Abstract
BackgroundMaternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.Methods/DesignThis is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews.The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.Trial RegistrationThe QUARITE trial is registered on the Current Controlled Trials website under the number ISRCTN46950658 .
Highlights
Maternal and perinatal mortality are major problems for which progress in subSaharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries
The broad strategies that have made it possible to reduce maternal and perinatal mortality are known: prenatal care, labour and delivery management by qualified personnel, and availability of emergency obstetric care (EmOC) [2]; their implementation is a major challenge in sub-Saharan Africa, where healthcare systems are fragile and still being developed
The objective is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality at referral hospitals in Mali and Senegal, as well as improvements in perinatal health, resource availability, service organization, medical practices, and the satisfaction of health personnel
Summary
Maternal and perinatal mortality in sub-Saharan Africa In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems for which progress has been inadequate. Aims The objective is to evaluate the effectiveness of the AIP in reducing maternal mortality at referral hospitals in Mali and Senegal, as well as improvements in perinatal health, resource availability, service organization, medical practices, and the satisfaction of health personnel Design This is an international, multi-centre, controlled clusterrandomized trial of a complex intervention. D) Educational outreach visits by external facilitators: A national opinion leader, chosen for his or her expertise and leadership, and the AIP international coordinator will visit all the hospitals in the intervention group every three months The purpose of these visits will be to support the local opinion leaders in their role of providing AIP training to all the health professionals in the maternity service and to ensure that audits are being carried out, by overseeing an audit meeting. The authorities were informed that 1) all centres had the option of withdrawing from the project at any time; 2) the AIP training
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