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Bruce Campbell


The Zimbabwe maternal and neonatal assessment provides data for the Ministry of Health and Child Welfare (“the Ministry”) to base policy, planning and other managerial and clinical decisions. It was designed in 2005 and completed by the Ministry in 2006, in close collaboration with UNFPA, UNICEF and WHO. Selected midwifery staff were involved in pre-testing and data collection. The assessment was intended to be the basis for a maternal and neonatal health road map, and allow the Ministry to find and use the most cost-effective interventions to reduce maternal and neonatal morbidity and mortality. Availability of baseline data would aid efforts to implement more evidence-based and results-oriented programming.


Cost considerations prevented designing the assessment so that it could measure the population-based maternal mortality ratio.


The assessment focused on shortages of supplies, the loss of professional staff, and the steady deterioration of infrastructure in the health system to understand the state of maternal and neonatal health services in Zimbabwe. The Ministry made the last reproductive health assessment in 1999, focusing largely on staffing and supplies. The 2005-6 study aimed to update essential information for effective and focused interventions within one year, as well as longer-term development initiatives for 2007-2011, the duration of the UN development assistance framework.


The broad objectives of the assessment were:

To assess availability, use and where possible, quality of MNH in Zimbabwe.
To fill gaps in knowledge about the leading causes of maternal death, including the “three delays”1 in accessing care, as well other avoidable factors at all levels of the health system (family and community; primary or clinic; secondary or district hospitals; tertiary or provincial hospitals and quarternary or referral hospitals). The concept of the “three delays” provides a practical framework to unravel and address the relevant factors for reducing maternal mortality.


Specific objectives were:

At the community level, to assess:

– knowledge of MNH issues amongst selected community members.

At each of the four institutional levels, to assess:

– accessibility of care;

– availability of staff;

– availability of essential drugs and supplies for MNH;

– availability of equipment.

To identify factors preventing adequate provision and use of quality MNH services and recommend actions to address each of the three delays. The concept of "the three delays" provides a practical framework through which factors relevant to the reduction of MMR can be unravelled and effectively addressed.

As part of their commitment to improve reproductive health throughout the country, the Ministry made adequate and accessible MNH services a priority. The MNH assessment concentrates on the rapidly declining conditions of the health system (shortages of professional staff and supplies, as well as deterioration of infrastructure) in order to learn about the state of MNH services in the country.


The basic questions were:

what were the avoidable factors associated with each of the three delays, at each
   level of the health system?

what resources were already in place to address those factors, such as human    resources, equipment and supplies, emergency transportation and communication?

what specific interventions would be most likely to reduce maternal and neonatal    morbidity and mortality?


The Ministry conducted the assessment in partnership with UNICEF, WHO and UNFPA, which are all committed, as part of their respective mandates, to support national efforts to reduce maternal and neonatal morbidity and mortality. Stakeholders during the instrument design stage included health workers, community leaders and family members. 


Choice of methodology The national assessment started with a rapid review of tools and methodologies, in search of a proven approach easily adapted to the Zimbabwean context. The instruments and methodology of Columbia University’s Averting Maternal Death and Disability (AMDD) programme were identified as a good starting point.3 The assessment was then designed to solicit information from sub-district, district, provincial and national level health personnel in relation to their MNH tasks and functions, and volunteer informants from the community. The study used seven different assessment tools, one for each of four institutional levels and the community, one for women of reproductive age (15-45); one for men; and one for young people.


Choice of Indicators A list of indicators for monitoring MNH programmes was jointly developed by WHO, UNFPA and UNICEF. The UN process indicators were based on the understanding that certain types of obstetric services must be available in order to prevent maternal deaths. The indicators give an idea as to whether programmes are saving women's lives.


Process indicators used were:

Skilled attendance at delivery;

Number of facilities providing basic emergency obstetric care per 500,000 population;

Number of facilities providing comprehensive emergency obstetric care
   per 500,000 population;

Met need: the proportion of all obstetric complications which were treated
   in MNH facilities;

C-section as a proportion of all births in the catchment population;

Case fatality rate: maternal deaths among women admitted with obstetric complications;

Maternal mortality ratio: maternal deaths per 100,000 live births;

Perinatal mortality ratio: newborn deaths per 1000 live births.


Choice of tool Generic, structured UN questionnaires and checklists developed by AMDD and UNICEF were used for the assessment. A preliminary meeting of all stakeholders adapted them to suit the Zimbabwean situation.

Comprehensive checklists were adopted, listing essential drugs and supplies, and    appropriate instruments and related equipment per level of health facility.

A different questionnaire was used for each of the four institutional levels, each one    tailored to the appropriate level for staff cadres, equipment, essential drugs and supplies.    The questionnaires were analysed and issues identified for each of the four levels.

The respondent to the questionnaire was the most senior person directly involved in the    provision of MNH services at the institution at each of the four different levels.

For the community element of the study, three different questionnaires were used: one    for women of reproductive age (15-45); one for men; and one for young people.

Three community members from each of these three categories were interviewed for    each health facility visited. In total, 646 women, 769 men, and 1,615 youth were    interviewed. The average age of women was 27.6, with a mean of three pregnancies.

Female respondents were women who had been pregnant in the previous two years.    Male respondents were husbands or spouses of women who had been pregnant in the    previous two years.

The community-level instrument was designed to assess first, the individual's knowledge    about possible complications during pregnancy and childbirth, and second,
   health-seeking behaviour if complications occur.

One of the enumerators of the assessment team conducted the staff interview.

The review of the availability of essential drugs, supplies and equipment was part of the    staff interview. For example, the inventory of selected essential drugs and equipment
   was conducted by asking nurses in charge or medical personnel on duty, and
   by physically checking that supplies were available and equipment was present
   and functioning.


Costs and funding The costs for the assessment included two consultants; adaptation of instruments; pre-testing of instruments and simultaneous training of enumerators; transport and logistics; per diem for the enumeration team, and three stakeholder meetings. Funding was secured largely from UNFPA core resources, with technical assistance input from WHO and UNICEF as well as UNFPA. A technical writer put together the final report. Total costs were in the range of $US 80,000.


Human resources For the interviewing, 40 senior health personnel from the provinces were trained as enumerators, supervised by 10 senior provincial managers. A three-day workshop to train enumerators and supervisors was facilitated by the two consultants, the Ministry’s reproductive health coordinator and partners from UNICEF, WHO and UNFPA. The objectives were to enhance interviewing knowledge and skills, and to review and practise tools and data collection techniques. The group was split into ten provincial teams of four enumerators and a supervisor. In order to minimize bias, none of the enumerators came from the province in which they worked; but supervisors were drawn from their home provinces, to interpret the particularities of the health system and people in that province. At national level, four two-member teams supervised the completed fieldwork.


Staff members in the selected institutions were interviewed by each of the four team members, The supervisor's role was to continuously check the quality of the data gathered in the field and to collect the questionnaires once they had been completed. The supervisors were also responsible for sending the completed questionnaires to the supervisory teams at Ministry headquarters.


Technical assistance Two national consultants were hired to supervise and lead the training of the required data collection teams, the training of data entry clerks, and to analyse and finalise the outcome of the study. Terms of reference for this task required that the consultants had previous demonstrated capacity in supporting assessments of a similar nature.


Analysis and Dissemination
The findings and recommendations of the study were to be used by the Ministry for policy review and development of the national MNH road map, with special emphasis on the reduction of morbidity and mortality. The results were also disseminated through workshops with staff from studied facilities, and continued exchanges with managers and policy makers throughout the development of the road map.

Linking Needs Assessment to Implementation

The link between the needs assessment and implementation was established at the outset. The assessment was designed around avoidable factors contributing to each of the three delays, and in this way provided a framework for the MNH road map. In fact, the executive summary of the MNH assessment became the overall outline for the now fully costed MNH road map. Also, it is important to note, that designing the assessment in this way ensured an inextricable linkage between the assessment and follow-up action.


Previous experience, literature and common sense provided some ideas about possible interventions even before the assessment began. Mapping ideas for interventions in line with each of the three delays provided a practical framework for both the assessment and the subsequent road map. Indicators were selected that would answer questions about each of the three delays, as well as questions about potential interventions to overcome each delay. Also, it is very important to note that the assessment made every attempt to identify indicators that could be routinely monitored through HMIS, logistics MIS, DHS, and other existing data sets. This can make all the difference between a one-time assessment and a living programming process. Those responsible can monitor progress on a monthly or annual basis, and chart results (or their absence). The programme remains
dynamic, always adapting and responding to priority needs in the most cost-effective manner possible.


A sample questionnaires used by this tool can be found at:
the Bank of Sample Questionnaire

Zimbabwe Photo

© Milton Grant/United Nations

1 First Delay: Recognizing the need for medical care, and in deciding when to seek medical care
Second Delay: Reaching a medical facility that provides needed care.
Third Delay: Receiving adequate and
appropriate treatment

2 Indicators for Monitoring the Availability and Use of Obstetric Services: A Handbook.  WHO, UNFPA, UNICEF, Columbia University.

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