A systemic approach to improving pregnancy monitoring in Cobly

 {Photo credit: Dr. Abdougafarou Mamam, Médecin Chef}Staff members of the maternity providing an awareness session to pregnant women on signs of danger during pregnancy.Photo credit: Dr. Abdougafarou Mamam, Médecin Chef

To read this article in French, please click here.

The availability of maternal, newborn, and child health services across Benin varies significantly. While more than 70 percent of health facilities offer family planning and preventive care for children, according to the 2018 Service Availability and Readiness Assessment, only 7 percent provide comprehensive obstetric care. Addressing these gaps requires building the skills of health service providers to deliver quality health services. 

Concrete support on the ground to strengthen staff capacity

The USAID Integrated Health Services Activity implemented a strategy to supervise health workers in Activity-supported health zones (HZs) using the On-site Training and Supportive Supervision (OTSS) approach, which aims to assess and correct identified gaps in the availability of services.

In the HZ of Tanguiéta-Matéri-Cobly (TMC), in the department of Atacora, OTSS coaches noted the low attendance of antenatal care (ANC) visits following an assessment in the Cobly community health center. For the first ANC visit (ANC1), coverage only reached 21% in 2018, compared to the national target of 99%. The fourth ANC visit (ANC4) followed the same pattern, with 9% coverage that year compared to the national target of 34%.

These weak results are due to the lack of competency and skills of health agents to promote the ANC calendar; an unawareness of the importance of antenatal check-ups and ANC visits at the community level; and the cost of an antenatal check-up, making it unaffordable for most women.

Following the supervision visit, Activity staff and HZ coaches provided health facility staff with a series of recommendations and actions to implement. First, coaches working with health staff used the OTSS checklist of standards of care to identify gaps and thereafter develop a quality improvement plan. The exercise focused as well on real-time training of providers during the physical exam of pregnant women and proper implementation of guidance in identifying risk factors for pregnant women, correct diagnosis and care of common obstetric diseases. The coaches used this opportunity to advise staff on acquiring necessary equipment, such as tensiometers and garbage cans.

Another aspect of the training focused on strengthening the community’s awareness of the importance of attending all four ANC visits and antenatal laboratory check-ups. Through this work, the Médecin Chef decided that from now on, a lab technician would visit hard-to-reach areas to provide antenatal care services to pregnant women living farther from the health facility.

Finally, to address the financial barrier to the uptake of ANC services, coaches and members of the HZ revised the antenatal laboratory check-up to reduce costs while still maintaining the standard testing needed to monitor the patient’s health. The HZ agreed to provide financial support to women unable to pay the full amount of the check-up, effectively lowering the cost of a laboratory check-up to 4,500 FCFA (just over 8 USD) from the original price of 11,200 FCFA (just over 20 USD) for this group.

[Pregnant women wait for their ANC visit. Photo credit: Elodie Nouemou, assistant nurse of the maternity of Cobly]Pregnant women wait for their ANC visit. Photo credit: Elodie Nouemou, assistant nurse of the maternity of Cobly

Efforts that enable steady results

These efforts have led to positive results for the number of women attending antenatal laboratory checkups and attending all four ANC visits. The percentage of pregnant women that completed an antenatal laboratory checkup required at ANC1 visit increased from 9% in 2018 to 11% in 2019 and 13% in 2020. For ANC visits, results are even more striking. The coverage for ANC1 went from 21% in 2018 to 42% in 2019 and to 48% in 2020. For ANC4, the coverage tripled between 2018 and 2019, going from 9% to 27%. Although this ANC4 coverage decreased to 22% in 2020, this decrease needs further investigation and could be partly explained by the overall decrease of health visits due to the COVID-19 pandemic. In 2020, overall attendance at health facilities dropped to 65% compared to 73% in 2019 in the TMC HZ.

Although it is necessary to acknowledge the efforts still needed to reach the national targets, the progress noted above is encouraging and underscores the importance of taking a systemic approach that mobilizes stakeholders and fully involves the public sector to promote sustainability and ultimately achieve objectives.

The health facility staff have welcomed the support provided by the HZ and the results obtained. The Médecin Chef indicated that “the number [of ANC1 visits] has almost doubled for certain months. This reassures us on the quality of care delivered in our centers.”

The Sage-Femme Responsable shared his observations by saying: “We thank our supervisors for accepting to reduce the cost of the antenatal check-up as it helped a number of pregnant women to perform this check-up. In turn, more check-ups help detect and treat potential problems and complications in a timely manner. The decision to reduce the cost of the antenatal laboratory check-up and the on-site training focusing on the respect of the ANC calendar for pregnant women, as well as the awareness sessions organized by staff members in the communities, has had a positive impact on the coverage of ANC visits.”