Maternal mortality in Cabinda, Angola - Description of the reproductive health care available

I ! ! Maternal Mortality in Cabinda, Angola Description of the Reproductive Health Care Available A dissertation presented by Sandra Cláudia Carvalho Rodrigues to the Faculty of Medicine the University of Porto In partial fulfilment of the requirements for the Masters degree in Epidemiology at the Faculty of Medicine of the University of Porto Advisor: Professor Henrique Barros, PhD Porto, October 2013 II III ! Thank you, Jorge – my husband. For the patience, support, and love throughout this journey. For the unconditional presence even when I was away for weeks. To my sister, Silvia, and my mother for understanding my absences and for all the affection. For making me a person able to take this study to the end, and ensuring all the comfort, love and support whenever I was away, and home. To my father, that left me the perseverance and the belief that everything is possible, especially with a smile. Mia first, for the honour of being my friend, and second, for the incentive, critical feedback and making me believe in myself. Moqui for the friendship and giving support. Professor Henrique Barros, for the challenge and support given throughout this journey, and specially for all the knowledge shared and for not allowing me to give up. Professor Nuno Lunet for being an inspiration, for listening and for guiding me in making the right decision when necessary. To Abel Gomes and Arnaldo Dias, my co-workers and “teachers”, for pushing me to apply to this masters program, and for making me fall in love with epidemiology. Samantha Morais for being my friend, colleague and companion in this learning path. This would not be possible without all your help and support. Inês Pimentel, a companion in the first steps of epidemiology and Olga L. for reading and providing feedback, for being a friend. Dr. Zeca, Cabinda Provincial Health Secretary, for giving me permission to conduct this research, providing the necessary resources to visit health units and for overall availability. Dr. Razão, the Director of Public Health for Cabinda for sharing his experience and knowledge of the province. To all the health personnel, involved in the different stages of this study that received me in their health units and shared experiences. To the people of Cabinda, particularly the women, for sharing their stories and lives, and for making me want to learn and understand their reality. IV V ! Table of Contents Abstract ...................................................................................................................... 1! 1. Demographics and Health in Cabinda, Angola ................................................... 7! 1.1. Country Demographics .......................................................................................... 9! 1.1.1. Cabinda: Province Demographics ............................................................. 10! 1.2. Health System in Angola ..................................................................................... 11! 1.2.1. Health Financing in Angola ........................................................................ 13! 1.3. Angola Trends in Maternal Health ...................................................................... 15! 2. Maternal Continuum of Care .............................................................................. 17! 2.1. Maternal Care ........................................................................................................ 19! 2.1.1. Antenatal Care ........................................................................................... 20! 2.1.2. Intrapartum Care ........................................................................................ 21! 2.2.3. Postpartum Care ........................................................................................ 23! 3. Information Sources and Definitions ................................................................. 27! 3.1. Methods ................................................................................................................. 29! 3.2. Main Data Sources ............................................................................................... 29! 3.3. Data analysis ........................................................................................................ 30! 3.4. Definitions ............................................................................................................. 30! 3.4.1. Maternal Mortality ...................................................................................... 30! 3.4.2. Maternal Mortality Statistical Measures ..................................................... 31! 3.4.3. Core Indicators of Maternal Health ............................................................ 31! 3.4.5. Causes of Maternal Death ......................................................................... 32! 4. Data Findings ....................................................................................................... 33! 4.1. National Context: Main social and health indicators ........................................ 35! 4.1.1. Mortality and Morbidity ............................................................................... 35! 4.1.2. Health Services Coverage ......................................................................... 36! 4.2. Site–Specific Maternal Health Characteristics .................................................. 37! 4.2.1. Health Facilities and Catchment Population .............................................. 37! 4.2.2. Maternal Health Services ........................................................................... 38! 4.2.2.1.!Family!planning!.......................................................................................................!39! 4.2.2.2.!Antenatal!Care!........................................................................................................!39! 4.2.2.3.!Intrapartum!Care!....................................................................................................!41! 4.2.2.4.!Postpartum!Care!.....................................................................................................!42! 4.2.3. Health Facilities and Community-Based Services ..................................... 42! 4.2.4. Referral Systems ....................................................................................... 42! VI 4.2.5. Human Resources for Health ..................................................................... 42! 4.3. Maternal Mortality in the Province ...................................................................... 43! 4.3.1. Causes of Maternal Mortality ..................................................................... 44! 5. Maternal Care in Context .................................................................................... 47! 6. Conclusion ........................................................................................................... 59! 7. References ........................................................................................................... 63! 8. Appendix A - Follow-up Antenatal Care Notebook .......................................... 69! VII ! List of Figures Figure 1 Geographical positioning of Angola ............................................................................ 9! Figure 2 Distribution of the service levels of the existing National Health Service of Angola . 12! Figure 3 Hierarchical organization and structure of health care in Angola ............................. 13! Figure 4 Continuum of Care for Women during Reproductive Age ........................................ 19! VIII List of Tables Table 1 Cabinda Province Indicators ...................................................................................... 10! Table 2 Distribution of Human Resources in 1980 and 2010 in Angola ................................. 12! Table 3 Health Expenditures of the State Budget for 2002-2011 ........................................... 14! Table 4 MMR for Angola 1990 – 2010 by quinquennial ......................................................... 16! Table 5 Sources of information used for data collection ......................................................... 29! Table 6 Health and economic indicators for Angola ............................................................... 35! Table 7 Utilization of Maternal Health Service, Angola .......................................................... 37! Table 8 Distribution of Health Units by Type in the Province Districts .................................... 37! Table 9 Health facilities and demographic characteristics of the catchment population in Cabinda Province for 2012 .............................................................................................. 38! Table 10 Available reported services by health units ............................................................. 39! Table 11 Number of Family Planning Visits Distribution According to Contraceptive Method Chosen for 2012. ............................................................................................................. 39! Table 12 Distribution of family planning and ANC across the health units in the province ..... 40! Table 13 Pregnant women on intermittent preventive treatment during 2012 ........................ 40! Table 14 Distribution of deliveries according to birth attendant .............................................. 41! Table 15 Birth distribution by health unit and delivery type .................................................... 41! Table 16 Distribution of human resources for 2012 ................................................................ 43! Table 17 Distribution of births by number of live and stillbirths in 2012 .................................. 44! Table 18 Neonatal deaths per live days for the year 2012 at Cabinda maternity 1st of May .. 44! Table 19 Major Causes of maternal deaths at Cabinda district maternity in 2012 ................. 45! Table 20 Mortality by malaria among pregnant women 2009-12 ........................................... 45! Table 21 Health, economic and reproductive indicators for the CPLP countries ................... 49! Table 22 Timeline of actions and outcome for study design implementation and data collection ......................................................................................................................... 50! Table 23 Priority medicines for mothers according to WHO treatment guidelines ................. 57! IX ! ! List of abbreviations AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care BHP Basic Health Law DHS Demographic Health Survey EmOc Emergency Obstetric Care GSB General State Budget GDP Gross Domestic Product HUR Health Unit Responsabile HDI Human Development Index HIV Human Imunodeficiency Virus ITN Insecticide-Treated mosquito Nets ITPp Intermittent Preventive Treatment in pregnancy IPC Intrapartum Care MMR Maternal Mortality Ratio MNH Maternal, Newborn Health MDG Millenium Development Goal MOMI Missed Opportunities in Maternal and Infant Health MICS Multiple Indicators Cluster Survey NHP National Health Plan NHS National Health System INEMA National Institute of Medical Emergency of Angola NIS National Institute of Statistics INEA National Institute of Statistics of Angola NPAD New Partnership for Africa´s Development OECD Organisation for Economic Co-operation and Development PMNCH Partnership for Maternal, Newborn and Children Health PWIS Population Welfare Integrated Survey PNC Posnatal Care PPC Postpartum Care PHS Provincial Health Secretary STD Sexually Transmited Disesases SBA Skilled Birth Attendant SADC Southern African Development Community SP Sulfadoxine and Pyrimeyhamine UN United Nations WHO/AFRO World Health Organization - Regional Section of Africa 6 A densidade de profissionais especializados foi 5.57/10,000 pessoas, abaixo da recomendada, 23/10,000 pessoas [9]. Conclusão: Em 2012, Cabinda teve uma TMM estimada de 234/100,00 nados vivos. A sugestão de que a província já atingiu o 5º ODM, estabelecido para Angola de 290/100,000 nados vivos, pode surgir. No entanto, e considerando os dados disponíveis tal não pode ser assumido. Isto é, a TMM permanece alta, apesar da disponibilidade de estabelecimentos e de profissionais de saúde, particularmente se compararmos estes valores com outros distritos da África Sub-Sariana. Um sub registo de mortes maternas foi observado na provincia e a estimativa dos principais indicadores não foi possível por falta de dados. Investigação, em cooperação com as autoridades locais, deve ser conduzida para recolha de dados primários que permitam conhecer o verdadeiro impacto da mortalidade e morbilidade materna e, definir estratégias para melhorar a qualidade dos cuidados. 7 ! ! 1. Demographics and Health in Cabinda, Angola 8 9 ! ! 1. Demographics and Health in Cabinda, Angola After almost 30 years of conflict, Angola has developed strategies and policies aimed at rebuilding and rehabilitating infrastructure, road networks, sewage systems, water supply, electricity and housing [10]. The health of the population and respective indicators has been the picture of this evolution even though its improvement occurs slowly and intermittently. 1.1. Country Demographics Angola is located on the west coast of southern Africa. It has a total area of 1,246,700 km2, a coastline of 1650 km, and eighteen provinces: Luanda, Cabinda, Zaire, Bie, Kwanza Norte, Kwanza Sul; Kubango, Lunda North, Lunda South; Uige, Moxico, Huila, Namibe, Benguela, Bengo, Malanje, Huambo and Cunene. It borders with the following countries: the Democratic Republic of Congo, Congo, Namibia and Zambia, and was in armed conflict until 2002. The projection data from the National Institute of Statistics of Angola [8], estimates a population of 18,576,568 inhabitants for 2012, 14.9 inhabitants/km2; where 47.3% are under the age of 14, 50.4% between 15 and 64 years, and only 2.3% are over 65. The life expectancy is 48.9 years, with 47.1 years for men and 50.8 years for women, result of the high child and maternal mortality ratios and also the impact of preventable infectious diseases among healthy and young population [11, 12]. Figure 1 Geographical positioning of Angola Source: WHO – Angola Factsheets of Health Statistics 2010 According to the Human Development Report 2013 [13], Angola is still in 148th place among 187 countries with a Human Development Index (HDI) of 0.508, and still classified as a country with a low HDI, despite the economical and technological advances made in the last decade. The health system constitutes one of the cornerstones of this development 10 along with education and economics, as they aim to decrease inequality among the population. "The changes in the political, social and economical development of Angola in recent decades directly affect the health of the population. The National Health System is today a landmark of social policy geared towards human development [14]”, but there is still a long way to go as we can see when analysing the HDI for inequality that is 0.298 [13], clearly showing high discrepancies among the population. 1.1.1. Cabinda: Province Demographics Cabinda is a province with 7,283km2, approximately 421,541 inhabitants [8], with a distribution of 58 inhabitants/km2. It consists of four municipalities: Cabinda, Buco Zau, Belize and Cacongo, 7 communes and 386 villages (bualas). The principal activities are: oil production (representing 70% of Angola production), wood, coffee, and other basic goods. The majority, around 70% of essential goods are imported. 80% of the population lives in Cabinda and the remaining are distributed in the other districts [15]. Since the end of the armed conflict in 2002, the government in collaboration with local authorities, including the Provincial Governor and Provincial Health Secretary (PHS) have developed projects aimed at not only the restructuring of infrastructure, as well as, increasing the accessibility of the population to primary health and hospital care [16]. In the last ten years, there has been an increase of approximately 55% in the number of units available, and an increase in the number of beds, specialties and diagnostics available [7]. The Population Welfare Integrated Survey (PWIS) [5, 6] provides an overview of the current status of welfare in the country; Table 1 presents data for Cabinda [17]. Table 1 Cabinda Province Indicators Indicators Data Population 407 836 (annual estimate of population for 2012)** 421 541 for 2013** Birth Registration 59.1% (children between 0 – 59 months) Pre-school 20.2% (attending) Malaria 42.1% (Households with at least one Impregnated Thread Net) Breastfeeding 84.5% (women between 12 – 49 years old with a living birth on the last 12 months, according to start of breastfeeding) Comprehensive knowledge of HIV/AIDS 92.9% (population with 12 or more years old, according the ways to prevent HIV/AIDS transmit ion) Child work 13.7% (children 5 – 14 years old) Household 95.7% (living in an inappropriately built home) Water 58.6% (use of potable source of drinking water) Basic Sewage 84.4% (uses appropriate sewage) Electricity 60.2% Source: INE Angola http://www.ine.gov.ao/xportal/xmain?xpid=ine&xpgid=indicators_province&indicators_province=6779467 ** INEA - Projecçao da Populaçao 2009-2015, 2012 11 ! ! 1.2. Health System in Angola Historically, the Angolan National Health System (NHS) has two phases: the pre-colonial, which lasted until 1975 and, after 1975, the post-independence. Its first milestone, Law 21- Bin 1992 [18] redefined the National Health Policy (NHP); further Law 9/75 [14, 19] fully socialized health care financing and created the possibility and necessity of extending health care to private entities with the aim of expanding the range of services and improving overall health conditions in the country. “The National Health Policy defined by Law 9/75 of December 13th, essentially aimed at improving the sanitary state of the country, the health care system adopted was of the National Health Service type, one that is fully socialized. The universal tendency is to progressively increase spending by the State in health care through the materialization of this principle. It urges the redefining of National Health Policy where a new funding system reorganizes the National Health Service in such a manner that it allows for the adaptation of existing resources and the private sector continues to exist. The association between the interests of the public and private sectors in a collective effort to improve these conditions, seeks to promote the opening of private medical-sanitary institutions, which may lead to ample opportunities for those who want to invest in this sector in order to contribute to the satisfaction or contributing to the needs of the population and improving the sanitary condition of the country.” The introduction of the Basic Health Law (BHL) Law 2/00 [20], marked another historic moment, its aim was to adapt the structure of the Angolan Health Ministry in order to make it more effective in the implementation of health policy change. In November 24th, 2010, through the Presidential Decree 262/10 [21], the Angolan government approved the National Plan of Health (NPH), as a way to address health challenges regionally, nationally and internationally. Further, with the aim of meeting commitments made in relation to the Millennium Development Goals, the policies and strategies of health in the African Union, the New Partnership for Africa's Development (NEPAD), the World Health Organization - Regional Section for Africa (WHO/AFRO) and the Southern African Development Community (SADC). Since 2002, the country has undergone a period of high economic growth, mainly 12 due to the petrol sector, which accounts for over 50% of the Gross Domestic Product (GDP) and 95% of exports. However, despite this economic development, "the health status of the Angolan population is characterized by low life expectancy at birth, high rates of maternal and infant mortality, a high burden of communicable diseases and increasing chronic and degenerative diseases, as well as premature mortality [21]”. The Angolan health care system is organized in three levels of care and it is currently estimated that, through the different levels of available health care, it provides assistance to 70% of the population [14] with human resources distributed as follows: Table 2 Distribution of Human Resources in 1980 and 2010 in Angola Year Doctors Nursing Professionals Diagnostic Technicians Therapeutic Technicians 1980 101 nationals 460 expatriates 573 expatriates (distributed through the different areas) 2010 1001 nationals 526 expatriates 27 465 (nursing auxiliaries, and few college/university graduates) 2120 (only 95 with college/university education) 2667 (72,6% with midlevel education and the remainder with basic) Source: Angola,!P.<P.d.R.d.!and!MINSA,!Decreto'Presidencial'nº262/10'–'Política'Nacional'de'Saúde,!in!Diário'da'República'I'Série,' Novembro,'Vol.'222.2010:!Luanda Figure 2 Distribution of the service levels of the existing National Health Service of Angola 13 ! ! Figure 3 Hierarchical organization and structure of health care in Angola 1.2.1. Health Financing in Angola Until 1992, the Angolan health care system was based on the universal model. Thereafter, the publication of Law 21-B/92 [18] legalized the private health sector and there became a need for citizens to contribute appropriate amounts to care provided, based on the type of care and socio-economic status. Therefore, the current funding model has a market economy philosophy. According to the source of capital, funding for the three sectors is as follows: • Public Sector: receives 87% of the funding and is obtained through the General State Budget (GSB), loans or grants from international organizations (WHO, the Food Bank Against Hunger, and others); • Private Sector: families and/or businesses pay for health services through acquisition plans or private health insurance; • Mixed Sector: resulting from public-private partnerships [14]. A summary of the progression of health investment by the government of Angola from 2002 to 2013 is shown below, in Table 3, using data collected from the General State Budget of the Ministry of Finance [22]. The progression is more clearly illustrated in Graphs 1 and 2, a significant increase in the GSB can be observed and was accompanied by an increase, albeit less pronounced, of the percentage allocated to various components of health care. To note, a decrease in this percentage between 2004 and 2007, from 5.69% to 3.68%, was perhaps due to the priority given to the reconstruction of infrastructure and reconciliation of the economy with a balance of debt and investment in roads, defence and restructuring of the country's politics. By 2007, the government's priorities included the reconstruction of the country, particularly infrastructure [22]. Public Sector - National Health Service - Armed Forces Health Services - Interior Ministry Health Services - Companies Private Sector - Profitable - Non-Profit (NPO and religious entities) Traditional Medicine Sector - Lack of knowledge about the number of providors for this type of care and lack of legal framework 14 Table 3 Health Expenditures of the State Budget for 2002-2011 Year Total SGB Kz % SGB in Health Amount Kz %OGE in Hospital Services Amount Kz % OGE for Public Debt 2002 197 296 687 958,00 4,57 9 021 694 656,00 0,27 1 054 646 707,00 28,79 2003 358 888 331 816,00 5,82 20 877 426 916,00 2,41 8 646 408 095,00 38,81 2004 665 347 988 813,00 5,69 37 845 011 108,00 2,24 14 916 730 438,00 27,77 2005 956 229 554 186,00 4,97 47 495 306 077,00 2,48 23 740 389 439,00 21,27 2006 2 176 922 260 474,00 4,42 96 171 680 163,00 4,02 87 509 410 311,00 9,04 2007 2 503 887 060 119,00 3,68 92 149 784 126,00 2,34 58 672 356 110,00 22,44 2008 2 544 768 949 743,00 6,68 169 919 092 280,00 3,17 80 609 979 271,00 11,54 2009 3 176 126 800 001,00 8,38 266 295 532 120,00 4,88 154 839 907 342,00 18,73 2010 3 092 272 166 646,00 5,02 155 265 840 845,00 2,9 89 672 452 187,00 18,73 2011 4 172 417 663 145,00 5,02 209 431 229 725,00 3,28 137 047 492 134,00 25,76 2012 4 501 106 290 500,00 5.14 231 307 058 854,00 3.42 153 723 760 293,00 21.28 2013 6 635 567 190 477, 00 5.56 369 156 757 565,00 2.48 164 862 267 253,00 10.79 Source: MINFIN.!República'de'Angola'G'Ministério'das'Finanças.!2013;!Available!from:!http://www.minfin.gv.ao/docs/dspOrcaPass.htm Graph 1 State Budget in 2002-2011 Kwanza [22] Graph 2 Percentage of State Budget Aimed at Health from 2002 to 2011 [22] y!=!4E+11x!<!4E+11! R²!=!0,95588! Orçamento*Geral*do*Estado* em*Kwanzas* Total!OGE!Kz! Linear!(Total!OGE!Kz)! %OGE!em! Saúde,! 2002,!4,57! %OGE!em! Saúde,! 2003,!5,82! %OGE!em! Saúde,! 2004,!5,69! %OGE!em! Saúde,! 2005,!4,97! %OGE!em! Saúde,! 2006,!4,42! %OGE!em! Saúde,! 2007,!3,68! %OGE!em! Saúde,! 2008,!6,68! %OGE!em! Saúde,! 2009,!8,38! %OGE!em! Saúde,! 2010,!5,02! %OGE!em! Saúde,! 2011,!5,02! y!=!0,0987x!+!4,882! R²!=!0,05072! Percentagem*do*OGE*para* Saúde* %OG E!em! Saúd 15 ! ! When analysing and comparing health financing over the years, it is clear that for the first years, spending was mostly related to public health and personnel. In 2006, there was a hospital investment boom, specifically related to the reconstruction of infrastructure destroyed by almost 30 years of conflict. After 2006, the capital intended for hospitals included both outpatient and emergency services, however these have been separated since 2007. Thereafter, the hospital budget has been divided to cover personnel, maintenance and goods and services. To note, this provision does not take into account revenue production units (there are no references on how and where provisioning is based), it appears to only concentrate on spending for local needs and political pressures [22]. The distribution of GSB to the provinces has varied and resulted from political and social pressures, and the increase of their respective population with a higher requirement of health services [19]. The budgeted funds are transferred monthly to the Provincial Governments and then to the respective hospitals, which are responsible for the management of payables and receivables. There is an absence of a hospital management philosophy based on increasing productivity and improving the quality of services, rather, it is focused on the payment of current expenses (fixed and variable costs). 1.3. Angola Trends in Maternal Health In a country whose national fertility rate was 6.7 children/woman in 2009 [5] and is estimated to currently be 5.66 children/woman. It is urgent to understand the conditions that determine maternal care [8] as it is well documented that high fertility rates increase the risk of maternal death, especially if unmet needs for family planning are present [1, 2, 23]. The Countdown Report for 2013 [1] refers that no data are available regarding postnatal care (PNC) coverage in Angola. Concerning antenatal care (ANC) only 32% (data from 1996) of women had access to at least 4 visits, 80% were seen at least once during pregnancy, and only 47% had a skilled birth attendant (SBA) at delivery. The causes of maternal deaths are unknown and are estimated to be the same as for the rest of Sub- Saharan Africa [1]. Angola is among the countries that most contributes to the high mortality rates observed worldwide. The MMR in 2010 was 450/100,000 live births. The proportion of deaths among women of reproductive age attributed to maternal causes is estimated to be 13.1%, indicating the high burden of maternal mortality on the country [2]. 22 Evidence based interventions [37, 39] at childbirth that can save women and children include: skilled birth attendance (i.e. doctors, nurses and midwives, both basic and comprehensive emergency obstetric care, surveillance or contact for at least 24 hours after birth, improved linkage of home and health facility, companion of the women’s choice at birth, and where there are no SBAs, support for clean childbirth practices and essential newborn care (drying the baby, warmth, cleanliness and early exclusive breastfeeding) at home. Around 90% of all pregnant women will experience an uneventful pregnancy, labour and delivery [39] especially in developed countries. However, in Africa, 15% of all pregnant women have childbirth complications that require emergency obstetric care (EmOC) [38, 39] and should be overseen by a SBA, which is only guaranteed to an average of 66% of all births with ranges that go from 45% in Sub Saharan Africa, to 84% in the Northern Africa [1, 40]. Kerber et al. (2007) refer that surveys from more than 20 African countries showed that less than a third of pregnant women who suffered a life threatening complication (haemorrhage, eclampsia, obstructed labour, sepsis, or unsafe abortion) received the necessary emergency obstetric care [4]. The fact is that the timing of death is clustered around labour, delivery and the immediate postpartum period [27, 37] so the provision of adequate and timely emergency obstetric care is critical at this stage of maternal care, and should be provided by SBA if a health system wants to address maternal mortality [37]. The provision of specialized care across the health system helps save lives and decreases the burden of morbidity by complications related to childbirth, and also impacts the infant mortality ratios [37, 39, 41]. One of the measures that allows us to see the progression that has been made worldwide is the availability of caesarean section. According to WHO guidelines, a range of 5 to 15% of all childbirths should occur through caesarean section [41]. Globally, access to caesarean section was 12% in 2006 (8.5% if China excluded), while in 51 Countdown countries the average was 7% with a range from 0 to 44% and only half of those countries were above the 5% minimum (data from 2000), showing restricted access to care and human resources [42-44]. Despite this, in the past decade an increase of SBA has been seen, as the interventions set to achieve the MDG 5 target have focused on ANC and assurance of SBA, but still 50% of births do not receive any kind of skilled attendance, and inequities are seen, especially between rural and urban areas, and the richest or poorest quintiles [45]. Further, a lack of trained professionals (i.e. physicians, nurses and midwives) is evident as the minimum threshold of 23-health professionals/10,000 population is only assured for 22% of the 68 countdown countries [9]. 23 ! ! 2.2.3. Postpartum Care Postpartum care (PPC), also known as postnatal care (PNC), refers to a set of interventions that aim to maintain and promote the health of women and newborns, as well as to develop an environment where support to family and community are present, covering health and social needs. The concept of partnership with the women is critical to guarantee individualized care that meets mother and newborn needs [35, 46]. Postpartum period “is a time where both women and children are at increased risk of illhealth and death” [45, 46]. More than half of maternal deaths and 40% of neonatal deaths occur during labour or the first two days after childbirth [1, 46], thus making this a critical moment to intervene. But the fact is that “(…) there is no accurate information about availability, timing and coverage for PPC in developing countries, a key requirement for improving processes in maternal and neonatal health (MNH) care [45]” and to define the interventions to meet regional and national needs. The postpartum period is defined as the first six weeks after childbirth [46, 47] and it is comprised of three moments: • Immediate postnatal period: first 24 hours after birth; • Early postnatal period: from day two until day seven after birth; • Late postnatal period: from day eight after partum until the forty-second day [46]. Today, there is a general acceptance that the postpartum period should be more than the originally defined 42 days, as the full recovery of women after childbirth can take up to a year; this puts women at increased risk of mortality and morbidity [48]. “Lack of care in this time period may result in death and disability as well as missed opportunities to promote healthy behaviours, affecting women, newborns and children” [47]. Only in the past century, as a result of the high rates of maternal and infant mortality observed in developed countries, has a core of postpartum care been defined, albeit it has remained static until recently. The core interventions have focused on routine observation and examination of vaginal blood loss, uterine involution, blood pressure and body temperature, as the signs and symptoms of the major death causes in women after childbirth [47]. This has led to a limited development of other competencies in the area by health professionals across the world but especially in developing countries [46, 47]. Guidelines in PPC appeared formally for the first time around 1998 with WHO publishing PPC of the Mother and Newborn: A Practical Guide. In 2003, in line with new developments and research, a follow-up and update was made, that specifically directed interventions to primary care, increasing the scope of action by health professionals. In 2010, WHO published the PPC guidelines [47] which defined the what, when, how and why of PPC. Clear concepts and time frames are now defined for the “supply” of PPC but a call of attention has 24 been made that reinforces the necessity of adapted measures to the different contexts, where packages fulfil the basic and essential components of PPC. Additionally, it integrates measures that answer to local needs. Timing of PPC provision is essential. The current guidelines refer that a minimum of 3 visits should be provided to the women during this time, one for each postnatal period [35, 46]. In fact, when we look at the immediate postpartum period, most guidelines refer that women should stay under the observation of a SBA or should be assessed at home before that timeline if discharged earlier [35, 47]. The identification of the key moments for PPC depends on the recognition of the clustering of adverse events and risks that surround it [1, 2, 4]. Despite this, there is still a lack of information on the incidence and severity of the medical conditions that put women at risk during the postnatal period in developing countries [1, 2, 4]. Promotion of healthy behaviours for mothers, newborns and children; early detection and referral of complications, specially those life threatening known as the “killers”; access to Basic and Comprehensive Emergency Obstetric Care (EmOC and CemOC); information on safe abortion; extra visits for preterm newborns; prevention of maternal to child transmission of HIV including appropriate feeding and family planning are critical in PNC in order to save lives [46]. A lack of effective PPC contributes to frequent, poorly spaced pregnancies [47] thus increasing the risk of morbidity and mortality. Consequently, an emphasis has been put on the identification, intervention and referral of critical health problems known as "the killers” and the necessity of access to family planning in an early stage of the postnatal period. To reiterate, knowledge is limited on the determinants o the use of PPC services, ”thus the need to collect information and describe regional and national contexts so that strategies are adjusted to the settings and answer to women’s, professionals and service’s needs, and impact the maternal health” [35]. The World Health Report 2013 [28] points to the need for research at different levels that supports evidence based practice and allows the Countdown Initiative and the world to understand what needs to be done. Areas such as PPC are lacking information in developing countries; specifically, Sub-Saharan Africa, as more than half of the world´s maternal deaths occur in this region [1]. We intend to describe maternal health care and coverage in the Province of Cabinda, so that we can: • Describe the maternal care structure at the province/district level; • Assess the maternal care available and its utilization; • Describe antenatal care, skilled birth attendance, and postpartum care; • Explore the extent of community participation in health care by describing the types of services delivered at the community level and the quality and coverage of such services; 25 ! ! • Assess the possibility of introducing interventions and potentially develop strategies to improve maternal health at the facility level. These findings will be presented in a format to allow, when feasible, the comparison of the situation at this district with other countries in Sub-Saharan Africa, as well as with the Countdown Initiative countries. 26 27 ! ! 3. Information Sources and Definitions 28 29 ! ! 3. Information Sources and Definitions 3.1. Methods A retrospective observational study was undertaken during 2013 (January to July) for the description of maternal care in the province of Cabinda. To get permission for the study and access to the necessary data to conduct this study, a set of contacts and actions were taken with the provincial health secretary (PHS), the head of health services for the entire province. 3.2. Main Data Sources The available data describing the health status of the Angolan population are limited. There has not been a recent Demographic and Health Survey (DHS) conducted in the country. The latest reliable national source for health indicators was the population welfare integrated survey (PWIS) [5, 6] completed in in 2008-2009, with data published in 2011. The previous PWIS was conducted in 2001 and the National Institute of Statistics (NIS) is organizing a DHS for 2014 [49]. Several international reports were assessed whenever national reports were not available. For Cabinda, we accessed reports by the health units of the province, which were aggregated in the Annual Activities Report for Cabinda Health Secretary 2012 [7]. Table 5 Sources of information used for data collection Data Information Sources Secondary Sources Year National Data • MICS/IBEP • Projecção da População 2009-2015, INEA • Estatísticas Sociais 2010, 2012, • Several International reports (Countdown Report to 2015; Health Life Expectancy for 187 countries; World Bank Database online; Unicef online country info; The World Fact book) 2008-9 2012-13 2010 Several years District Data • Annual Activities Report for the Province Health Secretary 2012 • 2012 Statistical Report for several health units (Provincial Hospital of Cabinda; Maternal-Child Dispensary; Municipal Hospital of Cabinda (Chinga); 1st of May Hospital (maternity); Municipal Hospital of Buco Zau; Regional Hospital Alzira da Fonseca; Municipal Hospital of Belize; Cabinda Health Centres and Posts; 28 of August Hospital; Municipal Hospital of Cacongo; Health Centres and Posts of Belize) 2012 2012 A framework that allowed the description of the relevant maternal care areas was designed and adapted from the MOMI project [45, 50] to collect data, intending to describe 30 the continuum for maternal care [3, 4], in the province under study, accounting for health services, interventions available, and people involved in the provision of care at all levels. Extraction of data at the national level was conducted to describe morbidity and mortality. At the province level, healthcare services description; maternal services availability; resources and timing of care provision; referral systems; workforce description; maternal mortality rate and its indicators, as well as burden of disease. 3.3. Data analysis Description data pertaining to the study characteristics is presented, synthetizing the features of the main areas defined in the framework for this study. Data was gathered and proportions of the core indicators were estimated using the population estimation for the province provided by the National Institute of Statistics of Angola (INEA) for 2012. The maternal mortality for the province was estimated using as a proxy the maternal mortality presented by the maternity health unit of the province, 1st of May Hospital, the only one with maternal deaths reported. 3.4. Definitions 3.4.1. Maternal Mortality WHO, in accordance with the International Classification of Diseases 10 (ICD – 10), defines maternal mortality as the “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” [48]. In 1990, the 43rd World Health Assembly recommended that countries consider the inclusion of questions regarding current pregnancy and pregnancy within 1 year preceding death, on death certificates, to promote improvement the quality and collection of maternal mortality data [51]. Thus, WHO and ICD-10 consider two concepts: Pregnancy-related death: The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. Late maternal death: The death of a woman from direct or indirect obstetric causes, more than 42 days, but less than 1 year after termination of pregnancy. ICD-10 defines “death during pregnancy, childbirth and the “puerperium” as any death temporal to pregnancy, childbirth or the postpartum period, even if it is due to accidental or incidental causes (formerly referred to as “pregnancy-related death”)”. This alternative definition allows measurement of deaths that are related to pregnancy, even though they do 31 ! ! not strictly conform to the standard concept of “maternal death”, particularly, in settings where accurate information about causes of death based on medical certificates is unavailable [2]. This is in line with some studies [27] conducted in India and Bangladesh, which suggest that contextual conditions, such as pregnancy, increase the number of murders, suicides and accidents among pregnant women, and should be recorded as maternal deaths. 3.4.2. Maternal Mortality Statistical Measures The most used maternal mortality statistical measures include [2]: Maternal Mortality Ratio (MMR) – Number of maternal deaths during a given period per 100,000 live births during the same time period Maternal Mortality Rate (MM Rate) – Number of maternal deaths in a given period per 100,000 women of reproductive age during the same time period Adult lifetime risk of maternal death – The probability that a 15-year-old women will die eventually from a maternal cause The proportion of maternal deaths among deaths of women of reproductive age (PM) – The number of maternal deaths in a given time period divided by the total deaths among women aged 15-49 years. 3.4.3. Core Indicators of Maternal Health “Countdown to 2015 was established in 2005 as a multi-disciplinary, multi-institutional collaboration, to track coverage levels for health interventions proven to reduce maternal, newborn and child mortality [1]” especially, in countries with low to middle income (i.e. the countdown countries) [1, 23, 26]. A set of indicators was defined by the Countdown Committee but, as those countries often lack adequate and quality data, the United Nations, WHO and other partners agreed to a set of basic indicators that allow stakeholders to monitor progression and analyse the changes needed to achieve MDG 5 targets [23]. There are six basic indicators in the measure of maternal health [23, 26]. One of them is MMR, which is relatively insensitive to changes, especially if short periods are considered. The other indicators are more sensitive to changes and use timely data, thus allowing the perception of almost real time changes; they are as per definition [23]: Met need for contraception – Percentage of women aged 15-49 years who are married or in union and who have met their need for family planning, i.e. who do not want any more children or want to wait at least two years before having a baby, and are using contraception; Antenatal coverage – Proportion of women aged 15-49 with a live birth who received antenatal care by a skilled health provider at least four times during pregnancy; 38 As presented in Table 9, the total catchment population covered by these health facilities, for 2012, was 407,836 people [8]. The female population represents 50.9% of the total population and women between 15-49 years old represent 22.9% [8]. According to the individual reports provided by the health units, there are 461 hospital beds available in the province, from which 79 (17.1%) are obstetrical [7]. Table 9 Health facilities and demographic characteristics of the catchment population in Cabinda Province for 2012 Province Health Facilities (n) 117 1 Hospital Beds (n) 461 1 Hospital Beds (/1000 population) 1.13* Catchment population 2012 407,836 2 Female Population (%)* 50.9 2 WCBA (%)* 22.9 2 Children under 5 (%)* 19.4 2 Infants (%)* 4.5 3 1. Source: CPHS, 2012 Anual Activities Report for the Province Health Units., 2013, Cabinda Provincial Health Secretary: Cabinda 2. Source: INEA and D.d.E.D.e. Sociais, Projecção Da Populaçao 2009-2015. , 2012, INEA - Instituto Nacional de Estatística de Angola: Luanda 3. Source: INEA, Inquérito Integrado Sobre o Bem-Estar da População/IBEP:Relatório de Tabelas Vol. II, 2011, INEA: Luanda. * - Estimated by the authors based on the population estimates for 2009 – 2015 referring to the year 2012 Na – not available; WCBA – women of childbearing age 4.2.2. Maternal Health Services The services provided by the health facilities across the province include ANC, IPC, abortion, immunization programs for children and adults, especially groups at risk such as pregnant women, family planning, and child care clinics. We could not quantify the percentage of units in the province that provided the services because some of the units have aggregated results. That is, health centres in Cabinda district give the total number of interventions for the group and not individualized, and the remaining units do not specify the number of women seen and proportion of intervention provision. 39 ! ! Table 10 Available reported services by health units Health Units Hosp. Beds Obst. Beds Services Provided Outpt. Cons Family Planning ANC IPC PPC Abortion Immun Child care Provincial Hospital de Cabinda 162 0 √ √ Mat-Inf Dispensary 0 0 √ √ √ √ √ Municipal Hospital Cabinda 40 5 √ √ √ √ √ 1 May Hospital 75 56 √ √ √ √ √ √ √ Health Centres and Posts of Cabinda √ √ √ √ √ 28 of August 11 0 √ Infectious diseases Hospital Buco Zau Hospital 55 6 √ √ √ √ Alzira Fonseca Hospital 63 8 √ √ √ √ Municipal Hospital do Belize 31 4 √ √ √ √ √ Health Centres and Posts of Belize √ √ √ √ √ Cacongo 24 √ Source: CPHS, 2012 Annual Activities Report for the Province Health Units., 2013, Cabinda Provincial Health Secretary: Cabinda Hosp beds: hospital beds, Obst. Beds: obstetrical beds; Outpat Cons: Outpatient Consults; ANC: antenatal; IPC: intrapartum; PPC: postpartum care; Immun.: Immunization 4.2.2.1. Family planning Family planning was only recorded in Cabinda district and accounts for a total of 7,342 consults. Table 11 presents the consults distribution according to contraceptive method chosen for 2012 as per the annual report of Reproductive Health [7]. A total of 7,510 consults was made and of those, 30 complications were related to the contraceptive methods, 11 to the pill and 19 to the birth control shot, but no other types of complications were mentioned. Table 11 Number of Family Planning Visits Distribution According to Contraceptive Method Chosen for 2012. Contraceptive Method Consults Pill 5919 Birth control shot 1531 Intrauterine Device (IUD) 18 Condom 0 Emergency contraception 42 Total 7510 Source: Reproductive Health Report for 2012 in CPHS, 2012 Annual Activities Report for the Province Health Units., 2013, Cabinda Provincial Health Secretary: Cabinda 4.2.2.2. Antenatal Care A total of 68,325 ANC visits (Table 12) were done in 2012, 34.6% were first consults and 65.4% follow up consults. However, the number of women seen was not reported. If the number of deliveries at Cabinda district (30,265) is used and the number of ANC are 40 accounted for in the district, we estimated that women would have had at least 2.3 appointments throughout the pregnancy. Table 12 Distribution of family planning and ANC across the health units in the province Health Units Outpatient Consults Family Planning Antenatal Care Consult First Followup Total Provincial Hospital of Cabinda 33022 0 0 0 Materno-child Dispensary 31424 1333 1244 3071 4315 Municipal Hospital Cabinda 34319 1827 3891 5718 1 Maio Hospital - maternity 15907 3160 3398 6245 9643 Health Centres & Health Posts Cabinda 257099 2849 15808 28050 43858 28 of Agosto of Hospital 6319 Buco Zau Hospital 8417 649 1663 2312 Alzira Fonseca Hospital 16038 94 286 380 Municipal Hospital of Belize 15943 630 1404 2034 Health Centres & Health Posts Belize 23888 65 Total (n) 442376 7342 23650 44610 68325 Source: Reproductive Health Report for 2012 in CPHS, 2012 Anual Activities Report for the Province Health Units. 2013, Cabinda Provincial Health Secretary: Cabinda A malaria program is included in ANC for pregnant women. During 2012, a total of 16,745 pregnant women were reported to have a first pregnancy consultation and 36.9% did the first intermittent preventive treatment (IPTp), 24% the second dose and only 1.5% completed the third dose (Table 13). Table 13 Pregnant women on intermittent preventive treatment during 2012 Malaria Prevention N (%) Pregnant women with 1st consultation 16,745 (100) 1st dose of IPTp (n) 6,179 (36.9) 2nd dose of IPTp (n) 4,020 (24) 3rd Dose of Pit (n) 259 (1.5) Source: Reproductive Health Report for 2012 in CPHS, 2012 Annual Activities Report for the Province Health Units. 2013, Cabinda Provincial Health Secretary: Cabinda IPTp - intermittent preventive treatment in pregnancy Cabinda has a prevention program for HIV/AIDS, which includes testing, counselling and follow-up of new cases. Screening, in 2012, was performed in 64,259 people, with 1,516 positive cases. From a total of 24,358 pregnant women screened, 445 positive cases were identified [7], meaning that 29.3% of all HIV positive cases were among pregnant women. From the total of 1516 positive cases, only 491 integrated in the ARV treatment program, 349 women (319 between 15-49 years) and 142 men. No data were available for the total number of pregnant women under the program of vertical transmission prevention (PVTP). 41 ! ! There were two hundred births on women doing VTP in the province, from those 185 were done in health units and 15 at home. Only 5 of those had a delivery by caesarean section [7]. 4.2.2.3. Intrapartum Care During 2012, 32,943 deliveries were reported, 96.6% were done by SBA, and 3.4% by a traditional birth attendant (TBA) or other person. Also, 98.7% were live births and 1.3% stillbirths (Table 14). A higher proportion of stillbirths were reported with SBA compared to TBA, 2.3% vs. 0.1%, respectively. Table 14 Distribution of deliveries according to birth attendant Birth attendant classification Live births Stillbirths Total births (n) Total births (%) Skilled Birth Attendant 31417 421 31838 96.6 Traditional Birth Attendant 1104 1 1105 3.4 Total 32521 422 32943 100 Source: Reproductive Health Report for 2012 in CPHS, 2012 Annual Activities Report for the Province Health Units. 2013, Cabinda Provincial Health Secretary: Cabinda Thirteen health units that reported 30,265 births, 95.6% were vaginal, 4.3% caesarean section and 0.1% mechanical. Only two units, Maternity Unit in Cabinda district and Alzira Fonseca Hospital in Buco Zau district, seem to have caesarean sections available. There was no mention of the type of EmOc (basic or comprehensive) provided to the women, in either report at the province level. Table 15 Birth distribution by health unit and delivery type Health Units Delivery Type (n) Vaginal Caesarean section Assisted Total Municipal Hospital Cabinda 1980 0 0 1980 1st May Hospital 14099 1293 19 15411 Health Centres and Posts of Cabinda 11863 0 4 11867 Buco Zau Hospital 505 0 0 505 Alzira Fonseca Hospital 48 4 0 52 Municipal Hospital of Belize 372 0 0 372 Health Centres and Posts of Belize 78 0 0 78 Total 28945 1297 23 30265 95.6 (%) 4.3 (%) 0.1 (%) Source: Reproductive Health Report for 2012 in CPHS, 2012 Annual Activities Report for the Province Health Units. 2013, Cabinda Provincial Health Secretary: Cabinda 42 From interviews with the health provincial secretary, I found that oxytocin, suturing of perineum and vitamin A are reported as being provided to women in labour or during the PPC period but no other details on the proportion of women covered are found in reports. Abortion is available at 1st of May Maternity in Cabinda district and the Municipal Hospital of Belize, a total of 1439 and 77, respectively, were conducted. No specification on the follow-up for those women was recorded [7]. 4.2.2.4. Postpartum Care Although there is no reference of the availability of PPC for women, the Follow-up Antenatal Care Notebook (Appendix A), which pregnant women use to record their appointments during pregnancy, labour and postpartum, mentions it and indicates that the first PPC appointment should occur on the 6th day after birth. As per the Antenatal Care Notebook, the following interventions are the core of the PPC consults in Cabinda: health state after delivery, check uterine involution, characteristics of the lochia, check tetanus immunization status (number of doses) of the woman, family planning information, specifically, contraceptive methods, breastfeeding promotion as well as status, and child immunization provision. The proportion of women receiving PPC is not recorded in any of the provincial´s or individual health units´ reports. 4.2.3. Health Facilities and Community-Based Services Some villages – “bualas” – have a tribal authority system, the “Soba”, that in cooperation with the Provincial Health Care System provide healthcare in mobile units or in their own homes. There are a total of 25 mobile health units distributed throughout the four districts. No reference to the type of care provided is mentioned in any of the reports available [7]. 4.2.4. Referral Systems The population is transferred between institutions by ambulance if they are available in the health unit or using their personal transportation. Since 2011, the province has the prehospital system provided by the National Institute of Emergency of Angola (INEMA). The proportion of units with ambulances is not mentioned in any of the reports and there was a reference to the use by employees of their own vehicles to ensure health care in certain areas. 4.2.5. Human Resources for Health The density of skilled health workers, in the province, was below the internationally recommended of 23/10,000 population [9] at 5.57/10,000 population. The density of health 43 ! ! workers was calculated dividing the total number of workers of a cadre by total catchment population they served for 2012. Overall, specialist doctors present higher density than general practitioners, midwives or nurses. The number of obstetric doctors for the whole province is 17, with a density of 0.42/10,000 population, if all catchment populations are considered and 1.82/10,000 if women at childbearing age (15-49 years) are used as a denominator [8]. Health care provision in the province relied mostly on auxiliary and nurse technicians. Table 16 Distribution of human resources for 2012 Workforce for Cabinda Province 2012 Human Resources* at Cabinda Province Nationals Foreign Total Prof. Dens/ 10 000 pop. Physicians Specialists 10 85* 95 2.33 General Practitioners 35 12 47 1.15 Midwifes -- 3 3 0.07 Nurses 72 10 82 2.01 Aux. Nurses 477 -- 477 11.7 Nurse Technician 779 -- 779 19.1 Mid-level Workers 361 5 366 8.97 Source: CPHS, 2012 Annual Activities Report for the Province Health Units. 2013, Cabinda Provincial Health Secretary: Cabinda *International Standard Classification of Occupations (ISCO, 2008 revision) in WHO. Classification of health workforce statistics. 2013; Available from: www.who.int/hrh/statistics/workforce_statistics. [54] Although training is provided for malaria and HIV prevention, there is no mention of specific training on maternal health. The Provincial Hospital of Cabinda made available a pedagogic department responsible for the training of its professionals but no information was provided on the subjects and training program. The province also has a Health School and Medical School since the end of 2011. 4.3. Maternal Mortality in the Province Only the 1st of May Maternity reported maternal deaths. A total of 35 maternal deaths per 14,937 live births were reported, this means the MMR estimated for that health unit was 234.3/100,000 live births. 44 Table 17 Distribution of births by number of live and stillbirths in 2012 Health units Stillbirths Live births (n) Total Live Dead Municipal Hospital Cabinda 25 1955 0 1980 1st May Hospital 474 14808 129 15411 Health Centres and Posts of Cabinda 398 11373 96 11867 Buco Zau Hospital 10 498 0 508 Alzira Fonseca Hospital 1 52 0 53 Municipal Hospital of Belize 6 366 0 372 Health Centres and Posts Belize 2 75 1 78 Total 916 29353 30269 Source: CPHS, 2012 Annual Activities Report for the Province Health Units, 2013, Cabinda Provincial Health Secretary: Cabinda Neonatal mortality, an indicator of the quality of IPC and PPC, as well as childcare, was 7.7/1,000 live births for the province (we used the data provided by the health units). Only the provincial maternity, 1st May Hospital, provided detailed information on the number and timing of neonatal deaths (Table 18). A total of 14,937 live births occurred in that unit with a neonatal mortality rate of 8.6/1,000 live births and an early neonatal mortality of 4/1,000 live births. Table 18 Neonatal deaths per live days for the year 2012 at Cabinda maternity 1st of May Neonatal deaths by days of birth Deaths (n) <1 day 0 1 day 9 2 - 3 days 23 4 - 6 days 28 7 or more days 69 Total 129 Source: CPHS, 2012 Annual Activities Report for the Province Health Units, 2013, Cabinda Provincial Health Secretary: Cabinda 4.3.1. Causes of Maternal Mortality The major causes of death at the Maternity of Cabinda district, used as a proxy for the province causes of maternal death, are presented in Table 19. Infections and haemorrhage represent more than 65% deaths, although hypertensive disorders also have a considerable proportion of attributed deaths (20%). The main diagnostics referred within infections include: septic shock due to abortions, malaria and pneumonia. 45 ! ! Table 19 Major Causes of maternal deaths at Cabinda district maternity in 2012 Major causes of maternal death Deaths (n) Proportion (%) Infections 13 37.1 Haemorrhage 10 28.6 Hypertensive disorders 7 20 Others 5 14.3 Total 35 100 Source: CPHS, 2012 Annual Activities Report for the Province Health Units, 2013, Cabinda Provincial Health Secretary: Cabinda Table 20 shows that only 3 pregnant women were reported to have died due to malaria in 2012. This was reported as a primary cause of death in the death certificate. When we analyse the maternity list of causes for all 35 maternal deaths (Table 19), malaria is among one of the most frequents but not as the primary cause and this seems to influence the data presented. Table 20 Mortality by malaria among pregnant women 2009-12 Years Dead Pregnant Women by Malaria 2009 2 2010 1 2011 na 2012 3 Source: Reproductive Health Report for 2012 in CPHS, 2012 Annual Activities Report for the Province Health Units, 2013, Cabinda Provincial Health Secretary: Cabinda na: not available HIV related maternal deaths are not mentioned on any reports available. 46 47 ! ! 5. Maternal Care in Context 54 continuity (at least four visits) seems to not be present, and cultural constraints and workforce availability should be addressed in future studies [4, 31, 34, 42]. A previous study [5] conducted nationally concluded that home deliveries in the province account for almost 20% of all births which makes us question the constraints for the services utilization [41]. We tried to assess if changes occurred from 2009 to 2012, but the reports reviewed did not allow us to determine the proportion of women with home births. However, from the Reproductive Health Report (RHR) one can deduce that a decrease happened. This can be a biased assumption, as only 60% of all children in Cabinda [5, 6] have a birth record, and women with home deliveries, are assisted by TBA or others (family or neighbours) that do not have formal connections to the health departments. Moreover, and according to an interview with PHS, 200 TBAs have formal relationships with the health units, thus meaning that only those will report births at home. In line with these findings, the 3.4% of home births, found in this study reflects an underreporting of what is happening in the community and, that a need to stimulate the record of those births is necessary if we want to capture the real scenario of births in the province. Despite this, Cabinda, unlike other Sub-Saharan countries [43, 44], has a higher proportion of SBA at childbirth. Nonetheless, one can question the quality of that care [41] as there is no program for delivery of EmCo by nurses or other health professional cadres, and the ratio doctors, midwives and nurses is lower than that of the population demand and international guidelines [41, 61]. Overall, SBA is still not universal at Cabinda district, but its coverage is higher than that of the country. SBA is a measure of the availability and quality of services as the presence of a SBA at birth is beneficial to women and children’s health [44, 62]. One can also relate the occurrence of home births to cultural constraints that go from maternal, social, facility and macro-level factors [44]. Moyers and Mustafa (2013) state that countries with higher percentages of government spending in health and expenditure per capita, seem to be associated with higher proportion of SBA [43]. Angola has increased spending on health but this has been mainly concentrated in the reconstruction of infrastructures, and may have affected the potential progression for the achievement of universal SBA in the country as well as at the provincial level. Another finding concerning SBA, in 2012, was that only two units performed caesarean sections, the 1st of May Maternity in the Cabinda district and Alzira Fonseca Hospital in the Belize district, with proportions of 8.4% and 7.7% of all births attended, respectively. This raises the question of inequalities across the province on the access to comprehensive EmCo. This is shown in the province proportion of caesarean section of 4.3%, which is below the WHO recommended minimum of 5% [9, 42]. If compared to the country caesarean section rate of 10.1% [52], Cabinda clearly shows that there are not only inequalities within the province but also across provinces in the country. This highlights that differences in 55 ! ! access to comprehensive EmCo go beyond the availability of health units and can be related to a lack of skilled health workers [42]. The health ministry states that the lack of skilled human resources has been a problem in trying to ensure healthcare staffing and quality [21]. When analysing the distribution of health care workers in the country, it becomes clear that health care personnel are scarce and concentrated in large cities, 85% of physicians in Luanda and provincial capitals [21]. The evolution of provisioning of the country's human resources requires an increase in the number of institutions, which provide training for qualified professionals. Although this has been observed in the last three years, the results will take several years to have an impact on the workforce [63]. In 2010, the ratio of physician/population was 1/10,000, nursing professionals was (very few or no graduates from the country) 17.5/10,000, and the diagnostic and therapeutic technicians (mid-level workers) was 3/10,000 [21]. When compared with other countries of the Organization for Economic Cooperation and Development [64] where the physician´s density average is 3.1/10,000, Angola has a distinct lack of these health care professionals. Although the ratio of nurses in Angola is higher than the 8.6/10,000 average for OECD [64], it should be made clear that training in Angola is at the level of secondary and basic education and that only a few dozen graduates work in the country. The comparison of these data is biased since these reflect different realities and technical skills. If compared with the ratios of the average African region [56] 2.5 doctors and 9.1 nursing professionals per 10,000, we would say that, with regard to medical personnel the country has a clear need and although the number of nursing professionals is above the African average, this measure does not take into account differences in training and in professional classification [65]. In the province, we found that the provision of care by skilled health professionals presents a higher density of doctors, 3.5/10,000, with specialists at 2.3/10,000, than the rest of the country and the African region [21]. Despite this, and concerning reproductive health, the density of obstetricians is very low as well as of midwives and nurses, 0.08/10,000 and 2/10,000, respectively. These numbers are below the recommended minimum 23 doctors, midwives and nurses necessary to guarantee proper access to SBA and availability of comprehensive EmOc [9]. Auxiliary nurses and nurse technicians, with unspecific training to conduct the needed comprehensive interventions that SBA requires, provided the majority of care in the province. According to Kruk and Prescott (2012), an increase of 10% in health care workers per 1,000 increases the odds of a woman having a safe delivery by 8%, thus making a real impact in maternal morbidity and mortality [66]. In 2012, the maternal mortality ratio (MMR) in the province could only be estimated for one health unit as none of the others provided data on maternal deaths. The MMR for 1st of May Maternity was 234.3/100,000 live births. The MMR for the province is below the national 56 average, which may be due to an underreporting of deaths or, other factors that we are unaware of [1, 2]. When comparing these results with a study [45] conducted in four other Sub-Saharan countries (Burkina Faso, Kenya, Malawi and Mozambique) at the services level, we observe that Cabinda presents the highest MMR which suggests that despite the high number of health units, technical and social limitations that lead to poor performance in this indicator may be present [43]. Maternal deaths may be subdivided into two groups: direct and indirect obstetric deaths [51]. “Separation of indirect obstetric deaths from direct causes is important because of the implications for intervention strategies and is especially relevant where these background diseases kill many women of reproductive age, including pregnant” [27]. Mortality is only the tip of the iceberg [67, 68]. Complications during pregnancy, labour or delivery may bring about disabilities to women, which impact their ability to function and be an active and independent member of society. This is especially important considering what they represent for a country´s healthy life expectation has these are indicators of the underlying functioning of social structures and the effectiveness of health systems [12, 45]. The latest systematic review on causes of maternal deaths by WHO [67], points that 82% are due to direct causes, haemorrhage representing 34% of those. Indirect causes account for 18% worldwide and in African countries, infectious diseases such as HIV and malaria are major causes [45, 67]. In fact, countries like South Africa and Nigeria had mortality increases between 1990 and 2000, due to high HIV prevalence and only after diagnosing and treating those women during pregnancy, was a decrease in maternal mortality observed [69]. Access to effective maternal health care along the continuum of care is essential, especially in regions that contribute largely to the high burden of maternal mortality and morbidity such as Sub-Saharan Africa and Asia [1]. Another fact is that globally, the number of unsafe abortions performed has increased from 19.6 million in 2003 to 21.6 million in 2008 [67], putting more women at risk of death and other morbidities and showing that the specification of the death cause and the overall health state of women is essential in order to know and understand the true burden of maternal mortality and morbidity. “Data on the incidence and severity of these medical conditions in developing countries are scarce’’[67]. As per the rest of the Sub-Saharan region [12, 67], Cabinda in 2012, presented as major maternal death causes, infections (37.1%) followed by haemorrhage (28.6%), and hypertensive disorders (20%). This raises again, the question on the quality of care available as these are all preventable direct death causes that should be addressed during pregnancy at ANC visits, during childbirth with SBA and access to comprehensive EmOc [4, 41, 67]. Further, questions that go beyond the availability of skilled health professionals should be raised such as, the availability of medicines essential to prevent or treat potentially lifethreatening conditions. Medicines concerning mothers´ health are listed below, in Table 23. 57 ! ! However, there is often a restricted access to medication in resource limited settings [70]. As observed, a low availability of contraceptives seems to be present in the province. Consequently, what other essential medicines, as defined by WHO treatment guidelines are missing? Is there availability of those products? Are the death causes strictly related to the human resources? To answer these questions, more studies are necessary to address and understand the impact of those on the burden of maternal death. The MOMI study (2013) [45, 50], has already begun to address this subject, but not enough data has been collected to compare, and our study could not, as previously referred, capture the availability of medicines in the province. !! Table 23 Priority medicines for mothers according to WHO treatment guidelines Source: Adapted from Hill, S.R., Putting priorities first: medicines for maternal and child health. Bulletin World Health Organization, 2012(90): p. 236-238 PPC, a core moment for the prevention of deaths among women, is not mentioned in any of the reports assessed for 2012. The lack of systematized reporting of interventions and women seen in this maternal care stage indicates the low relevance that is given to it by health workers and population alike. Women are normally discharged immediately (first or second day) after childbirth and are only seen on the 6th day after childbirth, if they return for their child’s vaccination. The value and importance of this moment is only centred on the newborns´ health and although women are seen, they are often not asked about their health. There is still a cultural belief that birth is a natural event with no need for medical care, and that women should be taken care of by their families, as per the local rituals. As showed in previous studies conducted in African countries [4], birth complications in Cabinda are 58 seen as a part of the events that surround birth and complications due to pregnancy or labour are only reported if they are life threatening, thus making women seek specialized medical care [4, 71]. The concept of an extended postpartum period is not mentioned, which is in line with previous evidence showing that after childbirth the number of women receiving any care drops considerably or is absent [45, 71]. The collection of data on health care in the country and province is difficult. Although most institutions have a system of data recording, they are inconsistent and there is a lack of surveillance departments and management. Although projects to improve the recording system are in development, none have been completed [24], and this does not allow for the proper evaluation of the coverage of maternal services as well as the quality of such care. Several elements affect the functionality of health systems: human resources capacity, health facility infrastructure, supply systems, financial resources, government stewardship, district–level management and monitoring [4, 27, 34], and this study describes a part of the provincial problem, mainly related to the training of the workforce, poor reporting systems, and cultural constraints related to reproductive health. Cabinda still presents an unacceptably high maternal mortality despite the availability of health units and workforce, and a reproductive health program in place [27, 37, 41]. Future studies should address those specific areas if efforts to scale up packages on maternal health are to happen, and if Angola wants to achieve MDG 5. 59 ! ! 6. Conclusion 60 61 ! ! 6. Conclusion The real burden of maternal mortality is still not known in the Cabinda province of Angola. Despite efforts made by the Provincial Health Secretary and the Ministry of Health, to formally develop methods to record interventions and outcomes at health units, the majority still do not have these systematized. Consequently, it becomes difficult to efficiently measure progression made and changes still required in order to achieve MDG5. Finally, specialized health workers are not generally available for the provision of core interventions, which guarantee universal access to reproductive health. In 2012, the province of Cabinda had a reported MMR of 234/100,00 live births. This may suggest that the province has already achieved the MDG5 set for Angola as a MMR of 290/100,000 live births. However, and considering the data available this cannot be assumed. That is, MMR is still high, despite availability of health units and health workers, particularly when compared to other districts in Sub-Saharan Africa. Expenditure necessary if MDG 5 is to be achieved should address: • Reinforcement of training for health workers, particularly aimed at reproductive health and core interventions [67]; • Definition of a framework to guarantee accesses to EmCo by SBA that goes beyond doctors and midwives if, universal access to SBA is to be achieved; • Improvement, supervision and surveillance of recording systems along with their implementation to efficiently measure maternal health; • Increased research focused on understanding the impact of social and maternal factors that constrain universal access to maternal care [28]. At this point in time, the MDG 5 target seems almost unattainable. However, if those committed to the project focus on the above measures, especially those adapted to the context and the resources, the realization of MDG5 target is still feasible. 62 63 ! ! 7. References 70