J.20_Sexual_and_Reproductive_Health_(SRH)_2018_Annual_Program_Report.pdf

MONITORING AND EVALUATION

Monitoring and Evaluation Unit Strategic Information Department

SIY I NQ A B A

KINGDOM OF ESWATINI

MINISTRY OF HEALTH

Annual Program

Report

SEXUAL AND

REPRODUCTIVE

HEALTH (SRH)

Acknowledgements

The report is based on the calendar year Jan 2017 - Dec 2017

The Ministry of Health acknowledges the technical and financial support provided by the Institute for Health Measurement (IHM) over the years.

The ministry also recognizes the work done by health care workers who are committed to documenting health information. The Ministry of health also acknowledges the financial support provided by UNFPA. Special thanks goes to the following individuals who were involved in the report writing process;

Nompumelelo Dlamini-Mthunzi Monitoring & Evaluation MoH

Bonisile Nhlabatsi Sexual and Reproductive Health MoH

Lindiwe Malaza Family Planning MoH

Nozipho Motsa Sexual Gender Based Violence MoH

Ntombikayise Dlamini-Madlopha Maternal Newborn and Child Health MoH

Mpumelelo Mavimbela Sexually Transmitted Infections MoH

Zandile Masangane Adolescent Sexual Reproductive Health MoH

Mgcineni Ndlangamandla Cancers of the Reproductive System MoH

Siyabonga Ndwandwe Sustainable Health Financing CHAI

Setsabile Gulwako Strategic Information FLAS

Thamary Silindza Maternal Health UNFPA

Lawrence Mashimbye Strategic information UNAIDS

Dr. Christopher Makwindi EGPAF

CONTENTS

CHAPTER 1: 7

1.1 Background 07

1.2 Overview of MNCH 08

1.3 SRH Policy 08

1.4 Methodology 08

2.1 Leadership / Governance 09

2.2 Health Workforce 10

2.3 Medical Products, Vaccines and Technology 11

2.4 Financing 12

2.5 Information 12

3.1 Maternal, Neonatal and Child 13

3.1.1 Antenatal Care 13

3.1.2 Deliveries 15

3.1.3 Low birth weight 17

3.1.4 Perinatal Deaths 17

3.2 Adolescent and Youth Sexual Reproductive

Health and Rights (ASRH) 20

3.3 Family Planning (FP) 24

3.4 Abortion and Post Abortion Care 26

3.5 STI’s and HIV/AIDS 27

3.6 Infertility 33

3.7 Cancers of the Reproductive System 34

3.8 Gender and Sexual and Reproductive

Health Including GBV 37

3.9 Sexual Dysfunction 38

3.10 Sexual and Reproductive and Health and Ageing 38

Policy and legal 39 Advocacy and IEC/SBCC 39 Capacity building 40 Service delivery 40

Action points 41

Introduction

CHAPTER 2: 9

Introduction

CHAPTER 2: 13

Program outputs

CHAPTER 4: 39

Program Achievements

CHAPTER 4: 39

Conclusion and action points

Figure 2-2-1; SRH program Organogram 10 Figure 2-2-2; Stock out Rates 11 Figure 3-1-1; Ante Natal Coverage 201-2018 14 Figure 3-1-2; Timing of ANC Bookings 14 Figure 3-1-3; ANC Intervention at first ANC booking 15 Figure 3-1-4; Place of delivery by Year 16 Figure 3-1-5; Proportion of C/S conducted 16 Figure 3-1-6: Number of Children with low birth weight by region, 2018 17 Figure 3-1-7; Perinatal deaths by Type 18 Figure 3-1-8; Women attending PNC within 7-14 days 18 Figure 3-2-1: Adolescent and youth friendliness 20 Figure 3-2-2; SRH services received through Dreams on Wheels 21 Figure 3-2-3; Pregnant women by age group 23 Figure 3-2-4; HIV positivity rate by age groups 23 Figure 3-3-2; Condoms Issued form CMS 25 Figure 3-3-3; Family Planning and HIV integration 25 Figure 3-4-1; No of Abortion at Out Patient Department 26 Figure 3-4-2; Admissions due to Abortion 27 Figure 3-5-1; Types of Sexually Transmitted Infections 28 Figure 3-5-2; Sexually Transmitted Infections, CMIS sites only 29 Figure 3-5-3; Urethral discharge syndrome by age 29 Figure 3-5-4; PMTCT Cascade for Pregnant women 32 Figure 3-5-5; PMTCT cascade for Exposed infants 32 Figure 3-6-1; Fertility Problem Episodes 33 Figure 3-7-1; Cervical Cancer Screening Trend 34 Figure 3-7-2; VIA Positive 35 Figure 3-7-3; Treatment for precancerous lesions 35 Figure 3-7-4; Admissions due Cancers of the Reproductive System 36 Figure 3-7-5; Mortality due to Reproductive system Cancers 36 Figure 3-5-5; PMTCT cascade for Exposed infants 37 Figure 3-10-1; Admissions due to Reproductive System Cancers by age 38

List of Tables Table 3-2-1; Facilities with teen clubs 22 Table 3-3-1; Family Planning Commodities Distributed 24 Table 3-5-1; Syphilis screening and Treatment at ANC 30 Table 3-5-2; HIV Testing Services at ANC 30 Table 3-5-3; HIV positivity rate at ANC 31 Table 3-5-4; Pregnant women on ART 31

List of Figures

ABBREVIATIONS

AND ACRONYMS

ANC Antenatal Care

ASRH Adolescent Sexual and Reproductive Health

CMS

CMIS

Central Medical Stores Client Management Information System

EmONC Emergency Obstetric and Neonatal Care FANC Focus Antenatal Care FP Family Planning

GBV Gender Based Violence

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

IATCC Inter-agency technical coordinating committee

ICPD International Conference on Population and Development

IHM Institute for Health Measurement

LLAPLa Life Long ART for Pregnant and Lactating women

M&E Monitoring and Evaluation

MDGs Millennium Development Goals

MICS Multiple Indicator Cluster Survey

MMR Maternal Mortality Ratio

MNCH Maternal, neonatal and child health

MoH Ministry of Health

NHSSP National Health Sector Strategic Plan

PAC Abortion and Post Abortion Care PHU Public Health Unit PMTCT Prevention of Mother to Child Transmission

DHS Swaziland Demographic and Health Survey SGBV Sexual Gender Based Violence SID Strategic Information Department

SRH Sexual and Reproductive Health

SRHR Sexual Reproductive Health and Rights

SDG’s Sustainable Development Goals STIs Sexually Transmitted Infections TT Tetanus

TWG Technical Working Group

VIA Visual inspection with acetic acid

Sexual And Reproductive Health Program_2018 Annual Report v

EXECUTIVE SUMMARY

Globally, women, new-born, children, adolescents and young people’s health continue to receive attention. The transi-tion from Millennium Development Goals (MDGs) to Sustainable Development Goals recognized unfinished business on maternal health (MDG5). A lot of achievements have been made by the country though there are noted slow progress in some key SRH indicators. However, there are still women and children dying from maternal and neonatal mortalities mostly from preventable causes; gender based violence; as well as the high HIV incidence among adolescents and high FP unmet need especially among women living with HIV and young people

Coverage for some indicators have improved over the years; almost all women, 99 percent attend ANC at least once during pregnancy; PNC has increased from 45 percent in 2014 to about 75 percent in 2018 which is significant for the prevention of maternal and perinatal deaths, as well as the prevention of mother to child HIV transmission through breastfeeding; syphilis positivity rate at ANC was 2 percent; HIV mother to child transmission at 6-8 weeks and PMTCT positivity rate is 1 percent and 35 percent respectively. Cervical cancer screening has increased from around 14,000 to over 18,000. Women who were found to be precancerous were treated at local facility level.

Action Points

• Subvention of facilities should be based on performance to improve on data reporting

• Implement the newly developed ANC guidelines to improve on the uptake of ANC (<30% both for 1st and 4th visits) to provide all the essential interventions from the first ANC visit.

• Ensure continuous supply of essential medicines of maternal

• Provide an enabling environment (affordable, accessible, skilled personnel, availability of essential commodi-ties) for women to deliver in health facilities particularly in the Lubombo region where most women deliver at home.

• Need to improve the referral system to ensure survival of women and newborns

• Consider non-traditional methods to target AGYW for SRH services for preventative services to curb early preg-nancy, HIV and STI’s incidence

• Improve programming (availability of services, equipment, creating awareness) for the infertility, ageing and sexual dysfunction thematic areas for improved uptake of quality service vi Sexual And Reproductive Health Program_2018 Annual Report

01C H

A P

TE

R

INTRODUCTION

1.1 Background

Globally, women, new-born, children, adolescents and young people’s health continue to receive attention. The transi-tion from Millennium Development Goals (MDGs) to Sustainable Development Goals recognized unfinished business on maternal health. This observation gave prominence for inclusion of women, newborn, children, adolescents and young people’s health under SDGs 3 and 5. The survival and well-being of these populations are cornerstones for the attain-ment of SDGs goals. Therefore, effort to curb maternal and neonatal mortality are crucial for the 2030 development agenda.

Global statistics show that maternal mortality declined by 44 percent between 1990 and 2015. However, this decline was not enough to meet the MDGs targets. Furthermore, the decline showed disparities between countries – with developing countries showing much slower decline. The MMR for the developing countries was averaged at 239 (per 100 000), about 20 times higher than the reported in developed countries. In 2015, developing countries accounted for about 99 percent of the maternal deaths.

Similarly, the global neonatal mortality has been declining, but much slower in developing countries compared to devel-oped countries. In 1990, neonatal mortality was recorded at 37 deaths per 1000, and declined to 19 deaths per 1000 in 2016. Under-five mortality declined to 41 deaths per 1000 in 2016 compared to 93 per 1000 live births in 1990.

The rate of skilled care during childbirth has increased from 58% in 1990 to 73% in 2013, mostly due to increases in facility-based births. However, evidence showed that giving birth in a health facility with a skilled attendant was not sufficient to reduce maternal and new-born deaths. Many women and their babies died from inadequate care practices, even after reaching a health facility. The increase in the skilled attendant at delivery is also at 88.3% whilst institutional deliveries at 87.7% .

An estimated 77% of women of reproductive age who were married or in-union had their need for family planning met with a modern method; the total fertility rate has dropped globally in the last 25 years reaching 2.5 in 2015 from 3.0 in 1990; adolescent child births continued to decrease reaching 44 per 1000 women aged 15-19 in 2017; contraceptive prevalence rate among women aged 15-49 increased to 63.6% in 2015 from 55.3% in 1990, the proportion of pregnant women receiving four or more antenatal visits increased to 62% in 2017 and 95% of women were screened for syphilis .

In Eswatini, current data shows that the adolescent birth rate is 87/1000 (MICS 2014). Given that WHO considers a rate of 100/1000 as high, more effort is needed to reduce the adolescent birth rate not only in the country. This could be through scaling up access to information and FP services for adolescents at all levels with concerted efforts in the rural settings.

A lot of achievements have been made by the country though there are noted slow progress in some key SRH indicators.

However, there are still women and children dying from maternal and neonatal mortalities mostly from preventable causes; gender based violence; as well as the high HIV incidence among adolescents and high FP unmet need especially among women living with HIV and young people.

Sexual And Reproductive Health Program_2018 Annual Report 07

CHAPTER ONE: INTRODUCTION

1.2 Overview of MNCH

Eswatini has made significant strides in creating an enabling environment for successful implementation of maternal and neonatal programmes. There is also effective leadership that enhance the implementation of interventions at national, regional, health facility and community levels. The SRH Strategic Plan ended in 2018, and a new plan is being developed to guide interventions.

1.3 SRH Policy

A healthy and well-informed population with universal access to quality SRH services, that are sustainable and provided through an efficient, effective and rights based support system.

To provide, facilitate and support an integrat-ed and well-coordi-nated sexual and reproductive health services and information upholding the rights of women, men, youth, adolescents and children in

Swaziland.

To guide establishment of an evidence-based framework for the implementation of a well-coordinated and integrated sexual and reproductive health and rights programmes in order to attain the highest level of health and well-being for all people of Swaziland.

Vision Mission Goal

1.4 Methodology

This report was compiled using three main sources of data: published reports, strategies and policy documents; and data from the health information systems. An analysis plan was developed prior the retrieval of data from the health information systems. This process involved merging data from the old data collection system (summarized data) and the client management information system (patient level). Data was scrubbed to ensure completeness and accurate-ness as well as the removal of duplicates. Analysis was done using STATA and Excel. Thereafter the findings were described by the M&E, partners and Program Officers. The report was then reviewed by peers, finalized and printed.

The report will look into addressing the Health Strengthening System (HSS) building blocks and ascertain how they seek to improve sexual and reproductive health outcomes in the country. This is however, dependent on availability of data from the various databases used in the country healthcare system.

08 Sexual And Reproductive Health Program_2018 Annual Report

02C

A P

TE

R

INTRODUCTION

2.1 Leadership / Governance

The Sexual and Reproductive Health Program, is mandated to coordinate all SRH interventions in the health sector and implementation is guided by the National Sexual Reproductive Health and Rights Strategic Plan 2014-2018 which has 11 focus areas as follows; MNCH, ASRH, Family Planning, Abortion and PAC, STI, TB, HIV and AIDS, Infertility, Cancers of the reproductive system, Gender and SRH including GBV, Sexual dysfunction, SRH and aging and Community involve-ment and participation.

The Unit’s Program Manager- oversees program implementation at national level and supervises the implementation of the thematic areas and ensures availability of services at facility level. As outlined in figure 2-1, the program has 7 officers at national level and only 2 officers’ salaries are paid through the programs center number. The unit does not have focal persons for all the components which result in poor performance for the other components. The affected components are: SRH and the ageing, sexual dysfunction, community participation and involvement and infertility.

Through the Global fund, the program was able to hire 300 community mentor mothers who are based at the different constituencies mainly to promote SRH/PMTCT services.

Sexual And Reproductive Health Program_2018 Annual Report 09

Program Manager

Family planning/condom programming focal

Adolescent SRH focal

Gender and family issues focal

Regional officers 2 each region

Support staff:

cleaner and 2 drivers

Cancers of the reproductive system focal

Community involvement focal

Safe motherhood focal

Figure 2-2-1; SRH program Organogram

2.2 Health Workforce

According to WHO, a knowledgeable, skilled and motivated health workforce is critical for reaching universal health coverage. Health workforce for SRH services may include those that provide health services such as doctors, midwives etc. and those that support the health services such as hospital managers, ambulance drivers etc. It is important to continuously train health care workers to ensure competency. The 2017 Service Availability and Readiness Assessment measured the number of health personnel both at public and private health facilities. There were 285 medical officers with 17 gynecologist across the country.

10 Sexual And Reproductive Health Program_2018 Annual Report

CHAPTER TWO: INTRODUCTION

Nursing cadre Hhohho Manzini Lubombo Shiselweni National Per 100 000 population

Matrons 14 21 13 6 54 4.9

Nursing sisters 101 105 60 51 317 29.1

General Nurses 57 107 70 51 285 26.2

Midwives 389 414 180 147 1130 103.9

Nursing Assistants 140 145 97 80 462 43

2.3 Medical Products, Vaccines and Technology

According to the SDG’s –target 3.b health systems should provide access to affordable essential medicines and vaccines. The availability of essential medical products, vaccines and laboratory services is necessary for universal health coverage. The central medical stores (CMS) manages the logistic management information system (LMIS) for family planning services. Lessons learnt is that, the LMIS needs to be scaled up to service the other SRH drugs; to prevent stock outs and drugs expiring in the facilities. During the year, there were stock outs of magnesium sulphate, oxytocin and family planning commodities as presented. The SARA showed that some facilities lacked essential drugs and commodities. Figure 2-2 shows the average stock- outs that were reported in 2018, which was based on 81% of FP Commodities.

Figure 2-2-2: Stock out Rates Source; Central Medical Stores, 2018

19% 15%

9%

15% 14% 15%

22% 19%

33%

58%

69% 69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18

Average Stock Out Rates at Facility Level, (Jan-Dec 2018)

Sexual And Reproductive Health Program_2018 Annual Report 11

2.4 Financing

There is limited data on the financing of sexual and reproductive implementation. Government had a budget line for the SRH program, and this include amongst other things, human resources, drugs and commodities, fuel. However there is a substantial contribution from both development and implementing partners.

2.5 Information

The Strategic Information Department (SID) is responsible for the collection, collation, analysis and reporting for all data. With the introduction of the client management information systems it is expected that data will improve as it is now better disaggregated and responds to a broader data need. There is still a greater need to train health care work-ers on documentation including the International Classification of Diseases (ICD) coding that is used by the country to ensure data quality.

12 Sexual And Reproductive Health Program_2018 Annual Report

03C

A P

TE

R

PROGRAM OUTPUTS

Data should inform programming and policy making. The culture of data use needs to be improved for better service uptake. This section will discuss program outputs using data mainly from the Health Management Information System

(HMIS).

3.1 Maternal, Neonatal and Child

Maternal, Neonatal and Child Health (MNCH) is the core of the wellbeing of any society and contributes towards the wellness and a healthy community. Investing in MNH assures reduced morbidity and mortality for both the mother and the baby and in turn ensuring a healthy family which leads to sustainable economy of the country. Decreasing the maternal mortality rate requires addressing the different challenges along the continuum of maternal care which includes ensuring women seek health care; that the health care provider knows how to respond; rationalization of human resources, equipment, drugs and other resources, ensuring a functional referral system; as well as having an accountability framework.

3.1.1 Antenatal Care

The antenatal coverage is at 99 percent (MICS 2014), almost all pregnant women in the kingdom of Eswatini attend antenatal care at least once during pregnancy. Previously, Eswatini was implementing the four focused ANC approach.

Moving forward the country will implement the new WHO recommendations which is to increase to eight contacts for a positive pregnancy outcome. To improve maternal and neonatal health outcomes, the MoH has undertaken a number of strategies such as ensuring increased coverage, accessibility and affordable to every woman in need of antenatal care. This has been achieved by removing clinic fees and investing in skilled services providers (88%) as well as the provision of essential medicines.

One hundred and eighty nine (189) facilities (SARA 2017) were found to provide ANC services, however, with readiness score, regions range between 52percent and 63percent.

Sexual And Reproductive Health Program_2018 Annual Report 13

CHAPTER THREE: PROGRAM OUTPUTS

Figure 3-1-1; Ante Natal Coverage 201-2018

Figure 3-1-2; Timing of ANC Bookings

Source: Health and Client Management Information System, 2018

Source: Health and Client Management Information System, 2018

97% 90% 88%

93% 92% 95% 96%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2013 2014 2015 2016 2017 2018

Antenatal Care Coverage

Timing of ANC Bookings

17%

20% 27%

33% 29%

28% 28%

25% 27%

29% 29%

29%

31%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2013 2014 2015 2016 2017 2018

The country has always maintained good coverage of 97 percent since 2007 (SDHS 2007). Figure 3-1-1 shows ANC coverage in the last 7 years. This is calculated using the number of pregnant women booking for the 1st ANC visit over the expected (population estimates) pregnancies in a year. The coverage declined since 2013 as the country was transi-tioning from a paper based to an electronic data collection system. In 2018, there were 31,808 women pregnant women presenting at health facilities for the 1st time.

3.1.1.1 Timing of ANC Booking

The ministry of health has been implementing the four focused antenatal care approach. The 1st visit at >16 weeks, 2nd visit 24-28 weeks, 3rd visit at 32 weeks and the 4th visit at 36-38 weeks of gestation. Eswatini is currently developing guidelines to be in-line with the WHO (2016) recommendations of 8 visits.

14 Sexual And Reproductive Health Program_2018 Annual Report

Figure 3-1-2 shows ANC access by pregnant woman at time of first contact and four focused visits. The graph shows that the country still has a long way to achieve the 60 percent target of women reporting to facilities as early as possible within the first 16 weeks as set in SRH strategic plan. A similar trend is also noted on the fourth focused visit which is between 36-38 weeks, which is a series of services at each specific cut point intended to monitor pregnancy progress and to maximize health outcomes of both mother and neonate at delivery

3.1.1.2 ANC interventions

It is advisable to seek antenatal care as soon as the 1st trimester. Baseline health information e.g. the blood pressure levels are ascertained at this stage. Early bookings also ensure that danger signs are identified early in the pregnancy.

Figure 3-1-3 below show five essential services/ interventions that should be given to pregnant women at first contact (data from CMIS sites only).

Pregnant women are more likely to be screened for HIV (90%) and syphilis (86%) than urinalysis (16%) at their first book-ing. Most of these women are done urine and HB test at their follow up visits. Findings from the SARA showed that 90 percent, 66 percent and 64 percent of facilities had urine dipsticks, HB tests and folic acid tablets available at health facilities by the time of the assessment and this could attribute to why the women did not receive the essential services timely.

Figure 3-1-3; ANC Intervention at first ANC booking Source: Health and Client Management Information System, 2018***Data from CMIS sites only

22547

20311 19303 16060

11247 4747 3719

90% 86%

71%

50%

21% 16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

10000

15000

20000

25000

No. of pregnant women

Women tested for HIV

Women tested for syphilis

Women screened for blood pressure

Women given folic acid

Women screened for Haemoglobin

Women done urinalysis

ANC Interventions at First Booking (CMIS Only)

3.1.2 Deliveries

The table 3-1-4 shows that there were 26,348 reported deliveries and 97 percent institutional deliveries. The observed decline could be attributed to the lack of documentation and reporting mainly by high volume facilities.

Facilities that use the CMIS account for 2/3 of the data reported and currently these facilities do not capture the place of delivery of the women. This has contributed to the decline of the number of home deliveries reported. Generally, home deliveries have been over 2000 in the past years and Lubombo is the highest contributor, mainly because the region has limited inpatient facilities that are accessible and affordable to all populations.

Sexual And Reproductive Health Program_2018 Annual Report 15

Figure 3-1-4; Place of delivery by Year Source: Health and Client Management Information System, 2018

2296 2402 2329 1492 600

26707 24961

26490 27155

25748

10000

15000

20000

25000

30000

35000

2014 2015 2016 2017 2018

Home Deliveries Institutional Deliveries

Place of Deliveries

3.1.2.1 Types of Delivery

The SARA had a 79 percent mean availability of tracer items for comprehensive obstetric care. Most facilities were found to have personnel trained on CEMOnC but only 36 percent had guidelines available. There are two modes of deliv-ery; vaginal and caesarian section. The MICS 2014 presented 11.6 percent of women delivering through C/S in the coun-try. WHO recommends 10-15 percent C/S and if countries are within this range it means health systems are able to respond to the needs of women who have complications during childbirth. The country needs to ensure that the C/S rate translates to a positive outcome for both the mother and the neonate.

Figure 3-1-5; Proportion of C/S conducted Source: Health Management Information System - In-patient 2018

11% 10% 10% 12% 14%

0%

20%

40%

60%

80%

100%

2014 2015 2016 2017 2018

Caesarean Section

Types of Deliveries

16 Sexual And Reproductive Health Program_2018 Annual Report

Caesarean section conducted have increased from previous years to 14 percent in 2018 (table 3-1-5). Further analysis of the data showed that the National Referral hospital had an increased proportion (20%) of C/S conducted in the year as compared to previous years and could have contributed to the increase nationally. Detailed data is essential to ascer-tain if women who delivered through C/S due birth complications had positives outcomes both for the mother and the newborn.

3.1.3 Low birth weight

Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of 2,499 g or less, regardless of gestational age. Subcategories include very low birth weight (VLBW), which is less than 1500 g, and extremely low birth weight (ELBW), which is less than 1000 g. Poor nutritional status of the mother is one of the risk factors contributing to low birth weight of the new born. Figure 3-1-6 shows that 1,903 children born in the country in 2018 had a low birth weight. This accounted to 10% of all live births across all regions

Figure 3-1-6: Number of Children with low birth weight by region, 2018 Source: Health Management Information System, 2018

289 289

1903 (10%)

HHOHHO LUBOMBO MANZINI SHISELWENI National

Low birth weight

3.1.4 Perinatal Deaths

A successful pregnancy is measured by delivery outcomes. The perinatal period is defined in diverse ways, it starts at the 20th to 28th week of gestation and ends 1 weeks after birth. Stillbirth is a classification of unsuccessful fetal outcomes at full term gestation and labor. Fresh stillbirth relates labor and delivery time lines whilst macerated relates to timelines (days/ weeks) prior to labor and delivery.

Figure 3-1-7 shows disaggregation of perinatal deaths in 2018 reported through Immediate Disease Notification Surveillance and Response (IDNSR). The data are reported on a weekly basis and shows a huge increase from those reported in previous years through routine data. This is an indication that data are under reported through the inpatient admission and discharge system. In total, there were 631 perinatal deaths reported in the year with a 37.9 percent attributed by macerated stillbirths.

Sexual And Reproductive Health Program_2018 Annual Report 17

Figure 3-1-7; Perinatal deaths by Type Source: Immediate Disease Notification System (IDNS), 2018

36%

38%

26%

Early Neo-natal Deaths Macerated Still BirthsFresh Still Births

Peri-natal Deaths

3.1.5 Post Natal Care (PNC)

The MICS estimated post natal care (whist at facility or a visit) received by both the mother and the child within 2 days at

87.5 percent and 90.4 percent respectively. The SRH program monitors women coming for PNC within 7-14 days post-delivery and the graph shows a constant increase since 2012 (45%) and in 2018, 75 percent of the women attended post-natal care. Post-natal care provides an opportunity for continuity of care both for the mother and the baby. If Eswatini is to reduce MMR and Neonatal Mortality rate (NMR), PNC needs to be strengthened throughout the continuum quality care.

Figure 3-1-8; Women attending PNC within 7-14 days Source: Immediate Disease Notification System (IDNS), 2018

11897 14889

18470 18358 20696 20257 19728

45% 47%

59% 67% 71% 71%

75%

0%

20%

40%

60%

80%

100%

10000

15000

20000

25000

2012 2013 2014 2015 2016 2017 2018

# of women attending PNC within 7-14 days of delivery

% women attending PNC within 7-14 days of delivery

Women attending PNC within 7-14 days

18 Sexual And Reproductive Health Program_2018 Annual Report

3.1.6 Maternal Deaths- Institutional maternal mortality ratio The Swaziland Demographic Household Survey 2012 estimated maternal mortality ratio at 593/100 000 live births despite the high ANC and skilled birth attendance. The Quality of care assessment noted that inadequate quality of care in the provision of intra-partum and postnatal care resulted in most of maternal and neonatal deaths.

In 2018, there were 30 maternal deaths. Since 2012 the range has been between 27 and 30 showing no decline. Most deaths in 2018 occurred between the 18 and 27 age group. Hhohho had the highest reported number of maternal deaths followed Manzini with Lubombo with the least number of maternal deaths.

Presented below is institutional mortality rate calculated as per WHO’s recommendation. Based on the number of deliv-eries reported, the institutional MMR is 117.

3.1.7 Discussion

Maternal and neonatal health is the fundamental core for any health system, thus a well functional health system leads to positive outcomes for both the mother and the baby. It is essential that quality and affordable MNCH services are available and accessible for all populations regardless of economic status and area of residence. As such WHO recom-mends a 5km radius to health facilities. Government provides subsidized maternal health services in public institutions which makes them affordable for women in need, and some private facilities are subvented by government. However, there is need to ensure that these subventions are based on performance and reporting of facilities. For better and improved outcomes addressing the different challenges along the continuum of maternal care which includes ensuring women seek care, that is early booking and readiness for complications, health care provider knows how to respond to emergencies from ANC through to PNC, rationalization of human resources, equipment, drugs and other resources, ensuring a functional referral system; as well as having an accountability framework.

The ANC coverage suggests that pregnant women have access to maternal services. However, the challenge still remains as observed in the previous years that fewer women book early (<16 weeks of gestation) delaying identification of obstetric complications that women may have and thus management of such cases is compromised. Since ANC visit consistency is influenced by both system and behavior, the Ministry of Health may need to explore on the challenges affecting the country’s ability on accessing health care both 1st <16weeks ANC booking and fourth focused visits

(FANC).

The MICS estimates that 88percent of women deliver in health facilities, which means 12 percent deliver at home. An increase in stillbirths is noted and could be attributed to improved reporting, however it is still important to reflect on both management in ANC and client behavior in accessing services to strengthen skills in management, communica-tion and messaging for all pregnant mothers including their families, as well as increased sensitization of frequent Antenatal care. There is also need to strengthen reporting through the HMIS system as there is a discrepancy between the IDNS and routine system.

The country has developed antenatal care guidelines with a minimum of 8 contacts in line with recommendations from WHO, and this will assist in ensuring quality ANC, thus reducing the number of still births as constant contact with the

Sexual And Reproductive Health Program_2018 Annual Report 19 health care worker to ensure that complications and any anomaly are recognized early and interventions are done accordingly. The rotation of staff policy particularly at maternity units compromises the quality of care as proficient staff are moved from one unit to another mostly not considering the strengths and specialties of the healthcare worker. In 2018 the country experienced a stock out of commodities (Oxytocin, misoprostol, magnesium sulphate) which then compromised the quality of care for both woman with no emergencies and those with obstetric emergencies.

3.2 Adolescent and Youth Sexual Reproductive Health and Rights (ASRH)

If Eswatini is to be successful in combating teenage pregnancy, early sexual debut and new HIV infections, amplified focus should be directed to adolescent and youth sexual health interventions, particularly the availability of information.

The SHIMSII already show a high HIV incidence among the adolescent and youth. The SARA demonstrated that 80 percent of facilities provide youth friendly services and 74% ready to provide ASRH services.

3.2.1 Adolescent and youth-friendly health services

The MoH (2010) defines youth-friendly health services as services that are provided in a setting and manner that is attractive to young people. The environment and the act of service provision should be attractive to young people. The argument behind the concept of AYFHS has been that these services are different from generic health services.

To improve adolescent and youth friendliness in health facilities, the Ministry adapted the AYFHS standards from the WHO (2015) Global standards in 2017. The Ministry came up with nine standards. In 2018, MoH with support from UNICEF conducted a baseline assessment, before the implementation of the standards. Figure 3-2-1 below illustrate the findings from the assessment.

Figure 3-2-1: Adolescent and youth friendliness Source; AYSRH standards report

77%

72%

66%

54%

49%

42%

39%

34%

31%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

HCP competence

AYFHS package

HF Charecteristics

Protection of ASRHR

AYP Knowledge

Alignement to policies

Community Involvement

Continous Improvement

Youth Involvement

Adolescent and youth friendliness

20 Sexual And Reproductive Health Program_2018 Annual Report

Apart from the traditional set up of service provision, non-traditional ways are used to target adolescent girls and young women and this is done amongst others; the Insika dreams on wheels project which provide (SRH) for AGYW.

Figure 3-2-2; SRH services received through Dreams on Wheels Source; SRH program data, 2018

N um be r o f P eo pl e

10 - 14 Years 15 - 19 Years 20 - 24 Years 25 - 29 Years

# Recieved STI education

Women attending PNC within 7-14 days

# Recieved STI Screening

Linked STI Treatment

# Recieved FP Counselling & Education

# Recieved Injectables

# Recieved Oral Contraceptives

# Recieved Implant

# Recieved Pregnancy Test

# Recieved SRH Info

Sexual And Reproductive Health Program_2018 Annual Report 21

Table 3-2-1; Facilities with teen clubs

Of the AGYW coming to the mobile units for services in this reporting period, 6044 received SRH information while 4044 received STI information. Of these, 3193 were screened for STIs and 3442 received FP counseling (Figure 3-2-1).

3.2.2 Existence of adolescent support groups

Adolescent support groups are essential, especially for purposes of prevention, treatment, care and support. At community level there are support groups for OVCs and adolescent girls & young women (AGYW). The core activities of the SBCC approach conducted by trained Mentors using age appropriate content and include topics such as condoms, GBV, SRH and HIV services. These sessions are reinforced using Whatsapp groups and other media including videos.

Complimentary educational materials such as the MoH’s dual or double up Z-cards, test and start flyers are also being used with AGYW as part of the mentorship sessions.

The country has support groups sustained by implementing partners and are placed at health facilities. In total there are 82 teen clubs attached to health facilities as referenced in table 3-2-1.

Lubombo

Region

Regional Coverage

Manzini

Hhohho

Shiselweni

Siphofaneni, Dvokodvweni, Lomahasha, Sithobela, Mpolonjeni

Mkhiweni, Ludzeludze, Lobamba lomdzala, Kwaluseni, Manzini North, Manzini South, Ngwempisi

Lobamba, Motjane, Piggs Peak, Ntfonjeni, Mhlangatane, Mbabane East, Mbabane West

Mtsambama, Maseyisini, Hosea, Mbangaweni, Somntongo

Cabrini Ministries, Bantwana, Compassionate Swaziland, Joyful Hearts Bantwana, Nazarene Compassionate, Joyful Hears, Lusweti, Compassionate Swaziland

Bantwana, Young Heroes, AMICAAL

Compassionate Swaziland, World Vision, VOOV

Tinkhundla Partners

3.2.2 Pregnancy rate among adolescents

Adolescent fertility rate (15-19years) is estimated at 87/1000 (MICS 2014). As outlined in the SRH strategic plan, there is need to scale up information and prevention services to avoid unintended pregnancies by the adolescent and the youth.

Figure 3-2-1 shows women who made their first ANC contact at health facilities by age group.

The MICS 2014 and inpatient data stipulated that of all women giving birth 16 percent were adolescent girls. 2018 routine data showed that 18.4 percent were either below 15 years or between 15-19 years. The highest peak was at the 20-24 age group which is the youth.

22 Sexual And Reproductive Health Program_2018 Annual Report

Figure 3-2-4; HIV positivity rate by age groups Source: Health Management Information System,2018

1% 1% 2% 2% 3% 6% 11%

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 yrs 1-4 yrs 5-9 yrs 10-14 yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+ yrs

HIV positivity rate among

3.2.3 HIV among Adolescents

Figure 3-2-2 shows HIV positivity rates among people who tested for HIV in 2018, by age groups. HIV positivity rates were at 2 percent for the lower adolescents but starts to increase with the 15-19 age group.

Figure 3-2-3; Pregnant women by age group Source: Health Management Information System,2018

Below 15 15-19 20-24 25-29 30-34 35-39 40-44 45+

Number 89 4168 6765 5452 3766 1992 463 73

Percent 0.4% 18% 30% 24% 17% 9% 2% 0.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Number Percent

Pregnant Women by Age Group

3.2.4 Discussion

When health services are youth friendly, AGYW will be able to access services mainly preventive services; in the process teenage pregnancy, STIs and new HIV infection amongst adolescents and young people will be reduced.

Sexual And Reproductive Health Program_2018 Annual Report 23

Table 3-3-1; Family Planning Commodities Distributed

Source: Health Management Information System, 2018

WHO (2015) underscores that AYFHS should be accessible, acceptable and appro-priate to the needs of the young and be provided in a non-judgmental way based on respect for human rights, as well as being all-inclusive or rights-based to ensure that all adolescents and young people are welcome. Additionally, availability of services has been identified as another critical characteristic of AYFHS.

Injectable

Commodity 2014 2015 2016 2017 2018

NST 199,81 164,697 142,824 141,485 79,388

DMPA 91,371 119,729 142,734 151,539 98,240

Norigynon 10,289 10737 9861 9,644 16,455

Total 301,47 295,1163 295,419 302,668 194,083

Orals

Lof 103,252 107,043 102,139 104,638 98,089

Ovral 73,025 68,096 65,064 26,843 66,748

Micro 24,361 22,893 23,342 20,328 27,817

Total 200,638 198,032 190,545 151,809 197,951

Implants

Jadelle 3,103 4,057 4,678 4,898 4,427

Implanon 513 170 2,14 5,507 7,697

Total 3,616 4,227 6,818 10,405 12,124

IUCDs IUCD 1,961 1,514 1,78 1,545 1,830

3.3.1 Condoms

Condoms are a critical component in a comprehensive and sustainable approach to the prevention of sexual transmit-ted infections (STIs) including HIV and are effective for preventing unwanted or unplanned pregnancies. Therefore, they are highly recommended as part of the dual protection package (FP commodity plus condom). Over the year’s condom issuing has increased but there’s still challenges in tracking condoms distributed on routine data.

24 Sexual And Reproductive Health Program_2018 Annual Report

CHAPTER THREE: PROGRAM OUTPUTS

This section discussed data from HMIS and other sources. Routine data showed that adolescent girls are getting preg-nant as early as eleven years old and 18 percent of the pregnancies are within the 15-19 age group. From figure 3-2-2 it is evident that most AGYW were reached with SRH, STI and family planning information. To effectively make an impact, the non-traditional methods of service provision needs to be explored.

3.3 Family Planning (FP)

Family Planning seeks to enable women of childbearing age and their partners to have universal access to the right information and services they need to make informed and voluntary decisions about their reproduction. According to the SARA report, 75 percent of facilities offer family planning services and only 38 percent of the facilities had tracer items essential to provide comprehensive FP services. This section therefore highlights on the performance of the country on the provision of FP services including information, modern contraceptives and condoms.

Table 3-3-1 shows the distribution of family planning commodities since 2014. The distribution of family planning commodities has been fluctuating over the years and this may be attributed to that most facilities use the client level data collection system.

Figure 3-3-2; Condoms Issued form CMS Source: Logistics Management Information System, 2018

Number of Condoms Distributed

FP and HIV integration, CMIS only 2018

Figure 3-3-3; Family Planning and HIV integration Source: Health Management Information System, CMIS sites only, 2018

2,107,439

3,842,011

2,266,032

1,377,423

2,500,019

75,131 206,269 127,498 99,516 420,758

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

2014 2015 2016 2017 2018

Male condoms Female condoms

3.3.2 Family planning and HIV

HIV services particularly HTS, are fully integrated at family planning sites. Women at FP are tested for HIV based on their eligibility, and eligibility is determined by the 1) HIV status of the woman, 2) recent exposure to STI’s & HIV and 3) when was the last test done. This simply means that not all women will be tested HIV at once. It is essential that unintended pregnancies are prevented especially for the HIV positive population to avert mother to child transmission of HIV.

50417

38717 (77%)

13955 (36%) 11686

12523 (86%)

10000

20000

30000

40000

50000

60000

Total women on FP

FP women who know their HIV status

Already HIV+ at FP

FP women tested for HIV

Testing + at FP

On ART

Sexual And Reproductive Health Program_2018 Annual Report 25

Figure 3-4-1; No of Abortion at Out Patient Department Source: Health Management Information System, 2018

No. of abortions

Of the women who came for family planning services 77 percent knew their HIV status with 11,700 not knowing. Thirty six percent of the known HIV status were already HIV positive and 5 percent tested positive at FP.

3.3.2 Discussion

The program has continued to improve FP service provision following the move to competency based Family Planning Training for nurses. This has been conducted in various interventions including the promotion of dual protection through the use of condoms with any long or short term contraceptive method, as well as increasing FP use among women living with HIV and on ART. The program has also strengthened FP integration with HIV and ART through collab-orative efforts with ENAP and RHM Program. The marketing strategy to increase FP uptake at community level was through the training of RHMs as well as Experts clients on the different commodities. As of 2018, 30 RHMs and 30 Expert clients were trained and these numbers will be increased in the following years.

As there is emphasis on dual protection, it is essential that in the future, data/reports are able to measure women who received both methods (modern contraceptives and condoms) and how it translates to reduced incidence of STI’s. In terms of condoms distributed at health facilities, data collection systems need to be improved to capture condoms distributed through other service points other than the family planning service area. Though the contraceptive preva-lence for the country is high (66%) evidence has also shown that a high number of women have unplanned pregnancies.

There is need for the reprogramming of family planning so that women in need are targeted.

3.4 Abortion and Post Abortion Care

Globally, reports (including the national confidential enquiry into maternal deaths report 2013) have shown that abor-tions are the third leading cause for maternal deaths. Abortion is defined as a termination of a non-viable fetus and it can be spontaneous or induced. Figure 3-4-1 illustrates the number of abortion cases seen at out-patient. In 2018, 3301 cases were seen at OPD. However, this date does not state if these cases were threatened or completed abortions.

2014 2015 2016 2017 2018

26 Sexual And Reproductive Health Program_2018 Annual Report

Figure 3-4-2; Admissions due to Abortion Source: Health Management Information System, 2018

Types of Abortion at Inpatient

3.4.1 Admissions to due abortion

Obstetric and gynecological admissions owing to abortion are high as shown in the graph. A limitation for this data was that; it cannot be ascertained if the abortions were complete or not. The leading classification is that of spontaneous abortion followed by unspecified

2014 2015 2016 2017 2018

Spontaneous Abortion 1219 1258 1023 862 917 Unspecified Abortion 114 139 118 686 735 Complications Following Abortion and Ectopic and Molar Pregnancies 222 312 136 165 161

Failed Attempted Abortion 139 233 219 130 79 Missed Abortion 140 154 202 122 86 Other types of abortion 32 84 259 260 7

3.4.2 Discussion

The abortion cases seen at OPD translates to 10% of the expected annual pregnancies resulting into abortions.

Mismanaged abortion can result to secondary infertility. The high number of reported abortion cases can be reduced by ensuring that women receive quality antenatal care and universal coverage of family planning services. This thematic area is an area that lacks leadership and coordination resulting in poor programming in terms of monitoring and target-ing interventions particularly FP demand creation, resource mobilization, training and developing skills for pre concep-tion and PAC, ensuring health information systems are functional and reliable in producing PAC data. There are also no guidelines stipulating on how to manage post abortion.

3.5 STI’s and HIV/AIDS

Globally, 357 million new cases of these four (chlamydia, gonorrhea, syphilis and trichomoniasis) curable STI’s are acquired annually mostly by people aged 15–49 years. Sexually transmitted infections (STI’s) remain a priority in HIV response. Some viral STI’s, like human papillomavirus (HPV), HSV2 and HIV, are still incurable and can be deadly, while some bacterial STI’s like chlamydia, gonorrhea, syphilis and chancroid are curable if detected and treated (WHO, 2015).

This section will focus on sexually transmitted diseases for the general population, syphilis among pregnant women, HIV service in maternal health as well as HIV services for exposed infants.

Sexual And Reproductive Health Program_2018 Annual Report 27

Figure 3-5-1; Types of Sexually Transmitted Infections Source: Health Management Information System, 2018

Types of STI syndrome 2017 and 2018

3.5.1Sexually Transmitted Infections (STIs) Sexually transmitted infections (STIs) are a major global cause of acute illness, infertility, long-term disability, congeni-tal disorders and death, with severe medical and psychological consequences for millions of infants and sexually active individuals.

The impact of these diseases is magnified by the potential to facilitate the spread of HIV infection. It is for this reason that improving access to STI services is an important part of WHO Global Strategy for Universal access to reproductive health care. Effective STI control depends on reliable, routine STI surveillance.

STIs are markers of unprotected sexual intercourse, surveillance for an incidence of STIs could serve as an early warn-ing of the HIV epidemic potential through sexual transmission. It is in this regard that the MoH recognized the need to strengthen STI interventions by facilitating STI control efforts at all levels using a multi-sectoral approach in reducing the burden of STIs.

35432

29607

18624

12759

18919 15489

10688

10000

15000

20000

25000

30000

35000

40000

Other STI Vaginal Discharge Urethral Discharge Genital Ulcer

2017 2018

Figure 3-5-1 shows the different types of STIs seen at outpatient departments from January to December 2018. Worth noting is that both urethral and vaginal discharge were more prevalent (10 688) when compared to genital ulcers which may reflect but not limited to issues of re-infection, poor partner notification and drug resistance. The syndrome trend show the same pattern with unclassified ‘other STI’s being the highest followed by vaginal discharge and genital ulcer being the lowest. When comparing the figure from 2017 to 2018 approximately a 50% reduction is evident. The reduction may be attributed to the transitioning from paper based system to an electronic version.

28 Sexual And Reproductive Health Program_2018 Annual Report

Figure 3-5-2; Sexually Transmitted Infections, CMIS sites only Source: Health Management Information System, 2018

Figure 3-5-3; Urethral discharge syndrome by age Source: Health Management Information System, 2018

STI at Facilities (CMIS)

Urethral Discharge Syndrome by age (CMIS)

60 56

6 4

Herpes Candadiasis Trichomonal Syphilis Anal Gonococcal Human papiloma

Figure 3-5-2 shows types of STI’s seen in facilities from January to December 2018 at CMIS sites only. The most preva-lent being herpes 147, followed by candidiasis at 113.