o.
mentioned problems among the                                        B
                                                                     l
                                                                                           ul
                                                                                               si
                                                                                                                  H
                                                                                                                      ea                       O
                                                                                                                                                                       ab
                                                                                                                                                                         d                      A
                                                                                                                                                                                                                   oo
                                                                                                                                                                                                                     d
                                                                                        v                                                                          e                                            bl
                                                                                     on                                                                         er
84.2% of women were:                                                                C
                                                                                                                                                       Se
                                                                                                                                                            v
                                                                                                                                                                                                       H
                                                                                                                                                                                                        ig
                                                                                                                                                                                                            h


 Responses that fitted the                                                                                                                                                                                               figure 1
    description of low apgar
    (37.3%)
 Prematurity (28%)
 High fever (9.1%)

Of all women, 29.5% had experienced problems during their most recent pregnancy, while
70.5% had not.
    Of those who had had problems, 65% sought help, while 35% stayed at home.

Of the 65% of women who sought help, the majority approached a medical facility or
medical person first:


12 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
      Of all respondents, 96.4% said that they had sought Antenatal Care during their most
  recent pregnancy whilst 3.6% said that they had not. The majority of women (75%) went
  to a primary health facility for ANC whilst another 20.5% went to a district or provincial
  hospital.
  Reasons mentioned for not seeking ANC by the women who had not were:
   The clinic is too far,
   No transport is available, and
   The service fee at the clinic is too high

   Places where help first sought (n=471)                                                         Places approached by respondents
                                    Clinic (44.5%)                                                         for ANC (n=449)
                                                                                                                                                     Clinic 75.7%



 Pvt. clinic (0.7%)
Pvt. doctor (3.0%)

                                                              Spirit. healer (3.0%)
                                                              Tradi. healer (2.2%)

                                                            TM (4.4%)                           Pvt. clinic 1.3%
                                                                                                Pvt. doctor 1.3%


                       Hospital (42.2%)
                                                                                                            Hospital 20.5%
                                                                                                                                       Other 1.1%

                                                                        figure 2                                                                                           figure 3

  Of all deliveries, 18.7% were performed by traditional midwives while another 20.1% were
  attended by other unskilled individuals.

  Most common specific reasons for not having had skilled assistance at birth were:

        The clinic is too far (20%)
        Lack of transport to the clinic
         (23.6%)                                                                         Reasons for not being delivered by a health
        Lack of staff at the clinic (10%)                                                             worker (n=89)
                                                                                                          Lack of transport
                                                                                                               23.6%
  However, the greatest number of                                                                                                                      Clinic too far
                                                                                                                                                           20.2%
  women (38%) gave many different
                                                                                              Service fee too high
  reasons for not having been attended to                                                            3.4%

  by a health professional, ranging from                                                     No staff at the clinic
                                                                                                    10.1%
  “sudden, forceful onset of labour” to
  “domestic disputes”.
                                                                                                                                         Other
                                                                                                                                         42.7%

                                                                                                                                                                            figure 4




  Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 13
Men
A total number of 769 men were interviewed. The average number of children among them
was 3.

When asked whether they knew any problems or complications of pregnancy that could put
the life of a mother in danger, 84.6% responded positively, whilst 15.4% did not know of any
problems.

The most common problems mentioned among the 84.6% of men were:
 High blood pressure (19.8%)
 Severe abdominal pain (16.9%)
 Bleeding (14.9%)

The men‟s reported knowledge of complications during delivery or soon after delivery that
can put the life of a baby in danger was more limited than that of the women: 78.3% of the
men said they knew of such complications
                                                Complications of pregnancy mentioned by women
whilst 21.7% said they did not.                                       (n=846)
                                                                                                      Convulsions/fits
                                                                                              Headaches    1.3%
                                                                                                                         Bleeding
The most frequently mentioned problems                                                           6.7%
                                                                                                                          19.3%

were:
 Descriptions matching low apgar                                                      Oedema
                                                                                        13.5%

   (31.9%), and
 Prematurity (28.7%)
                                                                                                                            High blood pressure
                                                                                   Severe abdo. Pain                               18.9%
When asked what they would do if their                                                   13.7%
                                                                                                              Anemia

wife/partner experienced problems during                                                                       4.4%

                                                                                                                                            figure 5
pregnancy, the most frequent answers
were:
 Take her to the clinic (73.7%), and
 Take her to a private clinic (5.5%)

Like with the women interviewed, there                                   What men would do if their wife/partner experienced
were an additional rather large percentage                                     problems during pregnancy (n=544)
of men who thought of many other ways
                                                                             to a pvt. clinic (5.5%)
to approach the crisis of their wives, ways                               to a comm. HW (2.0%)
that cannot be specified within the context                                      to a TM (3.7%)
                                                                        to a trad. healer (3.1%)
of this report. Another group of men                                           No action (0.4%)                                to the clinic (73.7%)

(approximately 8-10%) thought it best to
                                                                                  Other (11.6%)
approach local traditional healers of
midwives, and a few men considered it
best “to wait and see” and take no action.
(See tables 47-49 in Annex.)
                                                                                                                                            figure 6




14 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Discussion
As appears from the community level data gathered above,
                                                                             A considerable
although a large amount of women opt to seek ANC, a
                                                                      percentage of women
considerable percentage of women who did develop a
                                                                           who developed a
complication stayed at home for the delivery of their baby. At      complication stayed at
the same time: despite the fact that the majority of women did    home for the delivery of
have skilled attendance at birth, there still are a significant                 their baby.
number of women who did not. The responses given point in
the direction of the following barriers to care:
 “Family disputes”: family practices and traditional attitudes, and the powerful role of
    other members of the extended family prevent or delay women from help in getting care
    or deciding to get care independently.
 Lack of knowledge regarding appropriate care: Of the women who developed
    complications and did manage to seek care, 10% still opted to go to traditional midwives
    or healers, i.e. unskilled birth attendants.

The data also indicate that although a large amount of women
                                                                           A great variety of
and men do have some knowledge regarding problems that                  socio-cultural factors
may occur during pregnancy and childbirth, their knowledge           influence health-seeking
remains general and not specific enough to see the need for                   behaviour in the
taking urgent action.                                                              community.
 A large amount of women and men e.g. describe a problem
    as “severe abdominal pain”, or “headaches”, realising the existence of a problem, yet not
    connecting symptoms with a specific pregnancy related syndrome.
 The lack of responses describing “convulsions/fits” indicates a similar lack of knowledge
    regarding one of the main serious complications of pregnancy: eclampsia.
 The obvious signs of bleeding are recognised by a rather large percentage of women, but
    again it is not clear symptoms are being understood as related to a specific complication.
 Besides mentioning symptoms that are indicating serious pregnancy related problems, the
    largest percentage of male respondents described reasons for illness that do not
    necessarily match such problems: inability to connect specific symptoms of illness to a
    serious pregnancy related problem may cause delayed
                                                                          The fact that most
    action for a pending life threatening situation, when
                                                                         frequently mentioned
    observed problems are not taken seriously enough.                   problems of newborns
 As complications endangering the life of a newborn, both               are characterized as
    men and women most frequently described symptoms that                 prematurity and low
    describe “low Apgar” and “prematurity”. Here of note is:             Apgar, give evidence
    Once more, complications are described by means of               that HIV AIDS leaves a
    symptoms: a connection between danger signs and the                       heavy toll in the
    underlying problem is not apparent.                                            community.
 It is known that there is a direct correlation between
    HIV/AIDS and positive mothers and babies born prematurely, as well as babies with low
    apgar scores. The fact that the most frequently mentioned problems of newborns by both
    women and men are characterized as prematurity and low Apgar (over 60%), gives
    evidence that HIV/AIDS leaves a heavy toll in the community of women of childbearing
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 15
     age and their newborns, without the necessary awareness among community members
     regarding the devastating effects of the illness on newborns. Similarly, malaria, maternal
     malnutrition, syphilis and other diseases during pregnancy may also contribute to
     problems that community members associate with low Apgar scores.
    A large percentage of men either considered many different symptoms that may not
     necessarily describe a life –threatening condition for a newborn, or mentioned signs
     without necessarily relating these to a serious condition: Lack of awareness of danger
     signs thus appears acute.
    Whether they share a correct recognition of danger signs with their pregnant wives or not,
     the majority of men (79%) will try to take their women to clinic when there is evidence of
     unusual pregnancy or delivery related distress. The complications of these women who
     have support from home will have a reasonable chance of a positive outcome if a well-
     functioning EmOC system is in place.
    It is the 20% of women who develop complications while         Even when transport was
     not having support from their husbands or relatives for              available, a lack of
     seeking professional medical attention that have much less         economic means often
     chance: their first barrier to help starts at home and their      prevented women from
     tragic outcome of pregnancy may stay at home, before               seeking help from the
     having even reached the first level of health care.               formal health system.


Other barriers to regular delivery care are quoted to be:
 Transport: either the clinic is too far away, or most people who did not seek help do not
   have access to public or private transport. If transport is available, a lack of economic
   means prevented women to seek help from the formal health system.
 The overall downward trend of socio-economic conditions for the people in Zimbabwe
   will continue to be most severely felt in the least affluent regions of the country. Lack of
   financial means is therefore a real barrier to care for many women facing labour and
   delivery. The growing influence of deteriorating economic
   conditions on the road and transport system in the country         Knowledge of pregnancy
   should be considered a growing barrier to care as well.           related complications are
                                                                                                                    general and
                                                                                                           symptomatic, rather
Knowledge regarding Family Planning and HIV/AIDS
                                                                                                             than informed and
among the youth
                                                                                                                       specific.
One of the most effective ways to prevent maternal death is to
prevent unwanted pregnancy. Universal access to Family
Planning is thus a critical component of an effective national MNH programme.

A total of 1,284 youth were interviewed: 619 young women, and 666 young men.
The average age of the youth was 18.8 years. The lowest age was 10, whilst the highest was
24 years. Females comprised 48.2% of the youth, and males 51.8%.




16 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Of all the young women, 91.6% said they knew methods that a
young couple could use to avoid becoming pregnant, whilst                                                                               One of the most
                                                                                                                                       effective ways to
90.2% of the young men knew of such methods. Methods
                                                                                                                                prevent maternal death
mentioned, in order of highest frequency, were:
                                                                                                                                 is to prevent unwanted
 The male condom (28.1%)                                                                                                          pregnancy. Universal
 The pill (24.5%)                                                                                                                      access to Family
 The female condom (14.7%)                                                                                                         Planning is a critical
 Abstinence (14.6%)                                                                                                                    component of an
                                                                                                                                         effective MNH
Other methods were much less frequently mentioned, and                                                                                        programme
apparently less known.

Places most frequently used as source of information regarding Family Planning were:
 Health facility (33.5%)
 School (21.4%)

Much less frequently mentioned were:
 TV and radio (13.7%)
                                                                                     Sources of contraceptives as mentioned by
 Community workers (10%)                                                                          youth (n=814)
 Poster/flyers (5.7%), and                                                                                                                  Health facility
                                                                                                                                                53.3%
 Youth clinics (4%).
                                                                                      Community worker
Places most frequently approached by                                                      12.4%

young people in order to obtain                                                                Youth clinic
                                                                                                  2.8%
contraceptives, were:
                                                                                                Private clinic
 Health facility (53.3%)                                                                           4.4%


 Community Worker (12.4%)
                                                                                                          Pharmacy
                                                                                                            10.9%                  Other
                                                                                                                                   16.1%
 Pharmacy (10.9%)                                                                                                                                               figure 7

A considerable amount of youth sought other, not precisely described ways to obtain
contraceptives.

Of all youth, 34.3% were currently using a contraceptive whilst 64.7% said that they were
not. Of the young women interviewed, 26.7% were currently using a contraceptive, whilst
of the young men 47.5% said to be doing so.
    Among the young men, 47.3% said they ever used a condom, versus 12.8% among the
young women.
    Overall, 69.4% had never used a condom before, the most dominant reason for which
was: not being sexually active.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 17
Perception of barriers to the use of contraceptives among youth
The most commonly mentioned reasons for non-use of contraceptives among young people
were:                                           Factors that might prevent young people
 Lack of knowledge (31.6%)                                using contraceptives (n=668)
 Shyness/embarrassment (29.5%)                                       Lack of knowledge
                                                                            31.6%
 Negative attitude of health providers
                                                      Lack of money
   (14.5%).                                                8.4%

 Lack of money and lack of services
                                                                                        Lack of services
                                                                                              6.9%

   were other, albeit less prominent           Negative provider atti                   Other
                                                      14.5%                             9.1%
   reasons mentioned.

                                                                                                       Shyness
Most of the youth (72.4%) said they                                 29.5%

would like to be tested for HIV: 80.3% of                                             figure 8
the young men, whilst 73.9% of the young
women indicated a willingness to be tested.
    The majority of youth (78.4%) also said they were aware of a place where they could be
tested for HIV.
    Of all young men participating in the survey, 21.1% said they had been tested for HIV
before, and 11.9% of all young women said to have been tested before.
    New Start Centres featured as the most frequented place for possible testing (48.7%),
followed by health facilities (33.8%).

Regarding ways to prevent HIV/Aids, the                                     Places for HIV testing as mentioned by
                                                                                         youth (n=532)
youth mentioned most often:
 Condom use (45.7%), and
                                                                                                                       Health facility
                                                                                                                          33.8%

 Abstinence (37.8%).
(See tables 50-54 in the Annex.)
                                                                            New Start Centre
                                                       48.7%                        Others
Discussion                                                                           2.6%
The percentages of young women and
men showing awareness of one or more                                          Private clinic/hosp.
                                                                                     14.8%
ways to prevent           pregnancy are                                                         figure 9
commendable. The above data on current
use may indicate a discrepancy between knowledge and actual
use of contraceptives, especially for young women, who, as the        Although the knowledge
data indicate, know more about contraceptives, but use them less         of family planning is
                                                                     high, only 15% of young
than young men. Low rates for condom use among young
                                                                        women versus 47% of
women is confirmed by the 2004 study done by the MOHCW in
                                                                     young men used condoms
collaboration with USAID and the national AIDS council: the            to protect themselves
study reported that only 15% of young women versus 47% of             during their last sexual
young men used condoms to protect themselves. The much                                 encounter.
lower percentage of young women currently using a
contraceptive than that of young men using one suggests a higher barrier to protect
themselves for young women. That, combined with the notion that young women exposed to
unprotected sexual activity are the ones left with the burden of pregnancy and delivery, and
18 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
thus with the risk of complications of childbearing at an early age, is of critical concern. It is
also known that women's risk of infection during unprotected sex is as much as 2 to 4 times
higher than men's. The physiology of younger women puts them at even greater risk of HIV
infection. In many countries, and especially in sub-Saharan Africa, infections in adolescent
girls outnumber those in adolescent boys by a ratio of 2 to 1.

Considering that approximately 1/3 of all youth are sexually
active, as indicated by the responses of the youth in this study,       Although 1/3 of the
1/3 of all youth claim not to know of any methods of                  youth respondents are
                                                                       were sexually active,
contraception, and 1/3 of all youth feel too shy or embarrassed to
                                                                    1/3 claim not to know of
seek protection from unwanted pregnancy, there seem to be a lot
                                                                               any method of
left to do in the area of informing and counselling young people.              contraception.
The data suggest that, specifically, attention should be given to
prevailing attitudes and norms regarding the ability of women to
demand safer sex, or to protect themselves from unwanted or risky sexual relations.

With the knowledge that a considerable amount of youth (more than 50%) choose to
approach health centres in order to gain information and to obtain contraceptives, pressure is
brought to these centres to perform well in their function as F.P. services provider. It can be
noted from the gathered survey data, however that the negative attitude of health staff very
often encountered by the young people will heighten the barrier to seek protection, or may
result in the not returning of young people in need of Family Planning services.

Positive is the large percentage of young people who are willing
                                                                       Negative attitudes of
to be tested for HIV, and the extensive role that firstly, New
                                                                     health staff, adversely
Start Centres and secondly, health facilities seem to be playing
                                                                         affect willingness of
in this regard. Of note is here again that the percentage of young      young people to seek
men wanted to be tested for HIV is larger than that of young         family planning services
women.
    Regarding the prevention of HIV/AIDS: it is interesting to
note the different perception of the youth regarding the use of condoms as a means of
protection against unwanted pregnancy and regarding it a means of protection against
HIV/AIDS: more than 45% of youth saw the condom as an effective means to prevent
HIV/AIDS, while a mere 28.1% knew the condom as a contraceptive means to prevent
pregnancy. Inconsistent use of the condom may result from seeing this contraceptive as
serving 2 different purposes, and suggests that a condom is more readily used when exposure
to HIV/AIDS is suspected.

Second Delay: Reaching care
COMMUNITY AND PRIMARY LEVEL: TRANSPORT AND COMMUNICATION
As mentioned under first delay, the two main reasons for staying at home rather than seeking
ANC and skilled attendance at birth in a medical facility were:
 Too long a distance to a health facility, and
 Lack of transportation.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 19
According to the present data, the maximum distance which a               Accessibility to the
person has to travel in order to get to a Primary Health Care                MNH services is
centre was 160 km. Considering that the goal of MoHCW is               severely hampered by
that every person in the country lives within 10 km of a              distances between the
primary health centre, this is a very long distance, even when      community and facilities,
translated into hours of travel needed to reach a facility by            or from one level of
road. The National Assessment of Essential Obstetric Care              referral to the next.
carried out in 2000 showed that only 41% of the population of
Zimbabwe live within an 8 km radius of a place offering MNH and at the same time
acknowledged the fact that this does not imply access in all cases.

The majority of people living in the rural areas have no private transport and public transport
usually only runs at specific times. Fees for public transport such as combis or minibuses are
often prohibitive, and even more so for taxis if they are available.

Ambulance transport has often not been available at the community level, and thus far has
never served the function of reaching out into the community. If available, they were rather
meant for transportation to other, higher levels of care. The concept of village ambulances,
which is being introduced at the community level at the time of the presentation of the current
study data, will hopefully improve some of the transportation problems of villagers.
    Overall, transportation remains a true barrier to health care at the community level: Of all
primary health care centres assessed, 47% had no ambulance transport available in case a
patient needs to be referred to a higher level of health care, thus compromising the quality of
care offered to patients who need EmOC and causing serious delays in the appropriate
medical care provided.

Of all primary health care centres 41% had no telephone
facilities available, whilst in 14% the telephone system was                                             Of all primary health
not functioning.      A functioning radio system was only                                              care centres assessed,
available in 16% of the centres, whilst at 21% it was                                                  47% had no ambulance
available, but not functioning.                                                                        transport available for
                                                                                                                     referral.

SECONDARY LEVEL HEALTH FACILITIES:
TRANSPORT AND COMMUNICATION
The maximum distance from the furthest referring centre was 315km. For the same reasons
as those noted with the primary health level facilities, this is a very long distance to travel
with a patient who needs emergency care.
    Only 1 out of 31 secondary level institutions did not have a functional telephone.
    All the secondary institutions had an ambulance system in place. However it is important
to note that the status of these ambulances was not verified and it may be assumed that a
considerable number of vehicles may not be functioning, or may not be available for
emergency transport 24 hours a day, 7 days a week.




20 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
TERTIARY HEALTH CARE LEVEL FACILITIES: TRANSPORT AND
COMMUNICATION
Excluding the two private hospitals in Harare and Bulawayo, the maximum distance from the
furthest referral centre is 300 km (mean distance 208 km), and to the next level referral
centre 300 km (mean distance 144 km). Even when interpreting these distances in the light
that there is usually an intervening district hospital between a tertiary institution and a
primary level facility, time needed to reach a tertiary health level facility will be substantial.

QUARTENARY HEALTH CARE LEVEL FACILITIES: TRANSPORT AND
COMMUNICATION
The distances from the furthest referring institutions were all
                                                                         Transportation and
above 250 km, and the distance from the furthest referring          communication problems
institution to Harare Maternity Hospital is 800 km. Like with      exist at all levels but to
the tertiary institutions, even when there are other intervening   varying degrees. There
hospitals that may be reached earlier, these long distances may           is a clear need to
prevent positive outcomes in cases needing specialist attention.          undertake further
     All of the 4 quartenary facilities included in the assessment         analysis of these
have a functioning ambulance transport system. Like with the         resources as part of a
tertiary facilities, accurate information regarding the number of       national strategy to
vehicles that were actually in running order, were not available       strengthen the MNH
                                                                                 programme.
however.

Discussion
The availability of ambulance transport between the 4 different levels of health care facilities
is of crucial importance for the realisation of prompt and expert EmOC care.

Table II:                   Time required reaching Care and Means of Communication
Level of Care                 Community to                              Primary to                       Secondary to                          Tertiary to
                              primary                                   secondary                        tertiary                              quartenary
Avg. Maximum                  160 km                                    110                              208                                   > 250 km
Distance                                                                (7-315)                          (144-300)
Means of                      47% had no ambulance                      100% had                         100% had ambulance,                   100% had ambulance,
Transport                                                               ambulance, but not               but not clear if they                 but not clear if they
                                                                        clear if they were               were roadworthy                       were roadworthy
                                                                        roadworthy
Estimated avg.                4 hours                                   2.5 hours                        4 hours                               4-6 hours
travel time
Means of                      Very limited,                             All but one had                  All had telephone                     All had telephone
Communication                 occasional cell phone                     telephone

A number of gaps become clear through the assessment:
 Transportation and communication problems exist at all levels, but to varying degrees.
   The community and primary health facility level are set back the most in terms of having
   reliable means to communicate and transport patients in need of EmOC.
 For the secondary, tertiary and quartenary facilities: although these facilities are well, or
   at least reasonably, endowed with installed transport and communication systems, the
   state of especially the transportation systems can be questioned. Ambulances and roads
   may be in a state of disrepair, and fuel supplies have tended to be erratic over the past few

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 21
     years. Due to the present economic conditions in the country vehicles are in short supply
     and not regularly being serviced.
    Distances to and from all level health care facilities, and between levels of care, are
     prohibitive for the ensuring of a quality continuum of EmOC from one level to the next.
     The delays encountered in referral from one level to another, indicate demand for very
     clear procedure and treatment protocols for each level of care, by staff cadre, and by each
     type of complication, in order to avoid unnecessary bypassing of health care levels and
     thus delaying the reaching of appropriate care.
    Telephone communication between the community and primary level facilities is very
     limited.

Third Delay: Receiving care
This section presents factors related to receiving care:
 Catchment Population size
 Maternal and Neonatal Health services offered at each level
 Human resource availability by level of care
 Drugs and Supplies
 Equipment

Levels of Health Care and Catchment Populations

PRIMARY HEALTH CARE LEVEL CENTRES
The survey included 265 primary health care centres. The mean catchment area population
for these institutions was 13,147. However, when compared with all Rural Health Care
centres and clinics in the country (1,095), the average catchment population is 10,642. The
estimated expected number of pregnancies for the nation as a whole is 349,223, of which
approximately 15% (+/- 17,500) will develop complications. More pragmatically, this
translates to approximately 319 deliveries per year, or a bit less than one every day at the
Rural Health Center level.
    If 15% of these deliveries are complicated, approximately one woman every week is in
serious danger. The rural health facility must be equipped with trained staff and supplies in
order to stabilize the complication, and refer her to the secondary level.

SECONDARY HEALTH LEVEL FACILITIES AND THEIR CATCHMENT
POPULATION
The survey included 31 secondary level institutions. These comprised 22 government
district hospitals, 8 mission hospitals and 1 private maternity hospital.
    The mean catchment population for all facilities (excluding the private maternity hospital
in Harare) was 125,913 with a minimum of 5,239 and a maximum of 309,821. The mean
number of referring centres was 19, with the maximum being 51 and the minimum being 0.
    From national figures, the average district population is 197,301, with an expected
number of pregnancies of 5,919. Of these pregnancies, approximately 888 of all pregnant
women in this catchment area will develop complications every year. If the referral system
22 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
functions smoothly every district or mission hospital might anticipate 2-3 complicated
pregnancies every day of the week, throughout the year.

TERTIARY HEALTH LEVEL FACILITIES AND THEIR CATCHMENT AREAS
Among the 10 institutions of this level included in the survey were 7 government provincial
hospitals, 1 mission hospital, and 2 private hospitals. (See table 16 in annex.)

Mutare provincial hospital had the largest catchment population: 2,261,843, and Bindura the
smallest: 71,584. The catchment populations for the 2 private hospitals (Avenues clinic in
Harare and Mater Dei hospital in Bulawayo) were unknown.

QUARTENARY HEALTH CARE FACILITIES AND THEIR CATCHMENT AREAS
The assessment included 4 quartenary health care facilities.
    The catchment population of quartenary institutions includes patients referred from many
different districts and provinces besides patients from the cities themselves, and a precise
figure is hard to obtain. According to the 2002 census the population of Harare is 1,903,510
people while that of Bulawayo is 676,787 people. As an indicator for catchment population
served, the number of referring institutions to the Quartenary hospitals is used.

Table 27 in the annex shows that the number of institutions referring to a quartenary facility
ranged from 24 to 37, while the distance from the furthest institutions ranged from 288 to 800
kilometers.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 23
Maternal and Neonatal Health care services

The following table outlines the range of maternal and neonatal health care services, as well
as the number of days per week they are offered. The study also presents those services that
are (in principal) offered 24 hours a day.

Table III:    Availability of Maternal and Neonatal Health services offered by number
of days per week
Service/Level                                         Primary               Secondary                   Tertiary            Quartenary
Antenatal Care
> 4 days a week                                                -                       -                      10%                    100%
5 days a week                                               91%                   83.9%                       90%                        -
6 days a week                                               10%                    3.2%                          -                       -
7 days 24 hrs                                                9%                   12.9%                          -                       -
Normal Delivery
5 days a week                                              3.5%
6 days a week                                              2.5%
7 days 24 hrs                                               94%                    100%                     100%                     100%
Neonatal Care
5 days a week                                                n.a.
7 days 24 hrs                                               55%                    100%                     100%                     100%
Postnatal Care
< 5 days a week                                                                                                 0%                     75%
5 days a week                                               80%                   80.7%
6 days a week                                               10%                    3.2%
7 days a week                                              9.5%                   16.1%                       20%                           -
Post Abortion Services
7 days a week                                                    -                        -                 100%                     100%

Antenatal services at the primary health level are offered from Monday to Friday on a
scheduled basis, whilst 10% offer these services on 1 weekend day, and 9% on 2 weekend
days. This shows an adequate amount of hours during which ANC services are available to
the population. The hours for ANC services offered at the
secondary level and very acceptable as well. It should be kept      Overall, the hours and
in mind however, that the availability of services in hours may    days of service offered
not equal the actual services provided: due to financial and                are acceptable.
                                                                          However, without
transport problems, women may decide to not return after their
                                                                  sufficient staff, supplies
first ANC visit, and thus be at higher risk for undetected direct
                                                                   and equipment, a gap in
complications and for indirect problems such as Malaria.          service delivery remains.
Although the study did not differentiate between 1 or more
ANC visits per women, the data suggest that many women did
perhaps not receive their Malaria prophylaxis, or treatment to prevent the development of
Anaemia.

Of all primary level centres, 94% offer normal delivery services from Monday to Sunday,
around the clock, whilst 3.5% offer them from Monday to Saturday only.
     Although the percentage for services offered is very high, the aim should be that ALL
primary level facilities are up to par with their normal delivery services, in order to avoid any
24 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
unnecessary referrals to the next level of care. The same counts for neonatal services: gaps
shown in the above table indicate that a substantial number of primary level facilities are
unable to stabilise an infant before referral to the next level of care because the service is not
offered.

Overall, hours and days of services offered are acceptable, and few adjustments seem needed
in scheduling of services to make the system function optimally. Priority of focus should
therefore be on staff levels and supply availability to make the services possible.

Human resource availability by level of care

One of the most critical factors related to receiving Maternal and Neonatal Health services is
the availability of trained service providers. This section outlines specific Maternal and
Neonatal care skills by staff cadre, and is followed by an analysis of staffing patterns by
institutional level. Overall, it appears as though there may be sufficient midwifery staff in the
country to support a national MNH programme, but as they are responsible for many other
tasks and functions beyond MNH, and because they are more often located in the urban areas,
rural catchment populations remain under-served.

Table IV:                   Analysis of specific Maternal and Neonatal care skills by staff cadre 8
Specific intervention                                                Routine and First                                                       Basic Emergency   Obstetric   Care                         Comprehensive
                                                                     Aid Services                                                            (BEmOC)                                                    (CEmOC)




                                                                                                                                                                            Assisted vaginal delivery
                                                                                                                                             Administer parenteral

                                                                                                                                             Administer parenteral

                                                                                                                                             Administer parenteral
                                                                     Antenatal Care ANC




                                                                                                                                             Removal of retained
                                                                                                                                             Manual removal of




                                                                                                                                                                                                                                    Blood Transfusion
                                                 Years of training




                                                                                                                                                                                                            Caesarean section
                                                                                          Normal Delivery




                                                                                                                                             anticonvulsants
                                                                                                                            Postnatal Care
                                                                                                            Neonatal Care




                                                                                                                                             antibiotics

                                                                                                                                             oxytocics




                                                                                                                                             products
                                                                                                                                             placenta




Staff Cadre
Auxiliary Nurse                             ½
RN/RGN                                      3
Registered          Nurse
Midwife (RNM)
                                            3+1                      x                    x                 x               x                x
State Certified Nurse
Midwife (SCNM)
Clinical Officer (CO)                       5                                                                                                x    x    x            x                                   x
General Medical Officer                     5                                                                                                x    x    x
Pharmacist                                  3+1                      x                    x                 x               x                x    x    x       x    x      x                            x                       x
Anesthetist                                 3                                                                                                                                                           x
RN Anaesthetist                             3+1                                                                                                                                                         x
Obstetrician            /
                                            5+1+1                    x                    x                 x               x                x    x    x       x    x      x                            x
Gynaecologist
Paediatrician                               5+1+1
X:             Staff trained to provide support function for /administer specific intervention


8
    The specific tasks and functions outlined in the above table require further discussion with the MOHCW.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 25
The above table suggests a broad range of tasks and functions being provided by various staff
cadres in relation to Maternal and Neonatal Health. However, further analysis is required, to
examine which functions are actually being provided by which staff, and at which level.
Ultimately, the goal of a successful national MNH programme will be to decentralize as
many of the Emergency Obstetric Care functions to the periphery as possible.

Table V:              Analysis of availability of staff by type of facility level
Level of Institution                                     Primary                Secondary        Tertiary              Quartenary
Staff Cadre and number of staff present during
survey
RN/RGN/SCN                                                                                                             Data not available
0                                                        40%                    -
1                                                        34%                    -
2-4                                                      16%                    -
>5                                                       10%                    -                18 per facility
RNM/SCM
0                                                        54%                    0%
1                                                        26%                    3.3%
2-4                                                      12%                    23.3%
>5                                                       10%                    73.4%            35 per facility       21 per facility
Clinical Officer (CO)                                                                                                  Data not available
0                                                        Not applicable         56.7%                                  -
1                                                        Not applicable         43.3%                                  -
2-4                                                      Not applicable         -                                      -
>5                                                       Not applicable         -                                      -
General Medical Officer                                                                                                Data not available
0                                                        Not applicable         20%                                    -
1                                                        Not applicable         30%                                    -
2-4                                                      Not applicable         47%                                    -
>5                                                       Not applicable         3%               4-5 per facility      -
Obstetrician / Gynaecologist
0                                                        Not applicable
1                                                        Not applicable                          1 per facility        1-2 per facility
2-4                                                      Not applicable
>5                                                       Not applicable
Paediatrician                                                                                    1-2 per facility      <1 per facility
Nurse Anaesthesist/Anaesthesist
0                                                        Not applicable         36.7%%
1                                                        Not applicable         46.7%%           1 per facility        2 per facility
2-4                                                      Not applicable         16.7%
>5                                                       Not applicable         0%
Laboratory technician
0                                                                               16.7%
1                                                                               50%              1-2 per facility
2-4                                                                             2%                                     4 per facility
>5                                                                              0%


Discussion: Human Resource Capacity and Staffing requirements
The above table shows percentages of staff cadres for the primary and secondary health care
facilities, and the human resources available for the tertiary and quartenary levels in the
country, if categories of staff would be evenly distributed among those higher-level facilities.

26 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Most striking are the serious shortages of nurses and midwives at the primary levels of care:
40% of primary facilities had no nurse, and 50% no midwife at post.
    The need for referral to the next level of care of not only mild complications but also a
considerable number of normal deliveries becomes obvious, and the primary level thus starts
to lose viability as an essential link in the health system for
                                                                       40% of Primary Care
Maternal and Neonatal Health.
                                                                     facilities had no nurse,
    The acknowledgement that nurses can in many cases               and 50% had no midwife
perform the same essential tasks as midwives do not make up                          at post.
for this hiatus: the lack of nurses is omnipresent as well,

Of the secondary institutions, 27% are functioning with 4 or fewer midwives, and 73% had
more than 4 at post.
    Considering that at present, 81% of all deliveries at the secondary health level are
attended by midwives alone, there still is a discrepancy between demand and actual
availability of staff.

In order to manage complications beyond the midwives‟
capacity, a standard presence of 2 General Medical Officers is       20% of the Secondary
required at the secondary level health facilities. However,        level institutions visited
20% of institutions at this level had no GMO at the time of the     did not have a General
                                                                            Medical Officer.
survey, and 30% had only one in post: patients presenting at
                                                                    facilities had no nurse,
these institutions would need to be referred to a higher level of
                                                                  and 50% had no midwife
                                                                                    offered
care, thus increasing delays in receiving care and hampering the quality of MNH at post.at
the secondary level.

More than half of the secondary institutions did not have Clinical Officers who can stand in
for GMO‟s when procedures like caesarean section or evacuation of the uterus are needed.

Furthermore, over 30% of secondary facilities do not have a Nurse Anaesthetist at post at
present, which leaves no option for caesarean sections in those institutions: once more,
referrals are needed, and delays created.

The same applies for the support staff cadre of laboratory technicians: for those 17% of
facilities that do not have staff provisions for laboratory tests, and for those 50% who have
only one technician, delays in appropriate care are unavoidable.

For the tertiary level facilities of note is: if applying a minimum standard for staff cadres
based on actual population numbers served, and comparing them with numbers of staff
available for the entire tertiary level of health care, it appears an acceptable pool of human
resources needed for the medical tasks at this level, is present in the country.
    However, when looking at numbers per staff cadre actually at post per facility, the range
is very wide: some facilities have more persons per specific staff cadre than the posts
established for that particular facility, whereas other institutions end up having none of their
established posts filled.

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 27
Table 18 in the Annex shows these variations that, logically, have many implications for the
functioning of each facility.
   All provincial hospitals had one or more staff cadres missing at post:
     St. Lukes/Matabeleland North had no Paediatrician.
     Gwanda/Matabeleland South had no Paedeatrican.
     Marondera/Mashonaland East had no Nurse Anaesthetist.
     Chinhoyi/Mashonaland East had no Laboratory Technician.
     Bindura/Mashonaland Central had no Obstetrician/Gyneacologist.
     Masvingo/Masvingo had no Laboratory Technician.
     Mater Dei (private) had no General Medical Officer, no Laboratory Technician, no
        Nurse Anaesthetist, no nurses, and no midwives.
     Avenues (private) had no General Medical Officer, no Laboratory Technician, and no
        Nurse Anaesthetist.

Mutare/Manicaland, with a catchment population much larger than most provinces, had only
1 Obstetrician/Gyneacologist, and 2 Paedeatricians.

As it appears, the quality of care to patients presenting at any of the tertiary level facilities is
often compromised in one way or another. As a result, there are frequent cases of further
referral of patients, thus increasing the possibility of complications developing into more
serious conditions.

Respondents in the assessment frequently indicated lack of
                                                                                                          Respondents in the
clarity regarding the standard for established posts in their
                                                                                                       assessment frequently
facility.    In a number of facilities, where there was an                                                indicated a lack of
indicated number of established posts, there were staff                                                 clarity regarding the
members present of a particular cadre who actually held posts                                       standard for established
elsewhere, but for unclear reasons were seconded, thus over                                           posts in their facility.
filling the number of established posts.

Human Resource Capacity and staffing norms
In order to examine operational implications from the staffing data available, it is imperative
to have information on staffing norms according to service delivery level. As these norms
were not readily available, an analytic template was developed to identify what MNH staffing
requirements are based on the total number of pregnancies, complications and C-sections that
could take place at each level, if all anticipated pregnancies were to receive Emergency
Obstetric Care.




28 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
The following table provides an analysis based on several assumptions, which can be
adjusted and adopted with further discussion:
     Staffing norms need to be established on the basis of
                                                                      Staffing norms need to
       ultimately achieving 90-100% skilled attendance at
                                                                      be established with the
       birth                                                         achievable goal of 90%-
     For the purpose of this projection, expected births are            100% coverage of all
       calculated with a Crude Birth Rate of 30 per thousand,                      deliveries.
       suggesting 349,223 births per year.
     Expected Complications are estimated at 15% of all
       births or 52,383 complicated deliveries per year.
     C-Section requirements are estimated at 5% of all births, or 17, 461 births per year.
     All Health Institutions were classified into three categories: 1) those able to provide
       normal deliveries and first aid including Rural Health centers and clinics (1,107
       institutions), 2) those able to provide Basic Emergency Obstetric Care including
       mission and district hospitals (203), and 3) those able to provide Comprehensive
       Emergency Obstetric Care including all Provincial and Central Hospitals (13).
     Based on data available from this study, an estimated percentage distribution of all
       normal and complicated pregnancies was assigned with 25% of all normal deliveries
       being attended to in Rural Health centers and clinics, 50% of all normal deliveries
       being attended to in District and Mission hospitals, and an the final 25% of all normal
       pregnancies being catered for in tertiary and quartenary facilities.
     Similarly for complicated cases, it was assumed that 50% would be attended for at
       District and Mission Hospitals, while the remaining 50% would be catered for in
       Provincial and Central Hospitals.
     Furthermore, C-Sections have been allocated to tertiary and quartenary facilities for
       the purpose of this analysis although a number of District and Mission hospitals are
       providing this service. More rigorous mapping of BEmOC and CEmOC are required
       to improve upon this analysis.
     Based on the number and type of cases to be seen at each level per day, the minimum
       number of staff required for MNH at each level was identified.

       As with all of these assumptions, the numbers entered in the following table will need to
       be reviewed and modified as required.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 29
  Table VI:             Estimated MNH Staffing Requirements by level
                                                           Number of Health Facilities that can Potentially
                                                         Provide the Following MNH Services After Training
                                                                     and Provision of Equipment
                                                          Normal Deliveries                 Basic Comprehensive
                                                              and first aid           Emergency      Emergency
                                                                                   Obstetric Care Obstetric Care
Assumptions and Calculations                                   Rural Health          Mission and Provincial and                        Total
                                                          Centres and clinics            District      Central
                                                                                       Hospitals      Hospitals
                                            Facilities                    1,107                203                  13                 1,323
Nationwide estimation of normal and complicated pregnancies                                                                      Total Cases
Total Normal deliveries                                                 87,306               174,611            87,306               349,223
Total Complicated Deliveries                                                                  26,192            26,192                52,383
Total C-Section Cases                                                                                           17,461                17,461
Avg. normal deliveries per year per facility                                 79                   860            6,716                 7,655
Avg. complicated deliveries per year per facility                                                 129            2,015                 2,144
Avg. C-sections per year per facility                                                                            1,343                 1,343
Daily workload at the individual facility level
Avg. normal deliveries per day                                              0.2                    2.4            18.4
Avg. complicated deliveries per day                                                                0.4              5.5
Avg. C-sections per day                                                                                             3.7
Proposed Minimum staff required for MNH services by type of institution
Paediatrician                                                                                                         2
Obstetrician/Gyneacologist                                                                           1                2
Doctor                                                                                               2                4
Nurse Midwife                                                                  2                     4                8
Nurse9                                                                         2                     4                8
Total Staff Required for MNH services by level                                                                                    Total Staff
Paediatrician                                                                                                       26                    26
Obstetrician/Gyneacologist                                                                        203               26                   229
Doctor                                                                                            406               52                   458
Nurse Midwife                                                             2,214                   812              104                 3,130
Nurse                                                                     2,214                   812              104                 3,130




  9
       It is assumed that a nurse and a nurse midwife are both able to manage normal deliveries
  30 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
When adopting the above staffing standards to actual numbers of staff members per tertiary
facility, the following gaps are shown:

Table VII:                  Example of Maternal and Neonatal Health staffing and gaps, at the
                            tertiary level
                                                                                        Actual Staff at post
                                         Ob/Gyn           Paedeatri-              Medical Midwives        Nurses                             Lab                      Nurse
                                                               cian                Doctor                                              technician                 Anesthetist
Proposed Staff norm                                2                    2                  4                   8              8                      3                           2
Mutare                                             1                    2                  5                  61             13                      1                           1
St. Lukes                                          1                    0                  3                  15            111                      1                           0
Gwanda                                             1                    0                  2                  13             67                      3                           3
Marondera                                          1                    1                  4                  29            110                      0                           0
Chinhoyi                                           2                    1                 11                  47            119                      6                           3
Bindura                                            0                    1                  7                  37             70                      0                           2
Masvingo                                           1                    0                  6                  38            125                      6                           3
Mater Dei                                      1110                     4                  0                  21              0                      0                           0
Avenues                                        2611                1712                    0                  29            110                      0                           0
                                                                                                                                                             Staff Required
Proposed Staff norm               2             2       4            8          8              3                 2
Mutare                            1                                                            2                 1
St. Lukes                         1                     1                                                        2
Gwanda                            1             2       2
Marondera                         1             1                                              3                 2
Chinhoyi                          1                                                            3
Bindura                           2             1                                              3
Masvingo                          1             2
Mater Dei                                               4                       8              3                 2
Avenues                           4                                                            3                 2
 * Private hospitals may adopt other staffing norms than the other tertiary facilities, in accordance with their
     set-up with visiting, non-permanent staff.

The gaps in staffing levels thus identified are merely part of an initial analysis. The wide
range in staffing levels between all tertiary facilities needs to be studied in detail, and any
possibilities for deployment of staff to facilities with highest needs demand to be explored.

For the quartenary level facilities the number of established posts was generally known and
occupancy rates could be calculated. Staff shortages were apparent at this level as well, the
main ones being:
    One of 4 national level facilities did not have an Obstetrician/Gynecologist at post, while
one did not have a Paedeatrician. One of 4 facilities did not have a Nurse Anesthetist,
although an Anaesthesist was at post; 1 national facility did not have a Laboratory
Technician; and 1 did not have a Pharmacist.
    Actual staff positions filled at each of the facilities were generally under the norm of
established posts.
The data of the study show that when patients in serious conditions reach the quartenary level
of care, immediate medical action may even then have to be delayed due to a specific
shortage of key staff members.

10
       Figures shown for both private hospitals Avenues Clinic and Mater Dei Hospitals are for specialists who
       have right of access to these institutions. These institutions do not directly employ specialist Doctors.
11
       ibid
12
       ibid
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 31
Essential Drugs, Supplies and Equipment

MATERNAL AND NEONATAL HEALTH DRUG AND SUPPLY
The following table provides an analysis of the non-availability of
specific drugs needed for the management of the main                 The lack of essential
complications of pregnancy and delivery at each level of health     drugs and supplies are
care in Zimbabwe.                                                   most immediate at the
    Based on this table, specific shortages in drugs and supplies   primary and secondary
can be calculated according to the estimated percentages of women         level health care
with each particular complication in Zimbabwe.

Table VIII:           NON-availability of essential EmOC drugs and supplies per facility level
                                                            Primary              Secondary                 Tertiary          Quartenary
                                                             N=265                   N=31                    N=10                  N=4
Antibiotics
Ampicillin, inj.
Amoxicillin                                                     64.9%                  74.2%
Benzylpenicillin                                                14.7%
Gentamycin, inj.
Metronidazole                                                   10.2%                  19.4%
Mebendazole
Doxycycline
Erythoromycin syrup
Ceftriaxone, inj.
Anticonvulsants/Antihypertensives
Diazepam, inj.                                                  28.3%
Hydralazine                                                                            74.2%                    70%
Nifepedine                                                      84.2%                  25.8%                    30%
Magnesium Sulphate                                              91.3%                   100%                    20%
Methyl-dopa                                                     55.1%
Oxytoxics
Oxytocin, inj.                                                  47.2%                   6.5%
Ergometrine                                                     73.6%                  35.5%                    20%                    75%
Analgesic
Pethidine, inj
Anaesthetics
Halothane gas                                                          -
Anesthaetics, inj.                                                     -
Lidocaine, inj.                                                        -
Nitrous Oxide                                                          -
IV fluids
Sodium Lactate (Ringers)                                        33.2%                    29%                    10%
Normal Saline                                                   58.1%                   6.5%
Dextrose 5%                                                     40.4%                   6.5%
Sodium Citrate
Half Dextrose/Darrows                                           75.5%                  51.6%                    20%                    50%
50% Dextrose                                                                           16.1%
Anti-Malarials
Chloroquine                                                        6%
Quinine, oral                                                    67.%                   3.2%
32 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
                                                                            Primary                  Secondary                        Tertiary               Quartenary
                                                                             N=265                        N=31                          N=10                       N=4
Quinine, inj.                                                                 50.9%                       6.5%                            10%
Fansidar                                                                      39.6%                      12.9%                                                            25%
Supplies
Blood Lancet, disp.
Catheter, Foley
Urine bag
Gauze pads
Gloves                                                                             14%                       22.6%
Suture materials                                                                   48%
Syringes
Infusion giving set
Paediatric infusion set
Cannula 18                                                                      78.9%
Cannula 22
Feeding tube
Laboratory test
Blood group test
Haemoglobin test
Blood count test
Urine test
Blood
Oxygen


Discussion: DRUGS AND SUPPLIES
When looking at the drugs and supply data above, it is obvious that there are some needs for
essential drugs, supplies and equipment at all levels of health facilities. Most striking are
the demands at the primary and secondary levels of health care: with the gaps in the
availability of basic drugs and supplies, and especially equipment, as shown, many of the
primary health centres will not be in a position to either manage the first stages of the main
complications, or to stabilise a patient who needs referral to a
                                                                      The assessment showed
higher level of care, or to provide services for normal                  an acute shortage of
deliveries. Secondary facilities with shortages of drugs as           oxytocin at 47% of the
indicated will be unable to provide services needed for a             primary health centres,
number of the main complications, and will be forced to refer           while ergometrine was
patients to a higher level of care: an avoidable delay in              out of stock at 75% of
receiving care is created.                                                   the facilities. If
 As haemorrhage is among the leading causes of maternal              bleeding is not managed
    death in Zimbabwe, drugs to manage this complication                 promptly at the first
                                                                            referral level, the
    should always be in stock at all health facility levels.
                                                                              woman’s life is in
    However, the survey showed a shortage of oxytocics at
                                                                              extreme danger.
    47% of the primary care health centres while ergometrine
    was out of stock at 74%. If bleeding is not managed
    promptly at the primary care level, the woman‟s life is in extreme danger. Of the
    secondary level institutions, 7% had no Oxytocin, while 35% had no ergometrine.



Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 33
    Taking in account that complications of abortion stand out above all as the pregnancy
     related problem of highest frequency at several levels of health facilities, shortages of
     medications for such complications can only lead to tragic
     outcomes for patients whose seeking of care is being                                                    Amoxicillin was out of
     delayed from level to level: Amoxicillin was out of stock                                          stock at 65% of primary
     at 65% of primary level institutions, while Ampicillin was                                          level institutions despite
     not available at 14.7%. Oxytocin and ergometrine are both                                            a high number of sepsis
     essential drugs for the management of all stages of                                                                complications.
     complications of abortion: Oxytocin was not available at
     47.2% of primary and 6.5% of secondary health facilities. The management of all cases
     of post partum and post abortal Haemorrhage is weakened significantly by the lack of
     Ergometrine at all levels of health care. Of all primary facilities, 73.6% did not have
     Ergometrine; at the secondary level, 35.5% of the facilities were out of stock; at the
     tertiary level 20% facilities and at the quartenary 25% of facilities did not have this drug.
 As pregnancy induced hypertensive disorders rank high on the list of common
     complications of pregnancy in Zimbabwe, a shortage of drugs for the treatment of such
     complications compromises EmOC for a significant proportion of women: Nifepidine
     was out of stock at 84% of the primary health centres while Methyl-dopa was not
     available at 55%. Diazepam for the treatment of Pre-eclampsia and Eclampsia was out of
     stock at 28% of all centres.                            Of the secondary health facilities 74% had no Di-
     hydrallazine in stock while 25% had no Nifepidine. Even at the tertiary level, care for
     patients with Pre-eclampsia and Eclampsia is imperilled by the lack of Di-hydralazine in
     70%, and lack of Nifepidine in 30% of the health facilities.
 An adequate supply of essential antibiotics should be available at all times for the
     treatment of peripartum, postpartum as well as postabortal sepsis: Amoxicillin was
     out of stock at 65% of primary level institutions. Metronidazole was not available at
     19.4% of the secondary facilities.
 Malaria is shown to be one of the, if not the, leading indirect pregnancy related
     complication in Zimbabwe and an adequate stock of
     several anti-malarial drugs, including Quinine and Fansidar                                                 Malaria one of the
                                                                                                            leading indirect causes
     for Chloroquine resistant malaria should be ensured at all
                                                                                                                         of pregnancy
     levels of care: the stock of primary health level centres for
                                                                                                             complication, yet both
     both oral and injectable Quinine was generally depleted.                                                     oral and injectable
     Of all centres, 40% were also out of Fansidar.                                                              quinine stocks were
           At 3.2% of the secondary level centres, oral Quinine                                           generally depleted. Of
     was not available, while injectable Quinine was depleted at                                             all centres, 40% were
     6.5%. There was a shortage of Fansidar at 12.9% of the                                                   also out of Fansidar.
     secondary level facilities. The lack of injectable Quinine
     was even noticeable at the tertiary and quartenary facilities: at 10% of the tertiary, and
     25% of the quartenary facilities this drug was out of stock, and patients referred from
     lower levels of health care will not receive the quality of care they needs at even the
     highest level of health care in the country.
 IV solutions need to be in stock at all levels of health facilities for the stabilisation and
     resuscitation of patients with acute or postpartum Haemorrhage, and those with severe
     Sepsis, as well as for the resuscitation of newborns with complications. Lack of such
34 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
       solutions at the primary and secondary health care levels will cause serious delays for
       patients needing immediate medical action taken: Ringer‟s lactate was not available at
       33% of the primary level centres whilst Normal Saline was not available at 58%. Half
       dextrose/Darrows was out of stock at 76% of the centres; at 29% of the secondary
       institutions Ringer‟s lactate, and at 7% Normal Saline was        IV solution is a pre-
       out of stock. Half strength dextrose/Darrows solution was       requisite for effective
       not available at 52% of the institutions; of the tertiary               management of
       institutions, 10% did not have Ringer‟s lactate, whilst 6.5%               Post partum
       were not able to provide resuscitation fluids for paediatric         haemorrhage, yet
       patients. (See tables 7,15,26, and 35 in Annex)               Ringer’s lactate was not
                                                                                                                                available at 33% of the
The tertiary and quartenary level facilities appear to be stocked                                                                 primary level centres,
with most drugs. However, the quantities of the drugs still                                                                      while normal saline was
                                                                                                                                not available at 76% of
available have not been verified by this study. The lack of a
                                                                                                                                      the centres. Half
few essential drugs in some facilities suggests that at present
                                                                                                                                                 strength
stock records, including the shelf life of each drug, are not kept
                                                                                                                                       dextrose/Darrows
up to date and shortages of other drugs may ensue from this in                                                                           solution was not
the near future.                                                                                                                available at 52% of the
                                                                                                                                 secondary institutions.
Because of the serious shortages of drugs at the primary and
secondary health level, most women who develop
complications of a mild or moderate severity cannot be treated at the appropriate level of
health care and need to be referred to the next level of care, thus putting unnecessary pressure
on tertiary and quartenary facilities which should be handling the most serious of
complications. At the same time, mild or moderately severe cases will develop into severe
and possibly fatal complications by the time the first and second delays are overcome.
Besides being unable to offer services to patients with initial danger signs of complications
due to specific drug shortages, the primary and secondary levels of care will not be able to
fully perform their main function of preventative action against the development of
complications: a clear example from this assessment is the indirect obstetric complication of
Malaria, the high incidence of which is of great concern in Zimbabwe. It may be assumed
that the lack of prophylactic anti-malarials for pregnant women as part of regular ANC
services at the primary and secondary levels directly contributes to the very high percentages
of Malaria complications with 81% at the secondary, 43% at the tertiary, and 18.6% at the
quartenary levels of health care. Lack of those drugs at even the higher levels of care leaves
no chance for positive outcomes for this complication.

MOHCW in Zimbabwe adheres to the policy that all facilities must use the minimum stock
level method for ordering drugs, i.e. order drugs when stocks reach re-order level. Problems
with stock management or lack of staff to keep stocks, especially at the lower level facilities
may contribute to the shortages of drugs as shown.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 35
MATERNAL AND NEONATAL HEALTH EQUIPMENT
The following table provides an analysis of the non-availability of standard Maternal and
Neonatal Health equipment for the management of the main complications of pregnancy and
delivery at each level of health care in Zimbabwe.

Table IX:             NON-availability of essential EmOC equipment and supplies per level
Health Center basic equipment                                   Primary            Secondary                Tertiary         Quartenary
                                                                 N=265                  N=31                  N=10                 N=4
Stethoscope                                                        4.5%                 9.7%                     3%                20%
Sphygmomanometer                                                   2.6%                 3.2%                     8%                25%
Instrument sterilizer                                              9.1%                25.8%                    33%                25%
Needle holder                                                     31.3%                25.8%
Vaginal speculum                                                    54%                22.6%
Cord Scissors                                                       49%                25.8%
Cord Ties                                                         73.6%                  71%
Cannula size 18                                                     78.9               45.2%
Artery forceps                                                    26.4%                32.3%
Sponge forceps                                                    43.8%                54.8%
Episiotomy scissors                                                 26%                48.4%
Stitch scissors                                                   55.1%                41.9%
Dissecting forceps                                                41.9%                38.7%                       2%
Gloves                                                              14%                22.6%
  Infant Laryngoscope                                                                  32.3%
Neonatal oxygen supplies
Neonatal oxygen masks                                                                     9.7%
Infant warmer                                                                            51.6%                    20%                  25%
At secondary, 3rd, 4th level +
Vacuum extractor                                                          X              16.1%                     8%                    3%
Outlet forceps                                                            X              61.3%
D&C packs                                                                 X
Equipment       for   Anaesthesia, blood                                  X
transfusions and laparatomy
Anaesthetic machine                                                       X               9.7%                     3%
Adult resuscitation machine                                               X              19.4%
Electrical suction machine                                                X               6.5%                    11%
Oxygen cylinder w/gauge                                                   X               3.2%
Oxygen masks                                                              X
Tubes and connectors                                                      X               6.5%                     2%
Obstetric laparatomy set                                                  X               3.2%
Caesarean section set                                                     X               3.2%
Blood Cross matching                                                      X              16.1%
Equipment for neonatal resuscitation                                      X
Mucous extractor                                                          X              87.1%
Endotracheal tubes                                                        X              38.7%
Ambu bags                                                                 X              16.1%                    20%
Neonatal suction machine                                                  X               9.7%                    20%
Neonatal suction catheters                                                X               9.7%
Paediatric emergency tray                                                 X                                       20%
Resuscitaire                                                              X                 29%



36 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
The following table provides an overview of the minimum estimated numbers of pieces of
equipment needed for the functioning of each level of care.

Table X:                    Minimum standards13 of equipment required by level
Health Center basic equipment                                                    Primary                 Secondary                     Tertiary              Quartenary
Stethoscope                                                                            4                         8                            8                       8
Sphygmomanometer                                                                       4                         8                            8                       8
Instrument sterilizer                                                                  2                         2                            2                       2
Needle holder                                                                          5                        10                           10                      10
Vaginal speculum                                                                       5                        10                           10                      10
Cord Scissors                                                                          5                        10                           10                      10
Cord Ties                                                                              5                        10                           10                      10
Cannula size 18                                                                        5                        10                           10                      10
Artery forceps                                                                         5                        10                           10                      10
Sponge forceps                                                                         5                        10                           10                      10
Episiotomy scissors                                                                    5                        10                           10                      10
Stitch scissors                                                                        5                        10                           10                      10
Dissecting forceps                                                                     5                        10                           10                      10
Gloves                                                                                 2                         2                            2                       2
Infant Laryngoscope                                                                                              2                            2                       2
Neonatal oxygen supplies                                                                                                                      2                       2
Neonatal oxygen masks                                                                                                                         2                       2
Infant warmer                                                                                                                                 2                       2
At secondary, 3rd, 4th level +
Vacuum extractor                                                                                                        2                           2                          2
Outlet forceps                                                                                                          2                           2                          2
D&C packs                                                                                                               2                           2                          2
Equipment       for   Anaesthesia, blood
transfusions and laparatomy
Anaesthetic machine                                                                                                     2                           2                          2
Adult resuscitation machine                                                                                             2                           2                          2
Electrical suction machine                                                                                              1                           2                          2
Oxygen cylinder w/gauge                                                                      2                          2                           2                          2
Oxygen masks                                                                                 2                          2                           2                          2
Tubes and connectors                                                                         2                          2                           2                          2
Obstetric laparatomy set                                                                                                2                           2                          2
Caesarean section set                                                                                                   2                           2                          2
Blood Cross matching                                                                                                    1                           1                          1
Equipment for neonatal resuscitation
Mucous extractor                                                                                                       2                           2                          2
Endotracheal tubes                                                                                                     1                           1                          1
Ambu bags                                                                                                              2                           2                          2
Neonatal suction machine                                                                                               1                           1                          1
Neonatal suction catheters                                                                                            10                          10                         10
Paediatric emergency tray                                                                                              2                           2                          2
Resuscitaire                                                                                                           1                           1                          1

13
       It is important to note, that formal standards for equipment and supplies are currently under development by
       the MOHCW. This table provides indicative figures based on international literature and the mother-baby
       package, thus allowing a preliminary assessment of actual commodity requirements. When official
       standards become available, this table and the projected requirements can be adjusted accordingly.

Note:         for the tertiary and Quartenary level, the percentages indicated imply the lack of functional pieces of
              equipment. In a considerable amount of the facilities at these levels, the needed pieces of equipment
              were available, but identified as no longer functioning.

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 37
Discussion: EQUIPMENT
Lack of basic equipment for MNH is, like that of drugs and
                                                                                Lack of basic
supplies, most evident at the primary and secondary levels of          equipment for EmOC
health care. At many primary and secondary health facilities at       is, like that of drugs
least several tasks for the management of normal delivery care or      and supplies, is most
of the initial stages of complication development cannot be evident at the primary
performed or are seriously hampered by the lack of specific            and secondary levels
items of equipment. Given the scope of medical tasks needing to               of health care.
be performed, and considering that secondary facilities are the
first significant level of care for the treatment of complications that are beyond the
capabilities of primary care institutions and Basic EmOC while still at closer distance from
the community, especially these secondary facilities are disadvantaged the most: at present,
many secondary institutions lack basic equipment
 for clean and safe deliveries: 26% did not have a functional instrument sterilizer.
 for assisted, instrumental deliveries: 55% of the institutions
     had no functioning sponge forceps, 39% had no dissecting        55% of the secondary
     forceps, 48% had no episiotomy scissors, 16% had no                 institutions had no
     vacuum extractors, and 61.3% had no obstetric outlet                 functioning sponge
     forceps.                                                          forceps, 48% had no
 caesarean sections: lack of a functional anaesthetic machine,         episiotomy scissors,
                                                                             and 61% had no
     laparatomy set, adult resuscitation tray, a suction machine, or
                                                                             obstetric outlet
     oxygen cylinders, tubes and connectors are leaving a
                                                                                   forceptsd.
     considerable percentage of facilities without a functioning
     operation theatre.
 for the management of neonatal complications,
 and for blood cross matching: only 16% of secondary facilities had the capacity for this
     critical component of Comprehensive Emergency Obstetric Care. (The assessment did not
     provide information on blood transfusion capacity. As this is an essential part of
     CEmOC, this capacity needs to be examined further in the near future))

Many of their patients will thus need to be unnecessarily referred to higher levels of care,
thus exposing these women to life-threatening and avoidable delays.

The three pieces of equipment that are lacking in a significant
                                                                                                                 Due to lack of
number of health facilities at all levels are: instrument
                                                                                                                 equipment and
sterilizers, stethoscopes and sphygmomanometers: no health
                                                                                                                 supplies, many
facility can afford to promote sepsis of any kind and thus be                                                 patients must be
without an instrument sterilizer at any time. Stethoscopes and                                              referred to higher
sphygmomanometers are incumbent for the detection of danger                                                 levels of care thus
signs of developing complications throughout all levels of care.                                             exposing women to
                                                                                                         unnecessary and life-
Even though the tertiary and quartenary level facilities are, as                                           threatening delays.
shown by the survey data, generally well equipped, it is
important to note that:


38 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
      While more or less all facilities have the needed equipment available, not all pieces of
       equipment are guaranteed to function. Lack of proper maintenance appears to cause
       avoidable non-functioning of equipment.
      Although the survey data indicate availability, rather than a non-availability of most
       pieces of equipment at the tertiary and quartenary level, it must be emphasized that some
       of the lacking items of equipment are essential for quality management of serious
       complications and the maintenance of a high standard of care.
      Considering the apparent severe drug and equipment
       shortages at the primary and secondary levels at present, and              Maintenance of
       thus the increased responsibility for quality care of the higher    existing equipment at
                                                                               the provincial and
       level facilities for patients who have managed to bypass
                                                                                  national health
       primary and secondary care levels and live, it is of utmost
                                                                              facilities deserves
       importance that every possible piece of equipment at the                         attention.
       highest levels of care are in an impeccable functioning state.
       (See tables 4, 13a, 13b, 14, 25a, 25b, 34 in Annex)

Within the scope of this study, it cannot be verified which pieces of equipment are missing in
which particular institutions, and institution specific inventories are needed to re-supply the
facilities in need. However, with the data available, standards established by experts in the
field from MoHCW, UNICEF and UNFPA and the most current MoHCW data on the
number of health facilities, the following population based demands for equipment were
calculated:

Table XI:                   Quantities of standard14 equipment required by level
Health Center basic equipment                                               Primary                  Secondary                   Tertiary +                            Total
                                                                                                                                Quartenary
Stethoscope                                                                         199                         158                      28                              385
Sphygmomanometer                                                                    115                          52                      34                              201
Instrument sterilizer                                                               201                         105                      15                              321
Needle holder                                                                     1,732                         524                       0                            2,256
Vaginal speculum                                                                  2,989                         459                       0                            3,448
Cord scissors                                                                     2,712                         524                       0                            3,236
Cord ties                                                                         4,074                       1,441                       0                            5,515
Cannula size 18                                                                   4,367                         918                       0                            5,285
Artery forceps                                                                    1,461                         656                       0                            2,117
Sponge forceps                                                                    2,424                       1,112                       0                            3,537
Episiotomy scissors                                                               1,439                         983                       0                            2,422
Stitch scissors                                                                   3,050                         851                       0                            3,900
Dissecting forceps                                                                2,319                         786                       3                            3,107
Gloves                                                                              310                          92                       0                              402
Infant laryngoscope                                                                   0                         131                       0                              131
Neonatal oxygen supplies                                                              0                           0                       0                                0
Neonatal oxygen masks                                                                 0                           0                       0                                0
Infant warmer                                                                         0                           0                      12                               12

14
       It is important to note, that formal standards for equipment and supplies are currently under review by the
       MOHCW. This table provides indicative figures based on international literature and the mother-baby
       package, thus allowing a preliminary assessment of actual commodity requirements. When official
       standards become available, this table and the projected requirements can be adjusted accordingly.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 39
Health Center basic equipment                                Primary             Secondary             Tertiary +                    Total
                                                                                                      Quartenary
At secondary, 3rd, 4th level                                           0                    0                   0                         0
Vacuum extractor                                                       0                   65                   3                        68
Outlet forceps                                                         0                  249                   0                       249
D&C packs                                                              0                    0                   0                         0
Equipment for anaesthesia, blood
transfusion and laparatomy                                             0                     0                      0                     0
Anaesthetic machine                                                    0                    39                      1                    40
Adult resuscitation machine                                            0                    79                      0                    79
Electrical suction machine                                             0                    13                      3                    16
Oxygen cylinder w/gauge                                                0                    13                      0                    13
Oxygen masks                                                           0                     0                      0                     0
Tubes and connectors                                                   0                    26                      1                    27
Obstetric laparatomy set                                               0                    13                      0                    13
Caesarean section set                                                  0                    13                      0                    13
Blood cross matching                                                   0                    33                      0                    33
Equipment for neonatal resuscitation
Mucous extractor                                                       0                  354                       0                   354
Endotracheal tubes                                                     0                   79                       0                    79
Ambu bags                                                              0                   65                       5                    71
Neonatal suction machine                                               0                   20                       3                    22
Neonatal suction catheters                                             0                  197                       0                   197
Paediatric emergency tray                                              0                    0                       5                     5
Resuscitaire                                                           0                   59                       0                    59


As the data indicate throughout this section on the third delay, it is clear that some of the
greatest gaps in human resources, drugs and equipment are at the primary and secondary
health care level and shortages at those levels thus deserve the greatest priority.




40 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
MONITORING THE NATIONAL                                                                                              MATERNAL                                     AND
NEONATAL HEALTH PROGRAMME

The UN process indicators are based on the understanding that, in order to prevent maternal
deaths, certain types of obstetric services must be available. These services must be used in
sufficient quantity, and the women who experience life-threatening obstetric emergencies use
them. The process indicators give an indication as to whether women‟s lives are being saved
as a result of the programs put in place.

The following process indicators were used for the assessment:
1) Skilled Attendance at delivery
2) Number of facilities providing BEmOC per 500,000 population
3) Number of facilities providing CEmOC per 500,000 population
4) Met Need: proportion of total no. of obstetric complications treated in MNH facilities
5) C-section as a proportion of all births in the catchment population
6) Case Fatality Rate: total number of maternal deaths from direct obstetric complications
   among the number of women admitted with these conditions
7) Maternal Mortality Ratio: number of maternal deaths in 100,000 live births
8) Perinatal Mortality Ratio: number of newborn deaths in 1000 live births.

A summary of the baseline data for all of this information can be seen as follows:

Table XII:                  Baseline Indicators for Monitoring the national Maternal and Neonatal
                            Health Programme
      Indicator                                    National                     Primary              Secondary                  Tertiary                  Quartenary
1     Skilled Attendance at                        53.6%15                      8.3%                 29.1%                      6.4%                      8.8%
      delivery
2     Number of facilities
      providing BEmOC per                          During the fieldwork of the study, the BEmOC signal functions were not formally
      500,000 population                           assessed, either by observation or by interviews. Therefore, it was not possible to
      (standard is 4 per                           calculate coverage of Basic EmOC at the various levels.
      500,000)
3     Number of facilities                         1.216                        Not                  1.2                        1.2                       1.2
      providing CEmOC per                                                       applicable           (average)                  (average)                 (average)
      500,000 population
      (standard is 1 per
      500,000)




15
       The percentage of skilled attendance at delivery reflected at the national level is the sum total of the
       coverage at each of the four institutional levels, as assessed from the study. This figure is likely to vary
       from the routine Health Management Information System data, and will also be different from the
       upcoming DHS data, as it only reflects the sites visited during the assessment.
16
       The average CEmOC sites per 500,000 population is calculated for the nation as a whole, by dividing total
       CEmOC sites by the total population and multiplying by 500.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 41
     Indicator                          National                Primary          Secondary            Tertiary            Quartenary
4    Met Need: proportion of            38.1%                   Not              14.7%                26.1%               23.3%
     total number of obstetric          population              available        Institution          Institution         Institution based
     complications treated in           based                                    based                based               estimation
     EmOC facilities17                  estimation                               estimation           estimation
5    C-section as a proportion          3.6%                    Not              Population           Population          Population based
     of all births in the                                       applicable       based <5%            based <5%           <5%
     catchment population18
                                                                                 Institution          Institution         Institution based
                                                                                 based 6.2%           based 22.6%         34.7%
6    Case Fatality Rate: total          Range from 0.3          0.3% total       1.7% total           1.2% total          1.5% total
     number of maternal                 at primary level
     deaths from direct                 to 1.7 at                                0.98% for            0.6% for            1.2% for direct
     obstetric complications            secondary level                          direct causes        direct causes       causes
     among the number of
     women admitted with                                                         8.7% for             6.5% for            13.7% for
     these conditions                                                            indirect             indirect            indirect causes
                                                                                 causes               causes
7    Maternal Mortality Ratio:          Institution             Data not         238/100,000          350/100,000         338/100,000
     number of maternal                 based figures           available        (institution         (institution        (institution
     deaths per 100,000 live            ranged from                              based)               based)              based)
     births19                           238-338 per
                                        100,000 live
                                        births
8    Perinatal Mortality Ratio:                                 Data not         32.5/1000            55.4/1000           Data not
     number of newborn                                          available                                                 available
     deaths in 1000 live births




17
     See Table 42 in Annex.
18
     See Table 40 in Annex.
19
     It is important to note, that this study could only provide a Maternal Mortality ratio for institution-based
     deliveries. This figure is often far less than a population-based maternal mortality figure. In order to
     calculate a population based Maternal Mortality Rate, a large and nationally representative sample of all
     births and maternal deaths is required.
42 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
1)      SKILLED ATTENDANCE AT DELIVERY
Perhaps the single most important indicator to monitor in national MNH programmes is that
of “skilled attendance at delivery”. If skilled and equipped staff are at every delivery, the
chances of complications becoming serious is greatly reduced. The following table depicts

Table XIII:                 Skilled attendance by staff cadre by institutional level
Unskilled attendance                                                   Primary20                     Secondary                           Tertiary              Quartenary
Traditional Midwives                                                      18.7%                              -                                  -                       -
Other                                                                     20.1%                              -                                  -                       -
Sub-total unskilled attendance                                            38.8%

Skilled attendance
RN/RGN                                                                                                         8.5%                             0%                          0%
                                                                              61.2%
RNM/SCM                                                                                                      80.7%                           67.1%                       84.2%
Clinical Officer                                                                   -                             0%                             0%                          0%
General Medical Officer                                                            -                             4%                          12.7%                       10.9%
Obstetrician/Gynaecologist                                                         -                           1.4%                          10.9%                        2.9%
Other                                                                              -                           5.4%                           9.3%                        1.7%
Total                                                                          100%                           100%                            100%                        100%

Skilled attendance at delivery                                                 8.3%                          29.1%                             6.4%                        8.8%
by institutional level


     Proportion of Skilled Attendance by Level                                                 Skilled Attendance as a percentage of
                                        Tertiary                                              deliveries by level (national total = 53.6 %)
                                                                                                               expected
                                         12%
                                                                                              35%

                                                           Quarternary                        30%                             29.1%
                                                              17%
                                                                                              25%

                                                                                              20%

                                                                                              15%
           Secondary                                                                          10%          8.3%                                                       8.8%
              55%                                           Primary
                                                              16%                                                                                 6.4%
                                                                                               5%

                                                                                               0%
                                                                                                         Primary           Secondary            Tertiary         Quarternary
                                                                       figure 10                                                                                        figure 11

Several important pieces of information stand out from the above data:
 Figure 12 explains that the secondary health level is burdened most by its responsibility
   for skilled attendance at birth in proportion to the number of expected deliveries nation
   wide. The need for immediate upgrading of this level of health care in terms of staffing
   levels, drugs and equipment thus becomes clear, especially considering the gaps
   identified earlier.
 Only 61.2% of all deliveries in the catchment area of the primary health facilities take
   place within an institution. This leaves a significant percentage of deliveries (38.8%)
   unattended by skilled personnel, and therefore at much greater risk for undetected and
20
       Assessment of EmOC Services, Final Draft, submitted by Dr. T.L. Magwalie and Dr. M.T. Manage,
       January 2005.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 43
     fatal complications. Recourse to untrained health workers in life-threatening situations
     causes serious delay in seeking appropriate care at a referral health facility.
    While the study did not specify the staff cadres attending the births that do take place
     within the primary level health centres, from the available data regarding the other levels
     of care the extensive role played by trained midwives becomes obvious. The fact that by
     far the majority of deliveries at even the quartenary level of care are done by midwives
     and not by specialists or at least medical officers, once more articulates the earlier
     observation that very often the lower levels of health facilities are bypassed by women
     who could have been appropriately attended to at those levels. In a well functioning
     referral system only the most complicated cases would need to reach and be treated at the
     quartenary level of care, and receive highly skilled medical attention.


2/3)    NUMBER OF FACILITIES PROVIDING BASIC AND COMPREHENSIVE
        EmOC per 500,000 population
In order to distinguish between a BEmOC (basic emergency obstetric care facility) and a
CEmOC (comprehensive emergency obstetric care facility) the 6 signal functions described
in the introduction need to be assessed. However, the signal functions of Basic Emergency
Obstetric Care were not consistently assessed throughout all potential BEmOC sites, making
it impossible to calculate coverage of this important indicator.

According to the criteria that prevent all nursing staff from performing a number of the signal
functions, the primary health care facilities do not qualify as BEmOC facilities at present.
While acknowledging that some of the district and provincial hospitals in the survey had not
carried out all signal functions (4 facilities out of 31), and therefore, strictly speaking, do not
all qualify as CEmOC facilities, the secondary and tertiary level of care were generally
considered to be expected to provide CEmOC care. This leaves the following, general
categories of care:
 Primary health facilities: EmOC first
    aid only                                              Coverage of CEm OC facilities per 500,000

 Secondary facilities: EmOC first aid +                                population

    BEmOC and occasional CEmOC
                                                           6
 Tertiary and quartenary facilities:                      5
    EmOC+BEmOC+CEmOC                                       4
                                                                                  3
UNICEF, WHO, and UNFPA recommend                                                  2
that there should be at least 1 facility that                                     1
                                                                                  0
offers CEmOC for every 500,000 people
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During the fieldwork of the study, the
                                                                                       figure 12
BEmOC signal functions were not formally
assessed, either by observation or by interviews. Therefore, it was not possible to calculate
coverage of Basic EmOC at the various levels.

44 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
However, more attention was given to CEmOC facilities and the adjacent chart suggests that
all provinces have sufficient capacity to provide Comprehensive Emergency Obstetric Care,
based on the standard ratio of 1 CEmOC facility per 500,000 population.

Table XIV:                  Coverage of CEmOC
Province                                      Number of CEmOC                                             Provincial                 Population covered per
                                                        facilities                                      population21                       CEmOC facility
                                                                                                                                        (Should be less than
                                                                                                                                                   500,000)
Matabeleland North                                                            8                                701,359                                    5.7
Matabeleland South                                                         5.02                                654,879                                   3.83
Mashonaland West                                                              7                               100,1558                                   3.49
Mashonaland East                                                           7.03                              1,125,335                                   3.12
Masvingo                                                                      8                              1,218,705                                   3.06
Mashonaland Central                                                        5.69                                998,265                                   2.85
Manicaland                                                                    8                              1,566,389                                   2.55
Midlands                                                                   6.36                              1,266,331                                   2.17
Total                                                                      55.1                            8,833,34122                                   3.12
NB. Excludes two urban provinces

The above data make clear that, all provinces have CEmOC coverage that is above standard
and should be able to absorb the majority of patients admitted with complications, if
appropriate staff, essential drugs and equipment are available.

4)    MET NEED
(Proportion of total number of obstetric complications treated in EmOC facilities)

Met Need is expressed as the proportion of total expected
                                                                                                                                   62% of the expected
obstetric complications treated. Out of the total number of
                                                                                                                                    numbers of obstetric
expected deliveries in a population it is expected that 15% will                                                                    complications are not
suffer complications.        Estimates for direct obstetric                                                                              being treated in
complications in a population are 15%. This is a low, if not                                                                      EmOC facilities at the
minimum estimate. The recommended Met Need for a                                                                                   district and provincial
population is 100%, i.e. all complications must be treated in                                                                                    hospitals
EmOC facilities.

In Zimbabwe, although the range between districts is wide, all districts but 1 have Met Needs
that are below 100%, and only 5 districts have Met Needs above 50%. This implies that most
of the obstetric complications that occur in pregnant women are presently not being treated in
EmOC facilities. This once more supports the assumption that many women with
complications do not seek appropriate help for their crisis, or never reach any level of care.
A contributing factor here will be the fact that primary health facilities cannot, by law, carry
out some of the key tasks characteristic of a BEmOC level of care.


21
       Based on 2002 Census data, CSO,
22
       Note that the urban Provinces of Harare and Bulawayo are not included and therefore the total is not equal
       to the national population.
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 45
The data for the secondary and tertiary health care facilities
suggest that approximately 62% of the expected number of                                                    Primary level health
                                                                                                                 facilities do not
obstetric complications are not being treated in EmOC facilities
                                                                                                               provide all of the
at the secondary and tertiary level of care.
                                                                                                         services the have the
                                                                                                              potential for, and
When the study data by district and province are adjusted for the                                          thus compromise the
total population of the country it can also be calculated that                                                    quality of care
38.1% of the expected direct obstetric complications in the total                                         nearest to a woman’s
population were treated at the national level in Zimbabwe in                                                                home.
2003/2004. This is a considerable percentage knowing that in an
optimally functioning health care system only the most complicated of cases should need the
highest level of care. (See table 41 in the Annex)

The following thoughts can be inferred:
 Primary level health facilities do not provide the tasks they have the potential for and thus
   compromise the quality of care nearest to a woman‟s home.
 The secondary and tertiary levels of health care admit the majority of complicated cases,
   but need to refer more than half of them out, suggesting a substantial gap between the
   expected capacity and actual limitations of care at these levels.

Table XV:       Obstetric COMPLICATIONS admitted, in order of highest incidence, by
health facility level
Direct Complication                                            Primary            Secondary                Tertiary         Quartenary
Haemorrhage                                                        13%                  9%                   10.2%                11%
Pre-eclampsia/eclampsia                                            18%                 10%                   18.9%                19%
Prolonged/obstructed labour                                        15%                 17%                   16.2%                12%
Complications of abortion                                          30%                 50%                   49.3%                36%
Puerperal sepsis                                                      -                 1%                    2.6%                   -
Ectopic pregnancy                                                     -                 1%                    2.3%                   -
Ruptured uterus                                                       -                   -                   0.5%                   -
Others                                                                -                12%                        -                  -
Indirect obstetric complications
Malaria                                                                   -                81%                  43%                 18.6%
Anaemia                                                                   -                 4%                28.6%                 15.7%
HIV/AIDS                                                                  -                 3%                12.9%                 37.3%
TB                                                                        -                 1%                 3.6%                 15/7%
Domestic Violence                                                         -                 2%                 0.4%                 10.8%
Other                                                                     -                 8%                11.5%                  1.9%




46 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
                 Primary Level Complications                                                            Secondary Level Complications
       Prolonged/obs. labour                                                                              Haemorrage
               20%                                        Preeclampsia/eclampsia
                                                                                                             49%
                                                                  24%                                                                                      Ruptured uterus
                                                                                                                                                                 9%



                                                                                                                                                              Ectopic
                                                                                                                                                                7%


                                                              Haemorrage                                                                                   Compli. of abortion
                                                                 17%                                                                                               9%
          Compli. of abortion
                 39%                                                                           Preeclampsia/eclampsia
                                                                                                       10%                             Obstruction
                                                                                                                                          16%

                                                                        figure 13                                                                                     figure 14
                  Tertiary Level Complications                                                          Quartenary Level Complications
                           Ectpoic pregnancy
                   Haemorrage     2.3%                                                                                          Preeclampsia/eclampsia
                     10.2%                                                                                                              24.0%
                                                                                                         Obstruction
                                                                                                           15.0%


    Obst./prol. labour                                          Comp. of Abortion
          16.2%                                                      49.3%
                                                                                                                                                            Haemorrage
                                                                                                                                                              14.0%
     Ruptured uterus
           0.5%
    Postpartum sepsis
          2.6%

        Pre-eclampsia/eclampsi
                18.9%
                                                                                                                     Compli. of abortion
                                                                                                                          47.0%
                                                                        figure 15                                                                                     figure 16

Especially alarming are the high percentages of women admitted with complications of
abortion at the primary, but also the tertiary and quartenary levels of care. Extensive and
special attention needs to be urgently given to this complication, from the community level
all the way up to the quartenary health facilities. The much lower percentage of abortion
complications at the secondary level of care suggests an inability to manage these problems at
this level and therefore a forced referral to the highest-level facilities. However, it is
important to note that an abortion case with or without complications (haemorrhage or sepsis)
may have been counted from the registers, thus causing over estimates.
        In any case, the high percentages of other complications at especially the primary
level suggest a strong need for basic education in the recognition of danger signs at the
community level.

Table XVI:                  Estimating EmOC Met Need
                                                                                    Primary               Secondary                 Tertiary             Quartenary
Total Institutional Deliveries                                                                                41,976                   1,966                 23,364
Direct complication                                                                                            5,633                   4,626                   5,334
Indirect complication                                                                                            553                     504                     102
Total complications                                                                                            6,185                   5,130                   5,436
Percent of obstetric complications treated                                                                    14.7%                   26.1%                   23.3%

See table 39 and 40 in the Annex.


Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 47
5)     C-SECTION:
(As a proportion of all expected births in the catchment population)
A minimum level of 5 % of deliveries by caesarean section has been suggested, based on
estimates from a variety of sources. A rate less than 5 % may indicate inadequate availability
and/or access to obstetrical care. While
5 % is considered a conservative                   Percentage C-Sections by Province
minimum caesarean section rate, it is           10.0%




                                                                                                                                                                    8.2%
greater than rates currently found in
                                                 8.0%
many developing countries.




                                                                                                                          5.0%
                                                                                          6.0%




                                                                                                                                 4.2%

                                                                                                                                        4.0%
The CS rates for the districts included in




                                                                                                                                                                           3.6%
                                                                                                                                                             3.4%
                                                                                                                   3.0%
                                                                                                     2.8%
                                               4.0%
the study were all below 5%, indicating




                                                                                                                                                      2.2%
                                                                                                            1.7%




                                                                                                                                               1.6%
an under serving of the population at the      2.0%
district and provincial level health
                                               0.0%
facilities.                                                    t       tr
                                                                          .           th           go           s             d          st        th        e            o      ta
                                                                                                                                                                                    l
                                                            es                     or                         nd           an         Ea                  ar           ay
                                                          W          en                         in         la           al                       ou    ar            w        To
As can be seen from the adjacent figure,            as
                                                       h.        h .C       a t.
                                                                                 N
                                                                                         M
                                                                                           a sv
                                                                                                      M
                                                                                                        id
                                                                                                                  an
                                                                                                                     ic
                                                                                                                                as
                                                                                                                                   h.
                                                                                                                                            at
                                                                                                                                               .S     H
                                                                                                                                                                u la
                                                  M           as          M                                     M             M           M                    B
                                                            M
the range of C-Section coverage varies                                                                                                                                      figure 17
from the lowest in Mash East, to the
highest in Bulawayo. The national average is 3.6 percent. (See tables 39 and 40 in Annex)




48 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
6)     CASE FATALITY RATE:
(Total number of maternal deaths from direct obstetric complications among the number
of women admitted with these conditions)

Table XVII: Case Fatality Rates by level
                                                       Primary                        Secondary                               Tertiary                     Quartenary
Direct Causes                                                 -                           0.98%                                  0.6%                            1.2%
Indirect Causes                                               -                            8.7%                                  6.5%                           13.7%
Total CFR                                                 0.3%                             1.7%                                  1.2%                            1.5%

When using the UNICEF/WHO/UNFPA guideline that the Case
Fatality Rate among women with obstetric complications in                                                                          Case Fatality Rates for
comprehensive EmOC facilities should not exceed 1%, these                                                                                  direct obstetric
                                                                                                                                   complications are above
rates are cause for concern: if not including the primary care
                                                                                                                                          1% at secondary,
level, all of them are above 1%. If an efficient referral system is
                                                                                                                                   tertiary and quartenary
in place, naturally the highest Case Fatality Rates will occur for                                                                          levels of care.
the most sophisticated intervention level to which the most
complicated cases are referred, while the lowest will appear for
the primary care level.

However, the highest total Case Fatality Rate for direct causes is shown at the secondary
level, thus suggesting that the shortages of essential drugs, equipment and supplies noted by
the assessment at this level, may have contributed to these higher
                                                                       The highest total Case
rates.
                                                                      Fatality Rate for direct
    At the same time it must be kept in mind that the CFR as an        causes is shown at the
indicator of quality of performance is bound to limitations: if          secondary level, thus
women are admitted in very poor condition, CFR‟s may be                     suggesting that the
unduly high even if the facility is functioning well. Conversely,       shortages of essential
a low CFR does not necessarily mean a high standard of care.             drugs, equipment and
    No distinction between direct and indirect causes could be           supplies noted by the
made when calculating the Case Fatality Rate for the primary          assessment at this level
health care level. However, it can be assumed that contributing      may have contributed to
to the low Total Case Fatality for this level is the fact that many        these higher rates.
women will never reach the primary level facility and die at
home, or die due to transport delays or during transport between referral levels. Those deaths
will not be included in the Rates calculated above.

The Case Fatality Rates for indirect causes are all very high, and are likely influenced by the
strong impact of HIV/Aids and related illnesses such as TB, as well as Malaria, since these
conditions severely weaken the condition of a pregnant woman and all are highly frequent
causes of morbidity in Zimbabwe.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 49
7)      MATERNAL MORTALITY RATIO:
(Number of maternal deaths per 100,000 live births from hospital data)
It is important to note, that the internationally accepted definition for Maternal Mortality, is
the number of maternal deaths that occur for each 100,000 live births. As this assessment
was institution-based in nature, the MMR was calculated using institutional data, rather than
catchment population data.

Table XVIII: Direct and Indirect causes of maternal death by level
Direct causes of death                                     Primary            Secondary                 Tertiary            Quartenary
Haemorrhage                                                      -                  50%                   42.3%                  30.8%
Complications of Abortion                                        -                 9.6%                   15.5%                   1.5%
Pre-eclampsia/eclampsia                                          -                11.5%                   23.1%                  58.5%
Obstructed Labour                                                -                   0%                      0%                     0%
Puerperal Sepsis                                                 -                   0%                    7.8%                     0%
Ruptured Uterus                                                  -                 9.6%                    9.1%                   7.7%
Ectopic Pregnancy                                                -                 7.7%                    9.1%                     0%
Other                                                            -                11.6%                    9.1%                   1.5%
Total MMR due to direct causes                                   -           238/100,000             350/100,000                      -
Indirect causes of death
Malaria                                                               -                         -             6.1%                  14.3%
HIV/Aids                                                              -                         -            15.2%                  35.8%
Anaemia                                                               -                         -            12.1%                   7.1%
TB                                                                    -                         -            42.4%                  21.4%
Domestic violence                                                     -                         -               0%                     0%
Other                                                                 -                         -            24.2%                  21.4%

                                                                               Secondary Level Direct Cause of Death
     Primary Level                                                                                      Haemorrage
                                                                                                          49.0%


     A significant number of Primary Health
     Care level facilities had not recorded the
     number of live births, making it
     impossible to provide a summary of                                                 Others                              Comp. of Abortion
     direct causes of maternal death                                                    12.0%                                    10.0%


                                                                                             Ectopic               Pre-eclampsia
                                                                                              8.0% Ruptured Uterus     11.0%
                                                                                                       10.0%

                                                                                                               figure 17
       Tertiary Level District Causes of Death                               Quarternary Level Direct Causes of Death
                                                                                                               Rupture
                                          Haemorrage                                                            8.0% Others
                                            36.0%
                                                                                                                       2.0%
                  Others
                   8.0%


              Ectopic
               8.0%
                                                                                                                              Haemorrage
                                                                                Pre-eclampsia
       Ruptured Uterus                                                                                                          30.0%
                                                                                    58.0%
            8.0%                                  Comp. of Abortion
                                                       13.0%
                    Sepsis
                     7.0%
                               Pre-eclampsia                                                                         Comp. of Abortion
                                   20.0%                                                                                   2.0%

                                                          figure 18                                                                 figure 19
50 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
The data provided by the study do not include sufficient information regarding Maternal
Mortality and its direct and indirect causes at the primary level. The table above however
gives insight in the causes of maternal deaths from the secondary health level onward.
    While Complications of Abortion and Haemorrhage account for the largest percentages of
complications admitted throughout all levels of care, Haemorrhage stands out as the main
cause of death, followed by Eclampsia and Complications of Abortion.

While Eclampsia occurs in less than 1% of pregnant women, it is a significant contributor to
maternal deaths. In Zimbabwe, especially at the quartenary level, the percentage of maternal
deaths is unacceptably high: 58.5%.

Every year almost 76,000 women die globally following complications of unsafe Abortion.
Abortion related deaths account for between 10% and 50% of all maternal deaths, depending
on the country.
    Mortality due to unsafe abortions is estimated by WHO to be 14% in Africa. Although
the percentages of death due to abortion complications stays under this estimate in secondary
and quartenary health facilities in Zimbabwe, the tertiary level shows a percentage above it,
of 15.5%.
    Considering the finding that Complications from Abortion are, besides Haemorrhage, the
leading cause for cases admitted, while not being the main direct cause of death for patients
referred to higher level of care, may indicate successful treatment for some of these patients
at the higher levels. At the same time, the high percentages of mortality due to Haemorrhage
at all higher levels of care may account for a number of cases of Abortion Complications, as
the 2 causes of death may not always have been clearly distinguished.

Overall, even when considering the limitations of using Maternal Mortality Ratios for small
samples, the high Maternal Mortality for the main pregnancy related complications as
observed in especially the secondary and tertiary level facilities is:
 Firstly, a rough indicator of delays in receiving care for patients who are in too serious a
   condition for even a reversal at the more sophisticated levels care, and
 Secondly, of sub-standard care due to lack of skilled personnel and the necessary drugs
   and supplies.




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 51
8)      PERINATAL MORTALITY RATIO:
(Number of newborn deaths amongst 1000 live births)
For every thousand babies born in developing countries, anywhere from 40 to 90% will be
stillborn or will not survive the first week of life. The main causes of Perinatal Mortality are
usually birth asphyxia, bacterial infection, congenital syphilis and pre-term birth23.

Table XIX:            Causes of perinatal death, by level of care
Cause of death                                Primary                  Secondary                         Tertiary            Quartenary
Pre-maturity                                  n/a                      n/a                                 60.5%                  63.9%
Low Apgar                                     n/a                      n/a                                 30.8%                  10.3%
Neonatal Jaundice                             n/a                      n/a                                  1.4%                   1.3%
Neonatal Sepsis                               n/a                      n/a                                  1.3%                   4.2%
Hypothermia                                   n/a                      n/a                                  0.4%                   0.1%
Neonatal Tetanus                              n/a                      n/a                                  0.0%                   0.0%
Congenital Anomalies                          n/a                      n/a                                  2.1%                   6.3%
Other                                         n/a                      n/a                                  3.5%                  13.9%

Neonatal Deaths per 1000 live                 -                        32.5/1000                       55.5/1000            Not available
births


Data regarding Perinatal Mortality were not available for the primary health institutions.
Here of note is that, often due to understaffing, more than half (55%) of the primary level
facilities did not offer neonatal services 7 days of the week, and the other 45% even less.
Infants with neonatal problems must therefore always be referred to a higher level of care. At
the same time, the serious lack of equipment for neonatal complications at the secondary
level will prevent appropriate treatment for infants with neonatal problems and thus increase
the need for further referrals. Infants that do not reach the tertiary level of care may not
always receive the optimal care they need since 20% of facilities at this level still lack some
essential items of equipment for neonatal resuscitation. At the quartenary level, 50% of
facilities did not have the IV fluid half-dextrose, which is an important solution for the
resuscitation of infants and children.

The percentages for causes of neonatal death shown for the quartenary level refer to 2 of the
4 institutions at that level, since two of the institutions had not recorded their neonatal deaths.
Zimbabwe‟s ratios for Perinatal Mortality remain comparable to other developing countries.
From the earlier analysis, delays in referral combined with lack of equipment, skilled
personnel, I.V. fluids and other critical supplies, appear to contribute to Neonatal Mortality in
Zimbabwe. (See tables 10, 23, 24, 32, and 33 in Annex)




23
     Mother Baby Package. Reproductive Health and Research Section, World Health Organization, 1999.
52 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
 SUMMARY OF RECOMMENDATIONS

First Delay

Delays have been noted in deciding to seek care.

Findings
The 3 leading causes of maternal death in Zimbabwe were Haemorrhage, Eclampsia, and
Complications of Abortion. If women with these conditions do not receive appropriate
attention within 2-6 hours, they will die.

The knowledge base regarding the complications of pregnancy and delivery in the
community is not thorough and specific enough to avoid tragedies from occurring before they
reach appropriate EmOC.

Knowledge of young men and women regarding Family Planning and Reproductive Health
issues is not complete enough, nor does knowledge match sexual activity patterns.

Recommendations
 Emphasis must be placed on the family and community level to recognize complications
   and immediately upon recognition of any danger sign to call for urgent assistance from
   the nearest health service provider, and/or mobilize appropriate emergency transport to
   the nearest first aid, basic or comprehensive EmOC facility
 With the considerable proportion of unskilled attendance during labour, family education
   must receive priority attention
 Information/education on danger signs of pregnancy and delivery should be extended to
   other community members and also community leaders. These can then be asked to fill
   an important communication role in case of an emergency, e.g. through cell phone access,
   or negotiation of transport.
 Traditional midwives and community based health cadres can be trained to recognize
   warning signals and advise immediate referrals accordingly, thus obtaining more official
   status as lowest link in the MNC pyramid.
 Simple, printed materials outlining MNH danger signs should be developed and
   distributed through all possible effective channels such as MOHCW static services and
   EPI outreach, ZNFPC static services and community based distribution schemes, and all
   government and civil society VCT/PMTCT sites.
 Recognition of danger signs and birth preparedness should become a focused ANC
   counseling component.
 Interventions for the reduction of Perinatal Mortality need to be strengthened at the
   community and health facility level. E.g. Health facility staff need to be trained to
   promote kangaroo mother care for pre-term infants and the importance of breastfeeding,

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 53
     cord care and hygiene in general for the well being of the baby. Also, if community health
     workers are present in the community, they could be trained to conduct 1-2 postpartum
     visits during the first week after delivery to check on the health and well being of the
     infant.
    Simple printed materials specifically addressing complications of abortion should be
     developed and distributed.
    In the longer term, mass media messages can be developed as part of a national
     communication strategy to ensure that MNH danger signs and the concept of emergency
     preparedness become “household language”. Similar messages, as well as clear
     information on the importance of avoiding unwanted pregnancies, should be incorporated
     in relevant school curriculum as widely as possible.

Delays have been noted in reaching care.

Findings
For many community members, long distances and transportation to a proper health facility
are prohibitive to reaching care.

Financial problems may impede community members in reaching care.

Not all community members have access to ways of communication that may provide the
first step in overcoming their problem.

Recommendations:
 Structured and strategic support should be rendered to all possible community referral and
   transport schemes such as the ox and donkey drawn ambulances that are currently being
   introduced.
 All options for community and trust-based revolving funds for the reimbursement of
   emergency transport costs should be further explored and developed
 Community leaders and civil society organizations should be encouraged to play a lead
   role in communication during emergency situations, and thus provide a crucial link
   between formal ambulance systems and the community. Reimbursement of such a
   service may not be needed in some communities, while in others such an incentive
   (provided by e.g. a community trust-based fund) may maintain a proper motivation for
   community service. All options need to be explored in this regard.
 At the facilities that do have an ambulance system in place, non-functioning vehicles
   should be identified and brought to a roadworthy condition where possible. Maintenance
   schedules have to reviewed and re-activated in order to keep the fleet of vehicles at all
   levels healthy.



54 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Delays have been noted in receiving care

Findings
Rural health clinics, district and provincial hospitals do not function to the limits of their
assumed and expected capacity, thus creating avoidable strain on the highest level of care.

Lack of appropriately trained staff, lack of essential drugs and pieces of equipment often
force referrals of patients to higher levels of care, who could have received more timely, less
traumatic, and less costly, life saving treatment closer to home.

Recommendations:
 Job descriptions and functional responsibilities of all staff cadres should be carefully
   reviewed.
 As many First Aid tasks and BEmOC functions need to be decentralized to the lowest
   levels of care: all nursing staff, from the lowest educational level upward, should be
   trained to provide Obstetric First Aid including: use of the partograph; measures to stop
   bleeding; measures in case of eclamptic convulsions; and administration of antibiotics
   and antipyretics orally as a temporary measure if transport to a higher level facility
   exceeds a few hours. These measures can then be taken by trained birth attendants at the
   home of the patient, or in low level facilities with minimal equipment, thus stabilizing a
   woman in serious conditions while transport is arranged to a higher level of care.
 Consideration should also be given to including the use of the manual vacuum aspirator
   for the evacuation of incomplete abortions in the training of primary health care
   personnel, in order to reduce referrals for incomplete abortions to the secondary level
   health facilities.
 A rapid nationwide 3-4 day orientation on Emergency Obstetric First Aid needs to be
   organized for all nurses and midwives.
 A refresher course for referral protocols needs to be organized for all staff at the district
   and provincial levels.
 All health facility staff at the lower level should be better oriented to emergency
   preparedness and rapid response in accordance with standardized clinical protocols. The
   contents of existing protocols thus need to be reviewed and re-approved for each staff
   cadre and familiarity of staff with them assessed.
 Staffing norms need to be reviewed in a structured way and by institutional level, based
   on actual and potential workload. A pragmatic and sustainable staff level can then be
   established for each level of health care.
 Staff and selected lowest level facilities should be upgraded in capacity to provide
   BEmOC, in order for women not to be forced to bypass the lower levels of health
   facilities and thus suffer through unduly delays in receiving care.



Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 55
    Based on the above mentioned staffing norms, a long-term Human Resource strategy
     needs to be developed. This plan should emphasize the production of sufficient midwives
     and nurses to fill vacant posts.
    Remuneration and/or incentive schemes should be researched and developed in order to
     keep existing lower level staff motivated and at post, especially at district level and
     below. At the same time, specific incentives should be developed for staff that is willing
     to start work at the district level and below.
    Remuneration schemes for temporary, rotational deployment of higher level EmOC
     personnel to understaffed facilities in need should be explored, as well as upgrading of
     salaries and benefits in the health sector in general, in order to avoid loss of EmOC staff.
    Existing, non-functional pieces of equipment need to be identified in a systematic way in
     each health facility, and to be repaired where possible. A special maintenance team may
     be employed and sent around to the various institutions. Maintenance guidelines need to
     be re-activated.
    Drugs, supplies and equipment, as outlined in this assessment, need to be procured and
     distributed to the appropriate levels of health care.
    Drug, supply and equipment standards need to be reviewed and used for requirements and
     procurement by level, and by complication.
    Stock keeping procedures need to be reviewed, clarified, and standardized for each level
     of care, with relevant staff members, in order to avoid erratic ordering mechanisms and
     lack of essential drugs.
    The concept of Reproductive Health Commodity Security needs to be expanded to
     include a careful selection of life-saving drugs. An annual review of commodity
     requirements needs to be organized for a consortium of government, multi-lateral and bi-
     lateral partners.
    Sufficient internal and external funds for the provision of RH commodity security should
     be ensured by an annual donor round-table.




56 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
ANNEX I: SOURCES OF INFORMATION

Table 1:                    Number of staff at primary health care facilities, by staff cadre
Number                        SCN                         SCN-midwife                         RGN staff                      RGN Midwife                         Nurse Aid
of staff              No. of         %. of all          No. of        %. of all           No. of        % of all           No. of         % of all           No. of         % of all
                    facilities       facilities       facilities      facilities        facilities      facilities       facilities       facilities       facilities       facilities
0                          116             44.4             153             58.6               91             35.4              129             49.2               27             10.3
1                           93             35.6              73             27.9               83             32.3               66             25.1              139             53.3
2-4                         39             14.9              24              9.1               46             17.9               40             15.2               70             26.8
≥5                          13              5.1              13              4.4               37             14.4               27             10.5               25              9.6
Total                      261             100              261             100               257             100               262             100               261             100


Table 2:                    Days of the week during which different services are offered at the
                            primary health care level
Days of the                 Antenatal Services                              Delivery                            Neonatal care                           Postnatal care
week                               (n=241)                                  (n=199)                                 (n=212)                                  (n=241)
                              No. of         % of                      No. of          % of                    No. of         % of                      No. of         % of
                            facilities   facilities                  facilities    facilities                facilities   facilities                  facilities   facilities
Mon. – Fri.                       194         80.5                            7           3.5                       79         37.3                         193         80.1
Mon. – Sat.                        25         10.4                            5           2.5                       16           7.5                         25         10.4
Mon. – Sun.                        22           9.1                        187             94                      117         55.2                          23           9.5


Table 3:                    Hours during which delivery services are offered at primary care centres
                            (n=197)
Periods of time                                                                               Number of Centres                                             % Total Centres
8am-12pm                                                                                                      1                                                         0.5
8am-16pm                                                                                                     18                                                         9.1
24Hrs.                                                                                                     178                                                         90.4


Table 4:                    Non-availability of basic equipment at the primary health care centres
Name of Equipment                                                                             Number of Centres                                             % Total Centres
Sphygmomanometer                                                                                              7                                                         2.6
Stethoscope                                                                                                  12                                                         4.5
Cannula Size 18                                                                                            209                                                         78.9
Suture Material                                                                                            128                                                         48.3
Instrument Sterilizer                                                                                        24                                                         9.1
Artery forceps                                                                                               70                                                        26.4
Episiotomy Scissors                                                                                          69                                                          26
Cord Scissors                                                                                              130                                                           49
Cord ties                                                                                                  195                                                         73.6
Gloves                                                                                                       37                                                          14
Sponge Forceps                                                                                             116                                                         43.8
Needle Holder                                                                                                83                                                        31.3
Stitch Scissors                                                                                            146                                                         55.1
Dissecting Forceps                                                                                         111                                                         41.9
Vaginal Speculum                                                                                           143                                                           54




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 57
Table 5:              Availability of ambulance transport at primary care centres (n=247)
                                                                                         Number                             % Total Centres
Available and functional                                                                    125                                        50.6
Available but not functional                                                                  6                                         2.4
Not available                                                                               116                                          47


Table 6:              Availability of telephone and radio services at primary care centres
                                                          Telephone (n=249)                                     Radio (n=248)
                                                          Number     % Total centres                          Number % Total Centres
Available and functional                                      113               45.4                               39           15.7
Available but not functional                                   35               14.1                               52             21
Not available                                                 101               40.5                              157           63.3

Table 7:              Primary centres where antibacterial and antimalarial drugs NOT
                      available (n=265)
Drug                                                                     Number of Centres                                  % Total Centres
Amoxycillin                                                                           172                                              64.9
Benzylpenicillin                                                                        39                                             14.7
Metronidazole (oral)                                                                    27                                             10.2
Chloroquine (oral)                                                                      16                                                6
Quinine (oral)                                                                        179                                              67.5
Quinine (injectable)                                                                  135                                              50.9
Fansidar                                                                              105                                              39.6
Oxytocin                                                                              125                                              47.2
Ergometrine                                                                           195                                              73.6
Nifedipine                                                                            223                                              84.2
Methyl-dopa                                                                           146                                              55.1
Magnesium Sulphate                                                                    242                                              91.3
Diazepam (Inj.)                                                                         75                                             28.3
Ringer‟s Lactate                                                                        88                                             33.2
Normal Saline                                                                         154                                              58.1
5% Dextrose                                                                           107                                              40.4
Half Dextrose/Darrows                                                                 200                                              75.5


Table 8:              Number of health providers by category at secondary level health
                      facilities (n=30)
Number                         GMOs                                         Midwife                                Clinical officer
of staff                 No. of     % of total                         No. of       % of total                     No. of        % of total
                       Facilities   Facilities                       facilities      facilities                  facilities        facilities
0                               6          20                                 0               0                         17              56.7
1                               9          30                                 1             3.3                         13              43.3
2-4                           14           47                                 7           23.3                            -                 -
≥5                              1            3                              22            73.4                            -                 -
Total                         30          100                               30             100                          30               100




58 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 9:                    Number of supporting staff at secondary level institutions, by cadre
                            (n=30)
Number                        Nurse Assistant                                              RNT             Lab. Sci./Technician                               Pharmacist or
of staff                                                                                                                                                    pharmaceutical
                                                                                                                                                                 technician
                        No. of                %. of                No. of                 %. of               No. of                % of                No. of        % of
                       Facility             Facility              facility              facility             facility             facility             facility     facility
0                           10                 33.3                    11                  36.7                     5                16.7                   13         43.3
1                           12                   40                    14                  46.7                   15                    50                  15            50
2-4                           8                26.7                      5                 16.7                     9                   30                    2          6.7
≥5                            -                    -                     -                     -                    1                  3.3                     -           -
Total                       30                  100                    30                   100                   30                  100                   30          100

Table 10:                   Deliveries, Maternal and Perinatal Mortality at secondary level
                            institutions
Cases Reported                                                                                                                                                            Number
Number of deliveries at secondary Institutions                                                                                                                              41976
Deliveries by TM                                                                                                                                                             1449
Deliveries by Others                                                                                                                                                         1603
Caesarean Sections                                                                                                                                                           2591
Maternal Deaths                                                                                                                                                                98
Fresh SB‟s                                                                                                                                                                    440
Macerated SB‟s                                                                                                                                                                355
Early neonatal deaths                                                                                                                                                         569

Table 11:                   Deliveries at secondary level institutions by different cadre of birth
                            attendants
Cadre                                                                                                                                           % Deliveries performed
RNM                                                                                                                                                                64.4
SCNM                                                                                                                                                               16.3
RGN                                                                                                                                                                 8.5
GMO                                                                                                                                                                   4
O&G                                                                                                                                                                 1.4
Other                                                                                                                                                               5.3


Table 12:                   Distribution of indirect obstetric complications at secondary institutions
Obstetric Complication                                                                         Number of Cases                     % Total Indirect Complications
Tuberculosis                                                                                                 8                                                1%
Malaria                                                                                                   448                                                81%
HIV/AIDS                                                                                                    17                                                3%
Anaemia                                                                                                     21                                                4%
Domestic Violence                                                                                           12                                                2%
Other                                                                                                       46                                                8%
Total Indirect Complications                                                                              552                                              100%




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 59
Table 13a:            Secondary institutions where basic equipment NOT available (n=31)
Name of Equipment                                                   Number of Institutions                                      % Institutions
Sphygmomanometer                                                                         1                                                 3.2
Stethoscope                                                                              3                                                 9.7
Instrument sterilizer                                                                    8                                                25.8
Cannula size 18                                                                         14                                                45.2
Suture material                                                                          2                                                 6.5
Sponge forceps                                                                          17                                                54.8
Needle holder                                                                            8                                                25.8
Stitch scissors                                                                         13                                                41.9
Dissection forceps                                                                      12                                                38.7
Vaginal speculum                                                                         7                                                22.6
Artery forceps                                                                          10                                                32.3
Episiotomy scissors                                                                     15                                                48.4
Cord scissors                                                                            8                                                25.8
Cord ties                                                                               22                                                  71
Gloves                                                                                   7                                                22.6
Vacuum extractor                                                                         5                                                16.1
Outlet forceps                                                                          19                                                61.3
D & C packs                                                                              0                                                   0

Table 13b:            Secondary institutions where equipment for neonatal resuscitation NOT
                      available (n=31)
Equipment                                                          Places where not available                                  % Total places
Mucus extractor                                                                            27                                            87.1
Neonatal masks                                                                              3                                             9.7
Suction catheters                                                                          12                                            38.7
Suction machine                                                                             3                                             9.7
Ambu bag                                                                                    5                                            16.1
Laryngoscopes                                                                              10                                            32.3
Endotracheal tubes                                                                         12                                            38.7
Infant warmer                                                                              16                                            51.6
Resuscitaire                                                                                9                                              29



Table 14:             Secondary institutions where basic equipment for anaesthesia, blood
                      transfusion and laparatomy NOT available (n=31)
Name of Equipment                                           Number of Institutions                                      % Total Institutions
Anaesthetic machine                                                              3                                                       9.7
Adult resuscitation tray                                                         6                                                      19.4
Suction machine                                                                  2                                                       6.5
Oxygen cylinder and gauge                                                        1                                                       3.2
Tubes and connectors                                                             2                                                       6.5
Obstetric laparatomy set                                                         1                                                       3.2
Caesarean section set                                                            1                                                       3.2
Blood cross-matching                                                             5                                                      16.1




60 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 15:                   Secondary institutions where essential drugs NOT available (n=31)
Name of Drug                                                                      Number of Institutions                                              % Total Institutions
Benzylpenicillin                                                                                       0                                                                  0
Gentamicin                                                                                             0                                                                  0
Metronidazole                                                                                          6                                                              19.4
Chloroquine                                                                                            0                                                                  0
Quinine (oral)                                                                                         1                                                                3.2
Quinine (IVI)                                                                                          2                                                                6.5
Fansidar                                                                                               4                                                              12.9
Ergometrine                                                                                           11                                                              35.5
Oxytocin                                                                                               2                                                                6.5
Di-hydrallazine                                                                                       23                                                              74.2
Nifedipine                                                                                             8                                                              25.8
Magnesium Sulphate                                                                                    31                                                               100
Diazepam (IVI)                                                                                         0                                                                  0
Ringer‟s Lactate                                                                                       9                                                                 29
Normal Saline                                                                                          2                                                                6.5
5% Dextrose                                                                                            2                                                                6.5
50% Dextrose                                                                                           5                                                              16.1
Half Dextrose/Darrows                                                                                 16                                                              51.6

Table 16:                   Catchment area Populations and number of referring centres for tertiary
                            level facilities
Name of Institution                  Province                                                Catchment Population                      Number of Referring Centers
Gwanda                               Matebeleland South                                                   141,826                                               25
Marondera                            Mashonaland East                                                     158,584                                               15
Avenues                              (Private)                                                                  -                                                2
Mutare                               Manicaland                                                         2,261,843                                                8
St. Lukes                            Matebeland North                                                      52,507                                               15
Mater Dei                            (Private)                                                                  -                                                0
Gweru                                Midlands                                                             749,196                                               29
Masvingo                             Masvingo                                                             673,927                                                9
Chinhoyi                             Mashonaland East                                                     175,088                                               33
Bindura                              Mashonaland Central                                                   72,584                                                4


Table 17:                   Distance from furthest referring centre and distance to referral centre for
                            tertiary facilities
Name of Institution                        Distance from Furthest Referring Centre (km)                                          Distance to Referral Centre (km)
Gwanda                                                                              195                                                                       126
Marondera                                                                           194                                                                         74
Avenues                                                                               3                                                                        0.7
Mutare                                                                              183                                                                       263
St. Lukes                                                                           299                                                                       140
Mater Dei                                                                             -                                                                          -
Gweru                                                                               210                                                                       192
Masvingo                                                                            300                                                                       300
Chinhoyi                                                                            242                                                                       115
Bindura                                                                             246                                                                         87
Mean                                                                                208                                                                     144.2




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 61
Table 18:             Number and category of medical staff working at the tertiary facilities
Institution                                                            Category of staff
                        O&G           GMO          Pediatricia         Lab.Sci.       RNM                     NA         SCNM               RGN
                                                             n
Gwanda                       1             2                 0                  3              27               3              13              67
Marondera                    1             4                 1                  3              14               0               3              92
Avenues                    26*             0              17*                   0              28               0               1             110
Mutare                       1             5                 2                  1              48               1              13             111
St. Lukes                    1             3                 0                  1              15               0               0              16
Mater Dei                  11*             0                4*                  0              21               0               0               0
Gweru                        1             7                 0                  0              41               2               9             249
Masvingo                     1             6                 0                  6              36               3               2             125
Chinhoyi                     2            11                 1                  0              25               2              22             119
Bindura                      0             7                 1                  4              35               3               2              70
Total                        8            45                 5                 18             290              14              65             959
*    Figures shown for Avenues Clinic and Mater Dei Hospitals are for specialists who have
     right of access to these institutions. These institutions do not directly employ specialist
     doctors.

Table 19:             Deliveries and caesarean sections at tertiary facilities
                                               Total deliveries                     Caesarean Section                       % of birth by CS
Gwanda                                                      1,422                                      73                                     5.1
Marondera                                                   1,624                                     302                                    18.6
Avenues                                                     1,704                                     599                                    35.2
Mutare                                                      2,316                                   1,023                                    44.2
St. Lukes                                                   1,600                                     109                                     6.8
Mater Dei                                                   1,213                                     455                                    37.5
Gweru                                                       2,514                                     746                                    29.7
Masvingo                                                    2,376                                     534                                    22.5
Chinhoyi                                                    2,856                                     447                                    15.7
Bindura                                                     2,044                                     159                                     7.8
Total                                                      19,669                                   4,447                                    22.6

Table 20:             Number of obstetric admissions and mean hospital stay (in days)
Institution                                               Number of admissions                                          Mean Hospital Stay
Gwanda                                                                   2,074                                                           3
Marondera                                                                1,958                                                           2
Avenues                                                                  1,662                                                           3
Mutare                                                                   5,116                                                           5
St. Lukes                                                                1,764                                                           6
Mater Dei                                                                1,333                                                           3
Gweru                                                                    2,753                                                           5
Masvingo                                                                 2,640                                                           2
Chinhoyi                                                                 3,005                                                           3
Bindura                                                                  2,724                                                           4
Total                                                                  25,029                                           3.6 (Mean average)




62 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 21:                   Distribution of direct obstetric complications treated at the tertiary
                            facilities
Condition                                                                                   Number of Cases                       % direct obstetric complications
Haemorrhage                                                                                             473                                                   10.2
Obstructed and prolonged labour                                                                         751                                                   16.2
Ruptured Uterus                                                                                          21                                                     0.5
Postpartum Sepsis                                                                                       119                                                     2.6
Pre-eclampsia/eclampsia                                                                                 876                                                   18.9
Complications of abortion                                                                             2,279                                                   49.3
Ectopic Pregnancy                                                                                       107                                                     2.3
Total                                                                                                 4,626                                                    100

Table 22:                   Obstetric complications admitted at the tertiary facilities (indirect causes)
Obstetric Complication                                                                      Number of Cases                   % indirect obstetric complications
Tuberculosis                                                                                             18                                                   3.6
Malaria                                                                                                217                                                     43
HIV/AIDS                                                                                                 65                                                 12.9
Anaemia                                                                                                144                                                  28.6
Domestic Violence                                                                                         2                                                   0.4
Other                                                                                                    58                                                 11.5
Total                                                                                                  504                                                   100

Table 23:                   Maternal Mortality due to direct causes (tertiary facilities)
Cause of Maternal Mortality                                                                 Number of Cases                                                   % Total Deaths
Direct causes
Haemorrhage                                                                                                          11                                                          42.3
Obstructed Labour                                                                                                     0                                                             0
Ruptured Uterus                                                                                                       1                                                           9.1
Postpartum Sepsis                                                                                                     2                                                           7.8
Pre-eclampsia                                                                                                         6                                                          23.1
Eclampsia
Complications of abortion                                                                                             4                                                          15.4
Ectopic Pregnancy                                                                                                     1                                                            9.1
Other                                                                                                                 1                                                            9.1
Sub-total                                                                                                            26                                                           100
In-direct causes
Tuberculosis                                                                                                         14                                                          42.4
Malaria                                                                                                               2                                                            6.1
HIV/AIDS                                                                                                              5                                                          15.2
Anaemia                                                                                                               4                                                          12.1
Other                                                                                                                 8                                                          24.2
Sub-total                                                                                                            33                                                           100

Table 24:                   Perinatal Mortality (tertiary institutions)
Cause of Death                                                                              Number of Cases                                                     % Total Cases
Prematurity                                                                                            598                                                               60.5
Low Apgar                                                                                              305                                                               30.8
Neonatal Jaundice                                                                                        14                                                                1.4
Neonatal Sepsis                                                                                          13                                                                1.3
Hypothermia                                                                                               4                                                                0.4
Neonatal Tetanus                                                                                          0                                                                  0
Congenital Anomalies                                                                                     21                                                                2.1
Others                                                                                                   34                                                                3.5
Total                                                                                                  989                                                                100



Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 63
Table 25a:            Availability and state of basic equipment for EmOC at tertiary facilities
Name of Equipment                                        Number available               Number Functional                       % Functional
Sphygmomanometer                                                      102                              94                                 92
Stethoscope                                                            35                              34                                 97
Cannula Size 18 (boxes)                                               280                             N/a                                N/a
Suture Material (boxes)                                            2,313                              N/a                                N/a
Instrument Sterilizer                                                  12                               8                                 67
Artery Forceps                                                        659                             659                                100
Episiotomy Scissors                                                   126                             126                                100
Cord Scissors                                                          99                              99                              100*
Cord Ties**                                                            10                             N/a                                N/a
Gloves (boxes)                                                     4,110                              N/a                                N/a
Sponge Forceps                                                         31                              31                              100*
Needle Holder                                                          42                              42                                100
Stitch Scissors                                                        35                              35                                100
Dissecting Forceps                                                     60                              59                                 98
Vaginal Speculum                                                       33                              33                             100**
Vacuum Extractor                                                       24                              22                                92*
Outlet Obstetric Forceps                                               19                              19                             100**
Anaesthetic Machine                                                    32                              31                                 97
Adult Resuscitation Tray                                               15                              15                                100
Electrical Suction Machine                                             37                              33                                 89
Oxygen Cylinder with Gauge                                             54                              54                                100
Oxygen Masks                                                          688                             688                              100*
Tubes and Connectors                                                   95                              93                                98*
Obstetric Laparatomy Set                                               41                              41                                100
Caesarean Section Set                                                  53                              53                                100

Table 25b:            Tertiary institutions where equipment for neonatal resuscitation available
Name of equipment                                                                                               % of places where available
Ambu bag                                                                                                                                80
Neonatal suction                                                                                                                        80
Paediatric emergency tray                                                                                                               80
Oxygen                                                                                                                                  80
Heat source                                                                                                                             80




64 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 26:                   Availability of essential drugs at the tertiary health facilities
Name of Drug                                                     Number of Institutions (available)                                                   % Total Institutions
Gentamicin                                                                                      10                                                                     100
Benzylpenicillin                                                                                10                                                                     100
Kanamycin                                                                                       10                                                                     100
Metronidazole (oral)                                                                            10                                                                     100
Chloroquine (oral)                                                                              10                                                                     100
Quinine (oral)                                                                                  10                                                                     100
Quinine (injectable)                                                                              9                                                                    90*
Fansidar                                                                                        10                                                                     100
Ergometrine                                                                                       8                                                                     80
Oxytocin                                                                                        10                                                                     100
Hydralazine (oral)                                                                                3                                                                     30
Nifedipine (oral)                                                                                 7                                                                     70
Magnesium Sulfate                                                                                 8                                                                     80
Diazepam (injectable)                                                                           10                                                                     100
Pethidine                                                                                       10                                                                     100
Ringer‟s Lactate                                                                                  9                                                                     90
Normal Saline                                                                                   10                                                                     100
5% Dextrose                                                                                     10                                                                     100
50% Dextrose                                                                                    10                                                                     100
½ Dextrose/Darrows                                                                                8                                                                     80


Table 27:                   Referring institutions for quartenary health facilities
                                                                                                             HMH               MNMH                     Mpilo                  UBH
Number of referring institutions                                                                                *                 35                      37                     24
Distance from furthest referring institution                                                                  800                  *                     288                    314

Table 28:                   Number of staff currently working and occupancy of established posts at
                            the quartenary health facilities
Staff                                                                                                                                                                Institution
Category                                     HMH                                     MNMH                                       Mpilo                                      UBH
                              No.        Occupancy                  No.            Occupancy                   No.          Occupancy                    No.         Occupancy
                             staff             rate                staff                 rate                 staff               rate                  staff               rate
O&G                            7*                80                  9*                  66.7                    0                   0                     1                33.3
Paed.                           0                 0                   3                  66.7                    2                66.7                     1                33.3
Anaes.                         3*                 0                   0                     0                    1                33.3                     2                   0
RNM                           109              69.8                  34                  53.1                   69                12.3                     *                54.3
Lab. Sc.                       30               100                   6                    60                    0                   0                     8                  40
NA                              2               100                   1                    50                    0                   0                     2                   0
Pharm.                          3               100                   0                     -                    3                27.3                     4                36.4
*      The figures for Harare Maternity and Mbuya Nehanda have included Obstetricians and
       Anaesthetists who work for the medical school of the University of Zimbabwe. These specialists
       provide the same service to the hospitals as their government counterparts. United Bulawayo
       Hospitals could not separate the number of registered midwives from registered nurses.

Table 29:                   Deliveries at quartenary facilities by cadre of health staff
Cadre of Health Staff                                                                                                                 Percentage of Total Deliveries
RNM                                                                                                                                                             84.5
GMO                                                                                                                                                             10.9
O&G                                                                                                                                                              2.9
SCNM                                                                                                                                                             1.7

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 65
Table 30:             Admissions, C/sections and mean hospital stay
Facility                      Obs. Admissions                         Deliveries                     C/Sections             Mean Hosp. Stay
HMH                                   13,562                               8,804                          1,478                           3
MNMH                                    4,259                              2,943                            484                           2
Mpilo                                   9,655                              9,312                          1,254                           3
UBH                                     2,894                              2,305                            408                           3
Total                                 30,370                             23,364                           3,624


Table 31:             Indirect obstetric complications admitted at quartenary facilities
Complication                                                    Number of Cases Admitted                % of indirect obs. complications
Tuberculosis                                                                          16                                            15.7
Malaria                                                                               19                                            18.6
HIV/AIDS                                                                              38                                            37.3
Anaemia                                                                               16                                            15.7
Domestic Violence                                                                     11                                            10.8
Other                                                                                  2                                              1.9
Total                                                                                102                                             100

Table 32:             Maternal Mortality due to direct causes (quartenary facilities)
Cause of Maternal Mortality                                                    Number of Cases                                % Total Deaths
Direct causes
Haemorrhage                                                                                        20                                        30.8
Obstructed Labour                                                                                   0                                            0
Ruptured Uterus                                                                                     5                                          7.7
Postpartum Sepsis                                                                                   0                                            0
Pre-eclampsia/Eclampsia                                                                            38                                        58.5
Complications of Miscarriage                                                                        1                                          1.5
Ectopic Pregnancy                                                                                   0                                            0
Other                                                                                               1                                          1.5
Total                                                                                              65                                         100
Indirect causes
Tuberculosis                                                                                        3                                        21.4
Malaria                                                                                             2                                        14.3
HIV/AIDS                                                                                            5                                        35.8
Anaemia                                                                                             1                                          7.1
Domestic Violence                                                                                   0                                            0
Other                                                                                               3                                        21.4
Total                                                                                              14                                         100
The case fatality rate for direct causes was 1.2% and for indirect 13.7%.

Table 33:             Perinatal Mortality (quartenary institutions)
Cause of Death                                                        Number of Cases                                          % Total Cases
Prematurity                                                                       818                                                   63.9
Low Apgar                                                                         132                                                   10.3
Neonatal Jaundice                                                                  17                                                     1.3
Neonatal Sepsis                                                                    54                                                     4.2
Hypothermia                                                                         1                                                     0.1
Neonatal Tetanus                                                                    0                                                       0
Congenital Anomalies                                                               80                                                     6.3
Others                                                                            178                                                   13.9
Total                                                                           1,280                                                    100




66 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 34:                   Availability and state of basic equipment for MNH at quartenary facilities
Name of Equipment                                                            Number available                   Number Functional                                % Functional
Sphygmomanometer                                                                           12                                   9                                          75
Stethoscope                                                                                 5                                   4                                          80
Instrument Sterilizer                                                                       4                                   3                                          75
Cannula Size 18 (boxes)                                                                   126                                 N/a                                         N/a
Suture Material (boxes)                                                                2,186                                  N/a                                         N/a
Artery Forceps                                                                             59                                  59                                       100*
Episiotomy Scissors                                                                       102                                 102                                         100
Cord Scissors                                                                              72                                  72                                         100
Cord Ties                                                                                   0                                   0                                         N/a
Gloves (boxes)                                                                            450                                 N/a                                         N/a
Sponge Forceps                                                                             42                                  42                                         100
Needle Holder                                                                              44                                  44                                         100
Stitch Scissors                                                                            41                                  41                                         100
Dissecting Forceps                                                                         60                                  60                                         100
Vaginal Speculum                                                                           15                                  15                                         100
Vacuum Extractor                                                                           29                                  28                                          97
Outlet Obstetric Forceps                                                                    8                                   8                                         100
Anaesthetic Machine                                                                         8                                   8                                         100
Adult Resuscitation Tray                                                                    5                                   5                                         100
Electrical Suction Machine                                                                  5                                   5                                         100
Oxygen Cylinder with Gauge                                                                  6                                   6                                         100
Oxygen Masks                                                                               71                                  71                                         100
Tubes and Connectors                                                                       33                                  33                                         100
Obstetric Laparatomy Set                                                                    4                                   4                                       100*
Caesarean Section Set                                                                      37                                  37                                         100


Table 35:                   Availability of essential drugs at the national level health facilities
Name of Drug                                                                            Number of Institutions                                       % Total Institutions
Gentamicin                                                                                                   4                                                        100
Benzylpenicillin                                                                                             4                                                        100
Kanamycin                                                                                                    4                                                        100
Metronidazole (oral)                                                                                         4                                                        100
Chloroquine (oral)                                                                                           4                                                        100
Quinine (oral)                                                                                               4                                                        100
Quinine (injectable)                                                                                         3                                                      75%*
Fansidar                                                                                                     4                                                        100
Ergometrine                                                                                                  1                                                         25
Oxytocin                                                                                                     4                                                        100
Hydralazine (oral)                                                                                           3                                                         75
Nifedipine (oral)                                                                                            4                                                        100
Magnesium Sulphate                                                                                           4                                                        100
Diazepam (injectable)                                                                                        4                                                        100
Pethidine                                                                                                    4                                                        100
Ringer‟s Lactate                                                                                             4                                                        100
Normal Saline                                                                                                4                                                        100
5% Dextrose                                                                                                  4                                                        100
50% Dextrose                                                                                                 4                                                        100
Half Dextrose Darrows                                                                                        2                                                        50*




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 67
Table 36:             District and population sampled by province
Province                  Total No. of           Number of             % district          Provincial        Population in        % population
                              districts            districts            assessed                 total        the sampled           covered in
                                                  assessed                                 population             districts          sampling
Mash West                              6                   3                  50%           1,001,558             668,932                67%
Mash Central                           7                   3                  43%             998,265             506,231                51%
Mat South                              6                   3                  50%             654,879             323,792                49%
Mat North                              7                   3                  43%             701,359             382,596                55%
Masvingo                               7                   3                  43%           1,318,705             625,925                47%
Midlands                               8                   3                  38%           1,466,331             523,105                36%
Manicaland                             7                   3                  43%           1,566,889             749,765                48%
Mash East                              9                   3                  33%           1,125,355             363,778                32%
Total                                 57                 24                   42%           8,833,341           4,144,124                47%


Table 37:             Coverage of comprehensive EmOC for 500,000 population by district
                      sampled
Province               District                     District                                  District         Number of           Coverage of
                                                    Hospital                               Population             EmOC               C-EmOC
                                                                                                                 facilities
Mash.                  Centenary                    St. Alberts Mission                        107,718                     1                   4.6
Central                Mazowe                       Concession                                 199,408                     1                   2.5
                       Mt. Darwin                   Mt. Darwin                                 199,105                     0                   0.0
Mash.                  Hwedza                       Hwedza                                      70,604                     0                   0.0
East                   Murewa                       Murewa                                     162,660                     1                   3.1
                       Mudzi                        Kotwa                                      130,514                     1                   3.8
Mash.                  Kadoma                       Kadoma                                     235,531                     1                   2.1
West                   Makonde                      Makonde Christian                          123,580                     1                   4.0
                       Hurungwe                     Karoi                                      309,821                     2                   3.2
Midlands               Kwekwe                       Silobela                                   160,621                     1                   3.1
                       Zvishavane                   Zvishavane                                  67,857                     1                   7.4
                       Gokwe South                  Gokwe                                      294,627                     0                   0.0
Masvingo               Gutu                         Gutu Mission                               198,130                     1                   2.5
                       Chiredzi                     Chiredzi                                   232,616                     1                   2.1
                       Masvingo                     Morgenster                                 195,179                     1                   2.6
Manicaland             Buhera                       Murambinda                                 218,570                     1                   2.3
                       Makoni                       Rusape                                     247,524                     1                   2.0
                       Chipinge                     Chipinge                                   283,671                     2                   3.5
Matebele-              Kezi/Matobo                  Maphisa                                     99,836                     1                   5.0
land South             Gwanda                       Manama                                     119,744                     0                   0.0
                       Beitbridge                   Beitbridge                                 104,212                     1                   4.8
Matebele-              Hwange                       Vic. Falls                                 144,551                     1                   3.5
land North             Binga                        Binga                                      118,824                     1                   4.2
                       Tsholotsho                   Tsholotsho                                 119,221                     1                   4.2




68 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 38:                   Coverage of comprehensive EmOC for 500,000 population by province
Province                          Total                  Total             % of sampled                      Number of                       Number of                  C-EmOC
                             provincial               number                     district                       district                 provincial and                 coverage
                             population             of district                hospitals                       hospitals               district hospitals
                                                     hospitals                providing                       providing                        providing
                                                                              C-EmOC                          C-EmOC                           C-EmOC
Mash West                      1,001,558                         6                 100%                                6                                7                        3.49
Mash Central                     998,265                         7                  67%                            4.69                             5.69                         2.85
Mat South                        654,879                         6                  67%                            4.02                             5.02                         3.83
Mat North                        701,359                         7                 100%                                7                                8                        5.70
Masvingo                       1,318,705                         7                 100%                                7                                8                        3.03
Midlands                       1,466,331                         8                  67%                            5.36                             6.36                         2.17
Manicaland                     1,566,889                         7                 100%                                7                                8                        2.55
Mash East                      1,125,355                         9                  67%                            6.03                             7.03                         3.12
Total                          8,833,341                        57                  93%                              53                             55.1                         3.12



Table 39:                   Proportion of births taking place in health facilities and % of all births by
                            Caesarean Section, by district and province, Adjusted for population
Health                              Population          Expected annual no.                        No. of                   No. of                    % of                 % of all
Facilities**                                                  of births 2003                 deliveries in              Caesarean             deliveries in               births by
                                                          (Crude birth rate                        health                  section                  health               Caesarean
                                                                  30.3/1000)                     facilities                                       facilities                section
Mash West
Chinhoyi                               1,001,558                            30,047                   2,856                       447                   9.5%                     1.5%
Kadoma                                   235,531                             7,066                   2,435                       159                  34.5%                     2.3%
Hurungwe                                 309,821                             9,295                    1958                        79                  21.1%                     0.8%
Makonde C                                123,580                             3,707                     562                        25                  15.2%                     0.7%
Provincial total                       1,001,558                            30,047                 10,252*                      840*                  34.1%                     2.8%
Mash central
Bindura                                  998,265                            29,948                     2044                      159                   6.8%                     0.5%
Centenary                                107,718                             3,232                     1627                      183                  50.0%                     5.7%
Mazoe                                    199,408                             5,982                      790                        3                  13.2%                     0.1%
Mt. Darwin                               199,105                             5,973                     1263                        0                  21.1%                     0.0%
Provincial total                         998,265                            29,948                   9,260*                     524*                  30.9%                     1.7%
Matebeleland South
Gwanda                                   654,879                           19,646                    1422                        73                    7.2%                     0.4%
Beitbridge                               104,212                            3,126                    2310                       137                   73.9%                     4.4%
Maphisa                                   99,836                            2,995                      984                       36                   32.9%                     1.2%
Manama Missio                            119,744                            3,592                      792                        0                   22.0%                     0.0%
Provincial total                         654,879                        19,646.37                9,760.78*                  426.06*                   49.7%                     2.2%
Mat North,
St. Lukes                                701,359                           21,041                    1600                       109                    7.6%                     0.5%
Vic. Falls                               144,551                            4,337                      963                      174                   22.2%                     4.0%
Binga                                    118,824                            3,565                      962                       39                   27.0%                     1.1%
Tsholotsho                               119,221                            3,577                    1248                        80                   34.9%                     2.2%
Provincial total                         701,359                        21,040.77                7,369.09*                  641.73*                   35.0%                     3.0%
Masvingo
Masvingo                               1,318,705                           39,561                   2640                       891                     6.7%                    2.25%
Gutu mission                             198,130                            5,944                   1429                       131                    24.0%                     2.2%
Chiredzi                                 232,616                            6,978                   3764                       262                    53.9%                     3.8%
Morgenster                               195,179                            5,855                   1833                       120                    31.3%                     2.0%
Provincial total                       1,318,705                        39,561.15              17,588.94*                 1982.49*                    44.5%                     5.0%
Midlands province
Gweru Hospital                         1,466,331                           43,990                     2514                     746                     5.7%                     1.7%
Silobela                                 160,621                            4,819                     1627                     183                    50.0%                     3.8%
Zvishavane                                67,857                            2,036                     2609                     220                    13.2%                     0.1%
Gokwe                                    294,627                            8,839                     1263                       0                    21.1%                     0.0%
Provincial total                       1,466,331                        43,989.93                  17,789*                1865.44*                    40.4%                     4.2%
Manicaland
Mutare                                 1,566,889                            47,007                     2316                     1023                    4.9%                     2.2%
Murambinda                               218,570                             6,557                     1033                      122                   50.0%                     1.9%
Rusape                                   247,524                             7,426                     1928                      113                   13.2%                     0.1%
Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 69
Health                       Population      Expected annual no.                No. of              No. of               % of            % of all
Facilities**                                       of births 2003         deliveries in         Caesarean        deliveries in          births by
                                               (Crude birth rate                health             section             health          Caesarean
                                                       30.3/1000)             facilities                             facilities           section
Chipinge                         283,671                    8,510                 1823                185              21.1%                0.0%
Provincial total               1,566,889                47,006.67          12,282.67*            1898.00*              26.1%                4.0%
Mashonaland East
Marondera                      1,125,355                 33,760.65             1624.00              203.00             4.81%               0.60%
Hwedza                            70,604                  2,118.12              549.00                0.00            25.92%               0.00%
Murewa                           162,660                   4,879.8             1454.00               42.00            29.80%               0.86%
Mudzi                            130,514                  3,915.42              993.00               61.00            25.36%               1.56%
Provincial total               1,125,355                    33,761          10,986.50*             524.88*            32.54%               1.55%
*       The total number of deliveries in health facilities and CS in a province has been adjusted by the total
        population. For example, the number of CS in the 3 sampled district hospitals in Mash West is 264, and
        the population covered in the sampled districts is 67% (see table 36). Then the total number of CS
        performed in the province is calculated as [(264/0.67) +447(CS in the provincial hospital)] =840. Same
        method of calculation is applied to the number of total deliveries in health facilities in a province.
**      The first health facility listed under each province is the provincial hospital.


Table 40:             Proportion of births taking place in health facilities and by CS, by
                      province
Province                      Population      Expected annual no.                   No. of         No. of CS              % of           % of all
                                                    of births 2003            deliveries in                       deliveries in         births by
                                                (Crude birth rate          health facilities                            health                CS
                                                        30.3/1000)                                                    facilities
Mash. West                     1,001,558                       30,047                10,252              840             34.1%               2.8%
Mash. Centr.                     998,265                       29,948                 9,260              524             30.9%               1.7%
Mat. North                       701,359                       21,041                 7,369              642             35.0%               3.0%
Masvingo                       1,318,705                       39,561                17,589            1,982             44.5%               5.0%
Midlands                       1,466,331                       43,990                17,789            1,865             40.4%               4.2%
Manicaland                     1,566,889                       47,007                12,283            1,898             26.1%               4.0%
Mash. East                     1,125,355                       33,761                10,987              525             32.5%               1.6%
Mat. South                       654,879                       19,646                 9,761              426             49.7%               2.2%
Harare                         1,903,510                       57,105                11,747            1,962             20.6%               3.4%
Bulawayo                         676,787                       20,304                11,617            1,662             57.2%               8.2%
Total                         11,413,638                      342,409               118,653           12,326             34.7%               3.6%


Table 41:             Proportion of obstetric complications treated by district and province
                              Population      Expected annual no.          Expected number of              No. of direct obs.           Met need
                                                    of births 2003                   obstetric               Complications
                                                (Crude birth rate               complications                        treated
                                                        30.3/1000)
Mash West
Chinhoyi                        1,001,558                   30,046.74                      4,507.01                    601.00                13%
Kadoma                            235,531                    7,065.93                       1059.89                    622.00              58.7%
Hurungwe                          309,821                    9,294.63                       1394.19                    475.00              34.1%
Makonde C                         123,580                     3,707.4                        556.11                      9.00               1.6%
Subtotal                        1,001,558                   30,046.74                      4,507.01                  2,251.75              50.0%
Mash Central
Bindura                           998,265                   29,947.95                      4,492.19                    382.00                 9%
Centenary                         107,718                    3,231.54                        484.73                    251.00                52%
Mazoe                             199,408                    5,982.24                        897.34                     66.00                 7%
Mt. Darwin                        199,105                    5,973.15                        895.97                    296.00                33%
Subtotal                          998,265                   29,947.95                      4,492.19                  1,583.96                35%
Mat North
St. Lukes                         701,359                   21,040.77                      3,156.12                    161.00               5.1%
Vic. Falls                         32,500                      975.00                        146.25                     46.00              31.5%

70 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
                                     Population           Expected annual no.                 Expected number of                      No. of direct obs.                  Met need
                                                                of births 2003                          obstetric                       Complications
                                                            (Crude birth rate                      complications                                treated
                                                                    30.3/1000)
Binga                                     118,824                     3,564.72                                    534.71                               10.00                   1.9%
Tsholotsho                                119,221                     3,576.63                                    536.49                               57.00                  10.6%
Subtotal                                  701,359                    21,040.77                                  3,156.12                              366.45                  11.6%
Masvingo
Masvingo                                1,318,705                          39,561.15                            5,934.17                              227.63                    3.8%
Gutu mission                              198,130                           5,943.90                              891.59                              183.00                   20.5%
Chiredzi                                  232,616                           6,978.48                            1,046.77                              276.00                   26.4%
Morgenster                                195,179                           5,855.37                              878.31                               93.00                   10.6%
Subtotal                                1,318,705                          39,561.15                            5,934.17                           1,402.09                   23.6%
Midlands
Gweru                                   1,466,331                          43,989.93                            6,598.49                              729.00                   11.0%
Provincial
Hospital
Zvishavane                                 67,857                               2,036                                 305                                251                  82.2%
Gokwe South                               294,627                               5,982                                 897                                457                  50.9%
Silobela                                  160,621                               5,973                                 896                                388                  43.3%
Subtotal                                1,466,331                              57,981                               8,697                              3,773                  43.4%
Manicaland Province
Mutare                                  1,566,889                              47,007                               7,051                              1,225                  17.4%
Chipinge                                  283,671                               8,510                               1,277                                276                  21.6%
Murambinda                                218,570                               6,557                                 984                                163                  16.6%
Rusape                                     25,054                                 752                                 113                                397                 352.1%
Subtotal                                1,566,889                              47,007                               7,051                              2,967                  42.1%
Mashonaland East
Marondera                               1,125,355                              33,761                               5,064                                 345                    7.0%
Hwedza                                     70,604                               2,118                                 318                                  19                  6.0%
Murewa                                    162,660                               4,880                                 732                                  49                  7.0%
Mudzi                                     130,514                               3,915                                 587                                  47                  8.0%
Subtotal                                1,125,355                              33,761                               5,064                                 704                 13.9%
Matebeleland South
Gwanda                                    654,879                              19,646                               2,947                                253                   8.6%
Manama                                    119,744                               3,592                                 539                                 94                  17.4%
Beitbridge                                104,212                               3,126                                 469                                221                  47.1%
Maphisa                                    99,836                               2,995                                 449                                149                  33.2%
Subtotal                                  654,879                              19,646                               2,947                              1,200                  40.7%
*      The total number of obstetric complications treated in a province has been adjusted by the total population.
       For example, the number of obstetric complications treated in the 3 sampled district hospitals in Mash West
       is 1,106, and the population covered in the sampled districts is 67% (see table 36). Then the total number of
       obstetric complications treated in the province is calculated as [(1,106/0.67) +601 (obstetric complications
       treated in the provincial hospital=2,251.75].




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 71
Table 42:             Met need by province
Province                   Population           Expected annual                    Expected             Number of direct              Met need
                                                number of births                  number of                   obstetric
                                               2003 (Crude birth                   obstetric              Complications
                                                  rate 30.3/1000)              complications                    treated
Mash West                   1,001,558                         30,047                      4,507                        2,252              50.0%
Mash. Centr.                  998,265                         29,948                      4,492                        1,584              35.3%
Mat. North                    701,359                         21,041                      3,156                          366              11.6%
Masvingo                    1,318,705                         39,561                      5,934                        1,402              23.6%
Midlands                    1,466,331                         43,990                      8,697                        3,773              43.4%
Manicaland                  1,566,889                         47,007                      7,051                        2,967              42.1%
Mash. East                  1,125,355                         33,761                      5,064                          704              13.9%
Mat. South                    654,879                         19,646                      2,947                        1,200              40.7%
Harare                      1,903,510                         57,105                      8,566                        3,919              45.8%
Bulawayo                      676,787                         20,304                      3,046                        1,415              46.5%
Total                      11,413,638                        342,409                     51,361                       19,583              38.1%


Table 43:             Complications of pregnancy mentioned by women (n=658)
Complication                                                           Number of responses                                % Total responses
Bleeding                                                                               163                                           24.8%
Convulsions/fits                                                                        11                                             1.7%
Headaches                                                                               57                                             8.7%
Oedema                                                                                 114                                           17.3%
Severe abdominal. Pain                                                                 116                                           17.6%
Anaemia                                                                                 37                                             5.6%
High blood pressure                                                                    160                                           24.3%
Total                                                                                  658                                            100%


Table 44:             Places where help first sought (n=471)
Place                                                                                   % Women
Clinic                                                                                  44.5
Private clinic                                                                          0.7
Private doctor                                                                          3
Community health worker                                                                 0
Hospital                                                                                42.2
TM                                                                                      4.4
Traditional healer                                                                      2.2
Spiritual healer                                                                        3
Total                                                                                   100

Table 45:             Places approached by respondents for ANC (n=449)
Place                                                                     Number of women                         % Women seeking ANC
Clinic                                                                                340                                          75.7
Private clinic                                                                          6                                            1.3
Private doctor                                                                          6                                            1.3
Community health worker                                                                 0                                              0
TM                                                                                      0                                              0
Hospital                                                                               92                                          20.5
Other                                                                                   5                                            1.1
Total                                                                                 449                                           100



72 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 46:                   Reasons for not being delivered by a health worker (n=89)
Reason                                                                                       Number of women                                                          % Women
Clinic too far                                                                                            18                                                              20.2
Lack of transport to clinic                                                                               21                                                              23.6
Service fee too high                                                                                       3                                                                3.4
No staff at the clinic                                                                                     9                                                              10.1
Other                                                                                                     38                                                              42.7
Total                                                                                                     89                                                               100


Table 47:                   Complications of pregnancy mentioned by men (n=769)
Complication                                                                 Number of times mentioned                                                   % Total responses
Bleeding                                                                                           115                                                                14.9
Convulsions/fits                                                                                     2                                                                  0.3
Headaches                                                                                           73                                                                  9.5
Oedema                                                                                              80                                                                10.4
Severe abdominal. Pain                                                                             130                                                                16.9
Anaemia                                                                                             55                                                                  7.1
High blood pressure                                                                                152                                                                19.8
Other                                                                                              162                                                                21.1
Total                                                                                              769                                                                 100

Table 48:                   Complications endangering a baby’s life as mentioned by the men (n=529)
Complication                                                                             Number of responses                                             % Total responses
Prematurity                                                                                              152                                                          28.7
Convulsions                                                                                                9                                                            1.7
High fever                                                                                                65                                                          12.3
Low apgar                                                                                                169                                                          31.9
Other                                                                                                    134                                                          25.3
Total                                                                                                    529                                                           100

Table 49:                   What men would do if their wife/partner experienced problems during
                            pregnancy (n=544)
Action                                                                                   Number of responses                                             % Total responses
Take her to the clinic                                                                                   401                                                          73.7
Take her to a private clinic                                                                              30                                                            5.5
Take her to a community health worker                                                                     11                                                              2
Take her to a TM                                                                                          20                                                            3.7
Take her to a traditional healer                                                                          17                                                            3.1
No action                                                                                                  2                                                            0.4
Other                                                                                                     63                                                          11.6
Total                                                                                                    544                                                           100

Table 50:                   Ways of preventing pregnancy as mentioned by the youth (n=1,284)
Way of preventing pregnancy                                                              Number of responses                                             % Total responses
Abstinence                                                                                               188                                                          14.6
The pill                                                                                                 315                                                          24.5
IUD                                                                                                       47                                                           3.7
Injectables                                                                                              124                                                           9.7
Implants                                                                                                  45                                                           3.5
Male condom                                                                                              361                                                          28.1
Female condom                                                                                            189                                                          14.7
Diaphragm                                                                                                 12                                                           0.9

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 73
Way of preventing pregnancy                                            Number of responses                                % Total responses
Foam or jelly                                                                            1                                               0.1
LAM                                                                                      2                                               0.2
Total                                                                                1,284                                              100

Table 51:             Sources of information on family planning as mentioned by the youth
(n=889)
Source of information                                                  Number of responses                                % Total responses
Health facility                                                                        298                                             33.5
Community worker                                                                        88                                                10
Youth clinic                                                                            36                                                 4
Private clinic                                                                          19                                               2.1
TV/Radio                                                                               122                                             13.7
Poster/fliers                                                                           51                                               5.7
School                                                                                 190                                             21.4
Other                                                                                   85                                               9.6
Total                                                                                  889                                              100

Table 52:             Sources of contraceptives as mentioned by the youth (n=814)
Source of contraceptives                                               Number of responses                                % Total responses
Health facility                                                                        434                                             53.3
Community worker                                                                       101                                             12.4
Youth clinic                                                                            23                                               2.8
Private clinic                                                                          36                                               4.4
Pharmacy                                                                                89                                             10.9
Other                                                                                  131                                             16.1
Total                                                                                  814                                              100

Table 53:             Factors which might prevent young people from using contraceptives
                      (n=668)
Factor                                                                 Number of responses                                % Total responses
Lack of services                                                                        46                                               6.9
Lack of knowledge                                                                      211                                             31.6
Lack of money                                                                           56                                               8.4
Negative provider attitudes                                                             97                                             14.5
Shyness/embarrassment                                                                  197                                             29.5
Other                                                                                   61                                               9.1
Total                                                                                  668                                              100


Table 54:             Places for HIV testing as mentioned by the youth (n=532)
Place for HIV testing                                                  Number of responses                                % Total responses
Health facility                                                                        180                                             33.8
New Start Centre                                                                       259                                             48.7
Private clinic/hosp.                                                                    79                                             14.9
Others                                                                                  14                                               2.6
Total                                                                                  532                                              100




74 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Table 55:                   District and population sampled by province
Province                          Total No. of               Number of             % of districts                Provincial           Population in                % Population
                                     districts                 districts                assessed                       total           the sampled                   covered in
                                                               assessed                                          population                districts                  sampling
Mash West                                         6                    3                         50%              1,001,558                 668,932                        67%
Mash Central                                      7                    3                         43%                998,265                 506,231                        51%
Mat South                                         6                    3                         50%                654,879                 323,792                        49%
Mat North                                         7                    3                         43%                701,359                 382,596                        55%
Masvingo                                          7                    3                         43%              1,318,705                 625,925                        47%
Midlands                                          8                    3                         38%              1,466,331                 523,105                        36%
Manicaland                                        7                    3                         43%              1,566,889                 749,765                        48%
Mash East                                         9                    3                         33%              1,125,355                 363,778                        32%
Total                                           57                        24                    42%                8,833,341                4,144,124                            47%




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 75
ANNEX II: SAMPLE QUESTIONAIRE

Primary Health Centre Level Questionnaire

Facility Code………………………..                                           Name of Interviewer………………………

Facility Name……………………….                                            Name of Supervisor……………………….

District……………………………….                                              Province…………………………………….

Designation of Interviewee………………………………………………………………………….

Administrative Authority                       Gvt          RDC                Mission               Private


What is the catchment population for this facility?
                 Enter population; if not known enter 0.
What is the maximum distance within catchment area?
                 Enter kilometers; if not known enter 0.
What is minimum distance within catchment area?
                 Enter kilometers; if not known enter 0
How far is the referral centre (in kilometres)
Is the catchment area map available?                                                                        Yes         No
What is the crude birth rate in the catchment area for this facility?
                 If not known; enter 0.
What is the ANC coverage rate?
Number of deliveries at the facility
Number of deliveries at home: by Traditional Midwives
Number of deliveries at home: other

NUMBER OF HEALTH WORKERS IN THE HEALTH FACILITY BY CATEGORY

Category of Health Worker                 No.           established No.    of                     posts Number of staff
                                          posts                     occupied                            currently working at
                                                                                                        the centre
Registered Nurse – Midwife
Registered Nurse
SCN
SCN – Midwife
EHT
Nurse Aides
General hand
Other specify


76 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                            Name of Interviewer………………………

Facility Name……………………….                                                             Name of Supervisor……………………….

District……………………………….                                                               Province…………………………………….

Designation of Interviewee………………………………………………………………………….

Administrative Authority                                  Gvt              RDC                     Mission                     Private


CADRE OF STAFF WHO ATTENDED DELIVERIES IN THE LAST 3 MONTHS

Cadre                                                                                                                               Number
Registered Nurse – Midwife
Registered Nurse
SCN
SCN – Midwife
Nurse Aides
General hand
EHT
Other (specify)


AVAILABILITY OF MARTENITY SERVICES
                           24-hours Day only                                                                                       Comments
           Monday – Sunday
ANC        Monday - Friday
           Monday – Sunday
PCN        Monday - Friday
           Monday – Sunday
Del        Monday - Friday
           Monday – Sunday
Neonatal   Monday - Friday
Care




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 77
Primary Health Centre Level Questionnaire

Facility Code………………………..                                           Name of Interviewer………………………

Facility Name……………………….                                            Name of Supervisor……………………….

District……………………………….                                              Province…………………………………….

Designation of Interviewee………………………………………………………………………….

Administrative Authority                       Gvt          RDC                Mission               Private



Tick Yes or No for each of the Yes                                          No         Comments
following items
Antenatal Care:
       Use of goal oriented antenatal care
Safe Delivery Services:
       Use of Partogram
       Vital signs
       Urinalysis
      Urinary output
Post Natal Care: 10 days
Mother:
      Check involution of uterus
      Establishment of lactation
      Lochia
Baby:
      Physical examination
      Cord check
      Weight
      Jaudice
Post Natal Care: 6 weeks
Mother:
      Mother involution of uterus
      Bleeding
      FP
      Cervical cancer screening
      Vitamin A for the mother
      General Health
Baby:
      Weight
      General health of the baby
      Baby feeding
78 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Tick Yes or No for each of the Yes                                                              No            Comments
following items
Family Planning Services:
       Pills
       Injectable
       IUD
       Implants
              Condoms:                    Male
                                          Female
STI Management:
       Syndromic management
       Availability of STI drugs
       Contact tracing
VCT:
       Pretest counseling
      Rapid testing for HIV
      Post test counseling
PMTCT:
      Pre-test counseling
      Post test counseling
      Partner counseling
      Partner testing
        Rapid testing
        Administration of Nevirapine:
                          Mother
                          Baby
       Administration of cotrimoxazole to
       baby at 6 weeks
Malaria in Pregnancy:
        IPT 1
        IPT 2
        Availability of S-P (Fansidar)
Cervical Cancer Screening:
        Pap Smear
        Visual Inspection with Acetic Acid
Tick Yes or No for each of the following items                                    Yes           No            Comments
Breast Cancer Screening
(verify with health education calendar)
Care of the Newborn:
         Resuscitation
         Cord care
         General examination of baby
         Check Jaundice

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 79
Tick Yes or No for each of the Yes                                          No         Comments
following items
        Vitamin K
        BCG
        Weight
        Initiation of feeding
             - Exclusive breastfeeding
             - Appropriate feeding
         Warmth
         Bonding
IEC materials:
        Materials on danger signs or
       complications during pregnancy
        Materials on nutrition during
       pregnancy
        Materials on postpartum
        materials on breastfeeding/newborn
       care
        Materials on family planning methods
        Materials on prevention, care and
        control of STIs, including HIV/AIDS
        At this health facility, do you provide
       RH related health and information?
        Other: (list)
Referral:
        Criteria for referral system
        Documentation




80 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                            Name of Interviewer………………………

Facility Name……………………….                                                             Name of Supervisor……………………….

District……………………………….                                                               Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                                  Gvt              RDC                     Mission                     Private


Tick Yes or No for each of the following items
Were     the    following services Yes No                                                    Source of data                  Comments
performed at least once during the
last 3 months?
(a) Parental antibiotics

(b)       Parenteral oxytocics

(c)       Parenteral
          sedatives/anticonvulsants

(d)       Manual removal of placenta

(e)       Removal of retained products

(f)       Assisted   vaginal    delivery
          (Vacuum Extraction Breech)

Resuscitation of Newborn
Suction
Bagad mask
Intubation




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 81
Primary Health Centre Level Questionnaire

Facility Code………………………..                                           Name of Interviewer………………………

Facility Name……………………….                                            Name of Supervisor……………………….

District……………………………….                                              Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                        Gvt         RDC                 Mission              Private




Year:                            July     Aug     Sept    Oct     Nov    Dec      Jan     Feb     March     April    May     June    Year’s
                                 2003                                    2003     2004                                       2004    Total
PROCESSING
INDICATORS
Number of Obstetric
Admissions
Number of Deliveries
Number of Caesarean
Sections
Average length of stay in
health facility per patient
Number of referrals
Maternal Deaths – Direct
Causes
Haemorrhage
Obstructed/prolonged
labour
Ruptured uterus
Postpartum sepsis
Pre-eclampsia/eclampsia
Complications of abortion
Ectopic pregnancy
Others
(specify)……………………
TOTAL




82 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                             Name of Interviewer………………………

Facility Name……………………….                                                              Name of Supervisor……………………….

District……………………………….                                                                Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                                  Gvt              RDC                     Mission                     Private

Year:                                          July       Aug       Sept       Oct        Nov       Dec        Jan       Feb        Mar       April      May       June       Year’s
                                               2003                                                 2003       2004                                                2004       Total
Maternal Deaths – Indirect
Causes
Malaria
HIV/AIDS
Anaemia
TB
Domestic violence
Others
(specify)…………………
TOTAL
Obstetric Complications –
direct causes
Haemorrhage
Obstructed/prolonged labour
Ruptured uterus
Postpartum sepsis
Pre-eclampsia/eclampsia
Complications of abortion
Ectopic pregnancy
Others
(specify)………………….
TOTAL
Obstetric Complications –
Indirect causes
Tuberculosis
Malaria
HIV/AIDS
Anaemia
Domestic violence
Others
(specify)………………………..
TOTAL

Case Fatality Rate – direct
causes
Haemorrhage

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 83
Year:                                 July    Aug      Sept    Oct     Nov      Dec     Jan      Feb     Mar      April   May     June     Year’s
                                      2003                                      2003    2004                                      2004     Total
Obstructed/prolonged labour
Ruptured Uterus
Postpartum sepsis
Pre-eclampsia/eclampisia
Complications                  of
abortion
Ectopic pregnancy
Others
(specify)…………………..
TOTAL
Case Fatality rate – Indirect
Causes
Malaria
HIV/AIDS
Anaemia
Domestic violence
TB
Other
(specify)………………………
……
TOTAL
Perinatal Deaths: Causes
Pre-maturity
Low Apgar
Neonatal Jaundice
Neonatal Sepsis
Hypothermia
Neonatal Tetanus
Congenital malformation
Others




84 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                            Name of Interviewer………………………

Facility Name……………………….                                                             Name of Supervisor……………………….

District……………………………….                                                               Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                                  Gvt              RDC                     Mission                     Private


                                                                                      Available            Available             Not available/Remarks
INFRASTRUCTURE                                                                        &                    but     not
                                                                                      functional           Functional
Waiting area
Client seats
IEC materials
Chalk boards
Toilets
Consultation/examination room
Good ventilation
Visual privacy
Auditory privacy
24-hour running water
Sink
Elbow tap
Borehole water
Toilets
Labour/Delivery room
24-hour running water and sink + elbow tap
Toilet (attached to Labour/Delivery room)
Utilities
Electric power supply (line)
Alternate power supply (generator, solar)
24-hour supply of power in labour/delivery room
Door separating delivery from rest of the facility
Water supply (24 hrs)
Sink
Elbow tap
Ventilation
Adequate lighting
Sewage system
Waste disposal (incinerator)
Waste disposal (secure pit)
Placenta/Otto way pit
Sluice Room
24-hour running water

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 85
                                                                     Available       Available         Not available/Remarks
INFRASTRUCTURE                                                       &               but     not
                                                                     functional      Functional
Transportation & Communication
Access to transport (Ambulance Services)
Radio Communication
Telephone
Others (specify)……………………
Ward(s)
Number of beds
Patients toilets
Bathrooms for female patients only
Nursing station
Air vents
Windows
Portable drinking water
Sink
Elbow water tap
Does the institution have food facilities? Yes    No            If
yes do they have:
Food facility for patients
Cooking stove
Pantry
Refrigerator
Dish washing facilities
Does the Institution have a mother’s waiting shelter?
Yes        No        If yes does it have:-

Cooking facilities
Patients food trolley
Portable, water
Lighting
Linen
 Beds
Toilets
Bathrooms
Lockable lockers/cupboards
Chairs or benches
Radio
Television
What is the distance between ward and waiting shelter?




86 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                            Name of Interviewer………………………

Facility Name……………………….                                                             Name of Supervisor……………………….

District……………………………….                                                               Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                                  Gvt              RDC                     Mission                     Private


                                                                            No. Available &             No. Available            Not available/Remarks
                                                                            functional                  but        not
                                                                                                        Functional
Labour/Delivery room
Furniture
Delivery bed
Stirrups
Leggings
Equipment
Hanging/standing spot light
IV drip stand
Revolving stool
Buckets or bowls for decontaminants
Linen carrier
Sharps disposal box
Waste container with lid and pedal
Oxygen;
       cylinder
       stand
      gauge
      masks
           tubings
Suckers manual
Suckers electrical
Resuscitaire
Goggles
Delivery pack
Cord clamps
Gloves (different sizes);
            surgical gloves
            disposable elbow size
Gum boots
Linen
Linen for labour/delivery
Draw mackintosh
Linen savers
Pillows with water proof cover
Pillow cases
Plastic aprons
Caps
Bed sheets

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 87
                                                            No. Available &        No. Available       Not available/Remarks
                                                            functional             but        not
                                                                                   Functional
Face masks
Draw sheets
Blankets for mother
Blankets for baby
Gowns : Nurses
          Baby
          Mother
Mattresses with water proof cover
Sanitary pads
Stationery
Sterilizing packs
Partogram
Post Natal Ward
Furniture
Beds
Baby cot
Pedal bins
Wall mirror
Benches for relatives
Wheel chairs
Stretchers
Table for nursing station
Chairs for nursing station
Medicine cupboards
Patient lockers
Linen
Bed sheets
Pillows with water proof cover
Pillow cases
Patient gowns - mother
                baby
Baby napkins
Screening curtains
Window curtains
Equipment
Medicine trolley
Movable spot light
Cleaning materials;
           broom
           mops
           mop bucket

Comments:
…………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………




88 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Primary Health Centre Level Questionnaire

Facility Code………………………..                                                            Name of Interviewer………………………

Facility Name……………………….                                                             Name of Supervisor……………………….

District……………………………….                                                               Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                                  Gvt              RDC                     Mission                     Private


This list of equipment is adapted from Mother Baby Package, WHO, 1994. All the consumable items in the list are to be
replaced as and when necessary.

Basic equipment                                                             No.                         No.        Not available/Remarks
                                                                            Available                   Available
                                                                            &                           but    not
                                                                            functional                  Functional
Sphygmomanometer
Stethoscope
Baby weighing scale (pan type)
Adult standing scale
Fetoscope
Instrument sterilizer (autoclave)
Plain dissecting forceps (stainless steel)
Dressing forceps (stainless steel)
Cheatle forceps (stainless steel)
Kidney basins (receivers) (stainless steel)
Sponge bowls (stainless steel)
Clinical thermometer (Celsius scale)
Low reading thermometer (Celsius
scale)
Heat source/heaters
Syringes 2 mls
          5 mls
          10 mls
          20 mls
Needles 26 gauge
         23 gauge
         21 gauge
          18 gauge
Suturing material
IV stand
Urinary catheters bags
Urinary catheter stand
Adult ventilator bag and mask
Airway: sizes -Small

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 89
Basic equipment                                             No.                    No.        Not available/Remarks
                                                            Available              Available
                                                            &                      but    not
                                                            functional             Functional
               Medium
               Large
Tongue retractor
Nasogastrict tubes
Litmus paper
Spigot
Surgical gloves
Rubbish bins
Sharps disposal containers
Delivery Packs
Ambubag
Mask
Mucus extractors/suckers manual
Mucus extractors/suckers electrical
Suction machine
Suction tubes
Endotracheal tubes - Adult
                    Paediatric
laryngoscope
Artery forceps
Cord-cutting/blunt-ended scissors
Straight scissor
Diagnostic set
Cord ties
clamps
Gloves
Plastic sheeting
Gauze swabs
Cotton swabs
Dressing towels
Torch
Torch batteries
Perineal/Vaginal/Cervical Repair Pack (set
episiotomy)
Sponge forceps
Artery forceps - large
Artery forceps - small
Needle holder
Stitch scissors
Dissecting forceps, toothed
Vaginal speculum; Sims - small
                            medium
                            large
Vaginal speculum; cuscos - small
                            medium

90 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Basic equipment                                                             No.                         No.        Not available/Remarks
                                                                            Available                   Available
                                                                            &                           but    not
                                                                            functional                  Functional
                                         large
Suturing material
Neonatal Resuscitation Pack (state
number of packs available)
Mucus extractor
Infant face mask (2 different sizes)
Ambubag
Suction Catheter (different sizes)
Infant laryngoscope with spare bulb, batteries and
different size blades
Endotracheal tubes 3.5
Endotracheal tubes 3.0
Endotracheal tubes 2.5
Suction apparatus: electrical
Suction apparatus: manual
Infant warmer
Oral airways; size 00
               size o
Adult cannulae; size 16g
                  Size 18g
New born cannulae size 24g
Scalp vein; size 23g
             size 21 g
Warm towels




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 91
Primary Health Centre Level Questionnaire

Facility Code………………………..                                           Name of Interviewer………………………

Facility Name……………………….                                            Name of Supervisor……………………….

District……………………………….                                              Province……………………………………..

Designation of Interviewee……………………………………………………………………………

Administrative Authority                       Gvt          RDC                Mission               Private


Drug                                          Quantity Available       Remarks
                                              (not past expiry
                                              date)
Antibiotics
Amoxicillin
Amplicillin (oral)
Benzathine penicillin (injectable)
Benzylpenicillin (injectable)
Procaine penicillin (injectable)
Erythromycin
Metronidazole (oral)
Co-triomoxazole
Kanamycin
Tetracycline Eye ointment
Others
Ampicillin (injectable)
Penicillin (oral)
Cephalosporin – ciprofloxacin)
Ceftriaxone (injectable)
Cloxacillin
Gentamicin (injectable)
Metronidazole (injectable)
Nitrofurantoin
IV fluids
Water for injection
Dextrose 5%
Dextrose 10%
Dextrose 50%
Normal saline
Ringer’s lactate
½ DD
Anticonvulsants (injectables)
Magnesium sulphate
Diazepam (oral)
Diazepam (injectable)
Phenyntoin
Phenobarb

92 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
Drug                                                     Quantity Available               Remarks
                                                         (not past expiry
                                                         date)
Antihypertensives
Methyldopa
Hydrochlorothiazide (HCT)
Other
Hydralazine (oral)
Hydralazine (injectable)
Nifedipine (oral)

Oxytocics
Ergometrine (oral)
Ergometrine (injectable)
Oxytocin (injectable)

Antimalarials
Quinine (inject able)
Chloroquine (oral)
Fansidar (SP)
Other
Tocolytics
Salbutamol

Other drugs
Heparin
Protamine sulphate
Cimetidine
Tetanus toxoid
Vitamin K
Ferrous sulphate
Folic Acid
Vitamin A

Contraceptives
Subdermal implants e.g.
Norplant
Jadelle
Low-dose          combined    oral
contraceptive (lofeminal)
Progestin only oral contraceptive
(ovrette)
Depot medroxy-progesterone acetate
(injectable)
Other
Barrier Methods
Female condoms
Male condoms
Diaphragms with spermicide
Intrauterine device

Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 93
Drug                                          Quantity Available       Remarks
                                              (not past expiry
                                              date)
Copper –containing devices –
Copper T
Multiload
Others
Drugs         used                     in
resuscitation
Adrenaline (injectable)
Aminophylline (injectable)
Atropine sulphate (injectable)
Calcium (injectable)
Glucopacte
Diphenhydramine (injectable)
Dopamine (injectable)
Furosimide (injectable)
Naloxone (injectable)
Nitroglycerine (Sublingual)
Promethazine (oral)
Sodium citrate
Lignocaine
Plasma expanders
Analgesics
Ibuprofen
Lignocaine
Indomethacin
Diclofenac
Paracetamol
Pethidine
Codein
Others
Disinfectants/antiseptics
Chlorhexidine (solution)
Cetrinide (solution)
Iodine (solution)
Hydrogen peroxide
Cetrimide
Surgical spirit (solution)
Sodium hypochlorite (jik)
Soap




94 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
   Primary Health Centre Level Questionnaire

   Facility Code………………………..                                                            Name of Interviewer………………………

   Facility Name……………………….                                                             Name of Supervisor……………………….

   District……………………………….                                                               Province……………………………………..

   Designation of Interviewee……………………………………………………………………………

   Administrative Authority                                  Gvt              RDC                     Mission                       Private


   MNH HEALTH MANAGEMENT INFORMATION SYSTEM QUESTIONNAIRE (All
   levels)

          1)     The first step is to understand how information is recorded in the facility. Ask staff to identify all sources of
                 information on women who come for reproductive health services at the facility. In the “comments” column, note
                 such things as:
                    Are the forms or register easily accessible to staff?
                    Are they well maintained?
                    Are they up-to-date?
                    Are they adequately filled out?

                                         Available           Easily               Well                 Up to         Adequately           Comments
Data Source                                                  accessible           maintained           date          filled in
                                         Y        N          Y         N          Y          N         Y      N      Y          N         Y=yes; N=No

Registers
OPD (T12)
Admission/discharge
Delivery
Maternity ward
Female ward
Antenatal Care
Post Natal Care
Family Planning
Voluntary Counseling &
Testing
Prevention of Parent to
Child Transmission
Kangaroo care
Records
Individual patient records
Birth record
Maternal mortality
Perinatal mortality
T6
T5
Others (specify)


          Note: A facility may not have all these records. They are listed here to guide the discussion with the staff.




   Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 95
     2)    Which are the key data sources you would need to get a complete count of all women with obstetric
           complications? Please list.
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………

     3)    Is there a column for recording diagnoses (i.e. obstetric complications) in the data sources (key registers)?
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           …………………………………………………………………………………………………………………….

     4)    Is diagnosis column routinely filled in?
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………

     5)    Is there a column in the register for recording treatment of the women with obstetric complications and the
           outcome (women alive or dead)?
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           …………………………………………………………………………………………………………………….

     6)    Who is responsible for filling in these records?
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………

     7)    Are these records/registers filled in
                - as they occur
                - within 24 hours
                - within 7 days
                - at particular times - specify

     8)    Are there regular reviews or analysis of records by staff? Yes                 No       If yes, how often
                    o Weekly

                      o     Monthly

                      o     Quarterly

                      o     Bi-annually

                      o     Annually

                      o     Other

     9)    Are there changes in the record system needed to gather information on obstetric complications and deaths?
           Yes/No
           If yes specify……………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………
           ……………………………………………………………………………………………………………………………………



96 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
       10) Standard Guidelines, Policy documents and relevant training

Name of guidelines/manual                                                                               Availability                       Training received
                                                                                                        Yes          No                    Yes         No
Goal oriented ANC protocol
National Reproductive Health guidelines
PMTCT guidelines
Post Abortion Care guidelines
Malaria in pregnancy guidelines
Neonatal care guidelines
EPI modules
Discharge guidelines
Home based care guidelines
STI guidelines
Kangaroo guidelines
Others (specify)
Policies
EPI
HIV/AIDS
Code of ethics
Gender
Patients charter
Others (specify)




Assessment of Maternal and Neonatal Health Services in Zimbabwe .................................................................................................................... 97
ANNEX III: REFERENCES

1. AMDD Working Group on Indicators. Program note: Using UN process indicators in
   emergency obstetric services: Bhutan, Cameroon, Rajasthan. International Journal of
   Gynecology and Obstetrics 2002; 77(3). 277-284.
2. Assessment of Coverage and Utilization of Essential Obstetric Care in Zimbabwe.
   November 2000 Report. Ministry of Health and Child Welfare, Zimbabwe.
3. Central Statistical Office, 1994. Indicator Monitoring Survey 1993. Central Statistical
   Office, Harare, Zimbabwe.
4. Central Statistical Office, 2000. Zimbabwe Demographic and Health Survey 1999.
   Central Statistical Office, Harare, Zimbabwe.
5. Central Statistical Office, 2003. Zimbabwe National Population Census 2002. Central
   Statistical Office, Harare, Zimbabwe.
6. Lawson JB, Stewart DB. Malaria in Pregnancy In: Obstetrics and Gynecology in the
   Tropics and Developing Countries. Edward Arnold (Publishers) Pvt. Ltd. London 1967.
   59-72.
7. Maternal Mortality and Morbidity Study. Department of Health Services, Ministry of
   Health, Nepal, 1998.
8. Mbizvo MT et al. 1994. A Community Based Study of Maternal Mortality in Zimbabwe.
   University of Zimbabwe, Harare, Zimbabwe.
9. Mother-Baby package. Reproductive Health and Research Section, World Health
   Organization, 1999.
10. National Health Information and Surveillance Unit, 1998. Zimbabwe National Health
    Profile 1996, Ministry of Health and Child Welfare, Zimbabwe.
11. National Health Strategy for Zimbabwe 1997-2007.                                        Ministry of Health and Child
    Welfare.
12. National Reproductive Health Care Assessment 1999. Ministry of Health and Child
    Welfare, Zimbabwe. Department of Family and Child Health.
13. Paxton A, Maine D, Hijab N (contributors). Using the UN Process Indicators of
    Emergency Obstetric Services. AMDD Workbook. Columbia University. Mailman
    School of Public Health.
14. Programming for Safe Motherhood. Guidelines for Maternal and Neonatal Survival.
15. Rooks J, Wininikoff B, Bruce J, 1990. Technical Summary: Seminar on „Reassessment of
    the Concept of Reproductive Risk in Maternity Care and Family Planning Services. New
    York: The Population Council.
16. Sikhosana PLN, Hlabangana D, Moyo I. Quantifying Morbidity in Pregnant Women in a
    Rural Population in Tsholotsho District in Zimbabwe. Central African Journal of
    Medicine 1997.43(4): 93-98.
17. The HIV and AIDS Epidemic in Zimbabwe. Ministry of Health and Child
    Welfare/National AIDS Council/USAID, 2004


98 ............................................................................... Assessment of Maternal and Neonatal Health Services in Zimbabwe
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Description: Assessment of Newborn Baby