101502 Maternal and Child Nutrition and Health Results Project Technical Brief: The Gambia December 2015 Health, Nutrition, and Population Global Practice Impact Evaluation Baseline Report: Maternal Health and Nutrition Key Messages •• Only 8 percent of women scheduled their first antenatal care (ANC) visit within the first 12 weeks of pregnancy. •• Less than half of deliveries were carried out by a skilled attendant. •• Barriers to accessing skilled delivery included delays in deciding to seek care, reaching the health facility, and receiving appropriate treatment at the health facility. •• Traditional birth attendants (TBAs) play an important role in delivery care, treatment for complications, and postnatal care (PNC). •• Only 7 percent of women received the three recommended PNC visits. •• Frequent stockouts in supplies negatively impacted the quality of ANC, skilled delivery, and PNC visits. •• Women were generally satisfied with services at health facilities, but some felt certain staff lacked thoroughness and attentiveness. Introduction were collected on three regions: Central The government of The Gambia is imple- River Region (CRR), North Bank Region- menting the Maternal and Child Nutrition West (NBR-W), and Upper River Region and Health Results Project (MCNHRP) to (URR). Its purpose was to establish a increase the use of community nutrition baseline against which project performance and primary maternal and child health will be assessed in the future. This technical services. In collaboration with the govern- brief summarizes the baseline report find- ment, the World Bank is conducting an ings related to maternal health and nutrition. impact evaluation to assess the project’s impact on key aspects of maternal and Pregnancy Outcomes child nutrition and health. The MCNHRP The baseline evaluation found that rates of baseline evaluation was conducted stillbirth were low, but more than 10 ­percent between November 2014 and February of babies were born with low birth weight. 2015. Quantitative and qualitative data Across the three regions, there was an average This brief was prepared by a core team comprising Laura Ferguson (Principal Investigator, University of Southern This series of policy briefs was produced in direct California), Rifat Hasan (co-Principal Investigator, Health Specialist, World Bank), and Hannah Thomas based on the response to a request from the government of The Gambia to share the findings of the Maternal and Impact Evaluation Baseline Report produced by Laura Ferguson, Rifat Hasan, Guenther Fink, Yaya Jallow, and Child Nutrition and Health Results Project Impact Chantelle Boudreaux. The Impact Evaluation Baseline Report benefited from substantial inputs from The Gambia Evaluation Baseline Survey. Bureau of Statistics, Mariama Dibba, Halimatou Bah, Momodou Conteh, Sering Fye, Alexandra Nicholson, Hannah Thomas, and Steven Strozza. The team benefited from the general guidance of Vera Songwe (former Country Director), Louise Cord (Country Director), and Trina Haque (Health, Nutrition, and Population Practice Manager). Helpful comments were received from the Project Implementation Committee led by Modou Cheyassin Phall (Executive Director, The Gambia National Nutrition Agency) and comprised of Haddy Badjie, Abdou Aziz Ceesay, Ousman Ceesay, Modou Lamin Darboe, Malang Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Lamin Njie, and Matty Njie, and Menno Mulder-Sibanda (Senior Nutrition Specialist, World Bank). The work was made possible by support from the Health Results Innovation Trust Fund. 1 of 3.8 neonatal deaths and 1.8 maternal Reported receipt of antenatal supple- deaths per facility, with significantly more ments was also low, with only 48 percent of deaths occurring in CRR than in the other women in their first pregnancy receiving regions. two doses of tetanus toxoid, 26 percent receiving at least 90 days’ supply of iron Antenatal Care supplements, and 63 percent receiving at Uptake of ANC Services least two doses of intermittent preventive Increasing uptake of ANC and skilled delivery treatment for malaria. services can improve ­ pregnancy outcomes. Unavailability of necessary supplies could National guidelines recommend four ANC explain, in part, why not all women received visits, with one visit in the first 12 weeks of the services and supplements recommended pregnancy. Receiving ANC at least once during in the FANC guidelines. Although the guide- pregnancy was nearly universal, and 68 lines indicate that all pregnant women should percent of women received at least four visits. receive syphilis and urine tests, these services However, only 8 percent of women scheduled were rare at the facilities visited. Only 55 their first appointment within the first 12 syphilis tests had been given across URR in weeks of pregnancy (figure 1). the three months before the survey, and only 83 urine tests had been given in CRR. In the ANC Services, Supplies, and Equipment 30 days before the survey, more than 90 The provision of adequate information and percent of health facilities reported stockouts services is necessary to ensure an effective of syphilis and urine protein tests. ANC visit. Provision of information and services recommended in the Focused Health Workers’ Knowledge of ANC ANC (FANC) guidelines was low, with only Service provision was also affected by the percent of women reporting having 21 ­ knowledge and actions of health workers. received syphilis testing and 19 percent When asked which follow-up services they reporting having had their blood type and would provide, health worker responses Rhesus factor assessed (figure 2). indicated that while 68 percent of workers knew to complete the antenatal card, ­ only 54 ­percent would schedule another ANC visit Figure 1. ANC Uptake in CRR, NBR-W, and URR and 25 percent knew to schedule the institu- 100 tional delivery. Failure to perform these “In local communities men have 100 recommended actions not only contributes to decide what the women 80 68 to poor quality of care but also discourages should or should not do. The hus- Percent 60 uptake of ANC and subsequent maternal and band will tell you to wait because 40 child health services. it is very early to go [to ANC] and 20 8 Furthermore, many health workers did not women cannot force themselves 0 provide the recommended advice to clients, to go without seeking and get- 1 or more 4 or more ANC within which could negatively impact pregnancy ting permission. Some men are ANC visits ANC visits first 12 weeks outcomes. Although 68 percent of workers very aggressive.” reported providing information on nutrition, – Community Health Nurse, CRR less than 10 percent reported providing Figure 2. Services Provided during ANC Visits in information on breastfeeding or contracep- CRR, NBR-W, and URR tion (figure 3). 100 82 Reasons for Not Using ANC Services 80 71 Difficulties accessing the health facility (such 60 Percent 60 as cost, time, and transportation) impeded 40 36 uptake of ANC services. Although most 21 19 health facilities reported fee waivers for 20 pregnant women, some women reported 0 paying for ANC services with a high reliance ass facto d advtary f em to d on syp d for nse IV HIVor ess r ice erg o in s ling * sus e an on out-of-pocket payments. Women cou ed H f ed Rec ncy hili e o at ice ted die te rhe d typ reported that the reproductive and child e cas wh adv eiv Tes Tes en health outreach services to the community en Giv o Blo Giv greatly improved the accessibility and use of these services. However, health workers *Based on 788 women who reported receiving reported that fuel shortages often hampered HIV counseling. these outreach activities. 2 Figure 3. Health Worker Knowledge (Advice) in Figure 4. Skilled Birth Attendance, by Region CRR, NBR-W, and URR 100 100 90 80 80 68 Percent 60 Percent 60 54 46 40 40 21 18 20 20 9 7 0 0 Central North Bank Upper Average and se ry tion ion yh r Use pleme acid HIV ed ne e g River Region River across enc s fo nts elp t tes ling id din cou unta ting tre sectic trit Region West Region three regions cep fee erg ign sup /folic Nu vol n ast at tra em ger s Institutional Skilled birth n Iron of i Con Bre delivery attendance Dan Most women believed that the first ANC Skilled Attendance at Birth 47% visit should take place in the second trimes- Uptake of Delivery Services of women were delivered by a ter of pregnancy, and many believed that Using skilled delivery services at a health skilled attendant ANC attendance was necessary every facility can reduce complications and improve month after the first visit, which discour- pregnancy outcomes. Approximately aged early attendance because it would 61 ­percent of women reported delivering in a imply a higher total number of visits. About health facility, and 47 percent were delivered half of the women interviewed agreed that by a skilled attendant (figure 4). Nurses or ANC was useful in preventing problems midwives were the most common delivery during pregnancy, whereas the other half assistants (44 percent of all deliveries), disagreed. followed by TBAs (40 percent of deliveries). Traditional beliefs around pregnancy Whereas 60 percent of women in the wealthi- appear to have affected women’s willingness est socioeconomic quintile had skilled atten- to attend ANC during the first trimester of dance at delivery, only 36 percent of women in pregnancy. Some women described how the lowest quintile reported skilled assistance. revealing a pregnancy early can lead to 40% Referral by a health care provider to a miscarriage or becoming bewitched, while health facility can improve health outcomes if unmarried women and recent mothers complications occur. While 71 percent of of births across CRR, reported wanting to hide their pregnancies women reported at least one postpartum NBR-W, and URR were out of shame. complication (abdominal pain, bleeding, or ­attended by TBAs headache), fewer than 20 percent of these Nutrition during Pregnancy women were referred. A balanced diet including sufficient iron intake is an important component of a Reasons for Not Delivering at a healthy pregnancy. The national Health Facility prevalence of anemia among pregnant ­ Most women believed that it was safer to women is 68 ­ percent (Gambia Bureau of deliver at a health facility and that the level Statistics 2014), and a high prevalence of of support received from health facility staff anemia was also noted by health workers ­ was higher than that received in the commu- in this survey. nity. However, barriers to institutional Health workers, village development delivery persist. committees, and village support groups Women were often slow to make the described providing pregnant women decision to seek care at a health facility due with information on an appropriate diet to a lack of knowledge or decision-making based on locally available foods. Several power. Respondents often believed a woman traditional beliefs were mentioned that was unable to tell her expected due date. could negatively affect pregnant women’s When women did not know when they nutrition. However, some respondents said were due to deliver, it took many of them that these beliefs were declining because of a long time to realize when they were in activities to raise awareness and because active labor. most women strive to eat a balanced diet The decision to seek care was usually when pregnant. made by the head of the household, which 3 often led to delays if the household head was delivery, and they did not see their role as unavailable or unwilling to allow seeking care. being diminished by this process. 7% Once the decision to attend a health facility was made, delays often occurred in Postnatal Care of women received the reaching the facility. The most frequently Uptake of PNC Services recommended three PNC visits mentioned barrier was difficulty getting to A woman should receive her first PNC visit the health facility due to long distances and within 24 hours of delivery, her second visit inadequate transport options. Particularly within one week, and her third visit within challenging was ensuring access at night and six weeks. While 72 percent of women during the rainy season. Many women reported having at least one PNC visit, only preferred home delivery because delivery en 37 percent received PNC within 24 hours, route to the health facility was common. The and only 7 percent received the recom- availability of a small vehicle at some health mended three visits. facilities to transport women in labor was Although 95 percent of health workers gratefully acknowledged. reported knowledge of when to prescribe iron, only 1.6 percent of women reported receiving Delivery Services, Supplies, and Equipment the recommended 90+ days of postpartum Many health facilities reported shortages in iron supplements. No women in NBR-W drugs and supplies, with only 25 percent of reported receiving the full dose. facilities having newborn resuscitation kits, ­ 29 percent having tape measures, and Reasons for Not Attending PNC 38 percent having delivery lights. No health Across all regions, qualitative data suggest <2% facilities in URR reported having a newborn resuscitation kit. All facilities had at least awareness of the importance of PNC was very low. TBAs played a critical role in of women reported receiving one dose of diazepam, with only 4 percent of providing PNC during home visits; however, the full dose of postpartum health facilities having had a stockout within low use of facility-​based PNC services iron supplementation the past 30 days. The opposite was true for remains a concern. Cost, time, and transpor- oxytocin, with no health facility having it on tation difficulties deterred uptake of PNC hand at the time of the survey. services, particularly when women did not feel sick at the time of scheduled visits. Role of TBAs TBAs played an important role in delivery Satisfaction with Maternal care, treatment for complications, and PNC. Health Services TBAs were held in high esteem by health Women were generally satisfied with mater- workers and community members. Some nal health services; however, some reported respondents noted that many of the TBAs that certain staff lacked thoroughness and are very old and that a problem of succession attentiveness. They reported receiving good is emerging. quality care during ANC and delivery. Almost Across all three regions, 37 percent of all women would return for ANC and would women reported preferring to deliver with a recommend the facility to a friend. Some TBA. In NBR-W, TBAs reportedly referred women stated a preference for female health and escorted women to health facilities workers because they felt ashamed to have for delivery whenever time allowed and male health workers see their body. Of referred women for pre- and postpartum concern were instances of reported health complications. In CRR and URR, TBAs worker negligence. reportedly referred some women while delivering those with no complications at home. Across the three regions, they often Reference Gambia Bureau of Statistics (GBOS) and ICF © 2015 International Bank for Reconstruction assisted in deliveries at health facilities. International. 2014. The Gambia Demographic and and Development / The World Bank. Some rights reserved. The findings, interpretations, Most TBAs appeared to embrace the idea of Health Survey 2013. Banjul, The Gambia, and and conclusions expressed in this work do not referring all women to the health facility for Rockville, MD: GBOS and ICF International. necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. This work is subject to a CC BY 3.0 IGO license (https://creativecommons.org/licenses/by/3.0/igo). The World Bank does not necessarily own each component of the content. It is your responsibility to determine whether permission is needed for reuse and to obtain permission from the copyright owner. If you have questions, email pubrights@ worldbank.org. SKU K8562 4