UON Network - Tackling Unmet Need for Major Obstetric Interventions 1 2 .4 .. 26 ...... 3 ...... 27 ...... 10 ...... 3 ...... 13 ...... 32 IGER N IN UON ONTENTS ...... 31 C ...... 29 ...... 26 hod ...... 7 ...... 6 lth Policy ...... nd Met ...... 3 ...... 28 ...... rmation ...... EXERCISE ...... tion ...... IST OF MAIN DOCUMENTS PUBLISHED BY THE BY PUBLISHED IST OF MAIN DOCUMENTS QUESTIONNAIRE FOR WOMEN QUESTIONNAIRE FORMATION FOR HEALTH QUESTIONNAIRE base...... 2: 3: L 1: UON Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling ONCLUSION TILISATION OF RESULTS ONTEXT Results...... Retro-info HE HE Equipment a Data Percep General ...... Maternal Hea NTRODUCTION NNEX NNEX NNEX BBREVIATIONS A 4. U A A 1. I 2. C A Case Studies Niger Tackling Unmet Needs for Major Obstetric Interventions Obstetric for Major Needs Unmet Tackling 3. T 5. C UON Network - Tackling Unmet Need for Major Obstetric Interventions 2 edical district for formation directorate of international man co-operation) Maternité sans Risque (Safe motherhood liale (Reproductive Health and Family planning) ire (National Health Information System) au Développement (Belgian cooperation) (Belgian au Développement iques Traditionnelles (Committee on traditional iques Traditionnelles e (Health Development Programme) oduction (Reproductive division) health National de Formation et de Recherche en Santé (National sammenarbeit (Ger de Formation et de Recherche (M de Formation et de oopération Internationale (General for International Development (Integrated Health Centre) (Integrated Health opical Medicine - Antwerp nical Co-operation Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling BBREVIATIONS co-operation) DH: District Hospital DHC: Departmental Hospital Centre DHS: Demographic and Health Survey DSR: Direction de la Santé de la Repr IHD: Indicator for Human Development Tr IMT-A: Institute of RENFORS: Réseau d'Encadrement network for Health Formation and Research) SNIS: Système National d’Information Sanita SOMAIR: Société de Mines de l’Aïr (Aîr Mine Society) SR/PF: Santé Reproductive et Planification Fami MOI: Major Obstetric Intervention MPH: Ministry of Public Health NGO: Non-Governmental Organisation PDS: Plan de Développement Sanitair EB: Expected Births EU: European Union GDP: Gross Domestic Product GNAMASARI: Groupe Nigérien d'Action pour une action group of Niger) GTZ: Gesellschaft für Technische Zu UNDP: United Nations Development Programme UNFPA: United Nations Population Fund UNICEF: United Nations Children's Fund UON: Unmet Obstetric Need UR: Uterine Rupture USAID: United States Agency WHO: World Health Organisation practices) Intégré CSI: Centre de Santé Urbaine deCUN: Communauté of Niamey) Niamey (Urban community DGCI: Direction Générale de la C and research) Nigérien sur les Prat CONIPRAT: Comité A Coopération Générale de AGCD: Agence AMI: Maternal Absolute Indication AMI: Maternal BTC: Belgian Tech and Management Team CAM: Co-ordination Médicale CiMéFoR: Circonscription UON Network - Tackling Unmet Need for Major Obstetric Interventions 3 . Given that 1 ly awaited by all set out the strategic would be a shame if ther to its capacity to ther to its capacity poorest on the planet. is not entirely finished, tive health care for the into the management or ng into account proximity to a he study or not. The creation of he study or not. The s comes from the adjustment we defined the urban or rural origin of 118 per cent and literacy rates of rman technical assistance through he large towns. In 1974-1976, this ctured feedback to the stakeholders ctured feedback to ical history over the last few years. In is striking in that, although it covers the in that, although is striking tting. We will firstly with a fall in GDP per head from US$391 end of the study is eager end of the study is 9. According to the UNDP IHD (Indicator of f the population is under 15. Indicators for for many years, and it . However, the process . However, the process es had very little input s when looking at deficits (i.e. the difference s when looking at udy was carried out in Niger. description of The ed approach of a social curative and preventive to democratic elections, which brought a new ountry’s health system. The involvement from the ountry’s health system. quantify the deficits, but ra quantify the deficits, ger. Finally, despite the absence of feedback, we ger. Finally, despite the absence of ders in maternal health perceived the study. ders in maternal health perceived the 267,000 sq km) among the s, there are currently 42 health districts in Niger the 173rd place Development out of 175 (Human ctures in 13 of the country’s 38 districts 13 of the country’s ctures in town with a hospital capable of undertaking Major of undertaking a hospital capable town with the UON study began, particularly in the area of the UON study began, particularly the anticipated results are more or less known, the the anticipated results to redynamise its maternal health policy. policy has centred on cura ong the worst in the world, much lower than the African out briefly the country context, which is particularly difficult, out briefly the country context, which istrative definition, but by taki , whether they participated in t , whether they participated 46, infant mortality rates of turned by a coup, and a self-proclaimed president ruled the y differential between urban and rural areas, which had not been ich are still mainly found in t report in Niger in that we have y phases of the process – stru y phases of the process rence that appears in the result th, and the active support of Ge th, and the active . The situation has even worsened recently 2 Niger is a vast sub Saharan country (1, Niger is a vast sub Saharan country Independent since had a difficult polit 1960, Niger has Since independence, Niger’s health The UON (Unmet Obstetric Needs) study in Niger Needs) study in (Unmet Obstetric The UON Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling In this case study we will set ONTEXT NTRODUCTION Following a Following modification in the administrative boundarie World Bank 1999 World Development Report 1998/99: Knowledge for Development. average: life expectancy at birth of 15 per cent health, nutrition and education are am 1 2 Its population of 10 million since hal is very young General in 1975 to US$269 in 1997 and then to US$190 in 199 Human Development) Niger today occupies Report 1997, UNDP). 1996, the third republic was over country. His assassination in April 1999 led president as head of state in November 1999. individual. Care was generally free and communiti financing of health facilities, wh policy was reoriented towards a more decentralis 1. I to 14 health stru it only relates entire country, only 11 per cent of births take place in a cent of births only 11 per we expected poor result Obstetric Interventions, and unmet needs). As between met needs was certainly not simply to aim of this study at a standstill a health policy seems to have been given the pervasive poverty and the geographical,given the pervasive poverty and the se mobilise the actors involved in developing the c of Heal outset of the Ministry the success of the study the Alafia project ensured one of the ke as, unfortunately, The feedback scheduled for the – has not yet begun. health system those involved in the Niger does not make use of this opportunity directions of the Ministry of Health when directions of the Ministry of Health how the st maternal health. We will then describe the results differs from the final the mother not by using the admin health structure. Another diffe have made concerning the fertilit made in Ni taken into account in the analyses will try to understand how the different stakehol will try to understand how the different 2. C UON Network - Tackling Unmet Need for Major Obstetric Interventions 4 a referral maternity preventive activities, preventive pment of the country. ger’s 38 districts, four ealth Centres offering a includes the creation of es…) Niger decided to es…) Niger decided the World Bank, WHO, onsultation, vaccination, km from a health centre rking at an optimal level rking at an ic needs through training eprosy and tuberculosis). e levels, the health district, he whole community, which community, he whole (Better Rural Health Project) (Better Rural maternal mortality, and by an and material resources, to onal recommendations on this and the District Hospital (DH); and the District Hospital ed towards the development of an ed towards the development th and its central directorates. spital Centre (DCH) or spital Centre (DCH) lation programme, which aimed to reduce ternal and child health care strategies were child health care ternal and care. In 1998, out of Ni illion dollars for this programme. However, the low levels of coverage of low levels was to sign all the regionalwas to sign and international for the fight against l people living within 5 he socio-economic develo egy of meeting obstetr prevention (antenatal c three phases in 1985; the Bamako Initiative in 1987; the s. The Plan de Développement Sanitaire (Health s. The Plan de Développement ase de Santé) and the village healthase de Santé) and team, the cent of its budget for health; this is not enough cent of its budget for health; this is district development plan ty participation supported by the central and ty participation supported Sun City, South AfricaSun City, in 1997; the Technical Conference on health agents) Integrated H sations (UNFPA, UNICEF, national Conference on Population and Development in Cairo egrated health care for t care for health egrated anagement of health servic anagement of health pyramid health system on three levels: pyramid health system , there are three administrativ pregnancies and delivery in rural areas. hed that the system was not wo the system was hed that crease the availability of hum wed regional and internati for the rural or urban district, for the rural or urban the Ministry of Public Heal hospitals and national hospital centres (the central maternity was to train doctors able to manage dystocia and to construct ng family planning, reducing and a referral hospital at the district level. The regional and and a referral hospital at the district only curative care, but also prevention, education and health and education also prevention, care, but curative only a departmental hospital and two referral maternity facilities. In two a departmental hospital and two referral eeting on safe motherhood was organised in Niamey. In 1992, the tion de la Santé Rurale (1980-1986) Santé Rurale (1980-1986) tion de la needs, and the government has to appeal for aid from NGOs and needs, and the government has to utions run hospital provision. 1994-2000 sets out decentralisation gear 1994-2000 sets out . But in 1994, having establis . But in 1994, 3 Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling per Each year the state allows five to six Since 1974, Niger has follo For these three operational levels In 2000, there are plans to in The first level includes: the Health Post (C Integrated Health Centre (IHC) Integrated Health On the second level: the Departmental Central Ho On the second level: facility; On the third level: the national planning, in Niamey, national centres for family

Lusaka Declaration relating to the Development Scenario in 3 (insufficient health coverage, irregular drug supply, irregular drug supply, health coverage, (insufficient traditional birth attendants to supervise began to train villagebegan to agents. health Later, Niger ma health care and in which primary declarations defined participation, poor m insufficient community to redress these problem change its health policy of Development Plan) level with full communi operational district This plan envisagesdepartmental level. a subject. In 1989, the regional m World Bank began to support the Niger’s popu nutrition and family planning) and towards a strat • demographic growth by promoti health care. In order to achieve this global, int this global, achieve order to care. In health would take into account, not account, take into would the Projet Améliora promotion, • Health Posts at the village level (run by village have a first level hospital, three other districts, private instit given the country’s enormous organi particularly from the large international EU). Health Policy Maternal strengthening women’s capacity to participate in t health policy in Niger remains oriented towards • the departmental health directorate, percentage of extend health coverage so that the cent. This increases from 32 per cent to 45 per minimum package of activities, national hospitals are responsible for tertiary health Among the aims of this programme operating theatres. The World Bank allowed 17.6 m World Summit for Children in New York in 1990; the Inter in 1994; the World Summit for Social Development in Copenhagen in 1995; the World Conference in Beijing on Women in 1995; the Regional Strategy on Reproductive Health in Safe Motherhood, Colombo, 1997 UON Network - Tackling Unmet Need for Major Obstetric Interventions 5 estimated that 7 , Paris: Ministère des led Niger to reorient obstetric emergencies their part the midwives their part hem are run privately) in a cohort of pregnant take place at home. The 8 areas. The MOMA study al behaviours and health care lity remained high, people lity remained and patients did not feel and patients tional Policy of Reproductive motherhood, the accent is on motherhood, the 100,000 live births. Elsewhere, 100,000 live births. nal mortality in a rural area at 1,050 failure of this strategy: in every kind of in every strategy: of this failure . 4 lculated. However, in 1990, WHO, on the lculated. However, 100,000 live births 000 live births, but this figure dates from the 000 live births, but insulted by them, for insulted howed that only 44 per cent of births are howed that only 44 per cent of births s, have not been put into practice, with the s, have not been put into practice, t: in these circumstances, essential obstetric t: in these circumstances, essential of births (81 per cent) Mortalité maternelle évitable en milieu urbain à Niamey ed out in Niger, 700 was the figure most widely ed out in Niger, 700 was the figure most rgicalemergencies. Niger covers a vast area, ing demographic pressure, ing demographic pressure, he country (and two of t h attendant, 40 per cent of cases by a midwife, h attendant, 40 per cent of cases by and 1,350 in the rural ternal and child morta and child ternal :279-285 ilities capable of managing ilities capable of managing fortable position between soci too few qualified personnel. The gap between personnel. The too few qualified 73 . post partum follow up and family planning. post partum follow Morbidité Morbidité maternelle en Afrique de l’Ouest many changes; the emphasis is still on increasingmany changes; the the vering the 1980s. Vangeenderhuizen et al. health practices only widened, health practices to develop a Declaration of Na to develop a Declaration ng contraceptive usage. For safe ng contraceptive usage. of 371 (149-764) per very low coverage both of skilled attendance at delivery and of very low coverage both of skilled visées pour 1990 de la mortalité maternelle, Nouvelle méthodologie , estimated a number at 1,200 per , estimated a number 5 men ignorant and unwilling men ignorant (8): 1069-1073. Ann. Soc. belge Med. Trop 38 . :49-54 5

using the sisterhood method estimated mater using the sisterhood method estimated 6 Soc. Sci. Med Cahiers Santé Maternal mortality is estimated at 700 per 100, Maternal mortality Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling analysis a situation In 1998 the relative revealed What is more, the coverage of health fac What is more, the WHO/UNICEF, 1996 ré Estimations De GroofD., Seyni Bagnou A., and Sekou H. 1993 [Estimate of maternal mortality in a rural area of Niger: use of the Vangeenderhuysen C., Banos J. -P., and Mahaman T. 1995 Bouvier Colle M. H., Prual A., and de Bernis L. 1998 Jaffré and Prual in Niger: an uncom A, 1994 Midwives Y. (Niger). constraints, 5 6 7 8 4 antenatal care, the management of delivery, antenatal care, the does not seem to have been reca DHS of 1992 and basis of a new methodology

health coverage, and of promoti health coverage, respected by the midwives, and sometimes even felt and sometimes even by the midwives, respected health and its policy on maternal this policy, there are not Health in 1998. In De Groof et al. co per 100,000 live births for a period in Niamey the level of mortality was around 450 established a more precise rate was carri women in Niamey. When the UON study of 1998 s used. The Demographic Health Survey traditional birt attended (most often by a ‘trained’ The majority and 2 per cent of cases by a doctor). policies, which have been promoted for many year result that there has been a facilities capable of managing obstetrical and su hospitals in t outside Niamey, there are only 12 be carried ou where obstetrical interventions can needs cannot be met. preventive activity coverage remained low, ma low, remained coverage activity preventive and there were informed, were insufficiently medicine and traditional modern the pregnant wo considered This, combined with unceas remained just as low. indirect sisterhood method]. Affaires Etrangères – Coopération et Francophonie UON Network - Tackling Unmet Need for Major Obstetric Interventions 6 visit visit visit CAM team visit CAM team CAM team CAM team to prepare the study IGER N the study having been used for a h to 10th December 1999, and 29 EXERCISE IN and took 16 days. Data collection in the UON elapsed between the two collection periods, due HRONOGAM OF THE HRONOGAM . C 1 (UNICEF funding) intended for

Preliminary discussions with Alafia'colleagues ken during two periods: from 6t 6-10.12.99 29.01-8.02.00 et Data collection in the rest of country of rest the in collection Data Preliminary analysis Interviews policy documentation health and Figure Final report draft Final Regionalmeeting in Abidjan Informal agreement to realise the study Network UON of part become to Niger off request Officialy committee Scientific National of meeting First Protocol and questionnaires elaboration collection in (20.05-6.06) Niamey Data EXERCISE

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

UON 1998 1999 2000 Data collection began in Niamey on 20 May 1999 Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling HE January to 8 February 2000. A considerable time to financial problems: the money Approach to the data collection in hospitals rest of the country was underta 3. T UON Network - Tackling Unmet Need for Major Obstetric Interventions 7 ) by Table 1 from the Ministry of from the Ministry formation on the study to formation on the study 1999-2000. The population in the final report from the of 0.9 per cent as estimated by by projecting the data from the indications, and the outcome for milarly slightly modified because from the Health Ministry representing thefrom the Health Ministry committee first trained the gynae- first trained the committee ogramme of reproductive health, a crude birth rate, because it enables . They then went in teams into the went in teams . They then 9 It was therefore necessary to contact the contact to necessary therefore It was of the districts concerned in Niamey. The concerned the districts of s per district were used. There is therefore the risk of undergoing a Major Obstetric the risk of undergoing a Major rnity facilities. In Niamey, members of the rnity facilities. In and it was available for the study year (DHS epartmental Directorates epartmental Directorates the country for the data collection. This work for the data collection. the country onment (urban and rural) were used to assess onment (urban and rural) were used entary modules: one is based on a “women” entary modules: l areas (source: DHS 1998). The total population l areas (source: DHS 1998). The total he UNFPA PlanningReproductive project, Health and Family mpilation of an inventory of human and material mpilation of an inventory of human figures and those published by Niger for expected figures and those published by Niger 1998 data collected in ed by Niger on the basis on the Crude Birth Rate. and themselves provided in and themselves provided necessary to pursue the data collection. pursue the to necessary llection in the capital’s facilities. llection in the capital’s went a Major Obstetric Intervention and/or who died during went a Major Obstetric Intervention Statistical Institute of Niger a collection, the scientific a collection, Obstetric Interventions, their r the intervention; the other module is based on a “health r the intervention; the other module maternity facility in Niamey in Niamey who is also teaching at the faculty of health maternity facility Niamey instead of 32,714 births icits. The reference rates is si fertility rate rather than the three teams of two people three teams that general fertility rate is lower in urban areas, so the expected AMI expected (1 per cent instead sponsible for developing the national pr zobi maternity facility, a senior technician facility, zobi maternity the perinatal period. These births have been calculated ( the perinatal period. These births The UON study comprises two complem The UON study Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling This study is retrospective and concerns In order to carry out the dat In order The expected births by district and by envir The expected births by district and The chairperson of the committee re management of reproductive health (DSR) and working at t representingone midwife the DSR, Dr Bossyns from the ALAFIA Project. 9 different hospitals and maternity facilities around facilities around hospitals and maternity different of two days per hospital. The D took an average the relevant hospitals and mate the personnel of carried out the data co scientific committee Method Equipment and Introduction questionnaire analysing Major the general assessment of reproductive health needs. needs. health reproductive of assessment general potential donors again to release the money the money to release again donors potential (administrative) role Health had a facilitative the women and the children afte the co formation” questionnaire which enables resources at each health facility. Population studied and rura using the general fertility rate in urban researchers were divided into were divided researchers be exposed to the number of women who could Intervention or of dying in has been estimated by the National obstetricians from the departments and the doctors and the from the departments obstetricians studied was all the women who under childbirth or as a result of childbirth.

1988 census. For this purpose, specific growth rate 1988 census. For this purpose, specific these some differences in the figures between births (we have 27,959 births in Ministry of Health), of MOI per the Ministry of Health) and of def we took into account the fact births in Niamey are fewer than those calculat us to differentiate between urban and rural areas carried out in Niger in 1998). We preferred to use the general gynaecologist-obstetrician from thegynaecologist-obstetrician Gazobi sciences, a paediatrician from the Ga UON Network - Tackling Unmet Need for Major Obstetric Interventions 8 , 1998 the UON study itself. , 1998 IGER ing 1998, underwent a he number of expected Referral rate , N he urban area of Niamey. IGER he questionnaire, the most , N and the personnel of the hospital Expected births Expected MOI/AMI the government of Niger (32,714 EB) performed ) on the basis of MOI per AMI carried out in the basis of MOI per AMI ) on eline data collected for ated on the basis of t an nationality who, dur ey for women from t iod of their pregnancy – whatever the cause of is attached as annex 1). The national research research team registered 296 MOI cases per AMI, research team registered 296 MOI cases Table 2 births Among the variables on t rding to the administrative divisions in Niger. Expected .06 per cent rounded down to 1 per cent, instead of .06 per cent rounded down to 1 per inhabitants by the scientific committee of Niger). he 28th week of pregnancy and the 42nd day post searchers to build up a “woman” file, as a baseline for the Diffa 217,154 12,663 Total 10,287,114 589,477 Dosso 1,476,519 86,856 Zinder 1,961,769 113,231 Maradi 2,033,519 116,763 Agadez 361,192 19,269 Tahoua 1,725,404 100,985 OPULATION OF REFERENCE BY REGION BY OF REFERENCE OPULATION Tillabéri 1,882,442 111,751 trained staff of the Districts Urban . P te used in the final report of population 1 ATABASE FOR CALCULATION OF REFERRAL RATE OF REFERRAL FOR CALCULATION ATABASE C.U. Niamey 629,115 27,959

Regions of Number . D 2

Table Niamey 629,115 27,959 296 1.06% Table This questionnaire enabled the re As explained above, the reference rate calcul The reference rate was (re) calculated ( The reference rate was (re) calculated The study was included all women of Nigeri Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling The district where the facility is situated: acco “Woman” Questionnaire For the 27,959 expected births in the town, the For the 27,959 expected births in the i.e. 1.06 per cent. Major Obstetric Intervention (between t partum), and/or died in a hospital during this per death. The variables studied analysis of deficits by district (the questionnaire team in collaboration with the maternity units filled in these questionnaires. significant are: The name of the health facility. Referral rate units of Niam 1998 in the hospitals and maternity made on the bas This calculation has therefore been births (EB) differs from the ra rate (1 and gives a slightly higher reference out 0.9 per cent used in the analysis carried Criteria for inclusion UON Network - Tackling Unmet Need for Major Obstetric Interventions 9 ric Interventions were illborn, died within 24 hat the mother gives an hat the mother rictl Hospital (DH), maternity rict Hospital (DH), maternity (DH), rict Hospital form Major Obstetric ation when she is admitted to the she is admitted ation when distinction was made according to distinction was made of Major Obstetric Interventions per health formation” file to analyse the human health formation” file to analyse the link this information with the “women” file. link this information with the “women” are also the same as those put forward in the are also the same as those put forward leaving the hospital, st are carried out, were considered as coming are carried out, were ological training: this includes all the carrying out Major Obstet carrying out Major corrected in our analysis: only those women corrected in our analysis: a provisional address, usually near the health address, usually a provisional re, during or after the intervention-infection, of interventions is that proposed in the UON of interventions is ire, the most important are: th facility able to per ation because it may be t ation because the ligature of hypogastric arteries, which was the ligature of hypogastric women living in a town, whether or not the town women living in a rding to the administrative divisions in Niger. r the data collection was the “woman” questionnaire mother died, complication, referred. ental Hospital Centre (DHC), Dist ental Hospital Centre (DHC), Dist Centre (DHC), Hospital ental : urban or rural. In Niger this : urban or rural. In my, version extraction, craniotomy ther: the mother gives this inform ther: the le to manage deliveries. information on individual cases 10 Concerning This questionnaire was used to construct a “ This questionnaire was used to construct Among the variables on this questionna Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Caesarean, laparotomy, hysterecto considered as coming from an urban area. considered as coming with the exception of The type of intervention: Interventions. The number of midwives and nurses with gynaec Absolute Maternal Indication, the support fo The material used for the data collection 10 The number of dystocic deliveries. The number of caesareans. The number of uterine rupture. The number of gynaecologists and doctors with surgical copetence: this includesThe number of gynaecologists and doctors with surgical copetence: this not only gynaecologists, but also all doctors in the heal paramedical personnel ab The total number of deliveries. The district where the facility is situated: acco The district where the facility is situated: The category of formation: Departm facility. The number of working operating theatres. living less than 15 km from a hospital capable of living less than 15 “Health formation” questionnaire facility, and to and material resources of each health The name of the health facility. The results for child: child born alive and aliveThe results for child: child born alive on hours of birth. death: befo The time and cause of the mother’s haemorrhage, hypertension. address that is not her permanent address, but address, but is not her permanent address that end of her pregnancy. towards the she may be living centre, where of the mother The area of origin structure where interventions possessed a health This data was later from an urban environment. major interventions, the list added to the list of protocol. indications The indication for the intervention: the UON protocol. The results for mother: nothing to report, the administrative divisionsthe administrative of the country, all hospital. Care has to be taken with this inform Care has to be taken hospital. The category of formation: Departm of formation: category The facility. mo of origin of the The district UON Network - Tackling Unmet Need for Major Obstetric Interventions 10 hose women who mentioned, but she know with these two rvention is known, but there are now only 2,295 the rural area (Bilma, Maîné- cation. The final total is 2,293 Say, Tillabéri, Gouré, Magaria, All women from districts that do the diagnosis are not known. ving 8 duplicates and 20 cases of actising operations. Nevertheless, dering as urban t (the hospital maternity units, i.e. all the maternity units, (the hospital of intervention is not inate two contentious cases for which the of the data on the file to rtain errors, and the following cases were not rtain errors, and the following cases ed for each case recorded according to the according recorded each case ed for placenta praevia (case added to AMI). er nor the type of inte ion and for an unknown diagnosis (was added ion and for an unknown diagnosis (was the indications were placenta praevia and retro- time, one having undergone a uterine curettage time, one having undergone a uterine l the cases were MOI, an” questionnaire included all the documents and all the documents included an” questionnaire ions were carried out in 1998) the supporting carried out in ions were ro, Guindan-Roumdji, Madarounfa, Mayahi, Bouza, onnaire, set out in annex 2. One questionnaire was onnaire, set out in died before any intervention was made. he file contained 2,320 cases to be analysed. he file contained 2,320 cases to be rupture (case added to the AMI). the admission and the interventionthe admission out. carried used by Niger for this study is purely administrative and rvention (14 AMI and 4 non-AMI) as they could not be rvention (14 AMI and 4 non-AMI) ak, Finningué, Kollo, Ouallam, for whom the intervention was not known (both were AMI, one for whom the intervention was not known ll be considered as coming from cilities in the study is situated. he type of intervention or the indi d one a brow presentation). stance from a health facility pr her for whom the operation and he three deaths mentioned above, one case of transverse lie and ther’s home milieu by only consi oportion had not been considered as AMI. 1,362 MOI are for AMI). ontained 2,348 cases. After remo he died from a haemorrhage). there were also 1,377 AMI and 943 non AMI and a correction has been information on the health facilities on the health information At the outset, the file c ce Some modifications were made to correct Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling for the “wom of information The sources Concerning Concerning After these corrections, we decided to elim The definition of urban and rural In relation to the original file in which al 18 cases of death before inte considered as MOI because the women considered as MOI because the women 2 (non-AMI) women died at an unrecorded 2 (non-AMI) women died at an unrecorded the moth 1 case where neither the result for for retained placenta, the ot to the AMI because the s died from haemorrhage after uterine foeto-pelvic disproportion an 1 mother who died after an unknown intervent 1 mother who died after an unknown and the type 1 mother died at an unrecorded time, 2 mothers who did not die but where the mother had a haemorrhage through where the mother had a haemorrhage

The “women” file t women who were not Nigerian nationals, completed for each health facility chosen. completed for each Data base used Description of data set out in annex 1. A questionnaire was complet was questionnaire 1. A in annex set out criteria. concerning of the health facility registers Obstetric Intervent in which Major hospitals “health formation” questi information was the be considered as MOI: • live in a town where one of the fa not have a functioning hospital wi Soroa, N’guimi, Boboye, Doutchi, Aguié, Dako • • does not take account of the di Illéla, Keita, Madaoua, Tchinta-Abal made because, in addition to t • • • MOI. In the original file two cases of foeto/pelvic dispr intervention shown was an internal version, while placental haematoma. It is impossible on the basis MOI and 1,381 AMI (of which we can partially correct the mo cases whether the error was in t UON Network - Tackling Unmet Need for Major Obstetric Interventions 11 , 1998 IGER ", N the cause of death are of the intervention for the Niamey, Maradi and Zinder Maradi Niamey, d not give the information). d not give 25 2.293 WOMEN FILE Total " that divides the type of interventions Data Data , 1998 cases) cases) Table 4 in variables, some missing information (not some missing in variables, records) records) 70 105 AMI IGER ng from the towns of the towns ng from 19 6 s. The time of death and ng in, respectively, six and 10 per cent of deaths 1.362 , N (2.318 1.362 931 Yes No No e those concerning the outcome Yes Whole file ( Whole file Mother's death ( Mother's death ( Missing Not noted Total Total 1.381 937 2.318 INDICATION Missing Not noted Total for Absolute Maternal Indications oned (where the source register di the source register oned (where MOI ISSING AND UNRECORDED DATA IN THE DATA UNRECORDED AND ISSING . M 3

Indication 21 1.0% 16 0.7% 37 1.6% Type of area 44 3.2% 44 3.2% Type of area 101 4.4% 101 4.4% ISTRIBUTION OF CASES ACCORDING TO CATEGORY OF INTERVENTION AND CATEGORY OF CATEGORY AND OF INTERVENTION ACCORDING TO CATEGORY OF CASES ISTRIBUTION Results for child 7 0.5% 7 0.5% 14 1% Table Results for child 52 2.2% 8 0.3% 60 2.6% . D When mother died 3 4.3% 1 1.4% 4 5.7% Results for mother 78 5.7% 78 5.7% Results for mother 137 6% 137 6% When mother died 5 4.8% 2 1.9% 7 6.7% 4

Type of intervention 6 0.3% 6 0.3% Cause of mother’ death 5 7.1% 1 1.4% 6 10% Cause of mother’ death 12 11.4% 2 1.9% 14 13.3% Variable Number (%) Number (%) Number (%) below gives problems. these unresolved a resume of Table Variable Number (%) Number (%) Number (%) The final file of 2,318 cases is summarised in The most important problems ar Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling remain for certa problems Some unresolved mother, which is missing in 6 per cent of case poorly registered since this information is missi following an MOI for an AMI. by the type of diagnosis. The Major Obstetric Interventions Total number of cases Mataméyé, Mirriah, et Tanout). All women comi All women Tanout). et Mirriah, Mataméyé, are of urban origin. are of encoded in the file) or not menti in the file) or not encoded Table 3 UON Network - Tackling Unmet Need for Major Obstetric Interventions 12 s of uterine rupture differing fertility rates the response of the the response ral area used in Niger. on the same dates and by on the same take into account the bias eating age (DHS 1988: 43.1 cases from urban areas. It is not ken into account. The data that ssion of cases of non-Nigerian ssion of cases of ct Hospitals, 4 Maternity Hospital, ct Hospitals, because the differing fertility rates me of admission. If mothers declare uterine rupture in uterine are still possible of errors in the estimate the definition in the UON protocol. The facilities participating in the study. The data in the hospitals of Loga, Gaya, Tera and in the hospitals of Loga, Gaya, Tera a functioning health facility. By contrast, the tals. Except for the absence of information for the absence tals. Except and the number of case and the number been used to project the estimated population. been used to project the estimated , but it can be avoided in the future by paying of carrying out interventions was not taken into cilities were filled in cilities were ition of urban area and ru r way of understanding the pitals could have been a handicap to accurate in the “woman” file. The differences observed in in the “woman” file. oncerning the removal of cases from the category oncerning the removal of cases from the setting can easily be corrected by only tion of women of procr information has been suppliedinformation facility. The for each rors, the data collection team included experienced rors, ailable, and it is difficult to estimate the bias caused by the ailable, and it is difficult to estimate al Fertility Rate according to the setting (201 per cent in urban al Fertility Rate according to the setting ber of MOI/AMI carried out” cannot on the 14 health facilities involved facilities 14 health on the Among these study. in the explained in part by the omi explained in part age of the mother was, not ta two cases where the intervention and the indication were the intervention and the indication two cases where here may be an over estimate of ned when the mother is admitted. laration of her domicile at the ti and 41.9 per cent in rural areas), or epartmental Hospital Centres, 4 Distri Hospital Centres, epartmental The most important bias concerns the defin The fact that there are no gynaecologists The fact that there are no gynaecologists The statistics from the census of 1988 have The statistics from the census of 1988 One questionnaire for each of the was filled in This file contains the data the file contains This Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling a temporary residence in town, t possible to control for this bias in the 1998 study more attention to the data obtai Because the proximity to a health facility capable account, the urban area does not correspond to denominator “expected births” according to considering as urban areas those towns that have correction for the numerator “num that occurs in the mother’s dec Tessaoua districts, and in the two private hos Biases in collection of data Biases due to inexact diagnosis diagnoses. er However, in order to limit these “Demographic” biases the same researchers as the “woman” questionnaire. the same researchers av These old figures are the only ones age of the figures. Using the Gener is a bette areas and 271 per cent in rural areas) would have precise estimate of expected births was not available. allowed a more gynaecologists. Reconciliation of data from the "woman"Reconciliation questionnaires and "health formation" facilities, there are 4 D facilities, The "health formation" file formation" "health The two of which are in Niamey, and 2 private hospi and 2 private are in Niamey, two of which cases of caesareans and the number of concerning all the essential maternity hospital, Poudrière questionnaires health fa to each of these relating of caesareans carried out (particularly the number However, there between the urban and rural areas. the propor expected births, by the estimate of per cent in urban areas according to the region and the of MOIs. Discussion of Biases admitted) correspond relatively well with those admitted) correspond numbers are the pre-correction omission of women, and the c incompatible, and in part by the modifications UON Network - Tackling Unmet Need for Major Obstetric Interventions 13 11 , . Our ). This Table 4 Table 4 rly that of Niamey. ). ve us a caesarean rate to grasp the levels and to grasp eas and 73 per cent in ssible that the number of . There is a clear disparity . There is a clear is not known are most often is not known are he DHS. Incidentally, the DHS epresent only 8 per cent of the the rural areas is one possible Table 11 data with the information obtained data with and obal by the distribution concerning results population and in particula Table 10 different settings to try different entions in the urban ar the urban areas and 0.3 in rural areas. A the urban areas and 0.3 in rural the UON study would gi ban areas and 2.7 for Niamey) this is mostly the rural areas. This probably indicates a delay the rural areas. This probably indicates carried out, so it is po (2,293 cases) whatever the indication, and the (2,293 cases) whatever , 1998 eys, Macro Internationaleys, Inc. 1998. Enquête Démographie ose to the rate in t based on the categories set out in based on the categories omies and hysterectomies may be reported as Then there will be a more specific analysis will be a more Then there to try and Non Absolute (937 cases). In the analyses and Non Absolute onsiderably from the rate set out in the DHS 1998 rventions were registered in 1998 ( rventions were registered IGER N cent of the cases of MOI for AMI. cent of the cases of Expected Births is 1.3 in urban areas (1.9 in Niamey) and NTERVENTIONS ACCORDING TO TYPE OF INTERVENTION AREA AND OF INTERVENTION TO TYPE ACCORDING NTERVENTIONS of 0.4 MOI per 100 expected births of 0.4 MOI per 100 (most often for uterine repair) r I rtality, and finally to link this finally to link this rtality, and , the women whose area of origin , the women whose ng of women who are really from this hypothesis is nevertheless not sufficient to explain the high this hypothesis is nevertheless not Number % Number % Number % Number % Urban area Rural area area Unknown Total BSTETRIC O AJOR Total 1,001 100% 1,192 100% 100 100% 2,293 100% . M C-section 872 87.1% 872 73.20% 82 82% 1,826 79.6% 5

Craniotomy 15 1.5% 55 4.6% 70 3.1% Laparotomy 79 7.9% 187 15.7% 11 11% 277 12.1% Hysterectomy 3 0.3% 31 2.6% 3 3% 37 1.6% Table A total of 2,293 Major Obstetric Inte A total of 2,293 Caesareans represent 87 per cent of interv Caesareans represent 87 per cent The rate of caesareans per 100 The tables, graphs and maps below are The tables, graphs To begin with, we will simply we will with, To begin the gl describe Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Version and extraction 32 3.2% 47 3.9% 4 4% 83 3.6% CARE International, Niger, Demographic and Health Surv et Santé, Niger. “contamination” in the urban setti between settings: the average rates are 1.3 in between settings: the average rates explanation for this disparity, but rural areas. ( levels of deficits in both the urban and relies on the mother’s report of the intervention 11

omitted. They make up about three per omitted. They make Interventions The Major Obstetric average rate represents a national 0.2 in the rural areas. The urban rate differs c (caesarean rate/100 Expected Births: 2.1 for ur because the DHS uses the 1997 data for the urban Using the population data of 1997 in the results of of 2.5/100 expected births in Niamey which is cl caesareans may be overestimated as laparot caesareans by the women questioned. according to area (urban – rural) according to area in admitting women in rural areas. to pull out any differences that may exist between that may exist between any differences to pull out mo maternal and infant causes of formation” questionnaires. in the “health Major Obstetric Interventions interest lies in the Indications (1,381 cases) Absolute Maternal the rural areas, while laparotomies 16 per cent in interventions in rural areas against district of interventions, indications and deficits. interventions, indications district of Results UON Network - Tackling Unmet Need for Major Obstetric Interventions 14 and , 1998 Table 7 IGER , N cent of the major before or after the before or ). the health facilities, ent) out of the total eclampsia and a history of in urban areas and 79 per in urban areas and Table 7 cal treatments which are often areas (39 per cent) than in the areas (39 per cent) in the "woman" file. main indications (36 per cent) for main indications (36 the inaccessibility of indications (60 per c indications (60 per AMI; 22 mothers died AMI; 22 equent in urban areas. It is very likely that equent in urban areas. It is very likely ons only an for woman who were subjected to do not have the time to get to hospital and die do not have the time to get to hospital ther has benefited from a Major Obstetric ther has benefited from a Major ed labour make up 75 per ed labour make rural areas, which indicates a r twice as often in before benefiting from any surgical intervention. the setting: 68 per cent the setting: 68 per s. Non-progressing labour, caesarean (93% of the cases). Only six women were caesarean (93% of the cases). Only ention is not mentioned NDICATIONS ACCORDING TO TYPE OF AREA TO TYPE ACCORDING NDICATIONS Urban area Rural area Unknown area Total Number (%) Number (%) Number (%) Number (%) I Absolute Maternal Indications ( ). If we add the cases of uterine rupture and abnormal If we add the cases ). does not take into account medi Total 515 100% 822 100% 44 100% 1,381 100% upture 202 39.2% 285 34.7% 13 29.5% 500 36.2% here are a few more in the urban here are a few more ATERNAL ATERNAL M l. geographic. cultural…). Table 6 Foeto-pelvic disproportions are the Foeto-pelvic disproportions Uterine rupture 59 11.5% 205 24.9% 12 27.3% 276 20% BSOLUTE Severe haemorrhages 1 0.2% 2 0.2% 3 0.2% . A 6

Post-partum haemorrhages 2 0.4% 7 0.9% 1 2.3% 10 0.7% Ante-partum haemorrhages 163 31.7% 160 19.5% 11 25% 334 24.2% Table present the Non-Absolute Maternal Indicati Ante-partum haemorrhages are much more fr Ante-partum haemorrhages are much There were a total of 1,381 absolute maternal There were a total the mo For almost all these indications, There are 25 such cases, 19 AMI and 6 Non- 25 such cases, There are Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Transverse. facial and front presentation 88 17.1% 163 19.8% 7 15.9% 258 18.7% Foeto-pelvic disproportion and pre-r for whatever reason (financia Intervention. In most of the cases, it was a Intervention. In subjected to another type of intervention or died In these cases, the indication of the interv intervention, three did not die, but the indication was an AMI. but the indication three did not die, intervention, indications Absolute maternal cases. number of registered Intervention; t a Major Obstetric cent) ( rural areas (35 per proportion is high whatever interventions. This Cases of uterine rupture occu cent in rural areas. delay in managing cases, probably due to these urgent haemorrhage women from rural areas with serious at home or on the way to hospital. Non-Absolute maternal indications sufficient to take care of this kind of problem caesareans are the most frequent Non- Women who have not had an Major Obstetric Intervention an Major Obstetric have not had Women who problems linked to obstruct presentations, then a Major Obstetric Intervention and Table 8 UON Network - Tackling Unmet Need for Major Obstetric Interventions 15 , , 1998 ) we can IGER , N Table 8 U/R Ratio bilical cord where the (‰ EB) Rural rate ATIO OF URBAN RATES TO RURAL RATES RATES OF URBAN ATIO R he urban and rural settings. If we calculate (‰ EB) explained by the rapidly fatal nature of these explained by the rapidly fatal nature are more represented in the urban areas, respectively 14 and 12 times more frequent as respectively 14 and 12 times more Urban area Rural area Total , 1998 problems linked to the um Number (%) Number (%) Number (%) NDICATION NDICATION I IGER NDICATIONS ACCORDING TO TYPE OF AREA TO TYPE ACCORDING NDICATIONS I N rventions against the expected births, ( rventions against the expected births, Total 480Total 100% 491 389 100% 925 100% 389 937 Eclampsia 1.574 0.126 12 Other cause 0.019 0 Eclamsia 105 22% 66 17% 185 20% ATERNAL Foetal distress 0.720 0.067 11 Not mentionned 0.09 0.008 12 ATERNAL M l areas do not have time to get to a health facility and probably l areas do not have time to get to a Other cause 2 0% 10 3% 12 1% Dynamic dystocia 2.069 0.191 11 Missing value 11 2% 12 1% M Puerperal infection Foetal distress 48 10% 35 9% 89 10% Not mentioned 6 1% 4 1% 13 1% Breach presentation 0.165 0.044 4 Genital malformation 0.060 0.004 16 Vaginal haemorrhage 0.030 Dynamic dystocia 138 29% 100 26% 247 27% Prophylactic C-section 0.000 Puerperal infection 1 1 0% Antecedent of C-section 1.484 0.168 9 Extra-uterine pregnancy 0.300 0.021 14 Breach presentation 11 2% 23 6% 37 4% Indication Urban rate Genital malformation 4 1% 2 1% 6 1% Mother's medical problem 0.015 Vaginal haemorrhage 2 0% 2 0% Other obstetric antecedent 0.075 0.015 5 Prophylactic C-section 1 0% BSOLUTE Antecedent of C-section 99 21% 88 23% 202 22% Extra-uterine pregnancy 20 4% 11 3% 31 3% BSOLUTE -A Mother's medical problem 1 0% 1 0% -A Obstructed labor for other causeObstructed labor for other 0.135 0.015 9 Other obstetrical antecedent 5 1% 8 2% 14 2% ON Complications connected with cord 0.330 0.036 9 ON . N Obstructed labor for other causeObstructed labor for other 9 2% 8 2% 20 2% 8

. N Obstructed labor for other persentationObstructed labor for other 0.120 0.027 4 Complications connected with cord 22 5% 19 5% 41 4% 7

Obstructed labor for other presentationObstructed labor for other 8 2% 14 4% 23 3% Table Table All the non-absolute maternal indications There appears to be little difference between t There appears to be little difference * This total includes 58 cases where the mother’s area of origin is unknown Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling including such as foetal distress or indications see that ectopic pregnancies and eclampsia are indication MOI in the urban areas. This may be for pathologies. Women living in rura case. die before any management of their the incidence of the inte rates for each UON Network - Tackling Unmet Need for Major Obstetric Interventions 16 1 1 1 2 7 1 1 before before intervention , 1998 intervention 2 1 6 1 88 58 IGER 163 201 162 285 158 198 Total Mother died Total Mother died . N hat women in the rural in hat women type of type of Unknown Unknown intervention intervention less than 1 per cent of the rural area, which shows the y be that doctors in rural areas doctors in rural y be that tomy tomy the urban areas and 0.15 per 100 Cranio Cranio risk or where a precise diagnosis risk or where ea. The difference in the caesarean hen, interventions to save the baby’s to save interventions hen, Version been identified, which is rare given the low which is rare been identified, Version extraction extraction ion when the mother’s life is not in danger. the mother’s life is ion when may be due to the fact t to the fact be due may is seven times higher in the urban area (1.3 tomy Laparo tomy Laparo on when these women arrive in a hospital. almost 4 per cent in the tomy areas). Hysterectomies represent Hysterec tomy y unless their life is really at their life is really y unless Hysterec 77 per 100 Expected Births in r Absolute Maternal Indication r Absolute Maternal 252 32 1 110 1 40 11 rth attendants. Furthermore, it ma Furthermore, rth attendants. 58 27 2 1 C- 189 12 C- section section herefore 5 time higher in the urban ar Total 518 31 175 40 43 3 810 12 mother’s is endangered. In urban areas t areas In urban is endangered. mother’s Total 409 3 58 27 14 2 513 2 YPE OF INTERVENTION ACCORDING TO TYPE OF INDICATION AND AREA AND OF INDICATION TO TYPE ACCORDING OF YPE INTERVENTION pre-rupture . T presentation 9 pre-rupture

presentation Uterine rupture 25 172 1 Uterine rupture 2 56 Table Severe haemorrhage 1 The rate of MOI/AMI is 0. The 44 cases in which the mother’s place of residence is unknown be added to these should two tables. Rural Area Urban Area Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Severe haemorrhage 1 Post-partum haemorrhage 6 Ante-partum haemorrhage 156 1 1 Transverse. facial and front Post-partum haemorrhage 1 1 Ante-partum haemorrhage 162 1 Transverse. facial and front Transverse. facial and Foeto-pelvic disproportion and EB in the rural areas, t rate between settings is even greater since it MOI/100 EB against 0.2 in the rural MOI/AMI in the urban area against seriousness of the foeto-pelvic disproporti infant’s life, not the life, not infant’s life are carried out more often. This difference This difference often. out more carried life are facilit not go to a health areas do the baby’sconcerning own health has health or their bi of the level of qualification a major intervent before undertaking hesitate more fo Major Obstetric Interventions Foeto-pelvic disproportion and UON Network - Tackling Unmet Need for Major Obstetric Interventions 17 , Table 10 NDICATION I

6

3 4 ATERNAL

5 ) except for the urban ) except for M 32 highly populated and the highly populated Figure 2 BSOLUTE 33 35 33 35 A 2 36 34 18 17 12 The numbering of the Districts refers to 1 15 , 1998 13 37 13 14 14 IGER 21 19 23 , N NTERVENTIONS FOR 16 I 24 25 22 20 he towns concerned are not he towns ept in Niamey and in the town of Maradi. and in the town ept in Niamey 9 9 11 26 10 26 urban area are fairly minor ( are fairly minor urban area 8 BSTETRIC URBAN AREA 7 O

7

27 27 28

(25)

AJOR 29

M 31

30 40 (3) 60 (1)

to to 38 38 <= 20<= (9) Absolute numbers Absolute 21 Non-relevant Urban deficits 41 EFICITS IN . D 2

Figure In absolute terms the deficits in terms the deficits In absolute Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling community of Zinder (42 cases). However, t of Zinder (42 cases). community is fairly low exc expected cases number of Deficits in urban area Deficits in UON Network - Tackling Unmet Need for Major Obstetric Interventions 18 NDICATION I ATERNAL M these deficits are above he district of Tera (of whom ss contamination of data for BSOLUTE A , 1998 IGER I – for whatever indication – 14 including , N al hospital of Maradi, the private hospital in h the mother’s district of origin is unknown ation, there is no urban population in these districts the others, the relative deficits vary from 38 per eem to fulfil their mission of managing obstetric NTERVENTIONS FOR NTERVENTIONS x of the towns concerned, red to go the Gazobi maternity unit in Niamey. The to go the red I births Expected Performed Number (%) URBAN AREAS , are probably due to the cro BSTETRIC really from the rural areas. O Total 66,710 600 511 89 15% anaged there. Of the 22 women from t Table 10 AJOR BY DISTRICT BY M District Expected EFICITS IN 1 AGADEZ/TCHIRO 3,035 27 11 16 60% 234567 MAINE-SOROA ARLIT8 BILMA9 DIFFA 3,522 Non-relevant N'GUIMI Non-relevant BOBOYE 761 DOSSO DOUTCHI 32 Non-relevant Non-relevant 1,736 Non-relevant Non-relevant 7 Non-relevant 12 16 Non-relevant Non-relevant 20 2 62% Non-relevant 8 5 71% 8 49% 2526 TCHINTA/ABALAK2728 Non-relevant2930 FILINGUE31 OUALLAM32 KOLLO Non-relevant3334 Non-relevant Non-relevant TILLABERI Non-relevant SAY35 TERA36 GOURE37 MAGARIA MATAMEYE Non-relevant Non-relevant 749 Non-relevant MIRRIAH Non-relevant Non-relevant Non-relevant TANOUT Non-relevant Non-relevant ZINDER Non-relevant 7 Non-relevant Non-relevant Non-relevant 10,310 Non-relevant Non-relevant Non-relevant 0 93 Non-relevant Non-relevant 7 100% 51 42 45% 18192021 TESSAOUA2223 1,255 BOUZA24 ILLELA KEITA Non-relevant MADAOUA KONNI 11 Non-relevant TAHOUA Non-relevant Non-relevant 1,817 3,131 7 Non-relevant 16 Non-relevant 28 Non-relevant 4 Non-relevant 38% 16 11 0 17 2% 61% 1112131415 ROUMDJI GUIDAN 16 LOGA17 AGUIE DAKORO MARADOUNFA Non-relevant 255 Non-relevant Non-relevant Non-relevant MARADI MAYAHI 11,230 2 Non-relevant Non-relevant 101 Non-relevant Non-relevant Non-relevant 1 112 Non-relevant 1 56% -11 -11% 10 GAYA 950 9 5 4 42% . D

10

TILLABERI ZINDER MARADI TAHOUA GADEZ A DIFFA DOSSO Table Region N° MOI for AMI Deficits In relative deficits, only four hospitals s The negative values in The total MOI/AMI observed includes the cases for whic Non-relevant: according to our definition of urban popul Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling NIAMEY 38 NIAMEY 27,959 252 274 -22 -9% the urban setting by women who are as we will see 50 per cent. The hospital in Tera seems to be almost completely non-functioning; later, very few deliveries are m only one is from the town) who have undergone a MO the resident from the town of Tera itself, prefer Konni and the two maternity units in Niamey. For emergencies satisfactorily. These are the department cent in Tessaoua to 100 per cent in Tera. In si UON Network - Tackling Unmet Need for Major Obstetric Interventions 19 , Table 11 NDICATION I

6 Sciences Sociales

3 4 ATERNAL M 5 are essential factors. ). In relative terms, most relative terms, ). In 12 32 guie, does not seem much of MOI/AMI cases expected of MOI/AMI cases BSOLUTE A Figure 3 33 35 2 The numbering of districts refers to 36 34 18 12 eems ineffective if it is not linked to a eems ineffective if it is not linked 17 37 ternelle évitable en milieu urbain à Niamey (Niger), , 1998 1 facility. Loga, the only district that has a facility. Loga, the only district that also has very high deficits. The presence of also has very high deficits. The presence sy geographic access to all these facilities, access to all sy geographic 15 working there for years. This needs a closer This needs for years. there working coverage of relatively small rural areas which coverage of relatively 13 either. However, this hospital has existed for existed hospital has this However, either. 14 IGER , N 21 19 23 A., Aboucar S. 1998 A propos de quelques pratiques 16 ces necessary to manage obstetric emergencies. to manage ces necessary NTERVENTIONS FOR I llela, Tessaoua or even A s”, entre indentités professionnelle et sociale, the paramedical personnel and the persistence of the paramedical ). The only exceptions are Konni, where there is a ). The only exceptions 24 25 22 20 ations for the lack of recourse to hospitals in cases of to hospitals the lack of recourse ations for , 8, pp265-8. 9 ated areas where the number ated areas where BSTETRIC 11 RURAL AREA RURAL also near that hospital, and Matameye, which is not far from and Matameye, which is not also near that hospital, 26 10 O 8 Table 11 to the techniques of modern medicine to the techniques

7

27 eas have a high absolute deficit ( eas have a high absolute

28 AJOR

M Cahiers Santé 29 (3) (5)

rge regional hospital. The rge regional hospital.

31

30 80 (7) 200 (10) 120 (13)

38 EFICITS IN to to to

< = 40 81 41 Rural deficits Absolute numbers . D Non-relevant 121 3

, Vol XI, no. 2, pp64-80. Figure Except for the sparsely popul Except for the sparsely Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling the towns has ea the population of However, Jaffré Prual A,Y., 1993 “Le corps des sages-femme et Santé Vangeenderhuysen Ch., Olivier de Sardan JP, Moumouni Vangeenderhuysen Ch., Banos JP., Mahaman T. 1995 Mortalité ma Cahiers Santé, 5, pp 49-54. obstétricales populaires au Niger, network of radio communication and an ambulance,network of radio communication and are not too far from hospitals, such as Kollo, I are not too far from hospitals, such as from any better than areas which are far removed cases s resources capable of evacuating emergency structure that involved the community. private hospital, Madaoua, whichprivate hospital, Madaoua, is is a la Zinder where there 12 gets close to 40. all the rural ar gets close to 40. all 75 per cent ( districts are above Deficits in rural area hospital in Dosso does not seem to be working well to be working not seem does in Dosso hospital a very long time and expatriate doctors have been have been doctors and expatriate long time a very analysis. which contain the human and material resour the human which contain explan numerous possible Among the problems, the attitude of serious obstetric traditions that are in contradiction traditions that are UON Network - Tackling Unmet Need for Major Obstetric Interventions 20 ATERNAL M ll of them possess a BSOLUTE A , 1998 IGER , N in the rural area, A NTERVENTIONS FOR NTERVENTIONS I cient if there is no viable way of communicating RURAL AREAS RURAL the mother’s district of origin is not known. , BSTETRIC O births Expected Performed Number (%) tients is the private hospital in Konni. AJOR M no system for evacuating emergency cases is put in place. The Total 522,766 4,704 807 3,898 83% NDICATIONS BY DISTRICT BY NDICATIONS EFICITS IN I . D 11

1 AGADEZ/TCHIRO 6,714 60 0 60 100% 234567 MAINE-SOROA ARLIT8 BILMA9 DIFFA 5,428 5,363 N'GUIMI 635 BOBOYE 4,835 DOSSO 1,639 DOUTCHI 49 48 17,451 19,384 26,920 6 44 157 15 7 1 174 242 1 8 11 42 47 3 86% 98% 19 35 36 5 146 82% 83% 12 93% 155 207 80% 89% 86% 2526 TCHINTA/ABALAK2728 4,4352930 FILINGUE3132 OUALLAM KOLLO 22,867 403334 14,770 23,84235 TILLABERI SAY 206 TERA36 5 GOURE 10,71137 15,684 133 215 MAGARIA MATAMEYE 23,128 13,359 27,051 14 13,677 MIRRIAH 35 141 96 TANOUT 208 88% 21 37 34,290 ZINDER 192 120 243 14,544 123 93% 112 178 28 Non-relevant 13 309 84% 83% 14 131 13 56 35 113 194 83 80% 93% 87% 107 66 187 89% 88 17 77% Non-relevant 72% 243 79% 114 87% 18192021 TESSAOUA2223 16,60724 BOUZA ILLELA 13,504 KEITA 149 MADAOUA 13,597 KONNI 11,695 TAHOUA 17,963 122 18,875 122 15,968 32 105 162 170 15 117 144 79% 23 14 107 54 73 88% 99 22 81% 91 108 97 87% 67% 122 57% 85% 1112131415 ROUMDJI GUIDAN 16 LOGA17 18,372 AGUIE DAKORO MARADOUNFA 7,373 13,965 21,662 15,631 165 MARADI MAYAHI 126 66 195 141 Non-relevant 18,040 20 27 12 23 23 162 145 88% 172 118 Non-relevant 99 54 88% 84% 79% 82% 26 136 84% 10 GAYA 12,787 115 19 96 84% N° District MOI for AMI Deficits Table

No hospital claims to provide good coverage Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling

ZINDER TILLABERI TAHOUA MARADI DOSSO GADEZ A DIFFA Region Expected NIAMEY 38 NIAMEY Non-relevant Non-relevant working ambulance, but this is clearly not suffi with the health centres, and if only hospital that seems to “attract” pa The total MOI/AMI observed includes those cases where Non-relevant: only urban population, according to our definition of urban and rural areas UON Network - Tackling Unmet Need for Major Obstetric Interventions 21 -MOI), ON N AND AND (MOI follow a hysterectomy ent with an AMI die in the rural area 12 per cent the rural area 12 per This shows that in the rural ent of the absolute maternal cent of intra-hospital deaths , 1998 IGER , N 421% 914% 3 16% 11 17% the absolute maternal indications in the urban the absolute maternal Urban area Rural area , 1998 Number (%) Number (%) ), and what is more, in ), and what is more, cent of women who pres hs are mainly following a caesarean, while in the carried out for uterine rupture. aparotomy and 10 per cent IGER N Total 19 100% 66 100% eas as opposed to 37 per cent in urban areas. eas as opposed to 37 per cent in urban Table 6 Urban area Rural area Total** rupture rict of origin is unknown (12 cases) rict of origin is unknown urban areas represent 4 per c TYPES OF INTERVENTION AND NUMBER OF MATERNAL DEATHS OF MATERNAL NUMBER AND OF INTERVENTION TYPES below. We can see that 53 per : Number Deaths Number Deaths Number Deaths presentation Uterine rupture 7 37% 35 53% erectomy against 3% in urban area. erectomy against 3% in urban area. Total 59 7 205 34* 275 42* Sever haemorrhage 1 5% 2 3% ACCORDING TO TYPE OF AREA TO TYPE ACCORDING Table 13 Laparotomy 56 6 172 22 237 29 Post-partum haemorrhage 1 1% Anter-partum haemorrhageAnter-partum 4 21% 8 12% Transverse, facial and front HOSPITAL MATERNAL DEATHS ACCORDING TO INDICATIONS TO INDICATIONS ACCORDING DEATHS MATERNAL HOSPITAL in the rural area ( Hysterectomy 2 0 25 5 30 5 - TERINE RUPTURE TERINE . U NTRA ). In the urban areas the deat Foeto-pelvic disproportion and pre- 12 . I

13 Does not include one case is unknown of uterine rupture for which the type of area

) both of these operations are mostly Table Table 6 Mother died before intervention 1 1 7 7 8 8 Table The 19 deaths observed in the Uterine rupture accounts for 12 per cent of rupture accounts for 12 per cent of Uterine Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling This is also shown in * This total do not include one case for which the type of intervention one case for which the type of intervention * This total do not include is not known ** Includes cases where the mother’s dist Table 14 ( rural areas 44 per cent of deaths follow a l hospital ( indications while in the rural areas, eight per area, and 25 per cent area, and 25 per cent of these ruptures require a hyst Uterine ruptures Intra-hospital maternal deaths area the delay in deciding seriousness to go to a health facility increases the of obstetric emergencies. ar follow on from a uterine rupture in rural UON Network - Tackling Unmet Need for Major Obstetric Interventions 22 13 ). In AGAINST Table 16 (AMI (%) , 1998 IGER , N after the intervention. As area deaths history of caesarean, which history of caesarean, Number of ndication was not absolute does not reach 20 per cent of , 1998 died within 24 hours) when their been carried out because of an to analyse. As for the AMI, 46 per are due to a haemorrhage, usually MOI IGER , N Urban area Rural out for non-absolute obstetric indications. The out for non-absolute per cent are carried for an AMI ( will died after 24 hours against 1 per cent in . non-absolute maternal indication is also higher non-absolute maternal indication is (%) Number of 14 less than for deaths, where there is an Absolute less than for deaths, where there is ACCORDING TO GROUP OF INDICATIONS OF INDICATIONS TO GROUP ACCORDING he risk of dying according to the type of area is deaths), than if the i MOI Number (%) Number (%) deaths AMI Non-AMI of infants die (stillborn or Number of AND TYPE TO OF AREA Total 16 100% 53 100% men undergoing an MOI die during or men undergoing an MOI die during ogressing labour, eclampsia and a ogressing labour, C-section 9 56% 24 45% of cases of non-AMI is too low deaths are less frequent, the rate Craniotomy 1 2% ea as well as the rural area NDICATIONS AND ACCORDING TO TYPE OF AREA TO TYPE ACCORDING AND NDICATIONS Laparotomy 6 38% 23 43.5% -AMI) I Hysterectomy 5 9.5% more frequent if the operation has MOI ON N HOSPITAL MATERNAL DEATHS ACCORDING TO TYPE OF INTERVENTION FOR Number of - Version and extraction 1 6% ATERNAL NTRA M Does not include 14 women who died before any interventions andDoes not include 14 women type of intervention is unknown. 2 women for which the ATERNAL DEATHS AFTER AFTER DEATHS ATERNAL . I RuralTotal 807 1,362 53 6.6% 70 5.5% 385 931 8 2.1% 15 1.6% Urban 511 16 3.1% 490 6 1.2% . M Unknown 44 1 2.3% 56 1 1.8% 15

BSOLUTE BSOLUTE Table 14 Table A Table Globally, four per cent of wo In the rural areas, 45 per cent Maternal mortality after an intervention for a Maternal mortality after an intervention Major obstetric interventions are also carried Major obstetric interventions Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Chi-square = 18 p<0.000. Chi-square = 6.8 p<0.009 for AMI and Chi-square = 0.96 p<0.32 for non-AMI. occurring after the intervention. Absolute Maternal Indication (5.5 per cent of 13 14 in the rural areas, although the gap is slightly in the rural areas, although the gap Maternal Indication. The number cent of deaths in the urban ar is logical, deaths are these (1.6 per cent of deaths). This difference in t statistically significant for AMI but not for non-AMI mother has undergone an MOI – among which 85 the urban area, early perinatal most common of these are non-pr most common of these Child deaths

make up 70 per cent. newborns, but another 5 per cent of the newborns rural areas. UON Network - Tackling Unmet Need for Major Obstetric Interventions 23 (%) MOI, Number of deaths , 1998 he child is stillborn as hold of 1.2 per cent of ent), these babies are of 21 per cent of infant HOURS OF HOURS AN importance of the delay importance of the , 1998 hese interventions in the terms of early perinatal IGER 24 of MOI HOURS AMONG AMONG WOMEN WHO HOURS IGER , N perinatal deaths in the urban perinatal deaths areans carried out for non-AMI , N 24 problem in labour. In the urban (%) Number the rural area). The problems due to the rural area). The partum haemorrhage (48 per cent of maternal indications, the chances of the maternal indications, the chances per cent until the thres early perinatal deaths t most cases (78 per c Number l area this is the cause of deaths of newborns die after t intervention carried out, there is not usually any intervention carried out, there is not again shows the dramatic again shows the dramatic expected births, the benefit in of MOI er that 85 per cent of caes r Absolute Maternal Indication, 36 per cent of these deaths r Absolute Maternal ACCORDING TO CAESAREAN RATE overall for 52 per cent of early overall for 52 per (%) Number which four out of five are in which four out of five Caesarean rate (for 100 expected births) 100 expected (for rate Caesarean a health facility when there is a early perinatal death is ante- MOI UMBER OF CHILDREN STILLBORN AND DYING DYING WITHIN AND STILLBORN OF CHILDREN UMBER AMI Non-AMI Total Number of deaths . N ORTINATALITY AND NEONATAL MORTALITY WITHIN MORTALITY NEONATAL AND ORTINATALITY 16 HAVE HAD AN AN HAD HAVE

. M 0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6 1,8 4 0

ACCORDING TO GROUP OF INDICATIONS AND TYPE OF AREA TYPE AND OF INDICATIONS TO GROUP ACCORDING 80 60 40 20

120 100

of MOI Number MOI 100 / mortality perinatal Early Table Figure At around 0.3 caesareans per 100 For interventions carried out for non absolute For interventions carried out for non For interventions carried out fo For interventions carried Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling RuralTotal 807 1,362 456 57% 648 48% 385 931 81 21% 115 12% 1,192 2,293 537 45% 763 33% Urban 511 170 33% 490 29 6% 1,001 199 20% Unknown 44 22 50% 56 5 9% 100 27 27% mortality does not increase, and remains close to 30 caesareans. It should be noted, howev occur after a uterine rupture (of occur after a uterine are responsible obstructed labour the intervention is carried out. six per cent infant surviving are equally slim, since areas and 77 per cent in the rural areas. This areas and 77 per in taking the decision to go to area, one of the main cause of in the rura the indication of intervention), whereas the type of deaths. Whatever the indication or 92 per cent of hope of saving the infant because in rural areas. In urban areas and 21 per cent in the stillborn and the intervention was not able to save them. stillborn and the intervention was not UON Network - Tackling Unmet Need for Major Obstetric Interventions 24 of MOI pitals of that region Number and % , 1998 population, and one of its , 1998 ation of Tchinta-Abalak, the IGER NTERVENTIONS BY HEALTH I the proportion of births taking IGER , N s it was already probably too late too probably already s it was , N tals. This table sets out all the Major Hospital births Hospital hospital births Number and % of Number and % NumberEB of % BSTETRIC BSTETRIC O age. However, it is one of the less vast age. However, it is one of the less w coverage. They also have two hospitals 50 per cent of the AJOR M higher coverage, the two hos of EB (EB) Number and % Hospital birthsHospital MOI MOI/AMI deaths happened in the 24 hours following birth. following 24 hours in the happened deaths on of births in hospitals is low. Only the department of on of births in hospitals is low. Only Expected births OSPITAL ACTIVITIESREGION BY ge either. If we remove the popul (EB)* births . H in the different hospitals. Expected Diffa 12,663 542 4% 17 two most populous districts. Total 589,477 21,825 4%

ent, but also the least populated, he child, in 8 per cent of case per cent in 8 he child, Dosso 86,856 3,240 4% Zinder 113,231 2,492 2% Maradi 116,763 2,791 2% Niamey 27,959 6,849 24% Agadez 19,269 1,565 8% Tahoua 100,985 4,152 4% Tillabéri 111,751 194 0.2% Table status OLUME OF DELIVERIES AND AND OF DELIVERIES OLUME Hospital FORMATION AND STATUS OF THE FORMATION STATUS AND FORMATION . V 18 Arlit Privé 8,885 591 7% 37 6% 13 35%

Diffa Public 5,596 542 10% 25 4% 19 76% Tera Public 23,877 194 1% 8 4% 8 100% Loga Public 7,628 498 7% 9 2% 7 78% Total 192,574 21,825 11% 2,293 11% 1,362 59% Gaya Public 13,737 1,129 8% 23 2% 19 83% Konni Privé 20,692 1,364 7% 328 24% 180 55% Dosso Public 21,120 1,613 8% 108 7% 83 77% Zinder Public 10,310 2,492 24% 321 13% 242 75% below shows the appeal of the different hospi Maradi Public 11,230 1,021 9% 367 36% 255 69% Niamey Public 27,959 6,849 24% 881 13% 435 49% Agadez Public 9,749 974 10% 29 3% 16 55% Tahoua Public 19,098 2,788 15% 138 5% 68 49% Tessaoua Public 17,863 1,770 10% 19 1% 17 89% Health district Table formation's * Expected Births in the district where the hospital is situated. Table 19 The department of Tahoua also has a very lo The department of Tahoua also has Apart from Niamey, the proporti Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling The department of Dosso has very low cover The department of Dosso has very Obstetric Interventions carried out and the department is not very lar largest district of this departm districts has a radio communication system for referrals. districts has a radio communication place in hospital reach 5 per cent. does not Agadez, although it is very large, has a slightly Agadez, although it is very large, has resulted in saving the life of t the in saving resulted because the child was stillborn. The other stillborn. was the child because and resources Workload are situated in the department’s cover almost departments has three hospitals that UON Network - Tackling Unmet Need for Major Obstetric Interventions 25 ). , 1998 Table 11 IGER , N from the district) artling difference in ss of the cases or in their home, the same The hospital in Dosso districts, but it is not the and Loga, both of which eems just as near to Loga. Dosso. In Loga only half of % of women % of of a total of 18 different district travelling from from travelling a Number (%) of care and of the management of there is not a st Nigerian gynaecologists in this hospital). cases low or zero appeal. Out of 33 women from low or zero appeal. Out of 33 women obstetric needs of the rural areas ( plained by the seriousne Number of Number attracts patients from neighbouring districts attracts patients from neighbouring end the nearest facility to hat has a gynaecologist in residence. What is the hospitals of Gaya he outlying health centres. a working ambulance a radio-communication and Doutchi district, which s Dosso hospital including the presence of expatriate hospital, and 13 went to Dosso (1.6 per cent of labours, against 1 per cent in Total 2318 1078 47% department have at least two doctors each who can he CHD Dosso. But these hospitals are howeverhe CHD Dosso. But these hospitals not DH Tera 8 0 DH Gaya 25 7 28% DH Loga 9 0 DHC Diffa 27 12 44% DH Tahoua 143 75 52% DHC Dosso 112 76 68% DHC Maradi 370 181 49% DHC Agadez 29 8 28% women living in the neighbouring anagement of the cases, per cent of in-hospital labours in the three facilities). Lastly, Zinder Maternity 322 244 76% is that the road network makes it more accessible, but we do Tessaoua Maternity 19 3 16% of their district hospital: seven (out nother explanation is the quality Gazobi Niamey Maternity 809 279 34% Health facility Poudrière Niamey Maternity 79 18 23% Private Hospital Somair ArlitPrivate Hospital Somair 38 0 Private Hospital Galmi Konni 328 175 53% ROPORTION OF PATIENTS TRAVELLONG FROM A DIFFERENT DISTRICT . P 19

Table The Hospital in Zinder, quite logically, The Hospital in Zinder, quite logically, Regarding the quality of the m Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling system which keeps the hospital in touch with t system which keeps the hospital in carry out interventions. Dosso is the only one t (Magaria, Miriah and Matameye) who therefore att (Magaria, Miriah and Matameye) who for t goes for all the other facilities except Dosso draws in an equal number of are also only hospital in the department; there have a very have opened fairly recently and which district Gaya, only 18 were admitted to their the women used the services district has went to Dosso, even though Loga who live in also draws in almost all the women One of the possible explanations not have that information. A care. In fact, while the three hospitals of this more, while the other hospitals only have one midwife, Dosso has six. maternal mortality, which is slightly higher in Gaya and 0.2 per cent in Loga) which could be ex appealing enough to ensure good coverage of the appealing enough to ensure good coverage the peri mortality (between 6 and 7 we should not forget that Belgian aid supports gynaecologists in residence (there has never been any UON Network - Tackling Unmet Need for Major Obstetric Interventions 26

r 11 10 9 8 7 6 5 4 3 2 1 0 i

Soma

mi al G , 1998 oua ssa IGER Te , N

Tera hospital in Konni, and in IOM / physician / month IOM / physician es do not have any, while egional level. However, it is seems possible, at least on Loga jor obstetric interventions per onth. Apart from the hospital in are finally acted on. ya operate. The problem of human a ealth, but also and particularly by G

zobi a the 107 available so that in each hospital om

G one in residence (Gaya, Loga and the private s more deliveries per month than those in the s more deliveries per month than in Niamey, in the Galmi of personnel in the two maternity units in Niamey. of personnel in the two maternity units e six of these structur

der hat this feedback will dynamise the country’s health in Z ther at the national or r that the facility could function 24 hours a day. gui

ssi the MSP and its partners Ta i tors carry out less than two ma t in Niamey. It seems clear that the spread of personnel is t in Niamey. It seems clear that the over eight hospitals, and 10 of them work in Niamey, three in over eight hospitals, and 10 of them members of the Ministry of H carry out nine operations per m doctors everywhere who could Marad medical and paramedical personnel

Dosso Deliveries / midwives / months / midwives Deliveries ONTHLY WORKLOAD OF MEDICAL AND PARAMEDICAL STAFF

. M ffa 5

Di ez Agad Figure 5 0 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 100 Feedback has not been given yet ei In six of the hospitals, the doc Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling haves for midwives, three facilities only TILISATION OF RESULTS OF TILISATION Retro-information eagerly awaited, not only by the month, whereas in the maternity unit in Gazobi month, whereas in the maternity unit the maternity unit of Zinder, they Agadez, there are at least two sinc resources relates more to gynaecologists the actors in the field. They have high hopes t policy so that the declared intentions of Gazobi maternity unit, the bigges inadequate. A fairer division of 4. U there are a total of 21 spread out Zinder and three in Maradi. net surplus hospital in Somair), while there is a five time The midwife in Loga hospital attends paper. You “simply” need to move six midwives fr there are at least three, which would mean UON Network - Tackling Unmet Need for Major Obstetric Interventions 27 15 of international not involved in it. sectors of the ministry g, the member of the those from the regional ove women’s position in cated their willingness to cal NGOs (CONIPRAT cal NGOs ted by his peers and who ted by his peers and s according to them) and re quality of care, unequal h would allow it to translate ealth and the UON network ealth and the UON ems effectively. One of the ooperation (GTZ) and actively ooperation (GTZ) prepare him for the interviews, a prepare him for the four are members four are members pregnant women, particularly by determined to use this study as the that took part in the study. that took part in the study. Seven are part of the Ministry of are part of study. Seven e on the “community” aspect of the deficits, e on the “community” aspect of the the Ministry of H ation with the different on the decisions of Health. It of the Ministry ng maternal health. Two of these in particular o are members of lo o are members ing team on assignment in Niamey and the ing team on assignment iewed, and particularly fter which he carried out a test interview in real fter which he carried w protocol. Before leavin s so late. Some people from the ministry or from s so late. Some people from the ministry e the dean of the Faculty of Health Sciencese the dean of the and ernment support, to impr onal level also indi have he interviewer on the first four interviews. effect (like many other in public health, respec but some of them, and by no means the smallest, rmed about the study and were ernational organisations, bilateral organisations and age, together with medioc the German technical c the German technical tablished the list of people to be interviewed. tablished the list of maternal mortality in Niger, where the health network is way, poorly trained and often paid late. lack of the financial means, whic ction or analysis. In order to ction or analysis. In y follow up of the allocated finances, which make it difficult to are in possession of the results. Some interesting remarks are in possession of the results. to access health services by helping them to acquire not only handling the country’s health probl the hospital level, this study as an indicator for future and to use to try to improve the lot of l and three at the regional level), at the regional l and three the maternity units in Niamey the maternity units the MPS at the central level are ). One person is part of ). 16 Sixteen people were interviewed for the UON for the UON were interviewed Sixteen people Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling A member of the UON network co-ordinat A member of the The interviewer chosen with the agreement of The interviewer chosen At the ministry of health, some people interv At the ministry of health, some people There are many factors behind Local NGOs also support the aims of improvi Niger also suffers from a clear Committee on traditional practices of Niger Safe motherhood action group of Niger 15 16 and GNAMASARI Perception note Methodological involved two remaining ar in the study itself. The of one of the Medical Director Health (four at the central leve Health (four Health jointly es Director of Reproductive organisations (UNICEF, UNFPA, WHO, CARE) tw WHO, CARE) (UNICEF, UNFPA, organisations co-ordination team is a doctor who is qualified co-ordination team has not participated in the data colle has not participated essential problems in Niger is this low cover day was set aside for the methodology to follow, a day was set aside t UON network co-ordinating team accompanied Results info level, did not seem to have been officially Only two people from the ministry for exampl were made about the study methodology, at the facilitie like the reasons why women arrive have little local NGOs fear that this study will will dependthink that success, in terms of action, involved in this area. People working at the regi take account of these results improving the medical practice at results. largely inadequate for the task of distribution of personnel who are, any its health policy into action. Many partners (int NGOs) invest in the country to improve health, complain about the lack of budgetar unlock funds to continue projects. Nigerian society and to assist them the financial and logistical means to use services, but also the freedom to do so. conditions to clarify the questions in the intervie conditions to clarify the questions seems that the members of have been working for years, with very little gov basis for redefining maternal health policy in collabor basis for redefining maternal health UON Network - Tackling Unmet Need for Major Obstetric Interventions 28 often-illiterate mothers a health policy which ssential that structured he personnel at the first pregnancy and childbirth, It can also be seen in the ed way, and collaboration It seems in fact that many facility. Either because of tion of responsibilities at the the move towards managing the move ually evoked to explain high is essential, this study should stent attachment to traditional to be developed will need to number of health facilitiesnumber of that he Ministry of Health for many he Ministry material or other reasons, do not hese partners and the Ministry of hese partners and he UON study, by giving a clearer process which has been carried out measures to ensure satisfactory health satisfactory ensure to measures s remains very limited. If purely preventive very limited. If purely s remains of this study it is e ich will allow the country to move out of the e is no overall efficient system in place to e is no overall efficient system in large international organisations still seem large international ners are investing in the country to improve ners are investing he under-utilisation of health services both for he under-utilisation of health services he rural areas seem completely isolated from he rural areas seem completely isolated of problems and solutions. The Ministry itself is probably the way mothers are treated. The probably the way mothers are treated. or for other reasons, t achieve the aims of health service coverage. achieve the aims health ered adequately covered by functioning earnt at school and the , which includes all the levels of care. stries, which could have an impact on health in stries, which could have an impact ant to improve this situation, but perhaps because ant to improve this ors) are out of favour, ors) are out l, human and material resources to ensure efficient take up their role of managing emergency cases, take up their role of managing emergency The referral system one more theoretical study, but should pave a way ys work in a co-ordinat odern medicine, and finally and traditional language of long time, and is a very poor country and the budget long time, and is ng a new dynamism to the actors engaged in the fight level is carried out promptly. of the results. Finally, and this ovement in the situation. The in the situation. The ovement ion living in poverty, and a persi the problems which are most us observed are dramatic everywhere. network still seems in its infancy. The ministry has taken clear in its infancy. The ministry has taken network still seems actice and is badly served by a dilu quo, it is to be hoped that t Despite being the chief aim of t the chief aim Despite being cases referred from another health he women for cultural, financial, that the co-ordination between t that the co-ordination are only vaguely aware of the ssity, but effective actions are slow to see the light of day. Niger actions are slow to see the light of ssity, but effective able "cases referred" is not well recorded in the database. , for fear of being wrong, departments of the Ministry of Health. 17 Even in the areas, which could be consid Even in the areas, which could be An other important problem, responsible for t An other important problem, responsible Niger does not seem to have taken adequate taken adequate to have seem does not Niger Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Niger therefore combines all In the context of the status ONCLUSION Or perhaps because the vari health conditions, but it seems health conditions, enough to allow a global view Health is not strong that do not alwa split in different directions other mini between the Ministry of Health and study that there are only two inadequate diagnosis Niger has a high demographicNiger has a high growth rate, some overcoming that. Numerous part preoccupied with general, is less than optimal. 17 have the resources to manage obstetric emergencie resources to manage have the of risk fact (such as the identification measures a hospital maternal health through of this nece positions in favour political instabilityhas suffered from for a is certainly not enough to allocated for health absolutely necessaryInternational aid is w if we facilities, the hospitals seem able to scarcely hospital. Ther even for the people living near the rural areas. T transport emergency cases from the the health network and the deficits level do not refer women on, or t referred. go to the hospital where they were network have the support of an integrated health is normal labour and for obstetric emergencies, languagemidwives use scientific attitudes and l years there has been no visible impr has been no visible years there remain strongly attached to the practices service coverage of the country. of the country. service coverage 5. C and communication is difficult. level of maternal mortality: insufficient financia health coverage, an illiterate populat practices which are often in conflict with m in their country, and even less aware not, as some of the interviewees fear, remain for practical and effective decisions to be taken wh poverty of the health network. operates more in theory than in pr heart of the numerous and more concrete view of reality, will bri against maternal mortality. To make the best use feedback at the national and regional senior personnel at both levels UON Network - Tackling Unmet Need for Major Obstetric Interventions 29 = another formationother? __ which 4= r retro-placental haematoma _____/_____/_____/ eat / uterine rupture : : ______1= Urban 2= Rural Unknown 3= transverse presentation foeto-pelvic disproportion r frontal presentation QUESTIONNAIRE FOR WOMEN 1: 1=At home health formation this 2= Date of intervention: _____/_____/_____/ 3 Admission number Date of admission Year of birth: ______District: ______Village/city: ______Quarter: ______Department ______Department ______Health district MaT REF, DS)______of hospital (HN, CHD, Category health formation______Name of Date of delivery: _____/_____/_____/ Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling NNEX 1= Born living and emerged living Q12 – Results for child 3= Obstructed labor fo 4= Obstructed labor for 5= Obstructed labor for other presentation 7= Obstructed labor for dynamic dystocia 8= Obstructed labor for other cause 9= Other cause 10= Complication connected with cord 11= Ante-partum haemorrhage for placenta praevia 12= Ante-partum haemorrhage fo 13= Ante-partum haemorrhage for other cause 14= Post-partum haemorrhage 15= Toxaemia, eclampsia, pre-eclampsia 16= Puerperal infection 17= Breach presentation 18= Antecedent of caesarean 19= Other obstetric antecedent 20= Foetal distress 21= Cause not recorded 99= Other cause (specify) Q11 – Indication 1= Uterine rupture 2= Obstructed labor for Q9 – Major Obstetric Intervention Q10 – Type of intervention MOI 1= Caesarean 2= Hysterectomy 3= Laparotomy for uterine t Q6 – Health centre area Q6 – Health centre Q7– Type of area Q8 – Place of delivery 4= Version and extraction 5= Crâniotomy / Cranioclasy / Embryotomy 6= Hypogastric or uterine artery ligation 9= Other (specify) Q3 – Q4 – parturient Q5 – Address of Q1 – Identification of health formation of Identification Q1 – of parturient Q2 - Identification A UON Network - Tackling Unmet Need for Major Obstetric Interventions 30 _____/_____/______/_____/______(about problems during survey or other observation) (about problems during survey or other Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling Q20 – Check Observation Q17 – Date of mother's discharge Q18 – Name of interviewer Q19 – Date of completion of questionnaire: Q16 – Cause of mother'death 1= Hypertensive disorder 2= Haemorrhage 3= Infection 4= Other (specify) 5= Unknown Q14 – Type of complication died Q15 – When mother 1= Before intervention 2= During intervention 3= After intervention 4= Not recorded Q13 – Results for mother Q13 – Results to report 1= Nothing See Q14 2= Complication health formation 3= Referred to another and Q16 4= Died See Q15 2= Still-born hours within 24 and died living 3= Born 24 h and died after 4= Born living 5= Not recorded UON Network - Tackling Unmet Need for Major Obstetric Interventions 31 cal (with state diploma) res reserved for obstetric (see Q3) Questionnaire completed Questionnaire not completed (problems during survey) QUESTIONNAIRE FOR FORMATIONHEALTH 2: Activity of health formation Number of admissions to maternity unit Total number of deliveries including dystocics deliveries including eutocics deliveries Total number of still-births Total number of maternal deaths Total number of caesareans Total number of uterine ruptures Name of interviewer Date of completion of questionnaire _____/_____/_____ Results of the survey Number of surgeons and obstetric) Number of junior doctors (gynaecology formation Total number of physicians in the health Others: ______Paramedical Number of surgeon assistant Number of anaesthetist assistant Number of midwives / TSSO Number of IDE / TSSI Number of IC Number of other paramedical (certificated) Number of other paramedi Number of delivery beds Number of delivery Number of operating theatres Number of operation theat (mechanical) Number of functional vacuum extractor (electronic) Number of functional vacuum extractor Number of functional forceps Number of ambulances (BLU) Number of radio-communication system Human resources Medical Number of gynaecologists 1= Public1= National hospital 2= EPA4= Reference maternity other (specify):______9= Regional 2= hospital (CHD)Material resources beds Number of maternity 3= Private 3= District hospital (HD) in the health formation Total number of beds Other: ______9= Department: ______Department: Health district:______the formation:______Name of Address of the formation:______Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling NNEX Q26 Q19 Q14 Q4 Observations Q33 Q28 Q29 Q30 Q31 Q32 Q23 Q24 Q25 Q27 Q18 Q20 Q21 Q22 Q15 Q16 Q17 Q9 Q10 Q11 Q12 Q13 Q5 Q6 Q7 Q8 Q2 Type of hospital Q3 of formation Category Identification of formation Identification Q1 A UON Network - Tackling Unmet Need for Major Obstetric Interventions 32 IGER National de la Famille N tégie, Fonds des Nations IN UON ère de la Santé Publique, annexe amme de Santé de la Reproduction, santé de la reproduction, Ministère de la santé de la reproduction, Ministère de Ministère de la Santé Publique, 72 p. Planification Familiale, Projet SR/PF et Planification Familiale, Projet SR/PF stétricaux Non Couverts, Comité de pilotage stétricaux Non Couverts, ique du Niger et Office erts au Niger en 1998, Rapport final, Ministère en 1998, Rapport erts au Niger ts dans la Commune III de Niamey, thèse pour urbaine de Niamey et dans le département de iques de santé maternelle, République du Niger. iques de santé maternelle, de coordination, UON Network, Anvers, 19 p. de coordination, UON aux Non Couverts, Rapport de mission du 3 au 7 aux Non Couverts, Rapport de mission Non Couverts dans la Commune III de Niamey, ouverts au Niger: une proposition d'étude-action, ouverts au Niger: une proposition aux Non Couverts, Rapport de mission du 17 au 28 aux Non Couverts, en médecine, Bagna Beidou Aminaou, 76 p. ine, Soumaila Aminatou, 82 p. s Obstétricaux Non Couverts pour les Interventions s Obstétricaux Non ion 2000-2004 (Document de stra politique nationale de le Gouvernement du Niger, 33 p. que sectorielle de santé, Minist ion du grade de Docteur en médecine, Patale Tezere, 91 p. ération Sud-Sud d’appui au Progr de la Santé Familiale, 14 p. IST OF MAIN DOCUMENTSIST OF MAIN BY PUBLISHED THE 3: L Tackling Unmet Obstetric Needs: Niger Needs: Obstetric Unmet Tackling NNEX Thesis 2000 Etude des Besoins Obstétricaux Non Couver l'obtention du grade de Docteur en médec l'approche des Besoins Novembre 2000 Analyse du pronostic foeto-maternel basée sur Obstétricaux Non Couverts dans la communauté Tillabéri, thèse pour l'obtent Juillet 1999, Etude des Besoins Obstétricaux thèse pour l'obtention du grade de Docteur juillet 2000,13 p. Janvier 2000 L'approche des Besoins Obstétric Other documents used for the study Other documents used for the Août 2000 Projet de Coop Partie 1. Fabienne Richard, Equipe de gestion et Partie 1. Fabienne des Besoins Obstétric Juillet 2000 L'approche janvier 2000,5 p. Non C Mars 1999, Les Besoins Obstétricaux à Niamey du 17 au 27 mars 1999, Xavier de Béthune, 4 p, Rapport de mission de consultation la Santé Publ Coopération Française, Ministère de p. et de la Population de la Tunisie, 10 Reproduction et Juillet 2000 Projet de Santé de la Co-ordination team des Besoin Avril 2001 L'approche A The Ministry Health of Couv Obstétricaux Non Les Besoins Janvier 2001 Documentation des polit Obstétricales Majeures. Ministère de la Santé Publique 38 p. Juin 1998 Projet de déclaration de de la Santé Publique du Niger, 58 p. Publique du Niger, de la Santé de recherche sur les Besoins Ob Mai 1999 Protocole 18 p. de l'étude BONC, Santé Publique, Direction Unies pour l’Enfance (UNICEF) et Juillet 1995 Déclaration de politi 6, 11 p. Mars 1994 Plan de développement sanitaire 1994-2000, Juin 1998 Programme de Coopérat