Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records

Abstract

Background The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women’s homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births. Methods We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019–20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019. Results The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days. Conclusions The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

The use of a mobile obstetric emergency system to improve obstetric referrals in Bong County, Liberia: A pre‐post study

“…8 However, the CS rate did not reflect that improvement, with 6.1% born via CS in urban areas compared to 3.7% in rural areas, far below the 9%-19% of the ideal population coverage. 8,16,17 Furthermore, in 2019, about 84% of deliveries in Bong County occurred in a health facility, with 81% taking place within RHFs. 13 This study found that the MORES intervention was associated with approximately 1.8 times higher CS rate, indicating that the intervention may be improving the unmet need of CS.…”

“…Furthermore, a study conducted in Rwanda found that longer travel time from RHF to a hospital was significantly associated with adverse neonatal outcome, emphasizing the need for strategies to reduce the transfer delay from health centers to district hospitals 4 . Despite this need, only 40% of RHFs in Liberia were ready to make an emergency referral, defined as having access to a functional ambulance or other vehicle stationed at the facility or access to an ambulance and a functioning telephone, either a landline or a mobile phone 8 . Hence, there is a need for an efficient and effective communication mechanism between RHFs and hospitals.…”

The use of a mobile obstetric emergency system (MORES) to improve obstetric referrals in Bong County, Liberia: a pre/post-intervention descriptive study

“…Liberia's facility-based deliveries significantly increased between 2004 and 2017, from 37% to 80% (8). Most of the increase occurred in rural areas, closing the gap between urban and rural areas.…”

“…Furthermore, a study conducted in Rwanda found that longer travel time from RHF to a hospital was significantly associated with adverse neonatal outcome, emphasizing the need for strategies to reduce the transfer delay from health centers to district hospitals (4). Despite this need, only 40% of RHFs in Liberia were ready to make an emergency referral, defined as having access to a functional ambulance or other vehicle stationed at the facility or access to an ambulance and a functioning telephone, either a landline or a mobile phone (8). Hence, there is a great need to implement efficient and effective communication mechanisms between RHFs and hospitals to improve the referral process and ultimately maternal and newborn outcomes.…”

The effects of decentralized financing and funding levels on the breadth and quality of services provided in primary health facilities in Nigeria

“…18,[21][22][23][24] For example, increasing skilled birth attendance does not guarantee a reduction in maternal mortality, as was seen in Liberia and Ethiopia. 25,26 Taken in aggregate, these ndings suggest that structural quality is necessary but not su cient to increase utilization and improve quality.…”