Examining and addressing the structural and workforce challenges facing Burundi’s Emergency Obstetric and Neonatal Care (EmONC) Network

Thesis

In 2015, Burundi committed to reducing maternal mortality by 60% (from 334 to 140 maternal deaths per 100,000 livebirths) and halving neonatal mortality (from 23 to 12 newborn deaths per 1,000 livebirths) by 2030. To achieve this, the country established in 2017 a “maternity network” comprising 112 emergency obstetric and neonatal care (EmONC) facilities distributed nationally, supported by development partners and policies to enhance their capacity. Despite these political and financial efforts, maternal and newborn death rates remained persistently high, compounded by the ongoing challenges in resource allocation. I used multiple-methods spanning document review, clinical EmONC vignettes, facility surveys, stakeholder engagement, and employed various statistical approaches to identify structural and workforce challenges and to develop efficient, equitable workforce investment proposals that could improve EmONC facility readiness.

Initial explorations revealed that the classification of EmONC facilities into basic (BEmONC) and comprehensive (CEmONC) levels does not align with expected standards, as some BEmONC facilities perform CEmONC ‘signal functions’ and manage more deliveries and complications than hospitals. Using normative and expert resource thresholds, I identified deficits of approximately 162 doctors, 1,005 midwives and nurses, 132 delivery rooms, and 678 maternity beds, amongst others. Addressing these gaps would require United States dollar (USD) 32.9 million over five years, representing a 6% annual increase in health spending. A prioritisation framework identified 11 BEmONC and 13 CEmONC facilities, responsible for 30% of deliveries and 35% of complications but housing only 15% of available human resources, highlighting critical investment targets in the face of limited resources. Applying the Workload Indicator for Staffing Needs (WISN) methodology, I developed four workforce investment proposals, validated with stakeholders, and used a decision tree model to compare the costs and expected benefits. Results suggest that adding two midwives in each facility is more cost-effective, at approximately USD 2,381 per maternal life saved, nearly half the cost of full workforce packages. Using Burundi’s per capita gross domestic product (GDP) and the established cost-effectiveness thresholds (CETs) for maternal lives saved in low-income countries, the proposed investment falls within the CET for Burundi. Finally, a provider competence exam revealed generally poor EmONC skills among Burundian delivery care professionals, with doctors outperforming midwives and nurses. Most importantly, the current, routine EmONC training, costing nearly USD 8,131.99 per trainee, does not significantly improve competence of medical doctors. This underscores the need to redesign training modules and assessment tools tailored for doctors separately from midwives and nurses.

Authors: Habonimana, D

• DOI: 10.5287/ora-py9eeo10z
• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford
• Language: English
• Keywords: workforce investment; quality of care; Burundi; health system strengthening; emergency obstetric and neonatal care (EmONC)
• Subjects: Maternal and newborn health; Health systems