ENSIGN COLLEGE OF PUBLIC HEALTH, KPONG, 

EASTERN REGION, GHANA 

 

 

 

ASSESSMENT OF EMERGENCY OBSTETRIC AND NEWBORN CARE (EmONC) AT 

KADJEBI DISTRICT OF THE VOLTA REGION 

 

By 

ERIC KOJO AGBOKA 

 

 

A Thesis submitted to the Department of Community Health in the Faculty of 

Public Health in partial fulfilment of the requirement for the degree 

 

MASTER OF PUBLIC HEALTH 

 

 

 

 

 

Date submitted (May, 2016) 

 

 

 

 

                                                                                                                                            



DECLARATION 

I hereby declare that except for references to other people work, which I have dully cited, 

this project submitted to the school of Graduate Studies, Kwame Nkrumah University of 

Science and Technology, Kumasi is the results of my own investigation, and has not been 

presented for any other degree elsewhere. 

 

ERIC KOJO AGBOKA (147100013) ………………………………      ………………………………………………. 

(Student)                                    Signature                                                    Date 

 

 

Certified By: 

Dr. Phyllis Antwi          …………………………………………………         …………………………………………… 

(Supervisor)                                  Signature                                                    Date 

 

Certified By: 

Dr. Christopher N. Tetteh       …………………………………….       ………………………………………………. 

(Dean)                                         Signature                                                    Date 

 

 

 

 

 

ii 



DEDICATION 

This work is dedicated to my dear wife Elizabeth and my children Eveanunye and Dziedzorm 

who through their prayers, encouragement, sacrifice and understanding made this work 

possible. Also my supervisors who sacrificed for me in spite of the challenges she was going 

through and not the least Mr. Patrick Lotsu who struggled with me throughout. 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                                                            

iii 



ACKNOWLEDGEMENT 

 

I wish to express my appreciation to my academic supervisors, Dr. Phyllis Antwi and Dr. Frank Baiden 

for their support and direction during the writing of this dissertation. I highly appreciate the kindness 

and support of the District Director of Health Services, Kadjebi District, Mr. Dennis Gbeddy, and the 

entire staff of the District Health Administration (DHA), the management of Saint Theresa Hospital, 

Papase, Dr. Ametepe a medical officer, and the midwives of the various health centre. 

Lastly my gratitude goes to all the heads of the health facilities for their patience in enduring my 

questions. 

 

 

 

 

 

 

 

 

 

 

 

iv 



ABBREVATION/ACRONYMS 

AMDD.           Averting Maternal Death and Disability Program. 

BEMOC.         Basic Emergency Obstetric Care. 

CEmOC.         Comprehensive Emergency Obstetric Care. 

DDHS             District Director of Health Services. 

DHMT.           District Health Management Team. 

EmNC.            Emergency Newborn Care. 

EmOC             Emergency Obstetric Care. 

EmONC.         Emergency Obstetric and Newborn Care. 

EsOc.              Essential Obstetric Care. 

GDHS             Ghana Demographic Health Survey. 

GHS.                Ghana Health Service. 

H/C.                 Health Centre.  

IV                    Intra Venous. 

MCH               Maternal and Child Health. 

MDG.              Millennium Development Goals.   

MMR.             Maternal Mortality Ratio. 

MOH              Ministry of Health. 

NHIA             National Health Insurance Authority. 

NHIS              National Health Insurance Scheme. 

SDHT             Sub-District Health Team. 

UNFPA          United Nations Population Fund. 

UNICEF        United Nations Children's Fund. 

v 



WIFA            Women In Fertility Age. 

WHO             World Health Organization. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

vi 



ABSTRACT 

The functionality of emergency obstetric and newborn services (EmONC) is very important 

in the management of obstetric complications and reduction of maternal mortality. A 

descriptive and qualitative study was conducted in the Kadjebi District to assess the 

functionality of EmONC, and identify factors that affected it. Six facilities in the district a 

mission and public that provided obstetric services were studied. The EmONC Needs 

Assessment module 5, supervision checklist for hospitals and clinics was used to assess 

functionality. The following signal functions: ability to administer parenteral antibiotics, 

parenteral oxytocic drugs, parenteral anticonvulsants for pre-eclampsia and eclampsia, 

perform manual removal of placenta, retained products of conception, resuscitation of 

newborn and assisted vaginal delivery were used to identify a facility as providing basic 

essential obstetric care services. A comprehensive emergency obstetric care facility was 

identified as one able to perform all the signal functions for a basic essential obstetric care 

facility and in addition be able to perform caesarean section surgery and blood transfusion. 

An interview guide was designed and used to conduct key informant interviews with selected 

heads of facilities where obstetric services were provided. The key informant interviews were 

conducted to determine factors associated with functionality of services. Out of the 6 health 

facilities in the district, only one provided comprehensive emergency obstetric and newborn 

care services while the rest, provided basic obstetric care services however, none could 

perform all the signal functions needed to be identified as a facility providing basic essential 

obstetric care services. The function performed by all these facilities was newborn 

resuscitation and oxytoxic administration. None of them performed assisted vaginal 

deliveries. The factors found to be associated with functionality of emergency obstetric and 

newborn care services were lack of trained personnel due to inadequate number of midwives, 

managerial, supply and policy issues.  



To improve availability of essential obstetric services in the district these recommendations 

are being proposed to the District Director of Health Services. There should be continuing in-

service training for all staff to upgrade their skills especially on lifesaving skills. The need for 

collaboration with stakeholders for regular supply of basic equipment, drugs for efficient 

service delivery. 

 

 

 

 

 

 

 

 

 

 

 

 

vii 



TABLE OF CONTENTS 

  

Chapter 1 .................................................................................................................................. 1 

1.0 INTRODUCTION ............................................................................................................ 1 

1.1 Background Information ................................................................................................ 1 

1.2 Problem Statement ......................................................................................................... 3 

1.3 Rationale of Study ............................................................................................. ……………5 

1.4 Hypothesis/Conceptual framework ................................................................................ 5 

1.5 Research Questions........................................................................................................ 6 

1.6 General Objective(s) ...................................................................................................... 6 

1.7 Specific Objectives ........................................................................................................ 7 

1.8 Profile of Study Area ..................................................................................................... 7 

Chapter 2 ............................................................................................................................ 9 

2.0 LITERATURE REVIEW ................................................. Error! Bookmark not defined. 

Chapter 3 .............................................................................................................................. 18 

3.0 METHODOLOGY ............................................................................................................... 18 

3.1 Research Methods and Design (Study methods and design)Error! Bookmark not defined. 

3.2 Data Collection Techniques and Tools ........................................................................ 18 

3.3 Study Population .......................................................................................................... 20 

3.4 Study Variables ............................................................................................................ 20 

3.5 Pre-testing .................................................................................................................... 21 

3.6 Data Handling .............................................................................................................. 21 

363.7 Data Analysis ........................................................................................................... 21 

3.8 Ethical Consideration ..................................................... Error! Bookmark not defined.1 

     3.9 Limitation of study ………………………………………………………………………………………………….22 

Chapter 4 .................................................................................. Error! Bookmark not defined. 

4.0 RESULTS ....................................................................................................................... 23 



4.1 Introduction .................................................................... Error! Bookmark not defined.3 

Chapter 5 .............................................................................................................................. 38 

5.0 DISCUSSION ................................................................... Error! Bookmark not defined.8 

5.1 Introduction ................................................................... Error! Bookmark not defined.8 

5.2. Provision of Basic and Comprehensive Essential Obstetric Care at various health institutions

 ............................................................................................. Error! Bookmark not defined.8 

5.3 Functionality of emergency obstetric and newborn care ............................................. 39 

5.4 What are the major factors affecting the functionality of emergency obstetric and newborn care

 ............................................................................................. Error! Bookmark not defined.0 

5.5 The availability of equipment/supply at the facilities. ... Error! Bookmark not defined.1 

5.6 Adequate numbers of health workers with the right mix of skillsError! Bookmark not defined.2 

Chapter 6 ................................................................................ Error! Bookmark not defined.3 

6.0 CONCLUSIONS AND RECOMMENDATIONS ......... Error! Bookmark not defined.4 

6.1 Conclusions .................................................................... Error! Bookmark not defined.4 

6.2 Recommendations .......................................................... Error! Bookmark not defined.5 

References ............................................................................... Error! Bookmark not defined.7 

APPENDEX A ........................................................................ Error! Bookmark not defined.9 

APPENDEX B ........................................................................ Error! Bookmark not defined.4 

APPENDEX C ........................................................................ Error! Bookmark not defined.5 

APPENDEX D ........................................................................ Error! Bookmark not defined.7 

APPENDEX E ........................................................................ Error! Bookmark not defined.9 

 

 

 
 

 

viii 



LIST OF TABLES 

 

Table 1.     Signal functions provided by basic EmONC facilities in last three months 

Table 2.     Routine Newborn care services by basic facilities 

Table 3.     Supplies/equipment/human resource of basic facilities 

Table 4.     Reasons for antibiotics not administered 

Table 5.      Reasons for anticonvulsants not administered 

Table 6.      Reasons for non-removal of retained products 

Table 7.      Types of oxytoxics and anticonvulsants given by facilities 

Table 8.      Reasons for non-performance of assisted vaginal delivery 

Table 9.      Signal functions of comprehensive EmONC 

Table 10.    Comprehensive newborn care for Hospital 

Table 11.    Supplies/equipment/human resource of comprehensive facility 

Table 12.     DEMOGRAPHICS OF RESPONDENTS OF IN-DEPTH IN 

 

 

 

 

ix 



LIST OF FIGURES 

 

Graph 1.               Facilities offering the number of basic EmONC 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

x 



LIST OF MAPS 

 

 

 

Xi 



LIST OF APPENDICES 

APPENDEX A                         CHECKLIST ON EmONC 

APPENDEX B                         CHECKLIST ON ROUTINE NEWBORN CARE 

APPENDEX C                         SUPERVISION CHECKLIST FOR HOSPITAL 

                                                           SUPERVISION CHECKLIST FOR HEALTH CENTER  

APPENDEX D                         KEY INFORMANT INTERVIEW GUIDE. 

APPENDEX E                          CONSENT FORM 

 

 

 

 

 

 

 

 

 

xii 



 

 



 

 

1 

 

 

Chapter 1 

1.0 INTRODUCTION 

1.1 Background Information 

All pregnant women, even healthy ones, face some risk of complications that can 

result in death or serious disabilities if not effectively managed (Ijadunolal et al. 

2007). Each year, an estimated 515,000 women die from pregnancy-related causes, 

with most cases occurring in developing countries of Africa and Asia (Mavalankar & 

Rosenfield 2005), however it declined to 298,000 in 2013 (WHO). Globally over three 

million neonates die every year, overall under-5 mortality over the past decade has 

been significantly curtailed however the burden of neonatal deaths is more or less 

the same and these now represent about 40% of all deaths in children under the 

age of 5 (Turab et al. 2013). Majority of these neonates die in rural areas of 

underdeveloped countries and approximately two thirds are due to infection and 

complications related to low birth weight (LBW) and prematurity (Turab et al. 

2013). The World Health Organization (WHO) estimates that 515 000 women die 

each year from pregnancy related causes, and almost all of these deaths occur in 

developing countries with over 287,000 mothers died in 2010 worldwide (Turab et 

al. 2013). Globally maternal mortality ratio (MMR) has declined by nearly 50% from 

1990 to 2012 and in Sub Saharan Africa (SSA) by 41%; from 920 deaths per 100,000 

live births in 1990 to 500 deaths per 100,000 birth in 2010 (Bakari et al. 2015). The 

maternal mortality ratio for Africa is approximately1000 per 100000 live births, 

compared to 8 to 12 per 100 000 live births in North America (Ronsmans & Graham, 

2006). Ghana per the 2014 DHS has a maternity ratio of 350 per 100,000 live birth 



 

 

2 

 

with neonatal death of 28/1000 (World Bank Report, 2015). Although maternal 

mortality has declined dramatically in the developed world, the risk of such death 

remains a serious threat for women in much of Asia, Latin America, and Africa, 

particularly in rural settings (Mavalankar & Rosenfield 2005). This situation is 

particularly tragic because no new technologies or drugs are needed to radically 

lessen maternal mortality (Mavalankar & Rosenfield 2005). Rather, access to 

emergency obstetric and newborn care (EmONC), and more generally to 

community-based and hospital maternity care services, would lead to dramatic 

reductions in these unacceptably high ratios (Mavalankar & Rosenfield 2005). 

Significant declines in maternal mortality in Sri Lanka and Malaysia over the past 50 

to 60 years provide evidence that the implementation of maternal health 

interventions in developing countries is feasible (Mavalankar & Rosenfield 2005). 

Increased access to skilled birth attendance accompanied by the development of 

EmONC and other complementary health services were key contributors to the 

reductions achieved in those countries (Mavalankar & Rosenfield 2005). 

Appropriately trained personnel and the provision of necessary supplies and 

equipment are critical to the development and implementation of effective EmONC 

services (Gething et al. 2012). There must be at least five emergency obstetric care 

facilities (including at least one comprehensive facility) for every 500 000 population 

(WHO, 2011). The availability of EmONC determines the health care system ability 

to respond to obstetric and newborn complications and the contribution towards 

reducing maternal and newborn mortality and morbidity (Mavalankar & Rosenfield 

2005). 



 

 

3 

 

1.2 Problem Statement 

The United Nations Millennium Development Goals which are eight goals that all 

191 UN countries adopted with emphasis on Millennium Development Goals 

(MDGs) 4 and 5, call for a reduction in the child mortality rate by two thirds and the 

maternal mortality ratio by three quarters, respectively, between 1990 and 2015 

(Undesa 2012). Interventions to improve emergency obstetric and newborn services 

will have a significant positive impact on these two goals (Undesa 2012). Maternal 

death was, however, chosen as the outcome with which to judge progress towards 

this goal, thus bringing renewed attention to what is a 21st century problem 

essentially only for the poor, and one virtually eliminated for people with the means 

and status to access health care (Ronsmans & Graham, 2006). Such a marker of 

global inequity is an indication of wider development issues targeted in some of the 

other MDGs, especially on poverty, education and gender (Ronsmans & Graham, 

2006). The Millennium Declaration is, however, the first time that maternal 

mortality has featured so prominently in the high ranks of a global pronouncement, 

providing an opportunity to galvanize action and so help ensure that the risk of 

maternal death is minimized for all women (Ronsmans & Graham, 2006). Each year 

it is estimated 358,000 maternal deaths occurred worldwide in 2008, a 34% decline 

from the levels of 1990. About 99% of deaths occurs in developing countries 

(355,000). Asia and sub-Saharan Africa accounted for 87% (313,000) of global 

maternal deaths (WHO). Maternal deaths are not uniformly distributed throughout 

the world, and obstetric risk is highest by far in sub-Saharan Africa which is 

estimated to be nearly 1000 per 100,000 live births: almost twice that of south Asia, 

four times as high as in Latin America and the Caribbean, and nearly 50 times higher 



 

 

4 

 

than in industrialized countries (Bakari et al. 2015). Most maternal deaths occur in 

sub-Saharan Africa, with a staggering lifetime risk of 1 in 16, and south Asia with a 

lifetime risk of 1 in 43 (Ronsmans & Graham, 2006). Ghana maternal ratio is 

estimated to be 350 (GDHS 2015), 186 in 2009 by RCH report,2009. Achievement of 

the MDG will end by the year 2015 after which the Sustainable Development Goals 

come into force. Out of 17 goals, Goal 3 which is to ensure healthy lives and 

promote well-being for all at all ages has a component which by 2030, there must 

be reduction in the global maternal mortality ratio to less than 70 per 100,000 live 

births. In 2003, in an effort to improve maternal health and survival, the 

government of Ghana implemented a new policy that removed delivery fees in 

Health facilities in the four most-deprived regions of the country. Less than two 

years later, the government extended the policy to the rest of Ghana, removing 

delivery fees in all public, private and mission facilities (Immpact, PRB, 2007). On 

July 1st, 2008 the president of Ghana announced that the government is providing 

free maternal care for pregnant women to improve the attainment of MDG 4 and 5. 

The decision was made to implement this through NHIS (National Health insurance 

scheme) so that mothers have the full package of antenatal, prenatal and postnatal 

care (NHIS, 2008). Reducing maternal mortality and reaching the MDG5 target by 

2015 is proving a serious challenge for many countries, including Ghana. The 

estimate of MMR in Ghana in 2014 was 350 per 100,000 live births (GDHS 2015).The 

institutional MMR is around 210 per 100,000 live births (Opoku 2009). Translating 

MDG 5 for Ghana, a national target to reduce the (MMR) from 214 in 1990 to 54 by 

2015 (MMR = maternal deaths per 100,000 live births) was set (MOH, 2008). Ghana 

is in the category of countries with a high-burden of maternal mortality and Kadjebi 



 

 

5 

 

district is one of the district with the highest maternal mortality in the Volta Region 

and therefore there is the need to investigate the factors contributing to this. 

1.3 Rationale of Study 

The justification of this project is based on the problem identified. The problem 

identified is that, in 2015 out of 22 maternal mortality recorded in Volta Region, 6 

was recorded in Kadjebi District with 17 neonatal death. The high number of deaths 

demonstrates that most facilities might be having challenges with the functionality 

of emergency obstetric and newborn care in the district. Maternal mortality ratio is 

4\100,000 live births for Kadjebi District. If it is accepted that most pregnancy 

related complications are unpredictable then it is just humane to ensure availability, 

access and use of emergency obstetric and newborn care services to reduce 

maternal mortality and newborn if women and neonate really must live.  

1.4 Hypothesis/Conceptual framework 

In the Kadjebi District one of the health problems identified was high maternal and 

neonatal mortality. The 2015 annual report of the district shows that maternal 

mortality was high, that is 6 with neonatal deaths of 17. Unsupervised delivery is 

associated with high risk to babies and mothers. The large proportion of 

unsupervised deliveries suggest that women are delivering in facilities that lack the 

capacity to handle obstetric complications. Evidence shows that at least 15% of all 

pregnant women develop sudden serious complications that require lifesaving 

access to essential obstetric care. Since complications are sudden and cannot be 

predicted during pregnancies and deliveries, but can be treated, adequate 

preparations should be in place to handle such complications. Obstetric 



 

 

6 

 

complications are one of the causes of maternal mortality in Ghana, and the Kadjebi  

District for that matter has high maternal mortality. The national maternal mortality 

is 315\100,000 live births while that in the Kadjebi District is 4 \100,000 live births. 

(Source Institutional data 2016). These unacceptable figures could be due to the 

unavailability of emergency obstetric and newborn care services. The District 

Director of Health Services and his team want all pregnant women to have access to 

emergency obstetric and newborn care services in case of obstetric complications, 

but are the facilities, equipment, personnel and drugs available to cater for them? 

This study therefore seeks to assess the functionality of emergency obstetric and 

newborn care services in the Kadjebi District. 

1.5 Research Questions 

This study aims to address the following questions; 

The availability of equipment’s at the health facilities? 

Provision of basic and comprehensive essential obstetric care at various health 

institutions? 

Functionality of emergency obstetric and newborn care? 

What are the major factors affecting accessibility of emergency obstetric and 

newborn care? 

Do facilities have adequate numbers of health workers with the right mix of skills? 

1.6 General Objective(s) 

An assessment of Emergency Obstetric and Newborn Care (EmONC) at Kadjebi 

District  



 

 

7 

 

1.7 Specific Objectives 

1. To describe the basic and comprehensive essential obstetric services in the 

district. 

2. To identify factors that affect the functionality of essential obstetric care services. 

3. To make recommendations on improving the ability of the health system. 

1.8 Profile of Study Area 

The Kadjebi District is one of the 25 districts in the Volta Region. Its located about 

150km to the north of Ho the Regional Capital. The district has a projected 

population of 67,095 according to the 2010 census. The district has a n approximate 

size of about 675 sq. Km measuring 56-60 Km North to the South  and 15-30 Km 

East to West. It shares boundaries with Nkwanta District on the north, south by 

Jasikan District, west with Woraworwa District and east by the Republic of Togo. 

The district is also mountainous with an average height of about 450-850 Ft above 

sea level. Kadjebi District is traverse by many rivers and streams. Notable among 

them are Menu, Wawa and Asukawkaw all of these are tributaries of the River 

Volta, The road network in the district is among the worst in the region making 

accessibility to many communities difficult. This is further compounded with 

communication accessibility. The district is divided into five (5) sub-districts namely 

Kadjebi-Asato, Dodo, Dodi, Ahamansu and Dapaa-Pampawie sub-districts. The 

district has six (6) government health centres and one mission hospital, which 

serves as the district hospital. Agriculture is the main occupation of the people in 

the district.There are mixed ethnic groups in the district with the predominant 

groups being Akans, Ewes, Kotokoli and Basari , etc. The district health system is 



 

 

8 

 

made up of the District Health Management Team (DHMT) at the district level and 

six Sub-District Health Teams (SDHT's). Various types of health facilities and service 

providers are found in the district.. Even though most women received antenatal 

care, only about half had supervised deliveries. Antenatal coverage for 2015 was 

89.5%, while supervised deliveries was 58.4%. (The average national figure of 

supervised deliveries is 56.7%. GDHS, 2014). The percentage of unsupervised 

deliveries shows that most pregnant women were delivering in facilities that lack 

the capacity to handle obstetric complications. The total number of women in the 

fertility age (WIFA) is 16,104 (WIFA =24% of total population) and the expected 

pregnancy is 2,684 (4% of total population).  

 

 

 

 

 

 

 

 

 

 

 



 

 

9 

 

Chapter 2 

2.0 LITERATURE REVIEW 

Efforts to improve the lives of women and children around the world have 

intensified since world leaders adopted the United Nations Millennium Declaration 

in September 2000 and committed themselves to reaching Millennium 

Development Goals 4 and 5, on child mortality and maternal health. The original 

targets for these Goals were a two thirds reduction in the mortality of children 

under 5 and a three-quarters reduction in the maternal mortality ratio between 

1990 and 2015. There is worldwide consensus that, in order to reach these targets, 

good-quality essential services must be integrated into strong health systems. The 

addition in 2007 of a new target in Goal 5—universal access to reproductive health 

by 2015—reinforces this consensus: all people should have access to essential 

maternal, newborn, child and reproductive health services provided in a continuum 

of care. In order to reduce maternal mortality, Emergency Obstetric Care (EmOC) 

must be available and accessible to all women..(Maine et al. 2009). One way of 

reducing maternal mortality is by improving the availability, accessibility, quality 

and use of services for the treatment of complications that arise during pregnancy 

and childbirth. These services are collectively known as Emergency Obstetric and 

Newborn Care (EmONC). Essential obstetric care (EOC or EsOC), which, in some 

definitions, includes a broad array of services including family planning and 

antenatal, intrapartum, and postpartum care; and Emergency Obstetric Care (EOC 

or EmOC), which includes more specific interventions such as blood transfusions, 

intravenous antibiotics, caesarean section, the management of abortion 

complications, vacuum or forceps delivery. There is a fundamental difference 



 

 

10 

 

between the two approaches: EsOC, in some definitions, focuses on all pregnant 

women and is based on the idea that obstetric complications can be predicted and 

prevented, employing the concept of “high risk, EmOC, on the other hand, focuses 

on the prompt identification, referral, and treatment of women with obstetric 

complications (Measham & Kallianes n.d.). Over the years, the terminology has 

been adjusted so that the indicators relate specifically to treatment of the 

emergency obstetric complications that cause most maternal deaths. Emergency 

Obstetric and Newborn Care is defined for two different levels of the health care 

system: Basic essential obstetric care services at the health centre level should 

include at least the following: 

(1) Administer parenteral antibiotics: 

(2) Administer uterotonic drugs (i.e., parenteral oxytocin2) 

 (3) Administer parenteral anticonvulsants for preeclampsia and eclampsia (i.e., 

magnesium sulfate). 

 (4) Manually remove the placenta 

(5) Remove retained products (e.g. manual vacuum extraction, dilation and 

curettage) 

6) Perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery) 

(7) Perform basic neonatal resuscitation (e.g., with bag and mask) 

Comprehensive essential obstetric care services at the district hospital level (first 

referral level) should include all the above plus: 



 

 

11 

 

(8) Perform surgery (e.g., caesarean section) 

(9) Perform blood transfusion. (Qazi 2011) 

Routine New born Care involves, 

Thermal protection, immediate and exclusive breastfeeding, hygienic cord care anti-

biotics to mother if preterm/prolong PROM, corticosteriods in preterm mother, 

resuscitation with bag and mask of non-breathing baby, KMC for premature/very 

small babies, alternative feeding if baby unable to breastfeed, Injectable antibiotics 

for neonatal sepsis, (PMTCT) if HIV positive mother. Comprehensive  EmNC includes 

Intravenous fluids, safe administration of oxygen, availability of incubator (Gabrysch 

et al. 2012). For the services at a facility to be considered functional, the elements 

of care must have been provided during the 6 months previous to data 

collection.Skilled delivery care providers working in the right environment can 

prevent, detect, and treat complications, thus contributing to a reduction in 

stillbirths and maternal and neonatal mortality. Skilled care is most often 

approximated by assessing whether women deliver with a midwife, doctor, or other 

skilled birth attendant, but ensuring an enabling environment for uncomplicated 

(routine) and complicated childbirth is an equally important requirement for skilled 

care. Emergency obstetric care (EmOC) signal functions, a shortlist of key life-saving 

obstetric interventions, have been used to assess the functionality of health 

facilities with respect to EmOC and to construct indicators of service provision. They 

are thought to reflect responsiveness of the health services to the main obstetric 

complications at basic and comprehensive level, roughly corresponding to health 

centre level (with midwives) and first referral hospital level (with physicians).The 



 

 

12 

 

availability and density of facilities capable of providing EmOC have been suggested 

as useful health system output indicators for monitoring supply-side progress 

towards having sufficient services for reducing maternal mortality. In 1986 the 

World Health Organization (WHO) published Essential Obstetric Functions at First 

Referral Level, which describes key obstetric functions that hospitals should 

provide. These functions focused on emergency treatment for complications 

(surgical obstetrics, anaesthesia, blood replacement, manual procedures) but also 

included a monitoring function (the partograph), a preventive function (family 

planning support, which prevents pregnancy rather than complications in pregnant 

women), and an emergency newborn function (neonatal resuscitation). EmOC 

signal functions, described in the 1997 UN guidelines, focused more sharply on 

eight signal functions for treating the five main causes of maternal mortality 

(haemorrhage, hypertensive diseases of pregnancy, sepsis, obstructed labour, and 

unsafe abortion), and the monitoring, prevention, and neonatal treatment signal 

functions (partograph, surgical contraception, and newborn resuscitation). EmOC 

was subdivided into basic and comprehensive EmOC, with the former comprising six 

medical functions (parenteral antibiotics, parenteral oxytocic drugs, parenteral 

anticonvulsants, manual removal of placenta, removal of retained products, and 

assisted vaginal delivery) and the latter adding surgical capability (Caesarean 

section) and blood transfusion. There have been attempts to develop signal 

functions for children [but no similar signal functions have been widely agreed for 

newborns, except for newborn resuscitation. The latter function had been part of 

the 1986 Essential Obstetric Functions, was removed from EmOC as defined in 

1997, and then reintroduced as a basic EmOC signal function in the 2009 UN 



 

 

13 

 

handbook . Similarly, there has been little focus on signal functions for routine care 

for mothers or newborns; routine care saves lives by preventing complications or by 

intervening early before life-threatening complications develop. For example, 

effective elements of routine care which should be provided to all women and all 

newborns include using a partograph to detect prolonged labour in time, ensuring a 

clean delivery, providing active management of the third stage of labour to reduce 

the risk of post-partum haemorrhage, and encouraging early breastfeeding and 

keeping the baby warm. In view of the emerging consensus on the continuum of 

care linking mother and child, and the links between routine care and care for 

complications (Gabrysch et al. 2012). The UN guidelines contained in monitoring 

emergency obstetric care: A handbook, recommend that there should be at least 5 

EmONC facilities for every 500,000 population, at least one of which provides 

comprehensive care. National standards recommend five EmONC facilities for every 

200,000 people, at least one of which is a comprehensive facility. The National 

Assessment for Emergency Obstetric and Newborn Care Ghana, November 2011 

reports indicates Ghana’s total population of 24,232,431, should have 606 EmONC 

facilities. According to the assessment it has 89, which points to a gap of 517 

facilities. Ghana’s 76 comprehensive EmONC facilities are 45 short of the mark. 

Whereas Ghana should have 485 basic sites to meet the national standard of care, 

the country has 13, leaving a gap of 472. Out of the facilities surveyed, 97 percent 

provided parenteral oxytocics. This signal function had the highest coverage, 

followed by parenteral antibiotics (78 percent). Signal functions with the lowest 

coverage were assisted vaginal delivery (13 percent of facilities; nonperformance of 

this function kept many facilities out of the basic category), removal of retained 



 

 

14 

 

products (29 percent of facilities), and manual removal of placenta (46 percent of 

facilities. Oxytocin is the drug of choice for active management of the third stage of 

labour; it was the only drug used in 36 percent of facilities. Most facilities (62 

percent) used both oxytocin and ergometrine. Few used only ergometrine. Only 642 

(55 percent) of the 1157 facilities that were surveyed and had data to share had 

administered anticonvulsants in the three months preceding the survey (Table 

3.06). This proportion is low given the high incidence of severe preeclampsia and 

eclampsia in the country as well as the degree to which these conditions contribute 

to maternal mortality, find that only 29 percent of facilities provided removal of 

retained products; 53 percent of these used MVA. The share of facilities using MVA 

was lowest for health centres (35 percent) than for other facility types. We find that 

removal of retained products is least likely to be performed in lower-level facilities 

such as health centres (13 percent), health clinics (18 percent), maternity homes (20 

percent), and CHPS compounds (3 percent), find that assisted vaginal delivery was 

performed by only 13 percent of facilities, making it the least commonly performed 

signal function. Among facilities that did perform this procedure, most (94 percent) 

used only a vacuum extractor (Nations et al. 2011). A research conducted in 2014 at 

Hai District, Northern Tanzania indicate that the two comprehensive EmOC facilities 

(CEmOC) could provide all nine required signal functions while none of the basic 

EmOC   facilities (BEmOC) could provide the seven required signal functions. For a 

population of 214,454 in the district, the total number of health facilities designated 

to provide EmOC services exceeded the minimum required number which was 1 for 

CEmOC and 2 BEmOC (Bakari et al. 2015). To further understand what actions are 

needed to save women’s lives, we must also understand why so many women are 



 

 

15 

 

dying. In Ghana, as in many developing countries, deaths during pregnancy and 

childbirth are often linked to the three delays (GHS, 2006): 

1. Delays in the Home 

2. Delays in Accessing Health Facility 

3. Delays at Health Facility 

Causes of Maternal Deaths 

The major causes of newborn deaths include bleeding, hypertension, anaemia, 

unsafe abortions, infections and obstructed labor. A majority of these deaths can be 

prevented with adequate care (GHS, 2006). 

Infections 10%, Anaemia 12%, unsafe abortion 11%, other causes 24%, Obstructed 

labour 7%, Bleeding 17%, Hypertension 19%. 

Haemorrhage 

The prevalence of severe anaemia is substantial, so that a given degree of blood 

loss is more likely to cause hemodynamic instability; many women deliver at home 

and are often attended by unskilled providers (traditional birth attendants, family 

members) who are unable to recognize the signs of excessive bleeding (Gijs 

Walraven MD, Wanyonyi, & Stones, 2008). Once the problem is recognized and the 

decision to take the woman to a health facility is made, emergency transport might 

not be available or affordable, and distances might be long; gender relations can 

present barriers to care seeking; for example, it might not be possible to arrange 

transfer to a health facility without the authority of male relatives (Gijs Walraven 

MD, Wanyonyi, & Stones, 2008). Whether or not a pregnant woman arrives at a 



 

 

16 

 

health facility or hospital in time; the facility might not have the trained staff 

available or the necessary supplies and equipment to treat her. The provision of 

effective care for women with haemorrhage is often beyond the capacities of health 

systems and communities in countries where maternal mortality is high (Gijs 

Walraven MD, Wanyonyi, & Stones, 2008) 

Other Causes 

In developed countries, the most important cause of maternal death is "other direct 

causes" (21%), which includes largely complications during interventions such as 

those related to caesarean section and anaesthesia, followed by hypertensive 

disorders and embolism (WHO, 2006). It also includes ectopic pregnancy, renal 

failure and cardiac disorders (Senah, 2003). 

Anaemia 

The WHO has estimated that 52 percent of pregnant women in Africa – 56 percent 

in West Africa- have haemoglobin levels below 10.0 g/L (WHO 1982). Severe 

anaemia can contribute to maternal mortality by impairing a pregnant woman's 

ability to resist infection or severe haemorrhage, hi Ghana, parasitic infestation, 

especially malaria, significantly contributes to this condition (Senah, 2003). 

Obstructed Labour 

This is a complication in which the process of labour does not function normally due 

to mechanical blockage of the birth canal. In very severe cases, it may lead to 

fistulation in which urine and faecal matter gain entry into the reproductive system. 



 

 

17 

 

Obstructed labour may be due to early pregnancy, inadequate nutrition during 

childhood, fetal-pelvic disproportion, multiparity and abnormal fetal presentation 

(Senah, 2003). 

Abortion 

This is voluntary or involuntary termination of pregnancy before 20 weeks of 

gestation. It is characterized by bleeding, lower abdominal pains, and passage of 

fetal and placental tissue (Senah, 2003). 

Hypertensive Disorders (Hypertension) 

In pregnancy these are associated with pedal and facial oedema and protein in 

urine. They are the most difficult of the obstetric emergencies to prevent and 

manage. Yet they are an important cause of maternal death in Africa (Senah, 2003). 

If untreated, they may progress to eclampsia characterized by convulsion, brain 

damage, renal failure and death (Senah, 2003). 

Sepsis 

Infection occurs when aseptic procedures are not followed, when the amniotic sac 

ruptures long before delivery occurs, when vaginal examinations are too frequent 

or when obstructed labour occurs. Long term consequences of puerperal sepsis 

include pelvic inflammatory diseases, secondary infertility and in rare cases, 

maternal tetanus. 

 

 



 

 

18 

 

Chapter 3 
 

3.0 METHODOLOGY 
 

3.1 Research Methods and Design (Study methods and design)   
 

The study was descriptive and qualitative study to assess emergency obstetric and 

newborn care by facility at Kadjebi District in the Volta Region of Ghana to inform a 

community-level quality improvement intervention and to promote maternal and 

newborn health services access and utilization. . Both qualitative and quantitative 

methods were used since this approach offers a good way of ascertaining the views 

of the heads of the different health facilities where obstetric services were 

provided, and gives the opportunity to explore further emerging issues. An EmONC 

and supervision checklist were administered to one hospital and five health centres 

and were all answered by midwives after consent form signed. An in-depth 

interview using an interview guide were administered. A convenience sampling 

method was used to select the health staffs depending on their expertise of work 

and six health staffs comprising four midwives, one medical officer and the district 

director were selected after prior information given and consent sought. Each were 

interviewed at their respective place of work. 

3.2 Data Collection Techniques and Tools 

The EmONC Needs Assessment module 5: EmOC Signal Functions and Other 

Essential Services in addition to newborn checklist , a supervision checklist for 

hospitals and clinics was used to assess functionality of services (AMDD Data 

Collection Module(Anon n.d.). Signal functions were used to identify Basic and 



 

 

19 

 

Comprehensive facilities in the district. The identified obstetric care facilities were 

selected based on facilities with midwives conducting deliveries and checklist were 

administered. Health records were reviewed to determine the delivery being 

conducted. A key informant interview was then conducted with midwives in-charge 

of selected health facilities where obstetric services were provided to find out some 

of the problems they encountered with availability of equipment and personnel 

needed to provide essential obstetric care services. The materials used included 

available information from the district profile, health facility records and annual 

reports. Interviews using supervision checklist for hospitals and clinics and an 

interview guide were used. 

Supervision checklist (Appendix C): some of the variables on the list are: 

i. Number of trained personnel. . 

ii. Key drugs such as Oxytocics, Anticonvulsants, local anaesthetic and oxygen. 

iii. Equipment in the labour room such as vacuum extractor, IV infusion sets and 

fluids, vaginal speculum, curettes, and sphygmomanometers. 

A list of signal functions (Appendix A) was then used to identify a facility as basic or 

comprehensive EmONC facility. The variables on the list included ability to: 

i. Administer parenteral antibiotics 

ii. Administer parenteral oxytocic drugs 

iii. Administer parenteral anticonvulsant for pre-eclampsia and eclampsia 

iv. Perform manual removal of placenta 



 

 

20 

 

V. Perform removal of retained products (e.g., manual vacuum aspiration) 

vi. Perform assisted vaginal delivery 

vii. Perform surgery (Caesarean section) 

viii. Perform blood transfusion 

An interview guide was designed and used to conduct a key informant interview 

with heads of the facilities where obstetric services were provided and the District 

Director of Health. (Appendix D). Some of the variables included: 

i. Ability to perform manual removal of placenta and manual vacuum aspiration. 

ii. The frequency training sessions were organized for staffs. 

iii. The source logistics were received from and the frequency of receipt of logistics. 

iv. Some of the reasons for the unavailability of essential obstetric care services in 

the facility. 

v. Recommendations for improving the availability of obstetric services. 

3.3 Study Population 

All the five (5)  health centres and one (1) hospital providing obstetric care and 6 

staffs (midwives, medical officer and district director ) in the Kadjebi District 

3.4 Study Variables 

i. Administer parenteral antibiotics 

ii. Administer parenteral oxytocic drugs 

iii. Administer parenteral anticonvulsant for pre-eclampsia and eclampsia 



 

 

21 

 

iv. Perform manual removal of placenta 

V. Perform removal of retained products (e.g. manual vacuum aspiration) 

vi. Perform assisted vaginal delivery 

vii. Perform surgery (Caesarean section) 

viii. Perform blood transfusion 

3.5 Pre-testing 

This was carried out in Jasikan District at the Jasikan Hospital and one health centre 

since they have almost the same demographics and to assess if health personnel 

understands it. 

3.6 Data Handling 

Answered questionnaires and checklist were kept in files with the in-depth 

interview recordings being kept on a memory card. 

3.7 Data Analysis 

Data was analyse using Microsoft Excel.Facilities were grouped into health centres, 

and a hospital to facilitate analysis. Frequency distribution of all the variables was 

run and description, explanation and interpretation of findings were made.The 

results are presented using diagrams. 

3.8 Ethical Consideration 

It was sought from ethics review board of GHS and ENSIGN College of public health. 

The import of the study was discussed and a verbal informed consent obtained 

from the District Health Administration. The heads of the health facilities were 



 

 

22 

 

reassured that the study was not meant to identify problems for criticism and 

blame. 

3.9 Limitations of StudyInadequate funds and time constraints limited the study. 

For example, the head of the hospital was not met for an in-depth interview on how 

to improve the assessment of emergency obstetric and newborn care services in 

the Kadjebi District due to lack of time. Also due to familiarity with staffs some of 

the answers from the in-depth interview might have been compromised. Not all 

heads of facilities were interviewed as this could have given different perspectives 

to their unique challenges. 

 

 

 

 

 

 

 

 

 

 

 

 



 

 

23 

 

Chapter 4 

4.0 RESULTS 

4.1 Introduction 

I administered checklist on EmONC with routine newborn care for both basic and 

comprehensive facilities, supervision checklist for Health Centre’s and Hospitals, in-

depth interviews with key health workers. Six health care facilities at the district 

provides EmONC and they include; 

• One mission hospital 

• Five health centres 

This shows the various basic signal functions provided by the five various health 

centers in the district.  

Table 1. Signal functions provided by basic EmONC facilities in last three months  

 KADJEBI 

H/C 

DODO 

AMANFO 

H/C 

AHAMANSU 

H/C 

POASE 

CEMENT 

H/C 

MEMPEASEM  

H/C 

 

 

NUMBER 

 

 

% 

PARENTERAL 

ANTIBIOTICS 

YES YES NO NO NO 2 40 

OXYTOXIC 

ADMINISTRATION 

YES YES YES YES YES 5 100 

ANTICONVULSANT 

ADMINISTRATION 

YES YES NO NO NO 2 40 

MANUAL REMOVAL 

OF PLACENTA 

YES YES YES NO YES 4 80 



 

 

24 

 

REMOVAL OF 

RETAINED 

PRODUCTS 

YES YES NO NO NO 2 40 

ASSISTED VAGINAL 

DELIVERY 

NO NO NO NO NO 0 0 

NEWBORN 

RESUSCITATION 

YES YES YES YES YES 5 100 

 

The result shows that not all the signal functions were performed by the facilities. 

Graph 1. Facilities offering the number of basic EmONC 

 

The results shows that two facilities practice six of the signal functions. 

 

6 6

3

2

3

0

1

2

3

4

5

6

7

KADJEBI H/C DODO AMANFO H/C AHAMANSU H/C POASE CEMENT H/C MEMPEASEM H/C

N
U

M
B

ER
 O

F 
SI

G
N

A
L

FU
N

C
TI

O
N

S 
P

ER
FO

R
M

ED

BASIC FACILITIES

SIGNAL FUNCTIONS BY BASIC FACILITIES



 

 

25 

 

 

 

A checklist on routine newborn care services by basic facilities was administered 

and the results were as follows, 

Table 2. Routine Newborn care services by basic facilities 

 KADJEBI 

H/C 

DODO 

AMANFO 

H/C 

AHAMANSU 

H/C 

POASE 

CEMENT 

H/C 

MEMPEASEM  

H/C 

Thermal 

protection 

YES YES YES YES YES 

Immediate and 

exclusive 

breastfeeding 

YES YES YES YES YES 

Hygienic cord 

care 

YES YES YES YES YES 

Antibiotics to 

mother if 

preterm/prolong 

PROM 

YES YES YES YES YES 

Corticosteriods 

in preterm 

mother 

NO NO NO NO NO 

Resuscitation 

with bag and 

mask of non-

breathing baby 

YES YES YES YES YES 



 

 

26 

 

KMC for 

premature/very 

small babies 

YES NO NO NO NO 

Alternative 

feeding if baby 

unable to 

breastfeed 

NO NO NO NO NO 

Injectable 

antibiotics for 

neonatal sepsis 

YES YES YES NO NO 

(PMCT) if HIV 

positive mother 

YES YES YES NO NO 

 

The results shows that majority of the facilities practice newborn care. 

A checklist on the availability of supplies/equipment/human resources were used to 

administer on basic facilities and the results were as follows, 

Table 3. Supplies/equipment/human resource of basic facilities 

 KADJEBI 

H/C 

DODO 

AMANF 

H/C 

AHAMANSU 

H/C 

POASE 

CEMENT 

H/C 

MEMPEASEM  

H/C 

Medical Officer YES  YES NO NO NO 

Physician Assistant YES  YES NO NO NO 

Midwives YES YES YES YES YES 

Oxytocics YES YES YES YES YES 

Anticonvulsants YES YES NO NO NO 

Penicillin YES YES NO NO NO 

Gentamycin NO NO NO NO NO 



 

 

27 

 

Metronidazole YES YES YES YES YES 

Ampicillin NO NO NO NO NO 

I.V infusion sets YES YES YES YES YES 

I.V fluids YES YES YES YES YES 

Ovum forceps YES YES YES YES YES 

Vaginal speculum YES YES YES YES YES 

Artery forceps YES YES YES YES YES 

Needles YES YES YES YES YES 

Sutures YES YES YES YES YES 

Syringes YES YES YES YES YES 

Sterilizer YES YES YES YES YES 

Scissors YES YES YES YES YES 

Curette YES YES YES YES YES 

Sphygmomanometer YES YES YES YES YES 

Test tubes YES NO NO NO NO 

Slides YES NO NO NO NO 

 

The results indicate most facilities have issues with supplies. 

A checklist on reasons for non-administration of antibiotics by some basic facilities 

were administered and the results were as follows, 

Table 4.Reasons for antibiotics not administered 

 AHAMANSU 

H/C 

POASE CEMENT 

H/C 

MEMPEASEM  

H/C 

Human resource YES NO NO 

Training issues NO NO NO 

Supplies/equipment/drugs YES YES YES 

Managerial issues YES YES NO 



 

 

28 

 

Policy issues YES YES YES 

No indication NO NO NO 

 

The result shows that policy issues account mostly for this. 

A checklist on reasons for anticonvulsants not being used by some basic facilities 

were administered and the results were as follows, 

Table 5. Reasons for anticonvulsants not administered 

 AHAMANSU 

H/C 

POASE CEMENT 

H/C 

MEMPEASEM  

H/C 

Human resource NO NO NO 

Training issues NO NO NO 

Supplies/equipment/drugs NO YES YES 

Managerial issues NO YES NO 

Policy issues NO NO YES 

No indication YES YES NO 

 

The result shows supplies being a contributing factor. 

A checklist for reasons accounting for non-removal of retained products by some 

basic facilities administered shows results as follows, 

Table 6. Reasons for non-removal of retained products 

 AHAMANSU 

H/C 

POASE CEMENT 

H/C 

MEMPEASEM  

H/C 

Human resource NO NO NO 

Training issues NO NO NO 

Supplies/equipment/drugs NO YES YES 

Managerial issues NO NO YES 

Policy issues NO NO YES 



 

 

29 

 

No indication YES YES YES 

Most of the facilities did not encounter cases that have indication for retained 

products. 

A checklist on the type of oxytoxic and anticonvulsants being administered by basic 

facilities shows the following results, 

Table 7. Types of oxytoxics and anticonvulsants given by facilities 

 

 

 

KADJEBI 

H/C 

DODO 

AMANFO 

H/C 

AHAMANSU 

H/C 

POASE 

CEMENT 

H/C 

MEMPEASEM  

H/C 

ST MARY 

THERESA 

HOSPITAL 

OXYTOCIN YES YES YES YES YES YES 

ERGOMETRINE YES NO NO NO NO YES 

MAGNESSIUM 

SULFATE 

YES YES YES NO NO YES 

DIAZEPAM YES YES NO NO NO YES 

MISOPROSTOL YES NO NO NO NO YES 

 

The result indicates all the facilities using oxytocin. 

A checklist on reasons why some basic facilities were not performing assisted 

vaginal delivery were used and the results were as follows, 

Table 8. Reasons for non-performance of assisted vaginal delivery 

 KADJEBI 

H/C 

DODO 

AMANFO 

H/C 

AHAMANS

U 

H/C 

POASE 

CEMENT 

H/C 

MEMPEASEM  

H/C 

Human resource NO NO NO YES YES 

Training issues YES NO YES NO YES 

Supplies/equipment/

drugs 

NO YES YES YES YES 



 

 

30 

 

Managerial issues NO YES YES NO YES 

Policy issues YES YES YES YES YES 

No indication NO NO YES NO YES 

Result shows that policy issues accounting for the reasons why it is not being 

carried out. 

A checklist on signal function services administered on a comprehensive facility and 

the results were as follows, 

Table 9.Signal functions of comprehensive EmONC 

 SAINT MARY THERESA HOSPITAL 

PARENTERAL 

ANTIBIOTICS 

YES 

OXYTOXIC 

ADMINISTRATION 

YES 

ANTICONVULSANT 

ADMINISTRATION 

YES 

MANUAL REMOVAL OF PLACENTA YES 

REMOVAL OF RETAINED PRODUCTS YES 

ASSISTED VAGINAL DELIVERY YES 

NEWBORN RESUSCITATION YES 

BLOOD TRANSFUSION YES 

CESAREAN SECTION YES 

 

The result shows that all the signal function is being performed. 

 

 

 



 

 

31 

 

 

A checklist on newborn care services were administered on a comprehensive facility 

and the results were as follows, 

Table 10. Comprehensive newborn care for Hospital 

BASIC EmNC SAINT MARY THERESA HOSPITAL 

Thermal protection YES 

Immediate and exclusive breastfeeding YES 

Hygienic cord care YES 

Antibiotics to mother if preterm/prolong PROM YES 

Corticosteriods in preterm mother YES 

Resuscitation with bag and mask of non-breathing baby YES 

KMC for premature/very small babies YES 

Alternative feeding if baby unable to breastfeed YES 

Injectable antibiotics for neonatal sepsis YES 

(PMCT) if HIV positive mother YES 

COMPREHENSIVE EmNC  

Intravenous fluids YES 

Safe administration of oxygen YES 

Availability of incubator NO 

 

The result shows that the facility does not have an incubator. 

 

 

 

 



 

 

32 

 

 

A checklist on the availability of supplies/equipment/human resources by the 

hospital and the results were as follows, 

Table 11. Supplies/equipment/human resource of comprehensive facility 

 SAINT MARY THERESA HOSPITAL 

Doctors YES 

Aneasthetist YES 

Nurse/midwives YES 

Theatre attendant YES 

Oxytocics YES 

Anticonvulsants YES 

Procaine penicillin YES 

Crystalline penicillin YES 

Gentamycin YES 

Metronidazole YES 

Ampicillin YES 

Local anaesthetics YES 

General anaesthetic YES 

Oxygen YES 

Labour Room  

Vacuum extractor YES 

I.V infusion sets YES 

I.V fluids YES 

Ovum forceps YES 

Vaginal speculum YES 

Artery forceps YES 

Needles YES 



 

 

33 

 

Sutures YES 

Syringes YES 

Sterilizer YES 

Scissors YES 

Curette YES 

Sphygmomanometer YES 

Microscope YES 

Test tubes YES 

Slides YES 

Blood Bank  

Blood bags YES 

Anti-sera YES 

Storage capability YES 

Operating Theatre  

C-section set YES 

Laporatory set YES 

Neonatal intubation set YES 

 

The result shows that the facility is well equipped. 

 

 

 

 

 

 



 

 

34 

 

The table shows the demographic characteristics of the respondents of the in-depth 

interview conducted. 

Table 12. DEMOGRAPHICS OF RESPONDENTS OF IN-DEPTH INTERVIEW 

 SEX AGE  YEARS OF 

WORKING 

EXPERIENCE 

CURRENT 

POSITION 

NO. OF 

YEARS IN 

CURRENT 

POSITION 

1. MALE 56 DISTRICT 

DIRECTOR 

OF HEALTH 

SERVICES 

21YRS DISTRICT 

DIRECTOR 

7 

2. MALE 28 MEDICAL 

OFFICER 

2YRS MEDICAL 

OFFICER  

2 

3. FEMALE 48 SNR 

MIDWIFERY 

OFFICER 

18 YRS IN-CHARGE 

MATERNITY 

WARD-KHC 

7 

4. FEMALE 49 MIDWIFERY 

OFFICER 

15 YRS IN-CHARGE 

MATERNITY 

WARD- 

AHAMANSU 

H/C 

5 

5 FEMALE 31 STAFF 

MIDWIFERY  

6YRS 

9MONTHS 

IN-CHARGE 

MATERNITY 

WARD -

POASE 

CEMENT H/C 

9 MONTHS 



 

 

35 

 

6. FEMALE 30 STAFF 

MIDWIFERY 

6 YRS IN-CHARGE 

MATERNITY 

WARD- 

MEMPEASEM 

H/C 

6 MONTHS 

 

13.0 INDEPTH INTERVIEW 

13.1 Issues relating to nonuse of parenteral antibiotics and anticonvulsants 

Based on the in-depth interview responses drugs are not administered mainly 

because of non-availability. 

Could not get supplies from regional medical stores and its difficult getting from 

open market because there is no cash due to delay of reimbursement from National 

Health Insurance Authority (56years old male from the directorate) 

 Some of the antibiotics are not at our level of prescription so we cannot use since 

the health insurance will not pay and those at our level are not supplied from the 

district medical stores (31 year old female in charge) 

Not given from the district medical store although we requested for it because there 

is none there. (49 year old female in charge) 

The in-charge only uses the parenteral antibiotics at the general side (49 year old 

female in charge) 

 

 



 

 

36 

 

13.2 Non availability of equipment and supplies 

Based on the in-depth interview responses the lack of supplies, equipment are 

mainly due to issues relating to purchases. 

Region did not supply and it is difficult to buy because there is no funds to be use for 

it (56 years male officer at directorate) 

Most of the equipment’s are old and cannot be used and need to be replace (30 

years female in charge) 

The facilities generates less fund and cannot be used in purchasing these equipment 

(56 years male officer at directorate) 

We always request but always they say there is no money because NHIS have not 

paid (31 years female in charge) 

13.3 Availability of ergometrine and its uses 

  From the in-depth interview varied reasons account for the non-usage of 

ergometrine 

 I don’t like using it because if the person is hypertensive you can use it for her since 

it is contraindicated (31 year female in charge) 

It is not in the system and when we request it’s not given, I asked my colleagues at 

the other facilities and they say they don’t have it (49 year female in-charge) 

We prefer using oxytocin because were told not to use ergometrine (48 year female 

in charge) 

 



 

 

37 

 

13.4 Availability of blood in the blood bank 

From the in-depth interview although efforts are made for blood to be stocked in 

the blood bank, however human attitude plays a key role. 

There is reluctance of relatives to replace blood with the perception that if they 

donate, it will not be used on their relatives (28 year male officer at the hospital) 

Consumption is high due to other medical condition from general practice apart 

from obstetric cases as the need arises (28 year male officer at the hospital) 

A lot donate but upon screening some cannot be used (28 year male officer at the 

hospital) 

13.5 Frequency of in service training 

From the in-depth interview although efforts were made to organize in service 

training as frequent as possible, financial constraints affected it. 

We most often depend on region to organize it and when we are selected we send 

the staffs (56 year male officer at the directorate) 

Since I came to the district I have not attended any workshop before because it has 

not been organized before (30 year female officer in charge) 

There are not enough funds to organize workshop for staff so the district depends on 

stakeholders (56 year male officer at the directorate) 

 

 

 



 

 

38 

 

Chapter 5 

5.0 DISCUSSION 

5.1 Introduction 

Information on the study of the assessment emergency obstetric and newborn care 

in the Kadjebi District will not only be use by health managers and planners to 

assess the functionality of EmONC but also on how to improve on the health 

system. 

5.2. Provision of Basic and Comprehensive Essential Obstetric Care at various 

health institutions 

The number of facilities in the district, 1 comprehensive and 5 basic EmONC meets 

the minimum acceptable level. From Table 9, St. Mary Theresa Hospital which 

serves as the district hospital which could provide full comprehensive EmONC, none 

of the 5 basic EmONC facilities could provide all the services required to identify a 

facility as providing basic EmONC. It can thus be said that apart from the district 

hospital no facility in the district provided full basic EmONC services. There is the 

need therefore to upgrade the existing services to meet the signal functions. This 

will ensure prompt management of complicated cases and reduction in the number 

of referrals and delays in attending to complications thus, help reduce maternal 

mortality. In a study by Djan et al, (1994) an inventory checklist used to evaluate 

Juaben Teaching Health Center (JTHC), revealed shortages of basic drugs, 

equipment and supplies such as lack of surgical facilities and blood transfusion 

equipment. Material improvement in the form of upgrading the existing facility was 

made by converting 3 existing rooms into a surgical suite: one room was converted 

into a changing room, one into a sterilization and scrubbing area and one into an 



 

 

39 

 

operating room. The study showed that there is no need to wait for long periods to 

establish sophisticated health institutions at unaffordable cost before tackling 

obstetric problems. Also a study by Cynthia Sottie , (2000) in the Brim South of the 

Ashanti Region found out that out  of the 12 facilities only 1 provided full 

comprehensive essential obstetric care and the remaining 11 could not provide all 

the services needed to identify a facility as providing basic essential obstetric 

services. 

5.3 Functionality of emergency obstetric and newborn care 
 

From Table 1 and graph 1, none of the basic health facilities provided all the seven 

signal functions needed to identify the EmOnc status of a facility as providing basic 

EmONC. Two of them performed six of the seven signal functions. All the facilities 

provided parenteral oxytocic and newborn resuscitation, two of them gave 

parenteral antibiotics, anticonvulsants in the form of magnesium sulphate, and also 

performed removal of retained products needed to identify the facility as providing 

basic EmONC services. None of the facilities performed assisted vaginal delivery 

such as vacuum extraction, since none of them had vacuum extractor although a 

few have been trained to do so. All the nine signal functions needed to identify the 

EmONC status of the St. Mary Hospital as a comprehensive facility were available 

and performed during the year under consideration. (Ref table 9). The 2011 Ghana 

EmONC national report find that the country should have 606 EmONC facilities. 

According to the assessment it has 89, which points to a gap of 517 facilities (Ghs et 

al. 2011). Ghana’s 76 comprehensive EmONC facilities are 45 short of the mark (Ghs 

et al. 2011). Whereas Ghana should have 485 basic sites to meet the national 



 

 

40 

 

standard of care, the country has 13, leaving a gap of 472. Also a similar study by 

Cynthia Sottie , (2000) in the Brim South of the Ashanti Region found out that only 

twelve of the thirty public and private health facilities in the Birim South District, 

provided obstetric services. 

5.4 What are the major factors affecting the functionality of emergency 

obstetric and newborn care 

From Table 4, 5, 6, 8, 10, the major issues hindering the functionality of EmONC in 

the district includes human resource where there are inadequate midwives, training 

issues were most of the practicing midwives have not been trained in EmONC 

services, managerial issues with essential drugs are not available and policy issues 

due to the non-availability of medical officers or physician assistants at most of the 

facilities resulting in lower level of prescription.  From Table 16 one major factor 

was the capacity to store adequate number of blood in the facility blood bank. As 

one officer revealed during the in-depth interview “there is reluctance of relatives 

to replace the blood with the perception that if they donate it will not be used on 

their relatives”. A similar study conducted by Dr. Zaitoon Qazi in Puntland, Somali 

(2011) indicate reasons cited for not performing the signal functions, mainly the 

infrastructure, HR and supply constraints. The referral hospital though designated 

as CEmONC facilities, could not offer full range of CEmONC signal functions.  Lack of 

skills, human resources, supplies and equipment were the common explanation for 

not performing newborn resuscitation (Qazi 2011).  Many MCH facilities did not 

provide a signal function because there were no supplies (Injectable antibiotics, 

oxtyocics and anticonvulsants), space limitations or there was no indication – not 

necessarily because they were not capable of providing it(Qazi 2011). The majority 



 

 

41 

 

of facilities, however, failed to provide signal functions even when they were 

indicated. The reasons cited for not performing the removal of retained products 

included lack of human resources, training issues, lack of supplies and equipment, 

and management issues. While the reason for not doing assisted vaginal deliveries 

was the lack of supplies and equipment’s.  

5.5 The availability of equipment/supply at the facilities. 

Lack of equipment and supplies or malfunctioning equipment necessary for 

management of obstetric emergencies plagues health facilities in most developing 

countries. There is little question that this situation is due in part to the very real 

issue of limited resources but this is often perpetuated by poor management and 

organization of available resources. Sensitive equipment often is left unused for a 

long time because of minor faults. From Table 3, most of the equipment’s were 

available at the facilities. The key drugs needed were unavailable and inadequate. 

Oxytocic and anticonvulsant in the form of magnesium sulphate were available and 

adequate, however only 3 of the facilities are using oxytocics, magnesium sulphate, 

diazepam, and two uses misoprostol (Table 7). The rest of the items on the checklist 

needed in the labour room were all available, adequate and functioning, (see Table 

3). On laboratory equipment there was adequate equipment at two facilities with 

four having nonfunctional laboratories. Reagents needed in the blood bank were 

available and adequate with 10 bags of blood available.  

From point 13.1 0ne officer said “Region did not supply and because there is no 

funds to be use” and another said “The facilities generates less fund and cannot be 

used in purchasing these equipment’s” A similar study by Cynthia Sottie in the Brim 



 

 

42 

 

South (2011), showed that in the labour room of the maternity homes, all had IV 

infusion sets except one which claimed it had run out of stock the previous day. All 

had IV fluids and had at least one functioning sphygmomanometer except one, 

which had none. The Ghana EmONC National report (2011) also indicated that 

ergometrine injection and oxytocin are the most common oxytocics likely to be 

found at all levels of the health service. Misoprostol is a prostaglandin which is 

more likely available in hospitals than in health centres and lower level facilities(Ghs 

et al. 2011). A similar study by Ijadunal, K.T. et al in Ife South LGA observed that 

parenteral oxytocics were available in only half of the facilities, while parenteral 

anti-convulsants for the management of hypertensive diseases of pregnancy were 

available in 11.5% of the facilities. Further assessment of the availability of 

equipment and supplies necessary for EOC services showed that intravenous 

infusion fluids were not available in 20 (77%) health facilities, and there were no 

latex gloves in more than two-thirds of the facilities. Half of the facilities did not 

have sterile syringes and needles, while 69% had no vaginal speculums. More than a 

quarter (27%) of the facilities had no sphygmomanometers to monitor the blood 

pressure of obstetric clients under their care (Ijadunolal et al. 2007). 

5.6 Adequate numbers of health workers with the right mix of skills 
 

All the facilities have at least one midwife with 2 of the basic EmONC facilities 

having physician assistants (Table 3 and 11). Although there are other category of 

staffs who are assisting in delivery of services most of the health centres with the 

exception of Kadjebi health centre (having four), the rest of the health centres has 

one midwife and this will compromise care delivery since at least there must be two 



 

 

43 

 

midwives. The Ghana EmONC National report (2011) also indicated that, most 

health centres, clinics, maternity homes and CHPS Compounds had only 1 midwife 

(57%, 61%, 55%, and 41% of facilities, respectively) while 7%, 9%, 1% and 57% of 

these facilities had no midwife (Ghs et al. 2011). A total of 35% of health centres, 

29% of Health clinics, 44% of Maternity homes and 2% of CHPS compounds had two 

or more midwives currently working (Ghs et al. 2011). A similar study to assess basic 

emergency obstetric care in mid‐level  in health facilities in the districts of Ainaro 

and Manufahi in Timor shown that only two of the facilities admitted to having 

midwives present twenty‐four hours a day every day. On average, midwives 

interviewed assist with only seven births a month.  

 

 

 

 

 

 

 

 

 

 

 

 
 



 

 

44 

 

Chapter 6 
 

6.0 CONCLUSIONS AND RECOMMENDATIONS 
 

6.1 Conclusions 

There is no doubt as to the effectiveness and contributions of emergency obstetric 

and newborn services in reducing maternal and neonatal deaths. In the Kadjebi 

District there were five health facilities providing basic emergency obstetric and 

newborn services and one hospital providing comprehensive emergency obstetric 

and newborn services. None of the five facilities were able to provide the full range 

of signal functions needed to identify a facility as providing basic EmONC however 

the hospital provides all the signal functions needed for comprehensive EmONC. 

Most of the basic facilities provided nothing beyond normal delivery, complicated 

obstetric cases could not be handled at all these facilities and had to be referred to 

the hospital. 

Lifesaving skills such as removal of retained products, administration of parenteral 

antibiotics and anticonvulsants could not be performed by most of the health 

facility staff providing basic EmONC with none providing assisted vaginal delivery. 

The factors found to be associated with these were lack of trained health staff due 

to inappropriate distribution and inadequate number of trained staff, lack of 

equipment/supply and policy issues where the NHIS does not pay for such service 

rendered. Improvement in services is expected to have direct impact on the survival 

of women with obstetric complications who seek care and their new born. Once 

services become functional, community education and information activities will 

enhance utilization. Addressing key areas of improvement such as retention of 



 

 

45 

 

human resources and equipment/supply acquisition may increase provision of 

EmONC services. Increased EmONC availability and readiness across health facilities 

may help to reduce additional unnecessary delays in seeking and receiving medical 

services necessary to treat obstetric complications and, in the most serious cases, 

prevent maternal death. 

6.2 Recommendations 

In the light of the findings from the study, the following recommendations are being 

proposed to the District Director of Health Services, Kadjebi District to enable the 

district provide the needed emergency obstetric and newborn care services 

1. The DHMT need to upgrade services in the district to meet the required signal 

functions. This will mean providing each institution with trained personnel in life 

saving skills such as removal of retained products and assisted vaginal delivery. 

2. There should be regular monitoring and supervision of staff by the DHMT in order 

to improve performance and ensure also that record-keeping is maintained in all 

facilities. This will enable problems encountered on the ground are properly 

documented and addressed. 

3. Periodic in-service training must be organized for all midwives by the DHMT 

especially on lifesaving skills in order to upgrade their skills. The district directorate 

should have need assessment done on all midwives to be posted to the district. This 

is to enable the district identify the skills required by the midwives and provide the 

appropriate training to make them proficient. 

4. The DHMT must develop a rotation for remote midwives to practice obstetric 

skills in facilities with a higher number of abnormal obstetric cases. This facility must 

provide them with hands‐on practice.  



 

 

46 

 

5. The management of Saint Mary Theresa hospital must ensure provision of the 

necessary equipment for adequate obstetric care. The equipment provided must be 

regularly maintained. There is also an urgent need for education and regular 

organization for donation at the blood bank to have more blood stored in the blood 

bank.  

Blood donor policy should be instituted where families of all pregnant women will 

have to donate a pint of blood on their behalf and also the need to identify the 

period in which blood is used and measures put in place to stock it. This will 

augment the quantity of blood available at any given time. The study identified that 

there were periodic shortages of blood at the blood bank. 

6. The DHMT must engage the district NHIA for the need to reimbursed services 

rendered in terms of some of the signal functions. The district has only one hospital 

which is the mission hospital, but serves as the district hospital. 

8. The need for the DHMT to collaborate with stakeholders especially NGO’s for 

regular supply of basic equipment, drugs for efficient service delivery. 

9.The DHMT must engage with the Regional Health Directorate to post more staff 

especially midwives who are equipped with lifesaving skills to the district and in the 

long term the District Assembly to sponsor midwives who will come back to serve 

the district. Also motivational packages put in place to entice midwives to willing 

come and stay at the place and work. 

 



 

 

47 

 

References 

 

Anon, EmONC Needs Assessment. 

Bakari, R.M. et al., 2015. Assessment of Availability , Utilization and Quality of 

Emergency Obstetric Care in 2014 at Hai District , Northern Tanzania. , 3(3), 

pp.43–48. 

Gabrysch, S. et al., 2012. New Signal Functions to Measure the Ability of Health 

Facilities to Provide Routine and Emergency Newborn Care. , 9(11). 

GDHS, 2015. Key Findings From the 2014 Ghana Demographic and Health Survey 

National Health Summit. , pp.1–30. 

Gething, P.W. et al., 2012. Geographical access to care at birth in Ghana: a barrier to 

safe motherhood. BMC Public Health, 12(1), p.991. Available at: 

http://www.biomedcentral.com/1471-2458/12/991. 

Ghs, H., Unfpa, U. & Amdd, W.H.O., 2011. National Assessment for Emergency 

Obstetric and Newborn Care Ghana August 2011 Ministry of Health WHO Table 

of Contents. , (August). 

Ijadunolal, K.T. et al., 2007. Unavailability of essential obstetric care services in a 

local government area of south-west Nigeria. Journal of health, population, and 

nutrition, 25(1), pp.94–100. Available at: 

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3013269&tool=p

mcentrez&rendertype=abstract. 

Maine, D., Bailey, P. & Lobis, S., 2009. Monitoring Emergency Obstetric Care. 

Journal of Obstetrics & Gynaecology, 30(4), pp.1–153. Available at: 

www.who.int/reproductivehealth. 

Mavalankar, D. V. & Rosenfield, A., 2005. Maternal Mortality in Resource-Poor 

Settings: Policy Barriers to Care. American Journal of Public Health, 95(2), 

pp.200–203. Available at: 

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2003.036715. 



 

 

48 

 

Measham, D.M. & Kallianes, V.D., Report of a Technical Meeting. 

Nations, U., Fund, P. & Death, A.M., 2011. National Assessment for Emergency 

Obstetric and Newborn Care. , (November). 

Opoku, E.E. a, 2009. Utilization of Maternal Care services in Ghana by Region after 

the Implementation of the Free Maternal Care Policy. Public Health. Available 

at: http://digitalcommons.hsc.unt.edu/theses/78/. 

Qazi, Z., 2011. Neonatal Care ( EmONC ) Needs Assessment in Selected Health 

Facilities in NEZ , Puntland - September 2011. 

Turab, A. et al., 2013. Improved accessibility of emergency obstetrics and newborn 

care ( EmONC ) services for maternal and newborn health : a community based 

project. 

Undesa, 2012. The Millennium Development Goals Report. , pp.2000–2008. 

 Gijs Walraven MD, Wanyonyi, & Stones, 2008 

 

 

 

 

 

 

 

 

 

 
 

 



 

 

49 

 

APPENDEX A 
 

CHECKLIST ON EmONC (MPH ENSIGN COLLEGE OF PUBLIC HEALTH) 

Interviewee Name 
________________________________________________________________________ 

Date (dd/mm/yyyy): ___ / ___ / ___   INSTITUTION 
…………………………………………………………………………………..              
Instructions:    “parenteral” means by injection, either intramuscular or intravenous. 
 
 

1. Have antibiotics been administered 
parenterally in the last 3 months? 

Yes .........................................................1 
No ..........................................................0 

If “Yes,” skip 
to Item 4 

2.  If parenteral antibiotics were NOT 
administered in the last 3 months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 
___________________________ 

Spontaneously         Not mentioned 
mentioned 
 
 
 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 

 

3. If parenteral antibiotics were NOT 
administered in the last 3 months, 
were they administered in the last 
12 months? 

Yes .........................................................1 
No ..........................................................0 

 

4.  If parenteral antibiotics were NOT 
administered in the last 3 months, 
were they administered in the last 
12 months? 

Yes .........................................................1 
No ..........................................................0 

 

5 Have oxytocics been administered 
parenterally in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 7 

6 If parenteral oxytoxics were administered in 
the last 3 months, which type of oxytocic 
was used? 
(circle one) 

Oxytocin ................................................ 1 
Ergometrine .......................................... 2 
Both ...................................................... 3 
Other (specify)....................................... 4 

 

All responses 
to this item 
skip to 
Item 10 

7. If parenteral oxtyoxics were NOT 
administered in the last 3 months, why? 
(circle 1 for all spontaneous 
answer; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 

Spontaneously        Not mentioned   
Mentioned 
1                                0 
1                                0 
1                                0 
1                                0 
1                                0 
1                                0 
1                                0 

 

 

8. If parenteral oxytocics were NOT 
administered in the last 3 months, were 
they administered in the last12 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 10 

9. If parenteral oxytocics were administered in 
last 12 months, which type of oxytoxic was 
used? 
(circle one) 

Oxytocin ................................................ 1 
Ergometrine .......................................... 2 
Both ...................................................... 3 
Other (specify)....................................... 4 

 



 

 

50 

 

10.  Is misoprostol used in this facility for 
obstetric indications? 

Yes ....................................................... 1 
No ......................................................... 0 

 

11 Have anticonvulsants been administered 
parenterally in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 13 

12 If parenteral anticonvulsants were 
administered in the last 3 months, which 
type of anticonvulsant was used? 
(circle one) 

Magnesium sulfate ............................... 1 
Diazepam ............................................. 2 
Both ...................................................... 3 
Other (specify)....................................... 4 
_________________________________ 

All responses 
to this item 
skip to 
Item 16 

13 
 
 
 
 
 
 
 
 

If parenteral anticonvulsants were 
NOT administered in the last 3 months, 
why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify 

Spontaneously                  Not mentioned 
Mentioned 
 
 
 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 

 

14 If parenteral anticonvulsants were 
NOT administered in the last 3 months, 
were they administered in the last 12 
months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 16 

15. If parenteral anticonvulsants were 
administered in last 12 months, which type 
of medication was used? 
(circle one) 

Magnesium sulfate ............................... 1 
Diazepam ............................................. 2 
Both ...................................................... 3 
Other (specify)....................................... 4 

 

16 
 

Has manual removal of placenta been 
performed in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

 

If “Yes,” skip 
to Item 19 

17. If manual removal of placenta was NOT 
performed in the last 3 months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human 
resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 

Spontaneously        Not mentioned 
Mentioned 
 
 
 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 
1                               0 

 

18.  If manual removal of placenta was 
NOT performed in the last 3 months, has it 
been performed in the last 12 months? 

Yes ....................................................... 1 
No ......................................................... 0 

 

19. Has removal of retained products been 
performed in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 21 

20 If removal of retained products was 
performed in last 3 months, which method 
was used? 
(read options) 
a. Vacuum aspiration 
b. Dilatation and curettage (D&C) 
c. Dilatation and evacuation (D&E) 
d. Misoprostol 

Yes                       No 
 
 
 
1                            0 
1                            0 
1                            0 
1                            0 

 

21 If removal of retained products was NOT 
performed in the last 3 months, why? 

Spontaneously            Not mentioned 
Mentioned 

 



 

 

51 

 

(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify 

 
 
 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
1                                        0 

22. If removal of retained products was NOT 
performed in the last 3 months, has it been 
performed in the last 12 months? 

Yes ........................................................1 
No ..........................................................0 

 

23 
 
 
 

If removal of retained products was 
performed in last 12 months, which method 
was used? 
(read options) 
a. Vacuum aspiration 
b. Dilatation and curettage (D&C) 
c. Dilatation and evacuation (D&E) 
d. Misoprostol 
 
 

 

Yes                                  No 
 
 
 
1                                        0 
1                                        0 
1                                        0 
1                                        0 
 
 
 

 

 

24 Has assisted vaginal delivery (vacuum or 
forceps) been performed in the last 3 
months? 
 

Yes ........................................................1 
No ..........................................................0 
 
 

 

25 If assisted vaginal delivery was performed 
in last 3 months, what instrument was 
used? 
(circle one) 

Vacuum extractor ..................................1 
Forceps ..................................................2 
Both .......................................................3 

 

 26 
 
 
 

If assisted vaginal delivery (vacuum or 
forceps) was NOT performed in the last 3 
months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify 

 
Spontaneously                Not mentioned 
Mentioned 
 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 

27 If assisted vaginal delivery 
(vacuum or forceps) was NOT 
performed in the last 3 months, 
has it been performed in the last 
12 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 29 

28 If assisted vaginal delivery was performed 
in last 12 months, what instrument was 
used? 
(circle one) 

Vacuum extractor ................................. 1 
Forceps ................................................. 2 
Both ...................................................... 3 

 

29 Has newborn resuscitation with bag and 
mask been performed in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “Yes,” 
skip to 
Item 32 



 

 

52 

 

30 If newborn resuscitation with bag and mask 
was NOT performed in the last 3 months, 
why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify 

Spontaneously                Not mentioned 
Mentioned 
 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 

31 If newborn resuscitation with bag and mask 
was not performed in the last 3 months, 
has it been performed in the last 12 
months? 

Yes ....................................................... 1 
No ......................................................... 0 

 

 
32 

 
Has a cesarean been performed in the last 
3 months? 

 

 
Yes ....................................................... 1 
No ......................................................... 0 

 
If “Yes,” skip to 
Item 35 

33 If a cesarean was NOT performed in the 
last 3 months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 

Spontaneously                Not mentioned 
Mentioned 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 

34 If a cesarean was NOT performed in the 
last 3 months, has it been performed in the 
last 12 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” 
skip to 
Item 36 

35 What type of anesthesia is currently used 
when performing a cesarean delivery? 
(read options 
out loud) 
a. General 
b. Spinal/epidural 
c. Ketamine 
d. Other (specify 

Yes                                  No 
 
 
 
1                                        0 
1                                        0 
1                                        0 
1                                        0 

 

36 Has blood transfusion been performed in 
the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 38 

37 If blood transfusion was performed in the 
last 3 months, describe the primary supply 
of blood. 
(circle one) 

Blood comes from central blood bank . 1 
Blood comes from a facility blood bank .2 
Blood is collected from family or 
friends as needed 
(i.e., direct transfusion) ......................... 3 
Other (specify) ...................................... 4 

All 
responses 
to this item 
skip to 
Item 41 

38 If blood transfusion was NO performed in 
the last 3 months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify 

Spontaneously                Not mentioned 
Mentioned 
 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 



 

 

53 

 

39 If blood transfusion was NOT performed in 
the last 3 months, has it been performed in 
the last 12 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “No,” skip 
to Item 37 

40 If blood transfusion was performed 
in the last 12 months, describe the 
primary supply of blood: 
(circle one) 

Blood comes from central blood bank. 1 
Blood comes from a facility blood bank  2 
Blood is collected from family 
or friends as needed 
(i.e., direct transfusion) ......................... 3 
Other (specify) .......................................4 

 

41 Does staff routinely practice active 
management of the third stage of labor? 

Yes ....................................................... 1 
No ......................................................... 0 

 

42 Has a partograph been used to manage 
labor in the last 3 months? 

Yes ....................................................... 1 
No ......................................................... 0 

If “Yes,” 
skip to 
Item 43 

43 If a partograph has NOT been used to 
manage labor in the last 3 months, why? 
(circle 1 for all spontaneous 
answer; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 

Spontaneously                Not mentioned 
Mentioned 
 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 

44 Has a breech delivery been performed in 
the last 3 months? 

Yes ...................................................... 1 
No ....................................................... 0 

 

45 If a breech delivery was NOT performed in 
the last 3 months, why? 
(circle 1 for all spontaneous 
answers; otherwise circle 0) 
a. availability of human resources 
b. training issues 
c. supplies/equipment/drugs 
d. management issues 
e. policy issues 
f. no indication 
g. other (specify) 

Spontaneously                Not mentioned 
Mentioned 
 
 
 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 
1                                                0 

 

 

 

 

 

 

 

 



 

 

54 

 

APPENDEX B 
 

CHECKLIST ON ROUTINE NEWBORN CARE 

46 Thermal protection YES  -  1               NO -  0 

47 Immediate and exclusive breastfeeding YES  -  1               NO -  0 

48 Hygienic cord care YES  -  1               NO -  0 

49 Anti-biotics to mother if preterm/prolong PROM YES  -  1               NO -  0 

50 Corticosteriods in preterm mother YES  -  1               NO -  0 

51 Resuscitation with bag and mask of non-breathing 
baby 

YES  -  1               NO -  0 

52 KMC for premature/very small babies YES  -  1               NO -  0 

53 Alternative feeding if baby unable to breastfeed YES  -  1               NO -  0 

54 Injectable antibiotics for neonatal sepsis YES  -  1               NO -  0 

55 (PMTCT) if HIV positive mother YES  -  1               NO -  0 

   

 COMPREHENSIVE EmNC  

56 Intravenous fluids YES  -  1               NO -  0 

57 Safe administration of oxygen YES  -  1               NO -  0 

58 Availability of incubator YES  -  1               NO -  0 

 

 

 

 

 

 

 

 

 

 

 



 

 

55 

 

APPENDEX C 
 

SUPERVISION CHECKLIST FOR HOSPITAL 

 AVAILABILITY Comments (Eg .,reasons for 

nonavailability 
Doctors\obstetricians YES-1                 NO-0  

Nurse\midwives YES-1                 NO-0  

Anaesthetist YES-1                 NO-0  

Theatre attendant YES-1                 NO-0  

Oxytocics YES-1                 NO-0  

Anticonvulsants YES-1                 NO-0  

Procaine penicillin YES-1                 NO-0  

Crystalline penicillin YES-1                 NO-0  

Gentamycin YES-1                 NO-0  

Metronidazole YES-1                 NO-0  

Ampicillin YES-1                 NO-0  

Local anaesthetics YES-1                 NO-0  

General anaesthetic YES-1                 NO-0  

Oxygen YES-1                 NO-0  

Labour Room   

Vacuum extractor YES-1                 NO-0  

IV infusion sets YES-1                 NO-0  

IV fluids YES-1                 NO-0  

Ovum forceps YES-1                 NO-0  

Vaginal speculum YES-1                 NO-0  

Artery forceps YES-1                 NO-0  

Needles YES-1                 NO-0  

Sutures YES-1                 NO-0  

Syringes YES-1                 NO-0  

Sterilizer YES-1                 NO-0  

Scissors YES-1                 NO-0  

Curette YES-1                 NO-0  

Sphygmomanometer YES-1                 NO-0  

Microscope YES-1                 NO-0  

Test tubes YES-1                 NO-0  

Slides YES-1                 NO-0  

Blood bags YES-1                 NO-0  

Anti-sera YES-1                 NO-0  

Storage capability YES-1                 NO-0  

IV fluids YES-1                 NO-0  

Ovum forceps YES-1                 N