Maternal and Child Nutrition

and Health Results Project

Technical Brief: The Gambia

December 2015

Health, Nutrition, and

Population Global Practice Impact Evaluation Baseline Report:
Maternal Health and Nutrition
Key Messages
•• Only 8 percent of women scheduled their first antenatal care (ANC) visit within the first
12 weeks of pregnancy.
•• Less than half of deliveries were carried out by a skilled attendant.
•• Barriers to accessing skilled delivery included delays in deciding to seek care, reaching the
health facility, and receiving appropriate treatment at the health facility.
•• Traditional birth attendants (TBAs) play an important role in delivery care, treatment for
complications, and postnatal care (PNC).
•• Only 7 percent of women received the three recommended PNC visits.
•• Frequent stockouts in supplies negatively impacted the quality of ANC, skilled delivery,
and PNC visits.
•• Women were generally satisfied with services at health facilities, but some felt certain
staff lacked thoroughness and attentiveness.

Introduction were collected on three regions: Central

The government of The Gambia is imple- River Region (CRR), North Bank Region-
menting the Maternal and Child Nutrition West (NBR-W), and Upper River Region
and Health Results Project (MCNHRP) to (URR). Its purpose was to establish a
increase the use of community nutrition baseline against which project performance
and primary maternal and child health will be assessed in the future. This technical
services. In collaboration with the govern- brief summarizes the baseline report find-
ment, the World Bank is conducting an ings related to maternal health and nutrition.
impact evaluation to assess the project’s
impact on key aspects of maternal and Pregnancy Outcomes
child nutrition and health. The MCNHRP The baseline evaluation found that rates of
baseline evaluation was conducted stillbirth were low, but more than 10 ­percent
between November 2014 and February of babies were born with low birth weight.
2015. Quantitative and qualitative data Across the three regions, there was an average

This brief was prepared by a core team comprising Laura Ferguson (Principal Investigator, University of Southern
This series of policy briefs was produced in direct California), Rifat Hasan (co-Principal Investigator, Health Specialist, World Bank), and Hannah Thomas based on the
response to a request from the government of The
Gambia to share the findings of the Maternal and
Impact Evaluation Baseline Report produced by Laura Ferguson, Rifat Hasan, Guenther Fink, Yaya Jallow, and
Child Nutrition and Health Results Project Impact Chantelle Boudreaux. The Impact Evaluation Baseline Report benefited from substantial inputs from The Gambia
Evaluation Baseline Survey. Bureau of Statistics, Mariama Dibba, Halimatou Bah, Momodou Conteh, Sering Fye, Alexandra Nicholson, Hannah
Thomas, and Steven Strozza. The team benefited from the general guidance of Vera Songwe (former Country
Director), Louise Cord (Country Director), and Trina Haque (Health, Nutrition, and Population Practice Manager).
Helpful comments were received from the Project Implementation Committee led by Modou Cheyassin Phall
(Executive Director, The Gambia National Nutrition Agency) and comprised of Haddy Badjie, Abdou Aziz Ceesay,
Ousman Ceesay, Modou Lamin Darboe, Malang Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Lamin Njie,
and Matty Njie, and Menno Mulder-Sibanda (Senior Nutrition Specialist, World Bank). The work was made possible
by support from the Health Results Innovation Trust Fund.

1
 of 3.8 neonatal deaths and 1.8 maternal Reported receipt of antenatal supple-
deaths per facility, with significantly more ments was also low, with only 48 percent of
deaths occurring in CRR than in the other women in their first pregnancy receiving
regions. two doses of tetanus toxoid, 26 percent
receiving at least 90 days’ supply of iron
Antenatal Care supplements, and 63 percent receiving at
Uptake of ANC Services least two doses of intermittent preventive
Increasing uptake of ANC and skilled delivery treatment for malaria.
services can improve ­pregnancy outcomes. Unavailability of necessary supplies could
National guidelines recommend four ANC explain, in part, why not all women received
visits, with one visit in the first 12 weeks of the services and supplements recommended
pregnancy. Receiving ANC at least once during in the FANC guidelines. Although the guide-
pregnancy was nearly universal, and 68 lines indicate that all pregnant women should
percent of women received at least four visits. receive syphilis and urine tests, these services
However, only 8 percent of women scheduled were rare at the facilities visited. Only 55
their first appointment within the first 12 syphilis tests had been given across URR in
weeks of pregnancy (figure 1). the three months before the survey, and only
83 urine tests had been given in CRR. In the
ANC Services, Supplies, and Equipment 30 days before the survey, more than 90
The provision of adequate information and percent of health facilities reported stockouts
services is necessary to ensure an effective of syphilis and urine protein tests.
ANC visit. Provision of information and
services recommended in the Focused Health Workers’ Knowledge of ANC
ANC (FANC) guidelines was low, with only Service provision was also affected by the
21 ­percent of women reporting having knowledge and actions of health workers.
received syphilis testing and 19 percent When asked which follow-up services they
reporting having had their blood type and would provide, health worker responses
Rhesus factor assessed (figure 2). indicated that while 68 percent of workers
knew to complete the antenatal card, ­only
54 ­percent would schedule another ANC visit
Figure 1. ANC Uptake in CRR, NBR-W, and URR and 25 percent knew to schedule the institu-
100 tional delivery. Failure to perform these
“In local communities men have
100 recommended actions not only contributes
to decide what the women
80 68 to poor quality of care but also discourages
should or should not do. The hus-
Percent

60 uptake of ANC and subsequent maternal and

band will tell you to wait because 40 child health services.
it is very early to go [to ANC] and 20 8 Furthermore, many health workers did not
women cannot force themselves 0 provide the recommended advice to clients,
to go without seeking and get- 1 or more 4 or more ANC within which could negatively impact pregnancy
ting permission. Some men are ANC visits ANC visits first 12 weeks outcomes. Although 68 percent of workers
very aggressive.” reported providing information on nutrition,
– Community Health Nurse, CRR less than 10 percent reported providing
Figure 2. Services Provided during ANC Visits in information on breastfeeding or contracep-
CRR, NBR-W, and URR tion (figure 3).
100
82 Reasons for Not Using ANC Services
80 71 Difficulties accessing the health facility (such
60
Percent

60 as cost, time, and transportation) impeded

40 36 uptake of ANC services. Although most
21 19 health facilities reported fee waivers for
20
pregnant women, some women reported
0
paying for ANC services with a high reliance
ass facto d

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health outreach services to the community

en
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greatly improved the accessibility and use of

these services. However, health workers
*Based on 788 women who reported receiving reported that fuel shortages often hampered
HIV counseling. these outreach activities.

2
Figure 3. Health Worker Knowledge (Advice) in Figure 4. Skilled Birth Attendance, by Region
CRR, NBR-W, and URR
100
100 90
80 80
68

Percent
60
Percent

60 54
46
40 40
21 18 20
20
9 7 0
0
Central North Bank Upper Average
and se ry

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Use pleme acid

HIV ed ne e

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River Region River across
enc s fo

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elp

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id

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Region West Region three regions

cep

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Nu

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Institutional Skilled birth

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Iron

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delivery attendance
Dan

Most women believed that the first ANC Skilled Attendance at Birth 47%
visit should take place in the second trimes- Uptake of Delivery Services of women were delivered by a
ter of pregnancy, and many believed that Using skilled delivery services at a health skilled attendant
ANC attendance was necessary every facility can reduce complications and improve
month after the first visit, which discour- pregnancy outcomes. Approximately
aged early attendance because it would 61 ­percent of women reported delivering in a
imply a higher total number of visits. About health facility, and 47 percent were delivered
half of the women interviewed agreed that by a skilled attendant (figure 4). Nurses or
ANC was useful in preventing problems midwives were the most common delivery
during pregnancy, whereas the other half assistants (44 percent of all deliveries),
disagreed. followed by TBAs (40 percent of deliveries).
Traditional beliefs around pregnancy Whereas 60 percent of women in the wealthi-
appear to have affected women’s willingness est socioeconomic quintile had skilled atten-
to attend ANC during the first trimester of dance at delivery, only 36 percent of women in
pregnancy. Some women described how the lowest quintile reported skilled assistance.
revealing a pregnancy early can lead to
40%
Referral by a health care provider to a
miscarriage or becoming bewitched, while health facility can improve health outcomes if
unmarried women and recent mothers complications occur. While 71 percent of of births across CRR,
reported wanting to hide their pregnancies women reported at least one postpartum
NBR-W, and URR were
out of shame. complication (abdominal pain, bleeding, or
­attended by TBAs
headache), fewer than 20 percent of these
Nutrition during Pregnancy women were referred.
A balanced diet including sufficient iron
intake is an important component of a Reasons for Not Delivering at a
healthy pregnancy. The national Health Facility
­prevalence of anemia among pregnant Most women believed that it was safer to
women is 68 ­percent (Gambia Bureau of deliver at a health facility and that the level
Statistics 2014), and a high prevalence of of support received from health facility staff
­anemia was also noted by health workers was higher than that received in the commu-
in this survey. nity. However, barriers to institutional
Health workers, village development delivery persist.
committees, and village support groups Women were often slow to make the
described providing pregnant women decision to seek care at a health facility due
with information on an appropriate diet to a lack of knowledge or decision-making
based on locally available foods. Several power. Respondents often believed a woman
traditional beliefs were mentioned that was unable to tell her expected due date.
could negatively affect pregnant women’s When women did not know when they
nutrition. However, some respondents said were due to deliver, it took many of them
that these beliefs were declining because of a long time to realize when they were in
activities to raise awareness and because active labor.
most women strive to eat a balanced diet The decision to seek care was usually
when pregnant. made by the head of the household, which

3
 often led to delays if the household head was delivery, and they did not see their role as
unavailable or unwilling to allow seeking care. being diminished by this process.

7% Once the decision to attend a health

facility was made, delays often occurred in Postnatal Care
of women received the reaching the facility. The most frequently Uptake of PNC Services
recommended three PNC visits mentioned barrier was difficulty getting to A woman should receive her first PNC visit
the health facility due to long distances and within 24 hours of delivery, her second visit
inadequate transport options. Particularly within one week, and her third visit within
challenging was ensuring access at night and six weeks. While 72 percent of women
during the rainy season. Many women reported having at least one PNC visit, only
preferred home delivery because delivery en 37 percent received PNC within 24 hours,
route to the health facility was common. The and only 7 percent received the recom-
availability of a small vehicle at some health mended three visits.
facilities to transport women in labor was Although 95 percent of health workers
gratefully acknowledged. reported knowledge of when to prescribe iron,
only 1.6 percent of women reported receiving
Delivery Services, Supplies, and Equipment the recommended 90+ days of postpartum
Many health facilities reported shortages in iron supplements. No women in NBR-W
drugs and supplies, with only 25 percent of reported receiving the full dose.
­facilities having newborn resuscitation kits,
29 percent having tape measures, and Reasons for Not Attending PNC
38 percent having delivery lights. No health Across all regions, qualitative data suggest

<2% facilities in URR reported having a newborn

resuscitation kit. All facilities had at least
awareness of the importance of PNC was
very low. TBAs played a critical role in
of women reported receiving one dose of diazepam, with only 4 percent of providing PNC during home visits; however,
the full dose of postpartum health facilities having had a stockout within low use of facility-​based PNC services
iron supplementation
the past 30 days. The opposite was true for remains a concern. Cost, time, and transpor-
oxytocin, with no health facility having it on tation difficulties deterred uptake of PNC
hand at the time of the survey. services, particularly when women did not
feel sick at the time of scheduled visits.
Role of TBAs
TBAs played an important role in delivery Satisfaction with Maternal
care, treatment for complications, and PNC.
Health Services
TBAs were held in high esteem by health Women were generally satisfied with mater-
workers and community members. Some nal health services; however, some reported
respondents noted that many of the TBAs that certain staff lacked thoroughness and
are very old and that a problem of succession attentiveness. They reported receiving good
is emerging. quality care during ANC and delivery. Almost
Across all three regions, 37 percent of all women would return for ANC and would
women reported preferring to deliver with a recommend the facility to a friend. Some
TBA. In NBR-W, TBAs reportedly referred women stated a preference for female health
and escorted women to health facilities workers because they felt ashamed to have
for delivery whenever time allowed and male health workers see their body. Of
referred women for pre- and postpartum concern were instances of reported health
complications. In CRR and URR, TBAs worker negligence.
reportedly referred some women while
delivering those with no complications at
home. Across the three regions, they often Reference
Gambia Bureau of Statistics (GBOS) and ICF
© 2015 International Bank for Reconstruction assisted in deliveries at health facilities. International. 2014. The Gambia Demographic and
and Development / The World Bank. Some
rights reserved. The findings, interpretations, Most TBAs appeared to embrace the idea of Health Survey 2013. Banjul, The Gambia, and
and conclusions expressed in this work do not referring all women to the health facility for Rockville, MD: GBOS and ICF International.
necessarily reflect the views of The World Bank, its
Board of Executive Directors, or the governments
they represent. The World Bank does not guarantee
the accuracy of the data included in this work.
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