Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda

Abstract

ObjectivesMaternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services.MethodsThis was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach.ResultsThe availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.ConclusionsPost-conflict health systems face different challenges in the delivery of EmONC services and as such require context-specific interventions to improve the delivery of these services.

Assessing the functionality of an emergency obstetric referral system among public healthcare facilities in a low resource setting: an application of process mapping approach

“…As suggested by HCP in this study, unless leadership capacity is built to monitor and supervise processoriented practices, staff trained on the policies and process, and accountability demanded, variations between policy and practice are less likely to be addressed. These are recommendations consistent to that of other authors (10,(35)(36)(37)(38)(39)(40).…”

“…These ndings are consistent with two qualitative studies in Ghana (17,33), and a systematic review in India (40) where access, uptake and effective use of information technology such as electronic health records remain a challenge. Similar ndings in other low resource settings (17,39,41) also observed lack of coordination and feedback during referral. Non-adoption of a responsive and robust communication system in an increasingly complex health system may continue to have implications on quality of care (42), team cohesion and possibly create con ict due to miscommunication (43).…”

“…System of transport for emergency referral was also another major challenge as healthcare workers in higher institutions reported that patients arrived in taxis or private cars and in a few instances in ambulances unaccompanied or accompanied by staff and/or with relatives of the patient. These ndings of poor, absent or inappropriate means of transport are similar to several studies conducted in Ghana (17,30,41,44) and other resource-limited countries (29,32,37,39,40,45). This issue may be due to the fact that no budgetary allocations were made to support people who could not afford services during the referrals process (29) or pregnant women did not have money to cover transportation fees to travel to a health facility (17,32,46).…”

Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review

“…Generally, women expect to receive care promptly on reaching a health facility; therefore, long waiting times present a significant challenge to accessing health facility-based services [22, 29, 31, 53, 82, 87, 97, 107, 115, 123, 154, 155]. A shortage or absence of drugs and other essential supplies in health facilities were reported in other studies [31, 48, 56, 67, 76, 111, 115, 150, 155, 157, 163, 165–168], and poor referral practices/systems [104, 105, 159, 165] such as referred clients being transported unaccompanied by healthcare staff [89], lack of feedback mechanisms on referred patients [152], and late or no referral [29] hinder efficient patient care and may result in adverse outcomes.…”

Conflict and Contraception in Colombia

“…Conflict has also been linked to lower birth weight (O'Hare and Southall ; Camacho ; Brown ), reduced access to maternal health care (Chi et al. , , ; Østby et al. ), as well as poverty traps (Ibáñez and Moya ).…”