5 - 6 - Video 4.6 Challenges to EmOC Implementation in Developing Country Contexts (8 26), Childbirth A Global ...
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As you probably gathered from someof the examples in the last section,there are some significant challengesto the effective implementation anddelivery of EMOC in developing countries.In this part of a lecture we willdiscuss these challenges andalso consider the implications ofapplying fixed universal standards andideals to complex local realities.In conclusion, we'll touch onthe development of potential solutions foraddressing some of thesechallenges in unique settings.So, when talking about challenges forEmOC implementation, what I'm referringto is the actual performance of requiredservices at a fully functional level.Challenges to EmOC implementation largelyinvolve issues related to inadequateresources and quality where resourcesfall into three general categories.Human, technological and political.Human resources include problems relatedto the global maternal health workforce.This topic was covered inweek three of the course soI won't spend time on it here.But if you remember, some of the issuespertaining to workforce include a shortageof trained health workers and problemsretaining the workforce that does exist.Insufficient or uneven education andtraining of health workers.Problems with supervision andregulation of health workers.A lack of evidence-based treatmentprotocols that are consistent both across,and within, areas.Many of these workforce issues havemajor implications for quality ofcare as they affect health workers'ability to provide services effectively.When it comes to EmOC,it's not enough to ensure thattrained health workersare available to attend a birth.To qualify for either level of this care,health workers in a given health facilityneed adequate technological supports inorder to perform the skills required forthe various signal functions.In many settings,these supports are severely lacking or areonly available on an intermittent basis.Specifically, some of the supplies andequipment include gloves andother basic supplies needed toperform an uncomplicated delivery.Drugs and the equipment to safelystore and administer these drugs.Instruments required forthe removal of placental products andfor assisted delivery.Equipment needed to performcesarean sections andblood transfusions forcomprehensive EmOC facilities.What's also needed isbasic infrastructure.So the physical structure of the building,electricity with a backup generator, oran alternate light source,clean water supply and a latrine.In order to ensure that human andtechnological resources are available ina reliable matter, a good deal ofpolitical will is also needed.Governments and ministries of healthare always making very difficult decisionsabout how to allocate limited fundingto a number of high-priority problems.Political support for maternal health andsurvival is essential for reducingmaternal mortality and achieving MDG 5.So challenges to the delivery of EMOCare making this care available toall women who need it, typicallyinvolve problems and inequalities orinequities related to physical,economic, and sociocultural access.Where some women willfare better than others.Physical access is one problemeffecting the delivery of care.Specifically involving the geographicaldistribution of EmOC facilities andthe difficulties these women have inreaching these facilities particularly inrural areas.Significant transportation barriersexist in these settings where mostpeople don't have cars or motorcycles.They have to rely on buseslorries bikes bicycles orwalking to get to wherethey need to go some healthsystems don't provide an ambulance serviceto pick women up from their homes ortransport them from a primary carefacility to a health facility with EmOC,and even when functional vehiclesare available unpaved roads the roads thatare flooded or degraded canprevent women from reaching care.Economic access can be anotherproblem from EMOC delivery.Direct costs can include official fees forservice at health facilities,as well as fees for transportation.In addition, sometimes families payunofficial bribery fees as a result oflow-level corruptionperpetrated by health workers.Direct cost can also include requiringwomen to pay for their own supplies forbirth, ranging from gloves andsyringes to kerosene and disinfectant.Indirect costs may include food andlodging expenses for family memberstraveling with a woman to a town where shecan get EmOC, as well as opportunity costsassociated with leaving home for whatmight turn out to be a couple of days.In terms of social andsociocultural access,research shows that some womenexperience substantial neglect abuse anddisrespect in health facilitieswhen they seek child birth care.Such differential and discriminatorytreatment seems to be based on perceptionsof individuals womens standing in societyrelative to others, including factors suchas race, ethnicity, class, education,rural residence, HIV status, et cetera.More broadly, the general positioning andvalue of women in society canalso play a role in their ability toaccess services insofar as women are notalways in control of decisionmaking regarding their own health.Finally, sociocultural preferences andbeliefs regarding pregnancy andchildbirth can affect access to EMOC.Particularly if these preferences andbeliefs conflict with aspects of modern orallopathic medical practices.It is widely accepted thatincreasing the number of births withtrained health workers and increasing thenumber of health facilities of the EMOCare critical interventions forreducing maternal mortality.But there are assumption aboutimplementations, particularly quality anddelivery, upon whichthis conclusion depends.In settings with inadequate training,regulation, andtechnical supports, the bureaumist hassupposed success simply because the EMOCprocess indicators were met.Qualifying facilities that tendto perform services poorly orinconsistently are likely to havean impact in reducing maternal mortality.In addition, if most women using theseservices are those who can access thembecause they are relatively well off, wecertainly have not solved the problem ina way that is equitable, and therefore wereally haven't solved the problem at all.On the other hand, facilitiesthat reliably offer a measure ofappropriate life saving care but don'tqualify for EmOC, should not be dismissed.For example, one study assessing EmOC atthe district level in rural Kenya foundthat among 40 health facilitiesassessed none met the requirements forEMOC because none performedassisted delivery.But when the criterion was removed andthe minus 1 distinction applied,the ratio facilities with EMOC topopulation was 6.2 per 500,000.To avoid this kind of over generalizationand need to rely on the temporary minusone distinction, interpretation ofthe EmOC process indicator should besupplemented with informationthat is more specific to context.Particularly with respect to existingresources, quality of care, and ideally,some sense of ritual when receivingcare in terms of social andmaterial positioning.So, for example, are all women inthe given area accessing this care, ordo substantial inequalities exist?To a great degree, the right kind ofmonitoring assessment can help toprovide this information to programplanning, planners and managers.More targeted interventions that aretailored to particular localities can thenbe developed, implemented, and evaluated.However, even with the best processesin place there are still women whoare not reaching EmOC and who are notlikely to reach it in the near future.Community-based approaches versusfacility-based approaches, such as EmOC,can play an especially important role infacilitating access to obstetrics care,including community mobilizationto improving care in local healthfacilities and providing health educationand basic services at the community level.The remaining lectures in this course willfocus on community-based approaches toadvancing maternal health andsurvival in developing countries.>> The preceding program iscopyrighted by Emory University.
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