title: Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-saharan Africa: an integrated approach.
abstract: BACKGROUND
  Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.
  
  
  METHODS
  Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization's maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.
  
  
  RESULTS
  All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.
  
  
  CONCLUSIONS
  Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.
authors.affiliation: Projects Department, Doctors with Africa CUAMM, Padua, Italy; Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.
authors.forename: Calistus
authors.initials: C
authors.lastname: Wilunda
authors.affiliation: Projects Department, Doctors with Africa CUAMM, Padua, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Putoto
authors.affiliation: Projects Department, Doctors with Africa CUAMM, Padua, Italy.
authors.forename: Donata
authors.initials: D
authors.lastname: Dalla Riva
authors.affiliation: Projects Department, Doctors with Africa CUAMM, Padua, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Manenti
authors.affiliation: Projects Department, Doctors with Africa CUAMM, Padua, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Atzori
authors.affiliation: Doctors with Africa CUAMM, Wolisso, Ethiopia.
authors.forename: Federico
authors.initials: F
authors.lastname: Calia
authors.affiliation: WolissoHospital, Wolisso, Ethiopia.
authors.forename: Tigist
authors.initials: T
authors.lastname: Assefa
authors.affiliation: Doctors with Africa CUAMM, Aber, Uganda.
authors.forename: Bruno
authors.initials: B
authors.lastname: Turri
authors.affiliation: Aber Hospital, Aber, Uganda.
authors.forename: Onapa
authors.initials: O
authors.lastname: Emmanuel
authors.affiliation: Doctors with Africa CUAMM, Iringa, Tanzania.
authors.forename: Manuela
authors.initials: M
authors.lastname: Straneo
authors.affiliation: Ministry of Health and Social Welfare, Iringa, Tanzania.
authors.forename: Firma
authors.initials: F
authors.lastname: Kisika
authors.forename: Giorgio
authors.initials: G
authors.lastname: Tamburlini
authors.affiliation: European School for Maternal, Newborn, Child and Adolescent Health and Centro per la Salute del Bambino, Trieste, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Tarmbulini
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D002662:Child Health Services / Q000592:standards*; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000592:standards; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000592:standards*; D008428:Maternal Mortality; D009774:Obstetrics / Q000592:standards*; D011181:Postnatal Care / Q000592:standards*; D011247:Pregnancy; D011787:Quality of Health Care / Q000592:standards*