The facility assessment results illustrate the serious gaps in existing RH services among general referral hospitals in the DRC and suggest areas where improvement can be made in order to make good quality RH services accessible to the population.
General infrastructure
Issues of general infrastructure such as renovations to physical structures; re-organization of client flow through the facility; and installation or improvement of power, water, sanitation and waste management systems must be addressed to facilitate effective infection prevention and the provision of good quality RH services [27]. It is imperative for all facilities to maintain an adequate and sufficient water supply and to have clean water available inside the hospital. All hospitals must have at least two sources of electrical power, to ensure that power is available at all times without (or with minimal) interruption. Both primary and backup power systems require regular maintenance so that power outages are avoided.
Commodities management
Commodity security and management were clear gaps that were identified in all of the facilities. At the time of the facility assessments, most facilities lacked the essential drugs, equipment and supplies, such as ampicillin, oxytocin, needles and syringes, needed to perform signal functions. Of the two hospitals that had provided short- and long-term FP methods in the prior three months, only one hospital had any FP counseling materials. Three hospitals indicated that despite having trained staff, they never stocked FP methods. Various reasons for not procuring FP supplies were mentioned by staff: they assumed women did not want FP or they feared the religious missions that managed the hospitals would prohibit the provision of FP.
The six hospitals with the essential package to provide parenteral anticonvulsants used diazepam, a less effective treatment for eclampsia [39]. Magnesium sulfate, the simplest and most effective treatment of eclampsia, was available in only one hospital. Updated RH protocols and essential drugs lists must reflect the most modern and effective drugs, equipment and procedures; these drugs and equipment must be available to procure in the country; and staff must be trained to ensure their appropriate use.
Interventions are limited if effective and reliable medical supplies and equipment are unavailable. The lack of these inexpensive, basic supplies demonstrates the need for systems to manage drug and supply chains. Insufficient support and poorly functioning systems during years of war mean few or no staff have the skills to properly manage a supply system. Training for hospital managers and medical personnel on drug and equipment procurement and management must be prioritized.
Staffing
Implicit in the definition of an EmOC facility is that the signal functions be available to women 24 hours a day and seven days a week since demand for EmOC services cannot be predicted. The primary obstacle to the 24 hour provision of EmOC in the facilities studied was the lack of the essential health workers at the facility. According to the DRC's national protocol, a general referral hospital with 100 beds serving a population of 100,000 should have at least three doctors, one anesthetist and 16 nurses [40]. The majority of the hospitals assessed had fewer than this minimum. Unsurprisingly, the hospitals located in more remote and isolated areas had fewer staff than those in more urban or accessible areas. In many cases, the health zone medical officer (Médecin chef de zone) was counted as a doctor at the hospital despite his other non-clinical duties. The lack of a doctor is of particular importance with regards to procedures, such as cesarean deliveries, that only a doctor is authorized to perform. In some facilities, nurses were unofficially trained to perform cesareans. The researchers were unable to determine which procedures each level of provider was authorized to perform having received inconsistent responses from different MOH officials. Supporting the hiring and retention of skilled health workers at the facility (through provision of adequate housing and regular payment of salaries) and reviewing policies to expand the scope of services performed by non-physician clinicians would help improve 24 hour availability of EmOC [13, 33] and make a broader range of FP methods available at health facilities.
Training
Competency-based clinical training and continuing education are crucial to enable the health system to provide good quality care. In the nine hospitals assessed, lack of training was a barrier to the provision of both FP and EmOC services and was consistently ranked as the main reason that facilities did not provide RH services. For example, none of the nine hospitals was able to perform an assisted vaginal delivery due in part to lack of training. Conversations with Congolese physicians suggest that this signal function was often de-emphasized in physician training. Continuing education to update health workers on new more effective technologies was lacking as most facilities used outdated procedures and/or drugs. For example, all of the facilities performed dilation and curettage instead of manual vacuum aspiration (MVA), the relatively simple and safe alternative recommended by the WHO, for removal of retained products of conception.
Clinical training, including refresher training, should take into account both RH-specific and health systems approaches. An RH approach to training would provide hospital staff currently providing RH services with procedure-specific up-to-date in-service training. A health systems response to training would include a review of basic medical, nursing and midwifery training curricula to ensure the incorporation of appropriate training for the provision of FP methods, drugs and procedures to treat obstetric complications and infection prevention policies [41]. IRC is creating training centers at five supported hospitals to enable the trained staff to train clinicians from health centers in the health zone.
Infection prevention
Although infection prevention practices at all of the hospitals were inadequate, this is an area in which low cost, low technology interventions can make a difference. Infection prevention policies and procedures are effective and relatively simple to implement. It is essential that all facility staff, whether they provide clinical care or not, be trained in good infection prevention practices and that the necessary equipment and supplies, such as incinerators and sharps containers, be available so that infection prevention policies and procedures can be followed. Even where EmOC or FP services are available, failure to follow infection prevention procedures can put both staff and patients at unnecessary risk and result in poor clinical outcomes.
Policies and protocols
The availability and delivery of RH services are affected by national health policies and protocols; the omission of newer, safer and easier to use drugs and procedures from the DRC's RH policies and protocols has affected the availability of RH services at the studied facilities. Misoprostol, for example, an effective, inexpensive and easy-to-administer drug which can be used to prevent post-partum hemorrhage [42], is not included in the DRC's national RH norms. Although MVA does appear in the national RH norms [43], it is not consistently referenced in national RH policy documents. Further, MVA is found only in the norms for hospitals but not for health centers despite evidence that MVA can be safely provided at the health center level and performed by non-physician clinicians [44, 45].
Even when updated RH policies were in place, some discrepancies between policy and practice were noted. Although some new drugs or procedures have been included in recent revisions of national health protocols, the lack of training or failure to procure the necessary drugs and equipment prevented their use. For example, magnesium sulfate, which is on the essential drugs list, was available in only one of the nine hospitals assessed. Non-governmental organizations (NGOs) working in the DRC have reported difficulty in identifying a local source for procurement. Likewise, differences were noted between the standard equipment for general referral hospitals designated by national policy and what was actually observed in the hospitals assessed. For example, vacuum extractors and MVA kits were included in the standard equipment list for a hospital in the DRC, yet most of the hospitals did not have this equipment [15]. In addition, neither appeared in the MOH definitive list of RH commodities to be secured [46]. Reasons for these discrepancies are not known, but could include the lack of effective equipment management and planning by the hospital or MOH or the active discouragement of the use of the procedures (for example, by encouraging the use of cesarean over assisted vaginal delivery). As noted previously, even if these equipment were available, staff in half of the hospitals lacked training to use them. It is imperative not only for updated and more effective drugs and procedures to be consistently included in national policies but also for the MOH to facilitate their use and implementation in health facilities through training and procurement.
Referral systems
Effective, functioning referral systems are critical to the accessibility of RH services. All of the hospitals assessed are local referral hospitals for EmOC, yet travel to these hospitals may not be feasible for women experiencing obstetric complications because of distance, cost of transportation or poor road infrastructure. The lack of ambulances is a serious problem throughout the DRC; however, in some of the rural areas where these hospitals are located, roads are impassable to four-wheel vehicles during rainy season. Where transport is extremely difficult, CARE is ensuring that basic EmOC is available in health centers that are furthest and least accessible to the hospital. Alternative transportation options, such as motorcycle ambulances, bicycle taxis and commercial vehicles should be explored. Community savings groups, community insurance and income generation activities are all approaches that might be used to assist women and their families to pay for these critical services [47].
Information systems, monitoring and evaluation
A key feature of a sustainable and functioning health infrastructure is the assessment, monitoring and evaluation of services [33]. The UN Process Indicators have been shown effective tools to guide the design of EmOC programs and to monitor the provision of EmOC services [13, 48]. In the nine hospitals assessed, monitoring of EmOC was virtually nonexistent. The obstetric registers were so poor that it was difficult to determine reliable baseline levels for some of the UN Process Indicators. Monitoring performance allows facility staff to better understand which service areas are not functioning and the reasons why so that they can initiate improvements. At the facility level, all staff should receive training, regular supervision and support in maintaining and using monitoring systems.
Obstetric registers should be revised so that key data are included and less important data are excluded. Standard case definitions should be shared with all staff working in the maternity; the staff must understand the importance of collecting good quality data and how to use these data. Monitoring of services can help the facility management better understand patient flow and volume, which has implications for needed program inputs [10]. Furthermore, consistent monitoring using the UN Process Indicators has proven to be an effective way to assess maternal mortality reduction and improve the functioning of EmOC facilities [49]. In addition, facilities may wish to collect other information to gain more insight into the quality of care including the time elapsed between a woman's admission to an EmOC facility and her actual receipt of treatment, and detailed case reviews of both maternal deaths and 'near misses' (i.e., women who experience an obstetric complication, are treated in the facility and survive) [13, 50].
Study Limitations
The facility assessment only provides a snapshot of staff, services, equipment and supplies that were available and functioning on the day of the assessment and cannot evaluate those that were available at any other period of time. It is feasible that a hospital may have been able to provide certain services in the past but was classified as not being capable of doing so due to the lack of essential drugs, equipment, staff or supplies on the day of the assessment. In addition, this assessment did not explore the quality of the services provided by individual health workers. Despite these limitations, it is clear that major improvements are needed at all of the hospitals assessed.