Objective
We sought to describe obstetric care capacity of nongovernment organization (NGO)-/faith-based organization (FBO)-run institutions compared to government-run institutions in 3 African countries using the World Health Organization Global Survey. We also compared delivery characteristics and outcomes.
Study Design
This is a descriptive analysis of the 22 NGO-/FBO-run institutions in Uganda, Kenya and Democratic Republic of Congo delivering 11,594 women, compared to 20 government-run institutions delivering 25,825 women in the same countries and period.
Results
Infrastructure, obstetric services, diagnostic facilities, and anesthesiology at NGO/FBO institutions were comparable to government institutions. Women delivering at NGO/FBO institutions had more antenatal care, antenatal complications, and cesarean delivery. NGO/FBO institutions had higher obstetrician attendance and lower rates of eclampsia, preterm birth, stillbirth, Apgar <7, and neonatal near miss.
Conclusion
NGO/FBO institutions are comparable to government institutions in capacity to deliver obstetric care. NGO/FBOs have been found effective in providing delivery care in developing countries and should be appropriately recognized by stakeholders in their efforts to assist nations achieve international goals.
Of the 358,000 maternal and 4 million neonatal deaths occurring annually worldwide, most are avoidable and 99% occur in developing countries, where many women deliver at home unattended and reporting of adverse outcomes is unlikely. In 2002, the United Nations (UN) Millennium Development Goals (MDGs) 4 and 5 aimed to reduce the under-5 mortality rate by two-thirds and the maternal mortality ratio by three-quarters and to ensure universal access to reproductive health care. The 2005 World Health Report identified the need for partnerships to bridge the gap between knowledge and action in improving maternal and newborn health. These partnerships can bring together governments and UN agencies with donors, nongovernment organizations (NGOs), and faith-based organizations (FBOs) to develop innovative approaches to improve access to care. This was echoed by the UN Global Strategy on Women’s and Children’s Health, which in 2010 called for civil society to strengthen community capacity and advocate for further investment in women’s and children’s health. FBOs specifically can fill gaps in health services due to the technically efficient service they already provide in many low-income countries. Stronger partnerships can bring the capacity of NGOs and FBOs to achieving MDG 4 and 5.
Institutions run by FBOs have long provided a significant volume of health care in rural, poor, or politically unstable areas of the world where governments are unable to provide consistent and adequate health services. In several developing countries, including Haiti, Cameroon, Ghana, Malawi, Zambia, Uganda, Bolivia, Indonesia, and India, FBO hospitals are integrated into the public health system and provide up to 50% of health services. In 2006, the World Health Organization (WHO) estimated that 30-70% of health infrastructure across Africa is owned or run by FBOs. A 2008 review of mission hospitals identified positive working environments, financial support, access to trained expatriate experts, effective human resources, reliable supplies of essential medicines, and a high standard of clinical care as the key strengths of FBO-run hospitals. However, to the best of our knowledge, the capacity, quality, and contribution of FBO-run hospitals to maternal and newborn care has not been extensively examined.
In 2011, a systematic review examined the contribution of FBOs to maternal and newborn health in Africa over the last 2 decades. Only 6 articles were found, indicating the significant gap in the literature on this issue. The review concluded that FBOs provide a comparable service to government hospitals in maternal and newborn health, with a high quality of care and patient satisfaction. Greater efforts to analyze FBO-based care are required to understand and quantify their role and value in the current global health context.
This study aimed to describe the infrastructure and obstetric care capacity of African NGO/FBO institutions compared to government-run institutions operating in the same countries, using the database of the WHO Global Survey on Maternal and Perinatal Health (WHOGS). We also aimed to compare individual-level characteristics and outcomes of women and newborns delivering in those institutions.
Materials and Methods
The WHOGS is a multicountry, cross-sectional survey that collected data on all deliveries in participating institutions over a 2- or 3-month period (depending on annual volume of deliveries). Over 290,000 women delivering in 373 randomly selected institutions from 24 countries across Africa, Latin America, and Asia were included. The study was conducted from 2004 through 2005 (Africa and Latin America) and 2007 through 2008 (Asia). This analysis used the African WHOGS data set of 83,437 deliveries across 7 countries (Algeria, Angola, Democratic Republic of Congo (DRC), Kenya, Niger, Nigeria, and Uganda).
The methodological details of the survey have been published previously. In brief, a stratified, multistage sampling design was used to obtain a sample of countries and health institutions worldwide. Countries in WHO regions were grouped according to mortality levels for adults and children younger than 5 years and countries were selected from each subregion (probability proportional to population). In each country, the capital city and 2 randomly selected provinces (probability proportional to population size) were selected. In each province, 7 institutions were randomly selected (probability proportional to births per year) from a census of institutions with >1000 births per year and able to perform cesarean sections (CS). Trained data collectors reviewed medical records of deliveries to complete the individual data forms. An institutional form was completed by the hospital coordinator and the head of the obstetrics department on infrastructure and available obstetric, laboratory, and anesthesiology services.
We conducted an online questionnaire of WHOGS country coordinators to identify African institutions administrated by governments, NGOs, or FBOs. We defined NGOs as independent societal organizations that are private and not for profit. We defined FBOs as independent, not-for-profit religious organizations. Government-run institutions were defined as those administered by national, regional, or local governments or ministries of health within the same countries as the NGO-/FBO-run institutions. Deliveries occurring in institutions run privately, by universities, or by other organizations that did not fall in our 2 categories were excluded from this study.
This study focused on institutional care provided to mothers and newborns during delivery and postpartum. Only deliveries >20 weeks’ gestation were included. Deaths (mother or fetus) before admission, after discharge, or after seventh day postpartum were excluded. We compared institutional services and selected individual-level maternal and perinatal outcomes in NGO-/FBO-run institutions to government-run institutions in the same countries. Institutional services included infrastructure, hospital services (eg, blood bank and intensive care unit [ICU]), equipment for intrapartum care, laboratory tests, anesthesiology services, and patient expenses. The maternal and perinatal outcomes were maternal mortality, eclampsia, severe adverse maternal outcome, low birthweight (<2500 g), very low birthweight (<1500 g), preterm birth (<37 weeks’ gestation), stillbirth (fresh or macerated stillbirth), 5-minute Apgar score, neonatal death, and neonatal near miss. We defined “maternal medical complication” as ≥1 of: chronic hypertension, cardiac/renal disease, respiratory disease, diabetes, malaria, sickle cell anemia, or urine infection/pyelonephritis. We also defined “antenatal obstetric complication” as ≥1 of: premature rupture of membranes, pregnancy-induced hypertension, severe anemia, or vaginal bleeding in the second half of pregnancy. “Severe adverse maternal outcome” was defined as ≥1 of: admission to ICU, blood transfusion, or hysterectomy. “Neonatal near miss” was defined as ≥1 of: delivery <31 weeks, birthweight <1500 g, or 5-minute Apgar <5. These criteria were proposed and have been applied in previous analyses of the WHOGS. We performed descriptive analyses of FBO/NGO vs government institutions at the country level and an overall (grouped) level. Data were compared using Pearson χ 2 test and 1-way analysis of variance tables. P < .05 was considered statistically significant. Ethical clearance from all ministries of health of participating countries, WHO Ethics Review Committee, and subregional ethical boards was obtained.
Results
Our online survey identified 22 FBO/NGO institutions in the African data set (19 FBO and 3 NGO): 11 in the DRC, 6 in Kenya, and 5 in Uganda. We also identified 20 government-run institutions: 13 in Kenya, 5 in DRC, and 2 in Uganda. In total, 11,594 women (26.7% of all WHOGS deliveries for these 3 countries) delivered in the 22 FBO/NGO institutions and 25,825 women (59.4% of all WHOGS deliveries in these countries) delivered in the 20 government institutions during the study period. The remaining 13.9% delivered in other types of institutions that were excluded from this study ( Figure ). Trends in institutional variables were very similar across countries, whereas there was some heterogeneity for selected individual outcomes.
Characteristics of institutions
Over half of institutions were urban (14 FBO/NGO and 11 government) and there was no significant difference in level of facility ( P = .156). Essential infrastructure availability (reliable water, sewage, electricity, generator, refrigeration, telephone, radio call, ambulance, and emergency referral systems) was not significantly different except for generator (NGO/FBO 90.9% vs government 60%) and radio call equipment (50% vs 0%). Table 1 illustrates available obstetric services; availability of a biochemical laboratory (95.2% vs 70%), ability to administrate magnesium sulfate (86.4% vs 55%), and use of electronic fetal monitoring (31.8% vs 5%) were higher in NGO/FBO institutions, whereas availability of anesthesiology and other services were not significantly different. However, in Uganda, magnesium sulfate availability (60% vs 100%) was lower in NGO/FBO institutions and no institutions used electronic fetal monitoring (0% vs 0%). Routine diagnostic tests of pregnancy (protein in urine, HIV, malaria, and syphilis) were also not significantly different between institutional types (data not shown). Nearly all institutions charged a fee for delivery, however provision of delivery gowns was significantly higher at NGO/FBO institutions (61.9% vs 20%) (data not shown).
| Variable | NGO/FBO | Government | χ 2 P value a |
|---|---|---|---|
| n (%) | n (%) | ||
| Total | 22 | 20 | |
| Level of facility | |||
| Primary | 3 (13.6) | 0 (0.0) | .156 |
| Secondary | 13 (59.1) | 16 (80.0) | |
| Tertiary | 6 (27.3) | 3 (15.0) | |
| Other referral level | 0 (0.0) | 1 (5.0) | |
| Location of facility | |||
| Urban | 14 (63.6) | 11 (55.0) | .569 |
| Rural | 8 (36.4) | 9 (45.0) | |
| Blood bank | 16 (72.7) | 15 (75.0) | .867 |
| Adult ICU | 10 (45.5) | 4 (20.0) | .108 |
| Neonatal ICU | 9 (40.9) | 3 (15.0) | .091 |
| Incubator | 15 (68.2) | 10 (50.0) | .346 |
| Biochemical laboratory | 20 (95.2) | 14 (70.0) | .045 |
| Sterilization of equipment | 20 (90.9) | 20 (100.0) | .323 |
| Administer parenteral antibiotics | 22 (100.0) | 20 (100.0) | — |
| Administer parenteral oxytocics | 22 (100.0) | 19 (95.0) | .476 |
| Administer magnesium sulfate | 19 (86.4) | 11 (55.0) | .040 |
| Basic neonatal resuscitation | 21 (95.5) | 17 (85.0) | .333 |
| Perform surgery (hysterectomy) | 17 (77.3) | 19 (95.0) | .187 |
| Perform blood transfusion | 20 (90.9) | 19 (95.0) | .60 |
| Anesthesiology | |||
| 24-h anesthesiologist in facility | 9 (40.9) | 5 (25.0) | .338 |
| Anesthesiologist on call for facility | 7 (31.8) | 4 (20.0) | .491 |
| Fetal/obstetric ultrasound in use at facility | 15 (68.2) | 10 (50.0) | .346 |
| Electronic fetal monitoring in use at facility | 7 (31.8) | 1 (5.0) | .047 |
| Partograph in use at facility | 19 (86.4) | 18 (90.0) | .716 |
Characteristics of women and deliveries
Women delivering at NGO/FBO institutions were more likely to be married and of higher parity, and had more antenatal care ( Table 2 ). They were generally older and more educated, except in DRC. They were more likely to have an antenatal obstetric complication, although government institutions delivered more HIV-positive women than NGOs/FBOs (2.0% v 3.4%). Maternal medical complications were more common in NGO/FBO institutions overall, however country-level analysis showed rates were lower in NGO/FBO institutions in Kenya (7.1% vs 7.4%) and DRC (21.0% vs 46.6%). NGO/FBO institutions had higher rates of instrumental and CS deliveries and obstetrician attendance at birth ( Table 3 ). Overall, nurses and midwives performed approximately three fourths of all deliveries (73.4% vs 75.6%). Obstetrician deliveries were more common in NGO/FBO institutions overall (12.0% vs 1.6%), especially Kenya (49.1% vs 1.5%), however DRC had a lower rate (1% vs 5.4%). Table 4 shows the overall comparison of maternal and neonatal outcomes between FBO/NGO and government institutions. There was some heterogeneity between countries at the individual level. Severe adverse maternal outcomes (3.5% vs 1.7%) were significantly higher in NGO/FBO institutions overall, however rates varied by country: Kenya (1.1% vs 1.7%), Uganda (5.3% vs 1.0%), and DRC (3.3% vs 5.5%). NGO/FBO institutions had consistently lower rates of eclampsia (0.3% vs 0.5%), stillbirth (29.1 vs 37.6 per 1000 deliveries), Apgar <7 (5.5% vs 7.4%), and neonatal near miss (5.0% vs 6.1%) that persisted on country-level analysis. Preterm birth rates were lower in NGO/FBO institutions overall (9.6% vs 10.6%), but not in DRC (11.0% v 5.4%). Neonatal deaths were lower and low birthweight was higher overall in NGO/FBO institutions, however they also showed significant heterogeneity in the subgroup analysis (data not shown).
| Characteristic | NGO/FBO | Government | χ 2 P value a |
|---|---|---|---|
| n (%) | n (%) | ||
| Total | 11,594 | 25,825 | |
| Married | 10,477 (90.4) | 21,491 (83.2) | < .001 |
| Missing | 74 (0.6) | 306 (1.2) | |
| Mean maternal age, y (SD) | 27.22 (6.09) | 24.52 (5.78) | < .001 |
| Missing | 39 (0.3) | 437 (1.7) | |
| Maternal education, y | |||
| ≥10 | 6642 (57.3) | 7864 (30.5) | < .001 |
| 1-9 | 4252 (36.7) | 11,036 (42.7) | |
| 0 | 489 (4.2) | 503 (2.0) | |
| Missing | 271 (2.3) | 6422 (24.9) | |
| Parity | |||
| 0 | 3632 (31.3) | 10,906 (42.2) | < .001 |
| 1 | 2558 (22.1) | 6252 (24.2) | |
| ≥2 | 5358 (46.2) | 8542 (33.1) | |
| Missing | 46 (0.4) | 125 (0.5) | |
| No. of antenatal visits | |||
| ≥4 | 6055 (52.2) | 6657 (25.8) | < .001 |
| 1-3 | 4463 (38.5) | 8639 (33.5) | |
| 0 | 172 (1.5) | 717 (2.8) | |
| Missing | 904 (7.8) | 9812 (38.0) | |
| Diagnosed with HIV | 231 (2.0) | 867 (3.4) | < .001 |
| Missing | 500 (4.3) | 2323 (9.0) | |
| Any medical complication b | 2132 (18.4) | 2966 (11.5) | < .001 |
| Missing | 428 (3.7) | 2283 (8.8) | |
| Any antenatal obstetric complication c | 1475 (12.7) | 2357 (9.1) | < .001 |
| Missing | 9 (0.1) | 41 (0.2) |
a Calculated with missing values excluded;
b At least one of the following: chronic hypertension, cardiac/renal disease, respiratory disease, diabetes, malaria, sickle cell anemia, urine infection/pyelonephritis;
c At least one of the following: premature rupture of membranes, pregnancy-induced hypertension, severe anemia, vaginal bleeding in second half of pregnancy.
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