Access To Emergency Obstetric Care Research Articles

Third delay and associated factors among women who gave birth at public health facilities of Gurage zone, southern Ethiopia

BackgroundThe third delay is a delay in accessing emergency obstetric care timely and appropriately once a woman reaches a health facility. The third delay plays a crucial role as an indicator to assess the quality of obstetrics services and is often the leading contributing factor to maternal mortality in developing countries. Although considerable research has been conducted on pre-facility delays in healthcare access, there is a lack of focus on delays experienced upon arrival at health facilities, particularly in Ethiopia and the specific study areas of Gurage zone. This study aimed to assess the magnitude of the third delay and associated factors among women who gave birth at Public Health Facilities of Gurage Zone, Southern Ethiopia.MethodA facility-based cross-sectional study was conducted with 558 women who gave birth at public health facilities of Gurage Zone from January 01/2020 to March 30/2020. Multi-stage stratified sampling technique was used to select the nine facilities. The data was collected using a structured interviewer administer questionnaire and an observational checklist. Women who waited more than an hour to receive delivery services after arriving at the health facility were classified as experiencing the third delay. The data were entered and analyzed using Epi Data version 3.1 and SPSS version 20.0 software, respectively. Binary logistic regression was employed to identify the determinant factors for the third delay. Variables having a P-value < 0.25 in the binary analysis were a candidate for multivariable analysis. Variables with P < 0.05 were considered statistically significant.ResultThe magnitude of the third delay was 193 [(34.8%; 95% CI; (30.8%, 38.8%)]. Complication during labor [AOR = 2.0; 95% CI, (1.4, 3.0)], Presence of functional generator in a health facility [AOR = 2.8; 95% CI, (1.3, 6.3)], level of health institution [AOR = 2.8; 95% CI, (1.04, 7.8)] and BEMONC training in the last two years [AOR = 1.6; 95% CI, (2.0, 6.5)] were significantly associated with third delay.ConclusionThe magnitude of third delay was high compared to some low income countries, which shows most of mothers were not getting the service timely after they arrived at the health facility. Equipping health facilities with trained manpower and with necessary materials and infrastructure will contribute to hastening the provision of obstetric care.

Trend and Sociodemographic Correlates of Cesarean Section Utilization in Nepal: Evidence from Demographic and Health Surveys 2006-2016.

Background Addressing inequalities in accessing emergency obstetric care is crucial for reducing the maternal mortality ratio. This study was undertaken to examine the time trends and sociodemographic correlates of cesarean section (CS) utilization in Nepal between 2006 and 2016. Methods. Data from the Nepal Demographic and Health Surveys (NDHS) 2006, 2011, and 2016 were sourced for this study. Women who had a live birth in the last five years of the survey were the unit of analysis for this study. Absolute and relative inequalities in CS utilization were expressed in terms of rate difference and rate ratios, respectively. We used multivariable regression models to assess the CS rate by background sociodemographic characteristics of women. Results Age and parity-adjusted CS rates were found to have increased almost threefold (from 3.2%, 95% CI: 2.1-4.3 in 2006 to 10.5%; 95% CI: 8.9-11.9 in 2016) over the decade. In 2016, women from mountain region (3.0%), those from the lowest wealth quintile (2.4%), and those living in Karnali province (2.4%) had CS rate below 5%. Whereas women from the highest wealth quintile (25.1%), with higher education (21.2%), and those delivering in private facilities (37.1%) had CS rate above 15%. Women from the highest wealth quintile (OR-3.3; 95% CI: 1.6-7.0) compared to women from the lowest wealth quintile and those delivered in private/NGO-run facilities (OR-3.6; 95% CI: 2.7-4.9) compared to women delivering in public facilities were more than three times more likely to deliver by CS. Conclusion To improve maternal and newborn health, strategies need to be revised to address the underuse of CS among poor, those living in mountain region and Province 2, Lumbini province, Karnali province, and Sudhurpaschim province. Simultaneously, there is a pressing need for policies, guidelines, and continuous monitoring of CS rates to reduce overuse among rich women, women with higher education, and those giving childbirth in private facilities.

Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India

BackgroundThe study was conducted to estimate the prevalence and risk factors of obstetric fistula in the rural area of the south eastern community of India and the training of community health workers for its prevention.MethodsA population-based cross-sectional analytical study was conducted in the south eastern rural community of India. A total of 3939 women were included in the study and Probability proportional to size sampling was used in the study. Frequency distribution and logistic regression were computed to analyse the data using STATA version 11.2.ResultsOut of 3939 participants interviewed, 23.7% women reported obstetric fistula symptoms whereas after clinical diagnosis and speculum examination the obstetric morbidity pattern was: Obstetric fistula 0.3%, stress urinary incontinence 20.0%, pelvic inflammatory diseases 1.2%, uterine prolapse 1.4% and urinary tract infection 3.8%. The awareness level of the rural women regarding the obstetric fistula was assessed by a structured knowledge questionnaire and found to be very poor, hence community based fistula training was implemented among community health workers as a health system based strategy for its prevention. Obstetric fistula found to be more prevalent among women of poor educational level, low socioeconomic status, less no of antenatal visits, delay in accessing the emergency obstetric care and prolonged labour (p ≤ 0.05).ConclusionFinding of the study indicated that the prevalence and risk of developing obstetric fistula was associated with less number of antenatal visits, prolonged labour, delay in timely intervention, delay in accessing emergency obstetric care and more number of movements from home to the delivery place. Finally, our study suggests that emphasis needs to be placed on training of community health workers to facilitate early screening for identification and referral of women with obstetric fistula.

Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study

Background: In India, emergency obstetric care (EmOC) services were started under RCH-II program (2004) with the goal to reduce maternal mortality ratio <100/lakh live births and increase institutional deliveries to at least 80% by 2010. Implemented strategy was to enhance availability and accesses to EmOC services. Objective: This study was conducted in one of the blocks of Wardha district in Maharashtra to understand the accessibility for providing EmOC services at primary health center and rural hospital in the last 1 year. Materials and Methods: This cross-sectional qualitative study was conducted from May 2018 to October 2018. Data were collected by key informant interviews of service providers. Notes were transcribed and then translated into English. Respondents' verbatim that is significant and illustrative as per the theme of the study was used for analysis. Results: Equipment and drugs essential for EmOC were available; however, most of these were underutilized due to lack of skill in selected facilities. Basic EmOC training pattern was found inadequate in duration and practical skill. Training and recruitment of staff constantly were observed challenging for higher stakeholders. Of all EmOC signal functions, only parental antibiotics, oxytocics, and assisted vaginal delivery (episiotomy) were provided. Conclusion: Although building infrastructure, drugs, equipment, and transportation facilities were accessible, needy women may fail to receive timely and quality EmOC, due to lack of trained staff, low confidence, and lack of motivation in managing obstetric emergencies.

Emergency transport for obstetric emergencies: integrating community-level demand creation activities for improved access to maternal, newborn, and child health services in northern Nigeria.

PurposeEnsuring adequate access to skilled birth attendants during and after childbirth is a key strategy to reducing maternal and newborn mortalities. Transportation difficulties in emergency situations continue to be a significant barrier to accessing emergency obstetric care, especially in rural and hard-to-reach areas. Emergency transport schemes (ETS) have been introduced in various settings to increase access to emergency care and reduce the second obstetric delay with varying degrees of success. This qualitative study assessed the perceptions of stakeholders and beneficiaries of ETS in two states in northern Nigeria, comparing two models of ETS: one in which the ETS were introduced as a stand-alone intervention, and another in which ETS were part of a package of interventions for increasing demand and improving utilization of maternal and newborn health services.MethodsWe carried out focus group discussions with ETS drivers, mothers who delivered in the past year and utilized ETS, husbands of women who benefited from the schemes in the past year, health care providers, traditional birth attendants, and religious leaders, supplemented by in-depth interviews with program focal persons.ResultsDemand creation activities – especially working with traditional birth attendants and religious leaders – provided a strong linkage between the ETS and families of women in need of emergency transport services. Community members perceived the ETS model that included demand-generating activities as being more reliable and responsive to women’s needs.ConclusionETS remain a key solution to lack of transport as a barrier to utilizing maternal and newborn health services in emergency situations in many rural and hard-to-reach communities. Programs utilizing ETS to improve access to emergency obstetric care should explore the potential of increasing their utility and reach by integrating the schemes with additional demand-side interventions, especially engagement with traditional birth attendants and religious leaders.

Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti

BackgroundThe primary objective of this comparative, cross-sectional study was to identify factors affecting delays in accessing emergency obstetric care and clinical consequences of delays among preeclamptic and non-preeclamptic women in Port-au-Prince, Haiti.MethodsWe administered 524 surveys to women admitted to the Médecins Sans Frontières Centre de Référence en Urgences Obstétricales (CRUO) obstetric emergency hospital. Survey questions addressed first (at home), second (transport) and third (health facility) delays; demographic, clinical, and behavioral risk factors for delay; and clinical outcomes for women and infants. Bivariate statistics assessed relationships between preeclampsia status and delay, and between risk factors and delay.ResultsWe found longer delays to care for preeclamptic women (mean 14.6 h, SD 27.9 versus non-preeclamptic mean 6.8 h, SD 10.5, p < 0.01), primarily attributable to delays before leaving for hospital (mean 13.4 h, SD 30.0 versus non-preeclamptic mean 5.5 h, SD 10.5). Few demographic, clinical, or behavioral factors were associated with care access. Poor outcomes were more likely among preeclamptic women and infants, including intensive care unit admission (10.7%, vs. 0.5% among non-preeclamptic women, p < 0.01) and eclampsia (10.7% vs. no cases, p < 0.01) for women, and neonatal care unit admission (45.6% vs. 15.4%, p < 0.01) and stillbirth (9.9% vs. 0.5%, p < 0.01). Longer delays among both groups were not associated with poorer clinical outcomes.ConclusionPregnant women with preeclampsia in Port-au-Prince reported significant delays in accessing emergency obstetric care. This study provides clear evidence that hospital proximity alone does not mitigate the long delays in accessing emergency obstetrical care for Haitian urban, poor women.

Delays in Africa Accessing Emergency Obstetric Care in Sub-Saharan; Kenya Situation

Delay in accessing facility for delivery by a skilled person has huge impact on maternal health outcomes in developing countries. However, women’s deaths at birth in Sub-Saharan countries remain high due to challenges associated with accessing immediate Emergency Obstetric Care (EmOC) at birth.&#x0D; While the deaths are preventable through availability of EmOC and skilled persons attending to delivery, access to these services remain poor and most women continue to give birth at home without the assistance of a skilled person.&#x0D; The purpose of the study was to identify barriers to accessing EmOC in order to suggest ways of increasing skilled birth attendance in Kenya, a strategy that is known to reduce maternal mortality and morbidity. Relevant literature from abstracts of scholarly journals from major search engines were scanned and analyzed for results.&#x0D; Significant factors that were identified to cause delay in accessing EmOC are maternal education, financial status, ignorance, delay in decision making by family, preference for Traditional Birth Attendants (TBA), travel cost, means of transport, distance, and impassable roads. Further barriers are poor quality of care due to supplies and equipment shortage, rude, unwelcoming staff, user fees paid on admission and long waiting hours in the facilities.&#x0D; Based on the findings, various barriers that hinder women from accessing EmOC exist. To increase the number of births assisted by skilled professionals and reduce maternal deaths, these barriers need to be tackled from family, community, and facility levels.&#x0D; The recommendations include community sensitization and health education on pregnancy related danger signs, strengthening of health care systems to ensure availability of supplies, equipment, and improving referral systems. Integration of TBAs role to health care system will ensure timely referral and increased facility deliveries.

Maternal death and delays in accessing emergency obstetric care in Mozambique

BackgroundDespite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique.MethodsSecondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility.ResultsData were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa.ConclusionsThe delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.

Assisted vaginal delivery in low and middle income countries: an overview.

To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. Cross-sectional health facility assessments. Up to 40 countries in Latin America, sub-Saharan Africa and Asia. Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. Descriptive secondary data analysis. Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

BackgroundZambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.MethodA cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.ResultsA total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76).ConclusionsWomen in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Male involvement in utilization of emergency obstetric care and averting of deaths for maternal near misses in Rakai district in Central Uganda

Although studies have assessed male involvement in birth preparedness and complication readiness, little is known about their involvement after the onset of maternal near miss complications. This information is important in developing appropriate strategies for male involvement in accessing emergency obstetric care (EmOC) in order to reduce Uganda’s high maternal mortality ratio. The study examined the roles played by men after the onset of maternal near miss complications in Uganda. A qualitative study using narratives of 40 purposively selected maternal near misses and in-depth interviews of 10 randomly selected men was conducted. Results showed that men were involved in postpartum uptake of long term contraceptive methods, management of obstetric complications, decision making, social support, transport arrangements and provision of financial support to access EmOC. Therefore, men should be sensitized on the recommended haemorrhage medication during home births, the need for supervised deliveries and prompt referral of their wives to health facilities.

A feasible, acceptable and effective way to teach health care workers in low- and middle-income countries a method to manage acutely ill obstetric women

Maternal mortality is unacceptably high in Sub Saharan Africa, which accounts for 56% of all maternal deaths (WHO, 2012). Most maternal deaths are avoidable but with prompt recognition and timely intervention it is not inevitable that acute or critical maternal illness deteriorates to fatality (Firth and Ttendo, 2012). This paper discusses a project to provide multidisciplinary training in Maternal-Acute Illness Management (M-AIM) in a low resource setting in order to actively address the third delay to women accessing emergency obstetric care: prompt receipt of effective care on reaching a medical facility.

‘The clock keeps ticking’ – the role of a community-based intervention in reducing delays in seeking emergency obstetric care in rural Bangladesh: a quasi-experimental study

ObjectiveTo explore the role of a community-based intervention in reducing delays in accessing emergency obstetric care (EmOC) in rural Bangladesh, and the factors associated with delayed decision making, reaching the health facility and receiving treatment. Study designQuasi-experimental study. MethodsMultistage random sampling was used to select 540 villages, from which 1200 women who reported obstetric complications in March–April 2010 were interviewed. ResultsThe median time taken to make the decision to access health care was significantly lower in the intervention areas compared with the control areas (80 vs 90 min). In addition, the median time taken to reach the health facility was significantly lower in the intervention areas compared with the control areas (110 vs 135 min). However, no difference was found in the median time taken to receive treatment. Multiple linear regressions demonstrated that the community intervention significantly reduced decision making and time taken to reach the health facility when accessing EmOC in rural Bangladesh. However, for women experiencing haemorrhage, the delays were longer in the intervention areas. Protective factors against delayed decision making included access to television, previous medical exposure, knowledge, life-threatening complications during childbirth and use of a primary health facility. Financial constraints and traditional perceptions were associated with delayed decision making. Complications during labour, use of a motorized vehicle and use of a primary health facility were associated with faster access to EmOC, and poverty, distance, transportation difficulties and decision made by male guardian were associated with slower access to EmOC. ConclusionsThe intervention appeared to reduce the time taken to make the decision to access health care and the time taken to reach the health facility when accessing EmOC. This study provides support for a focus on emergency preparedness for timely referral from the community.

Why Are Women Dying When They Reach Hospital on Time? A Systematic Review of the ‘Third Delay’

BackgroundThe ‘three delays model’ attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries.Methods and FindingsFive electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%).ConclusionsThis review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.

Local use of geographic information systems to improve data utilisation and health services: mapping caesarean section coverage in rural Rwanda

To show the utility of combining routinely collected data with geographic location using a Geographic Information System (GIS) in order to facilitate a data-driven approach to identifying potential gaps in access to emergency obstetric care within a rural Rwandan health district. Total expected births in 2009 at sub-district levels were estimated using community health worker collected population data. Clinical data were extracted from birth registries at eight health centres (HCs) and the district hospital (DH). C-section rates as a proportion of total expected births were mapped by cell. Peri-partum foetal mortality rates per facility-based births, as well as the rate of uterine rupture as an indication for C-section, were compared between areas of low and high C-section rates. The lowest C-section rates were found in the more remote part of the hospital catchment area. The sector with significantly lower C-section rates had significantly higher facility-based peri-partum foetal mortality and incidence of uterine rupture than the sector with the highest C-section rates (P < 0.034). This simple approach for geographic monitoring and evaluation leveraging existing health service and GIS data facilitated evidence-based decision making and represents a feasible approach to further strengthen local data-driven decisions for resource allocation and quality improvement.

India's JSY cash transfer program for maternal health: Who participates and who doesn't - a report from Ujjain district

BackgroundIndia launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India.MethodsA cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery.ResultsThe majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home.ConclusionIn this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death.

Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study

BackgroundRecognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC.MethodsThis cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. Pearson's chi-square test, t-test and Mann-Whitney test were performed.ResultsThe median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in income-generating activities.ConclusionsManoshi program reduces the first delay for life-threatening conditions but not non-life-threatening complications even though providing financial assistance. Programme should give more emphasis on raising awareness through couple/family-based education about maternal complications and dispel fear of clinical care to accelerate seeking EmOC.

Availability of essential health services in post-conflict Liberia.

To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war. We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness. Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county's 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively. Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.

Emergency referral transport needs of pregnant women in rural Tanzania

For pregnant women in rural Africa, delays in reaching a health facility are inevitable. When complications occur, unless transport is found quickly to reach a facility providing essential obstetric care promptly, morbidity and mortality are common outcomes. The study aimed to explore the emergency transport needs of rural pregnant women in Erri village, Babati District, Tanzania. Communities were selected purposefully. A crosssectional design was used, 250 women of childbearing age were interviewed, 12 men and 12 women participated in focus group discussions (FGD), and 7 women were interviewed using the critical incidence technique. Information on community awareness of women's needs for locally available and functional transport for emergency obstetrics referrals was obtained using a structured questionnaire, FGD and critical incident interviews. The questionnaire revealed that 75% of women with 7 years of school in this study, were more likely to seek help from the district hospital than women with 5 or fewer years of schooling. Women who lived nearer to emergency obstetric facilitates were more likely to use these facilitates than those living far away. Having a bicycle in a household did not influence the woman's decision about where to seek help during an emergency. Seventy percent of respondents (43/61) who used a bicycle revealed that when women encounter emergencies it takes more than half a day to reach the district hospital. Almost every participant declared the hardship in accessing emergency obstetric care related to lack of funds and unavailability of the transport. During FGD women shared stories of mothers and newborns who had died on their way to emergency obstetric care. The study provides a small insight into the referral transport needs of pregnant women living in rural communities in Manyara region. Further participatory research is necessary to identify reliable and affordable transport options acceptable to pregnant women and their families; and evaluation is required to estimate the impact of emergency referral programmes on referral times and operational feasibility.

Did the strategy of skilled attendance at birth reach the poor in Indonesia?

To assess whether the strategy of "a midwife in every village" in Indonesia achieved its aim of increasing professional delivery care for the poorest women. Using pooled Demographic and Health Surveys (DHS) data from 1986-2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesias health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. There was no change in rates of professional attendance or caesarean section before the programmes full implementation (1986-1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles -- 11% per year compared with 6% per year for women in the middle quintile (P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor.