Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: A cross-sectional study

Setting and health facility selection

This study is an analysis of the baseline survey data from an ongoing project of “Improving the Quality of Maternal and Newborn Health Outcomes through the Development of a Model of Clinical Mentorship in DRC,” including 72 health facilities in the Kwangu and Kwilu provinces of the DRC, funded by the Bill & Melinda Gates Foundation (grant number OPP1144354). For the clinical mentoring project, among the 72 health facilities selected in this study, 48 were assigned to receive clinical mentoring intervention and 24 were assigned not to receive clinical mentoring intervention as a control group by the Ministry of Health and UNICEF in the DRC. After completion of the baseline survey, the Ministry of Health and UNICEF in the DRC will then implement a 24-month period clinical mentoring program in the group of 48 facilities. Process and outcome data on key maternal and newborn health (MNH) indicators will be collected to assess the performance of the clinical mentors and mentees, as well as the clinical mentoring program. Upon completion of the clinical mentoring implementation, we will conduct an endline survey on the same 72 facilities. We will compare MNH indicators collected from the endline survey of the intervention to baseline data, as well as between the groups with and without the implementation of the clinical mentorship program to assess the effectiveness of the clinical mentoring program.

For the present analysis of the baseline survey data, the final 72 facilities were a combination of two phases of baseline data collection. The first phase of data collection was conducted June–September 2017 and the second phase of data collection was conducted from December 2017–May 2018 (Figure 1). These 72 health facilities were selected by the DRC Ministry of Health and UNICEF, taking into account the coverage of health zones (each health zone usually includes at least one general referral hospital (GRH) and its affiliated primary health centers (HC)), accessibility, and ease of implementation for the clinical mentoring program. In each health zone, at least one GRH and its affiliated HCs were selected (Figure 1).

Figure 1. Health facility selection.

Ethics statement

This project was approved by Tulane Instuitional Review Board (IRB) (Reference number: 16-915240) and Kinshasa University School of Public Health Ethics Committee (Approval number: ESP/CE/087/2016).

Survey formation

To conduct the surveys, the data collectors visited each of the 72 health facilities. During the visits, the data collector used a pre-programmed, smartphone-based application, Open Data Kit¹⁰ (ODK Collect v1.16), to complete the following questionnaires:

Data collection

A total of six native speaking data collectors who had previous research or survey experience were recruited to conduct the baseline surveys. Data collectors were provided with a motorbike for travel to health facilities. Each of the six data collectors visited an average of one health facility per week and stayed at each health facility for 4–6 days. Data collection was completed via questionnaires programmed in Android phones using the ODK system. At each hospital or clinic, all healthcare providers who perform maternal and neonatal care were deemed eligible and subsequently approached to participate in the survey. Healthcare providers who agreed to participate signed a written informed consent that allowed the data collector to observe their routine maternal and neonatal care practice for ten antenatal care visits and two deliveries; we refer to these unique observations as provider-patient pairs. In addition, the data collectors completed the facility condition assessment and 3-month delivery extraction forms. Upon completion of observations, data collectors submitted the ODK forms to a protected server, where data was aggregated by the research team at the Tulane University Project Coordinating Center in New Orleans, USA.

Quality assurance and control

Data collectors were trained on how to use the ODK data collection system, how to ride their motorbikes, and how to complete the questionnaires and observations for the selected key indicators prior to the surveys. To ensure a high quality of data collection, a data collection coordination office was established in the capital city of Kikwit in Kwango province. A data coordinator organized and supervised the six data collectors to visit the GRHs and HCs. Hard copies of completed consent forms, delivery records, and questionnaires or facility condition assessment forms were delivered to the Kikwit office when completing the surveys in case there were errors with the ODK system. Additional quality control was managed in two ways: (1) ODK GPS data and server monitoring by the research team in the Tulane University Project Coordinating Center in New Orleans; and (2) weekly Skype calls between the Kinshasa School of Public Health and Tulane University teams to monitor study progress and discuss any issues or challenges raised while fielding the surveys.

Statistical analysis

Variables. This analysis used quantitative data from the facility condition assessment report. For facility condition data, availability was defined as a combination of medicines, supplies, and physical space that was both available and valid/functional or available and not valid/functional (raw data shown in Supplementary Table 5¹¹). Indicators from the antenatal care, labor, delivery, and postnatal care questionnaires were selected that related to EmONC. EmONC signal functions were compiled from the facility condition form based upon availability of supplies (e.g., antibiotics or a newborn ventilation kit were available) as well as the 3-month delivery record abstraction (Supplementary Table 3¹¹). Proportions of availability for all measures were generated and summed in order to understand the structural capacity to provide a package of EmONC care.

Analysis. Frequencies and percentages of facility conditions and MNH indicators of antenatal care, labor, delivery, and postnatal care were calculated for the final 72 facilities in aggregate, by province (Kwango and Kwilu), and by facility type (GRH and HC). Fisher’s exact test was used for bivariate comparisons of difference in the indicators between province and facility type. A majority of our expected cell counts were less than five; for continuity in the results, we used the more conservative estimate of Fisher’s exact test for the few relationships with expected cell counts greater than five. When cell count was greater than five, there was no change in significance between Pearson’s or Fisher’s exact test (data not shown). SAS Version 9.4 was used for all statistical analyses (SAS Institute Inc., Cary, NC).

Facility condition

Among 72 health facilities, facility conditions were variable, as outlined in Table 1. Maternity wards (n=70, 97.2%) and delivery rooms (n=71, 98.6%) had the highest overall availability among the six rooms assessed per facility. This pattern was observed across both province and facility type. Among all facilities, 40.3% (n=29) had room for antenatal care, 46.5% (n=33) had room for labor, and 38.9% (n=28) had room for surgical intervention. Two-thirds of GRH facilities had room for labor (66.7%, n=8) and 42.4% (n=25) of HC facilities had room for labor. Room for surgical intervention was available in 55.6% (n=15) of facilities in Kwango, 28.9% (n=13) of facilities in Kwilu, 91.7% (n=11) of GRH facilities, and 28.3% (n=17) of HC facilities. There was a difference in the availability of rooms for surgical intervention by province (p<0.05) and facility type (p<0.001).

Facilities had low observed levels of drinking water supply overall, across province, and by facility type (Table 1). There was a statistically significant difference in the availability of electricity to operating rooms by facility type (p<0.001). Electricity in operating rooms was available in 83.3% (n=10) of GRH facilities and 26.9% (n=14) of HC facilities.

Adult weigh scales, delivery tables, blood pressure devices, stethoscopes, fetoscopes, and delivery kits were available in frequencies greater than 75% both overall and across the two comparison groups (Table 1). There was a statistically significant difference (p<0.05) between facility type in availability of partograms, forceps, vacuum extractors, cesarean section kits, manual intra-uterine suction kits, newborn suction devices, manual newborn ventilation kits, and newborn incubators (Table 1). Partograms were available in 100% of GRH facilities (n=12) and 60% of HC facilities (n=36). Forceps were available in 50% (n=6) of GRH facilities and in 5.1% (n=3) of HC facilities. Vacuum extractors (83.3%, n=10), cesarean section kits (91.7%, n=11), and delivery kits (9.2%, n=11) were available in the highest frequency for GRH facilities. Kangaroo mother care kits were not available in any facilities in Kwilu. There was a significant difference (p<0.05) by province in the availability of vacuum extractors, cesarean section kits, and kangaroo mother care kits.

Umbilical-cord-clamping materials and anti-hypertensive medicines and supplies were available in the lowest frequencies both overall and across comparison groups. Availability of umbilical-cord-clamping materials was the only statistically significant difference by province (p<0.01); umbilical cord clamping materials were available in 33.3% (n=14) of facilities in Kwilu and in 40% of HC facilities (n=24). There was a statistically significant difference between stitching materials (p<0.05) by facility type. Stitching materials were available in 91.7% (n=11) of GRH facilities but in only 58.3% of HC facilities (n=35). Differences in umbilical cord clamping by facility type approached statistical significance (p=0.053).

Obstetric and neonatal care practices

Healthcare provider recruitment. Among the 24 facilities from the phase one survey, 240 health care providers were eligible, 127 (52.9%) were approached, and 123 (96.9%) consented to be observed for their routine MNH care practices (Figure 2). Among the 48 facilities from the phase two survey, 272 health care providers were eligible, 234 (86.1%) were approached, and all health care providers approached consented to be observed (n=234, 100%). We refer to these unique observations as provider-patient pairs.

Figure 2. Recruitment of healthcare providers across baseline phase 1 and phase 2.

Antenatal care. An average of 10 provider-patient antenatal care pairs were observed per facility. A total of 740 observations of patient-provider antenatal care pairs were observed (Table 2). A total of 269 (36.4%) provider-patient pairs were observed in Kwango, 471 (63.6%) in Kwilu, 127 (17.2%) in GRH facilities, and 613 (82.8%) in HC facilities. Blood pressure was measured in 94.9% (n=702) of all facilities and at a similar frequency across all comparison groups. Conversely, proteinuria was measured in 14.7% (n=109) of all observed provider-patient pairs. The highest frequency of screening for proteinuria occurred in GRH facilities (57.5%, n=73). There is a significant difference in HIV screening (p<0.0001), anemia screening (p<0.001), and blood pressure measurement (p<0.01) by province; there is no consistency in observed provider-patient pair screenings by province. There was a significant difference in all included screening measures and blood pressure measurement by facility type (all p<0.05, Table 2). Blood pressure measurement was 95.9% (n=114) in HC facilities and 89.8% (n=114) in GRH facilities; for all other screening tests, there were higher frequencies of observed provider-patient pair screenings in GRH facilities compared to HC facilities.

Labor, delivery, and postnatal care. On average, two provider-patient pairs for labor, delivery, and postnatal care were observed per facility. A total of 136 labor, delivery, and postnatal care patient-provider pairs were observed (Table 2). There were 54 (39.7%) facilities in Kwango, 82 (60.3%) in Kwilu, 23 (16.9%) in GRH facilities, and 113 (83.1%) in HC facilities. There was a statistically significant difference in documentation of stage of labor (p<0.001), women’s receipt of a uterotonic (p=0.005), and chlorohexidine applied to the umbilicus (p<0.05) by province. For all indicators, the frequency observed was higher in Kwango than Kwilu. There was a statistically significant difference in the use of a partogram to monitor labor by facility type (p<0.01). Progress of labor monitored by using a partogram and use of chlorohexidine on the umbilicus followed by dry cord care were observed in lower frequencies than other selected labor indicators. After delivery, mothers were provided with immediate postnatal care every 15 minutes in less than 50% of facilities both overall and across all groups; a range of 35.2% in Kwango to 46.3% in Kwilu.

Emergency obstetric and newborn care (EmONC)

Antibiotics, anticonvulsants, and oxytocin were available in more than 68.9% of facilities both overall and across province or facility type (Table 3, Figure 3). Availability of newborn resuscitation and whether placenta removal, removal of retained products, assisted delivery, cesarean sections, and blood transfusions were performed in the past 3 months in facility are shown as percentages among health facilities where information was available. Both Kwilu and HC facilities were missing one facility for manual newborn resuscitation kits and cesarean sections. Information was missing for all groups on manual removal of the placenta, removal of retained placenta products, assisted deliveries, and blood transfusions. When information was available, GRH facilities had the highest frequency of availability of newborn ventilation kits (83.3%, n=10), cesarean sections (100%, n=12), and blood transfusions (100%, n=8). Manual removal of placenta took place in 82.5% (n=33) of all facilities and 50% (n=3) of GRH facilities.

Figure 3.

The 7-9 EmONC signal functions for HC (A) and GRH (B) facilities.

When the EmONC signal functions were summed, only one GRH facility was able to provide all nine CEmONC signal functions (Figure 4). Two-thirds (66.7%, n=8) of GRH facilities provide six signal functions. Among the facilities that provide six signal functions, all provide antibiotics, anticonvulsants, oxytocin, and cesarean sections (see Supplemental Table 6 for additional patterns of availability¹¹). Among HC facilities, 74.7% were able to provide two to four signal functions. The most common signal functions that were not provided by the HC facilities were placenta removal, removal of retained products, cesarean sections, or blood transfusions. In these cases, signal functions were observed in low frequency and had high values of missing data (Table 3). For example, manual removal of the placenta was not observed in 29 (87.9%) of HC facilities where information was available and information on removal of retained placenta products was missing for 29 of a total 60 HC facilities.

Figure 4.

Sum of EmONC signal functions for HC (A) and GRH (B) facilities.

Underlying data

Source data examined in this study, available in xlsx, are available on OSF. DOI: http://doi.org/10.17605/OSF.IO/S5QJ7¹¹.

Extended data

Supplemental tables associated with this study are available on OSF. DOI: http://doi.org/10.17605/OSF.IO/S5QJ7¹¹.

Supplemental Table 1. Baseline facility condition assessment form.

Supplemental Table 2. Baseline questionnaire for antenatal, labor, delivery and postnatal care.

Supplemental Table 3. Three-month delivery record review and extraction form.

Supplemental Table 4. Availability and functionality of equipment, medicines, and supplies.

Supplemental Table 5. Data sources for EmONC signal functions.

Supplemental Table 6. Sum of EmONC signal functions by facility type with availability of key functions qualitatively identified.

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).