Summary of the thesis

Summary of the thesis Introduction

Maternal mortality is high in developing countries, such as in Africa where the risk of dying from maternal causes for a woman starting her reproductive live is 1 in 16, compared with 1 in 2400 in developed countries. In Burkina Faso, the risk of dying from maternal causes is 1 in 12 women. In the international literature, improving access to skilled care during delivery, and in particular to emergency obstetric care, is the key solution to reducing maternal mortality. But, many studies have reported that in rural areas, access to skilled care and emergency obstetric cares are limited by the existence of multiples barriers (socio-cultural, economic, barriers linked to health services organizations and to quality of care).

In the middle of the 1990s, studies in Africa reported that it possible to improve access to skilled care and emergency obstetric care by addressing locally the multiple barriers to care. At the end of the 1990s and the early 21

century, many projects were implemented in the rural districts of Burkina to improve access to skilled care and emergency obstetric care, with the aim of reducing maternal mortality.

The objective of this thesis is to better understand why the uptake of delivery by caesarean section in two rural districts (Houndé and Orodara in South west Burkina Faso) improved between 1999 and 2006 by analysing interventions implemented in the health system.

Methods

We used quantitative and qualitative methods. With a case study approach, we used many sources of data (document review, interview, participatory observation and field notes) to identify and to analyse the activities implemented at the district level that can influence utilisation of skilled care and emergency obstetric care. Quantitative approaches were used to study trends in delivery by caesarean section and associations with activities implemented. The results obtained in these two districts were compared with results from other districts in Burkina Faso, where maternal health projects were being implemented.

Results

Health system analysis identified in the Hounde and Orodara districts many activities to

educate and to mobilize the population, to improve the environment of maternal care and to

reinforce the competencies of health workers and traditional birth attendants. The main activities

were: training health workers and traditional births attendants, equipping health facilities,

reducing the cost of emergency obstetric care, and improving the referral systems. In Houndé

District, the Reproductive Health project in the western districts of Burkina Faso (SAREDO)

implemented most of these activities between 2000 and 2003 following a situation analysis.

Analysis of the implementation process of these project activities founded some failures including changes to what was planned, delays and an absence of monitoring. In Orodara district, there was no such project, but implementation of similar activities started after the appointment of a new Director of health who moved from Houndé in 2001. The activities in this district were implemented based on experiences in Hounde. In both districts, leadership, partnership between different actors and the rational use of resources played key roles in the success of the activities.

Trends in the utilisation of maternal health services during pregnancy and delivery showed an improvement between 1999 and 2006 in the two districts. Linear trends were found in the proportion of deliveries by caesarean section and the incidence of major obstetric interventions in Hounde district. But in Orodara district, there was no change between 1999 and 2002, followed by a sharp increase between 2003 and 2006. In 2005, the proportion of deliveries by caesarean section in Orodara had overtaken the level in Houndé district. Analysis comparing the trends in deliveries by caesarean section and the calendar of the implementation of activities suggested that improving quality of care (training health workers, equipping health services) and reducing the cost of emergency obstetric care were the most important activities that contributed to the improvement in the utilisation of emergency obstetric care in the two districts.

In Houndé district, an evaluation had noted that the quality of prenatal care was improved at health centre level following training of health workers and equipment of health facilities. Also, in facilities where a trained worker was responsible for maternity unit, utilisation of prenatal care, institutional deliveries and obstetric referral rates were significantly higher than in sites which an untrained worker was responsible for maternity unit. Deliveries by caesarean section and the incidence of MOI/AMI were also highest in the group of facilities where trained workers were responsible for maternity unit, but the differences may have been due to chance.

Theses results show that at health centre level, training health workers and equipping health facilities can improve quality of care and utilisation of maternal services, but do not increase utilisation of emergency obstetric care.

In Orodara district hospital, we found that the proportions of referral obstetric cases at

admission, referral cases managed locally and deliveries by caesarean section were significantly

improved after the introduction of surgical kits. At the same time, the proportions of cases with

infections following caesarean section, the proportion of referrals to a higher level, and the cost

of emergency obstetric care for women were reduced. The results observed in this hospital

showed that the introduction of surgical kits in a hospital can improved access and the quality of

emergency obstetric care.

In the other districts where projects were introduced to improve utilisation of maternal health services, we found that the activities were similar to the activities in Houndé and Orodara districts. Training of health workers, equipment of facilities, reduction of the cost of emergency obstetric care and improving the referral systems, were important in improving utilisation of emergency services. Trends in deliveries by caesarean section in each of these districts showed an improvement. Collaboration between different actors in these districts was also reported to be a key element in the success.

Conclusions

This work shows that in order to improve rate of deliveries by caesarean in rural districts

in Burkina Faso it is important to implement multiple activities to address the multiple barriers,

which limit access and quality of emergency obstetric care. The success of these activities

depends on collaboration between actors, leadership and rational utilisation of resources in the

district. In Burkina Faso, since 2003, the government has reduced the cost of maternal health

services to improve utilisation. To maintain the improving trend of deliveries by caesarean

section, activities to improve quality of care, referral systems and education and motivation of the

populations must be implemented together. Also, partnership, leadership and the rational use of

resources at the district level must be promoted.