Basic Emergency Obstetric And Neonatal Care Research Articles

Eight years into the horizon of aspirational maternal and newborn health pledges: a nationwide cross-sectional exploration of the Burundian EmONC network capacity and budget deficits

ObjectiveThe Burundian emergency obstetric and neonatal care (EmONC) programme, which was initiated in 2017 and supported by a specific policy, does not appear to reverse maternal and newborn mortality trends....

Geographical distribution of emergency obstetric and neonatal care signal functions in Ethiopian health facilities: 2021–2022 Ethiopian service Provision Assessment (SPA)

BackgroundThe maternal mortality ratio in Ethiopia is still high, with an estimate of 412 deaths per 100,000 live births in 2016. Signal functions for emergency obstetric and neonatal care must be accessible and usable in order to successfully prevent maternal deaths. It is an important strategy to reduce maternal and newborn morbidity and mortality in countries with limited resources. Hence, an assessment of the availability of fully functioning EmONC services and their coverage per 500,000 people in Ethiopia is crucial.MethodsThis study is a retrospective analysis of data from the Ethiopian Service Provision Assessment Survey (ESPA), a national-level survey data source. Data collection for the survey took place from August 11, 2021, to February 4, 2022. For this investigation, 905 healthcare facilities in total were evaluated for the availability of emergency obstetric and new-born care (EmONC) services at all hospitals, selected health centers, and private clinics were evaluated. Descriptive data analysis was done by the using statistical package for social science version 26 (SPSS) to run frequency and cross-tabs. Global Positioning System (GPS) (arc map 10.8) Software was used for spatial distribution in order to locate the physical accessibility of EmONC providing health facilities on flat map surfaces. It was projected based on Ethiopia’s geographic coordinate system at Adindan UTM zone 370N.ResultsOf 905 health facilities, only 442 (49%) could provide fully functioning BEmONC, and 250 (27.6%) health facilities have been providing fully functioning CEmONC. The overall coverage of BEmONC ratios in Ethiopia is 1.5–3.77 per 500,000 population and CEmONC (0.83–2.1) per 500,000 populations. Regions such as Amhara, SNNPR and Addis Ababa had found to have high BEmONC ratio. The geographical distribution of the EmONC showed that the central areas of the country, such as southwest Shewa and east Shewa, the Oromia region, the northern areas of the South Nation, nationalities, and peoples regions (SNNPR), including the Gurage zone and the Wolaita-Soddo zone, and the middle areas in the Amhara region (west Gojjam or around Bahir Dar town), and the southern areas, Debra Tabor and Debre Birhane zones, all had greater access to facilities offering complete EmONC services.ConclusionComprehensive emergency obstetrics and neonatal care (CEmONC) in Ethiopia met WHO recommendations, despite basic emergency obstetric and neonatal care (BEmONC) falling below those standards in Ethiopia. There are extremely large disparities in the accessibility of both basic and comprehensive emergency obstetrics and neonatal care in Ethiopia. Thus, Strategic planning is needed to improve infrastructures and inputs for EmONC services, particularly in remote areas of the country. Additionally, private facilities ought to place a priority on the provision of these services.

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021

BackgroundNepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved.MethodsCross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs.ResultsDespite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent.ConclusionsThe slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

Determinants of birth asphyxia among neonates admitted to neonatal intensive care units in hospitals of the Wolaita zone, Southern Ethiopia: A case-control study

BackgroundBirth asphyxia, according to the World Health Organization (WHO), is the inability of breathing to start and continue automatically at birth. Blood-gas exchange is impaired, which results in increased hypoxia, hyperapnea, and substantial metabolic acidosis. The aim of this study was to determine the factors contributing to birth asphyxia in infants admitted to neonatal intensive care units in hospitals in the Wolaita Zone. MethodsAn institution-based, unmatched case-control study among neonates admitted to neonatal intensive care units in Wolaita Zone hospitals was conducted from March 1 to April 15, 2021. With 148 cases and 294 controls and a case-to- control ratio of 1:2, a sample size of 442 was determined. The pre-tested and structured Open Data Kit collect mobile application (v1.26.1) was used to collect the data, and SPSS version 25 was used for analysis. Using adjusted odd ratios and their corresponding 95 % confidence intervals, bivariate and multivariable logistic regression analyzes were performed. ResultsA total of 143 cases and 286 controls were included making. the response rate 97 %. Meconium or blood-stained amniotic fluid (AOR = 5.43, 95%CI:3.10–9.50), mothers who experienced any of dangerous symptom during pregnancy (AOR = 3.71, 95%CI: 1.56–8.65), premature rupture of membrane (AOR = 3.12, 95%CI: 1.42–6.83), hypothermic newborn (AOR = 4.57, 95CI: 1.77–11.81), labor not supported by Basic Emergency Obstetric and Neonatal Care (BEMONC) trained health professional (AOR = 3.23, 95%CI: 1.83–5.71), birth weight of less than 2500 gm (AOR = 2.68, 95%CI: 1.04-6.92), sub-standard filling of partograph (AOR = 4.03, 95%CI: 2.19–7.41), not filling on partograph during follow-up (AOR = 8.16, 95%CI: 2.24-29.66) and assisted vaginal delivery (AOR = 1.87, 95%CI:1.03–3.39) were identified as determinants of birth asphyxia. ConclusionIn this study, fetal conditions such as hypothermia and low birth weight, changes in the color of amniotic fluid, dangerous pregnancy symptoms, membrane rupture, standard filling of the partograph, and BEMONC training were factors that predicted birth asphyxia. Therefore, prompt and effective management of fetal and maternal problems and as well as the development of health professionals' BEMONC competence are crucial.

Service availability and readiness for basic emergency obstetric and newborn care: Analysis from Nepal Health Facility Survey 2021.

Although there has been a significant focus on improving maternal and newborn health and expanding services in Nepal, the expected positive impact on the health of mothers and newborns has not been achieved to the desired extent. Nepal not only needs to focus on improving access to and coverage of services but also the quality to achieve Sustainable Development Goals (SDG) by 2030. In this context, we aimed to analyze Basic Emergency Obstetric and Neonatal Care (BEmONC) service availability and readiness in Health Facilities (HFs) of Nepal. We analyzed data from nationally representative Nepal Health Facility Survey (NHFS), 2021. BEmONC service availability and readiness in HFs was measured based on the "Service Availability and Readiness" manual of World Health Organization (WHO). We measured service availability by seven BEmONC signal functions. The readiness score was calculated for three domains- guidelines and staff training, essential equipment/supplies, and essential medicines on a scale of 100, and the average score for the three domains was the overall readiness score. We performed weighted descriptive and inferential analysis to account complex survey design of NHFS 2021. We summarized continuous variables with descriptive statistics like mean, standard deviation, median and interquartile range whereas categorical variables with percent and 95% confidence interval (CI). We applied simple, and multivariate linear regression to determine factors associated with the readiness of HFs for BEmONC services, and results were presented as beta (β) coefficients and 95% CI. Of total 804 HFs offering normal vaginal delivery services, 3.1%, 89.2%, 7.7% were federal/provincial hospitals, local HFs, and private hospitals respectively. A total of 45.0% (95% CI: 34.9, 55.6) federal/provincial hospitals, 0.3% (95% CI: 0.2, 0.6), local HFs (district hospital, primary health care centers, health posts, urban health centers) and 10.5% (95% CI: 6.6, 16.4) private hospitals, had all seven BEmONC signal functions. The overall readiness of federal/provincial hospitals, local HFs, and private hospitals were 72.9±13.6, 54.2±12.8, 53.1±15.1 respectively. In multivariate linear regression, local HFs (β = -12.64, 95% CI: -18.31, -6.96) and private hospitals had lower readiness score (β = -18.08, 95% CI: -24.08, -12.08) compared to federal/provincial level hospitals. HFs in rural settings (β = 2.60, 95% CI: 0.62, 4.58), mountain belts (β = 4.18, 95% CI: 1.65, 6.71), and HFs with external supervision (β = 2.99, 95% CI:1.08, 4.89), and quality assurance activities (β = 3.59, 95% CI:1.64, 5.54) had better readiness scores. The availability of all seven BEmONC signal functions and readiness of HFs for BEmONC services are relatively low in local HFs and private hospitals. Accelerating capacity development through training centers at the federal/provincial level, onsite coaching, and mentoring, improving procurement and supply of medicines through federal/provincial logistic management centers, and regular supportive supervision could improve the BEmONC service availability and readiness in facilities across the country.

Efektifitas the Safe Delivery App (SDA) secara Blended Learning terhadap Pengetahuan Bidan

Instroduction: Globally on the industrial revolution of 4.0 mobile learning (mLearning) tools were familiar and attracted considerable attention for healthcare workers as a means of continuous training. The Safe Delivery App’s innovation (SDA) is a smartphone mLearning app that contains information and skills for trained health workers, can be accessed directly, quckly, and based on evidence-based Basic Emergency Obstetric and Neonatal Care (BEmONC) content. Purpose: This study assessed the effect of the SDA intervention by blended learning on midwives’ knowledge. Methods: The study used a quasi-experimental group pre-and post-test design with control group. The research sample consisted of 48 midwives with randomized sampling grouping through by-wheel trial numbers, timing 3 to 6 month. An independent sample t-test was used to statistically, Confidence interval (Cls) and effect size by Cohen’s d were used. Results: The use of The SDA App has proven to be significantly effective in creasing knowledge, the mean differences before-after 5,39 (SD=2,37); 95% Cl 2,29 ± 4,28, p-value <0,001 and d=1,38 in one of the modules. Conclusion: The SDA App has proven very effective improved the quality of human resources for midwives, hope these benefits will be further disseminated wider by all heatlh cares provider.

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Participants was 35.3 (standard deviation: 7.1) years. The demographics (98%), foetal heart rate (80.5%), temperature, pulse and respiratory (74.5%) and maternal blood pressure (73.2%) section of the partograph were the most charted. The least charted sections were foetal descent (19.5%), cervical dilatation (21.5%) and uterine contractions (24.8%). Use of the partograph was associated with the female gender with a 58% (aOR: 0.42. 95% CI: 0.19-0.91) lower odds compared to male nurses. The findings highlight a persistent gap in the use of the partograph in Kenya despite the recent countrywide BEmONC training. There is a need for enhanced on-job training for nurses and midwives on the use of the partograph but also a need to explore the possibility of using the electronic partograph that are effective in reducing adverse foetal outcomes and improve adherence to labour care and strengthen routine support supervision to review nurses-midwives in the use of the partograph. In low resource setting, the completion rate of partograph is low despite heavy investment in training of healthcare workers on Basic Emergency Obstetric and Neonatal Care (BEmONC), which promotes the use of partographs to monitor the progress of labour. In Kenya, the rate of caesarean section, instrumental delivery and APGAR score less than 7 at 1 min has increased. Therefore, this study determined the extent of use of partograph as a tool for monitoring the progress of the mother and the foetus during labour in selected Western counties in Kenya. This cross-sectional study was conducted in Kisumu and Vihiga counties in Western Kenya between May and June 2019. Validated self-administered questionnaires and checklists were used to collect data from participants and randomly chosen participant-filled partograph. Sample characteristic and extent of use of partograph were described using frequencies and percentages while factors associated with partograph use were assessed using multivariable logistic regression. Statistical significance was set at p<0.05. Out of 149 participants, 104 (69.8%) were female, 144 (96.6%) were nurses, 52% worked in health centres, 37% had worked for seven or more years and trained on BEmONC within 1 to 2 years. Key words: Partograph, labour, antenatal care, skilled birth attendance, Kenya.

The effect of an mLearning application on nurses\u2019 and midwives\u2019 knowledge and skills for the management of postpartum hemorrhage and neonatal resuscitation: pre\u2013post intervention study

BackgroundGlobally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers’ knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR).MethodsThe study used a pre–post test design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior to SDA intervention and after 6 months of SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre–post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova were used to test for potential confounders.ResultsThe analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI 14.69 to 19.49 and 2.6% for PPH skills; 95% CI 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI 16.31 to 21.76 and 5.5% for NR skills; 95% CI 3.66 to 7.41. Increases were unaffected by participants’ attendance to in-service training 6 months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care.ConclusionThe SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers.

Simulation and team training embedded nurse mentoring programme and improvement in intrapartum and newborn care in a low-resource setting in Bihar, India.

BackgroundImprovement of the quality of maternal and child health care remains a focus in India. Working with the Government of Bihar, CARE-India facilitated a comprehensive set of quality of care improvement initiatives. PRONTO’s simulation and team-training was incorporated into the large-scale Apatkaleen Matritva evam Navjat Tatparta (AMANAT)nurse-mentoring program of the Government of Bihar supported by CARE-India to improve maternal and child health outcomes. Along-with the AMANAT program, the PRONTO components provided training on nontechnical and technical competencies for managing a variety of obstetric and neonatal conditions, as a team. This study assessed the effectiveness of nurse-mentoring including simulations on intrapartum and newborn care practices in 320 basic emergency obstetric and neonatal care (BEmONC) facilities.MethodsDeliveries were observed to obtain specific information on evidence-based practice (EBP) indicators before and after the intervention. Intrapartum and newborn care composite scores – were calculated using those EBP indicators. A web-based routine monitoring system provided total training days, weeks and days/week of training and counts of simulation and teamwork-communication activities. Multilevel linear regression was used to examine the exposure-outcome associations.ResultsThe final analysis included 668 normal spontaneous vaginal deliveries (NSVDs) from 289 public health facilities in Bihar. Facility-level intrapartum and newborn scores improved by 37 and 26-percentage points, respectively, from baseline to endline. Compared to the bottom one-third facilities that performed fewest NSVD simulations, the top one-third had 6 (95% confidence interval (CI) = 1-12) percentage points higher intrapartum score. Similar comparison using maternal complication simulations yielded 7 (95% CI = 1-12) percentage point higher scores. The highest newborn scores were observed in the middle one-third of facilities relative to the bottom one-third that did the fewest NSVD simulations (5, 95% CI: 1-10).ConclusionsFindings suggest significant overall improvement in intrapartum and newborn care practices after the AMANAT nurse-mentoring program in public sector BEmONC facilities. Simulation and team-training likely contributed towards the overall improvement, especially for intrapartum care.Study registrationClinicalTrials.gov number NCT02726230.

Simulation and team training embedded nurse mentoring programme and improvement in intrapartum and newborn care in a low-resource setting in Bihar, India

Background Improvement of the quality of maternal and child health care remains a focus in India. Working with the Government of Bihar, CARE-India facilitated a comprehensive set of quality of care improvement initiatives. PRONTO's simulation and team-training was incorporated into the large-scale Apatkaleen Matritva evam Navjat Tatparta (AMANAT)nurse-mentoring program of the Government of Bihar supported by CARE-India to improve maternal and child health outcomes. Along-with the AMANAT program, the PRONTO components provided training on nontechnical and technical competencies for managing a variety of obstetric and neonatal conditions, as a team. This study assessed the effectiveness of nurse-mentoring including simulations on intrapartum and newborn care practices in 320 basic emergency obstetric and neonatal care (BEmONC) facilities. Methods Deliveries were observed to obtain specific information on evidence-based practice (EBP) indicators before and after the intervention. Intrapartum and newborn care composite scores - were calculated using those EBP indicators. A web-based routine monitoring system provided total training days, weeks and days/week of training and counts of simulation and teamwork-communication activities. Multilevel linear regression was used to examine the exposure-outcome associations. Results The final analysis included 668 normal spontaneous vaginal deliveries (NSVDs) from 289 public health facilities in Bihar. Facility-level intrapartum and newborn scores improved by 37 and 26-percentage points, respectively, from baseline to endline. Compared to the bottom one-third facilities that performed fewest NSVD simulations, the top one-third had 6 (95% confidence interval (CI) = 1-12) percentage points higher intrapartum score. Similar comparison using maternal complication simulations yielded 7 (95% CI = 1-12) percentage point higher scores. The highest newborn scores were observed in the middle one-third of facilities relative to the bottom one-third that did the fewest NSVD simulations (5, 95% CI: 1-10). Conclusions Findings suggest significant overall improvement in intrapartum and newborn care practices after the AMANAT nurse-mentoring program in public sector BEmONC facilities. Simulation and team-training likely contributed towards the overall improvement, especially for intrapartum care. Study registration ClinicalTrials.gov number NCT02726230.

Facility readiness for basic emergency obstetric and neonatal care at PHC centres in Nigeria

Abstract Background Functionality of essential delivery services at primary health care (PHC) centres is crucial to achieving targeted improvements in maternal and neonatal outcomes in Nigeria. However, evidence suggests that PHC centres are often unable to adequately render basic emergency obstetric and neonatal care (BEmONC) services. This study assessed BEmONC availability and facility readiness at PHC centres in Edo State, Nigeria. Methods This facility-based cross-sectional survey was conducted in Edo State, Nigeria among 36 public primary health care centres selected by multistage sampling. The WHO service availability and readiness assessment tool was adapted to obtain data from PHC centres. BEmONC availability index was derived using 6 indicators (intravenous oxytotics, intravenous anticonvulsants, intravenous antibiotics, assisted deliveries, removal of retained products of conception and neonatal resuscitation). A composite readiness index was developed based on 26 indicators across five domains (trained staff, basic amenities, basic equipment, diagnostic tests and essential medicines). Indices were summarized as mean percentages and 95% confidence intervals. Results Among 36 facilities assessed, the mean BEmONC availability index score was 48.6% (CI = 41.7 - 55.5%) while the mean composite readiness index score was 58.9% (CI = 54.5 - 63.2%). Domain specific readiness indices showed marked variations with low mean scores for basic amenities (45.8%, CI = 38.4 - 55.3%) and trained staff (43.5%, CI = 33.1 - 53.9%), moderate score for basic equipment (53.5%, CI = 48.6 - 58.5%) and high scores for diagnostic tests (71.2%, CI = 60.5 - 82.1%) and essential medicines (80.1%, CI = 72.4 - 87.8%). Conclusions BEmONC availability and readiness at PHC centres in Edo State was suboptimal. Current efforts to improve services at PHC centres should strategically target availability of emergency obstetric functions, enhancing staff capacity and upgrading basic amenities. Key messages There are crucial gaps in the provision of BEmONC at primary health care level in Edo State, Nigeria that may negatively impact the quality of maternal and neonatal care. This study highlights the need for stakeholders to intensify PHC strengthening initiatives geared towards better pregnancy outcomes.

Health Surveillance Assistants’ Practices of Postnatal Care in Lilongwe District, Malawi

Health surveillance assistants (HSAs) participate in the provision of postnatal care in Malawi, although their knowledge and skills in maternal and reproductive health are limited. This article presents the findings of a mixed-methods study that was conducted in three selected health centres to document the practices of HSAs in the provision of postnatal care to mothers and babies in Lilongwe district in Malawi. A random sample of 97 HSAs participated in the quantitative part of this study and 30 of these participated in the qualitative aspect of the study. Quantitative data were analysed using descriptive statistics while qualitative data were analysed using thematic analysis. This study found that many respondents (>60%) had limited capacity to provide adequate postnatal care and 85.3% of them never checked the vital signs of mothers and babies. They also lacked knowledge and skills in some aspects of postnatal care including danger signs. Almost all the respondents (96.8%) had never received any training in Basic Emergency Obstetric and Neonatal Care (BEmONC), or Emergency Obstetric and Neonatal Care (EmONC). Considering that HSAs have limited capacity to provide postnatal care to mothers and their babies, shifting tasks of nurses or midwives to HSAs should not be considered as an “outright solution” for increasing access to postnatal care in low-resource settings because it may compromise the quality of care.

Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

ObjectivesOur study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.DesignWith a cross-sectional approach, two sets of surveys were administered...

Access to Essential Medications and Equipment for Obstetric and Neonatal Primary Care in Bombali District, Sierra Leone

The increased demand for basic emergency obstetric and neonatal care (BEmONC) services in Sierra Leone since the launch of the nationwide free maternity care initiative in 2010 has strained the capacity of the system to provide high‐quality care. In 2014, members of our research team visited all 97 functioning primary health‐care facilities in Bombali district in the Northern Province of Sierra Leone to evaluate gaps in access to BEmONC. Although most facilities had the equipment necessary for maternal and neonatal care, these were often not in satisfactory condition. Most of the facilities did not stock all of the essential medicines for BEmONC, and less than 10 percent of the facilities had sufficient stocks of unexpired and properly stored medications. Stronger supply chains will be necessary to improve health system performance in Sierra Leone, reduce maternal mortality, increase neonatal survival, and achieve targets associated with the Sustainable Development Goals (SDGs).

Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan \u2013 is the hospital fulfilling its role?

BackgroundProvision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care.MethodsA cross-sectional study using routine programme data (2013–2014).ResultsOf 29,876 admissions, 99% were self-referred, 0.4% referred by traditional birth attendants and 0.3% by health facilities. Geographic origins involved clustering around the hospital vicinity and the provincial road axis. While there was a steady increase in hospital caseload, the number and proportion of women with Direct Obstetric Complications (DOC) progressively dropped from 21% to 8% over 2 years. Admissions for normal deliveries continuously increased. In-hospital maternal deaths were 0.03%, neonatal deaths 1% and DOC case-fatality rate 0.2% (all within acceptable limits).ConclusionsDespite a high and ever increasing caseload, good quality Comprehensive EmONC could be offered in a conflict-affected setting in rural Afghanistan. However, the primary emergency role of the hospital is challenged by diversion of resources to normal deliveries that should happen at primary level. Strengthening Basic EmONC facilities and establishing an efficient referral system are essential to improve access for emergency cases and increase the potential impact on maternal mortality.

Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis

BackgroundMaternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility.MethodsThis study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software.ResultsOnce the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care.ConclusionsOur findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.

Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011

BackgroundWhile emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi.MethodsThis cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards.ResultsThe availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one.In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities.ConclusionAudits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.

Availability, Coverage and Geographical Distribution of Emergency Obstetric and Neonatal Care Services in Tanzania Mainland

In order to assess the availability of Emergency Obstetric and Neonatal Care (EmONC) services in Tanzania Mainland, a Cross-sectional survey of a National sample of obstetric care facilities was conducted in 2015. We adapted the Averting Maternal Deaths and Disabilities (AMDD) tool and did spatial mapping using a calibrated Global Positioning System (GPS) Essential Software for Android and Arc Geographical Information System (GIS) software. Data were analysed using STATA, SPSS and Excel computer programs. Ethical approval was granted by the National Institute for Medical Research and the Ministry of Health, Community Development, Gender, Elderly and Children. We identified 5207 obstetric care facilities which is equivalent to 59.7 facilities per 500,000 population. We surveyed 2405 (46.2%) facilities of which 251 (10.4%) had provided all the 7 Basic Emergency Obstetric and Neonatal Care (BEmONC) in past 3 months. Among these, 130 had provided Comprehensive Emergency Obstetric and Neonatal Care (CEmONC). The UN benchmarks for BEmONC and CEmONC facility densities were attained or exceeded by 40% and 76% in all 25 regions respectively. EmONC facilities were dominated by hospitals and were clustered in cities and townships. In conclusions, the distribution of EmONC facilities in Tanzania Mainland is suboptimal in more than half of regions with clustering around cities and townships.

Indicators of availability, use, and quality of emergency obstetric and neonatal care in Togo in 2012

ObjectiveTo assess the availability, utilization, and quality of emergency obstetric and neonatal care (EmONC) in Togo. MethodsA cross-sectional study of EmONC services in all public and private health facilities in the territory of Togo conducted from July to December, 2012. The generic tools developed by the Averting Maternal Death and Disability program were used as the basic tools for this evaluation. ResultsThe survey involved 1019 health facilities including 864 potential EmONC facilities that constituted the final sample. The results showed that there was low availability of functional EmONC health facilities (8 basic EmONC and 24 comprehensive EmONC) with a large urban/rural variation. Among the 24 current CEmONC, 22 were in urban areas and half were from the private sector. The national ratio of availability was 3 EmONC health facilities per 500 000 inhabitants. Nationally, the cesarean delivery rate was 3.5%. The lethality rate of direct obstetric causes was estimated at 1.3%. ConclusionNeeds assessment for EmONC showed low availability of EmONC services and underutilization of the available services.

The status of maternal and newborn health care services in Zanzibar.

BackgroundIt is estimated that 287,000 women worldwide die annually from pregnancy and childbirth-related conditions, and 6.9 million under-five children die each year, of which about 3 million are newborns. Most of these deaths occur in sub-Saharan Africa. The maternal health situation in Tanzania mainland and Zanzibar is similar to other sub-Saharan countries. This study assessed the availability, accessibility and quality of emergency obstetric care services and essential resources available for maternal and child health services in Zanzibar.MethodsFrom October and November 2012, a cross-sectional health facility survey was conducted in 79 health facilities in Zanzibar. The health facility tools developed by the Averting Maternal Death and Disability program were adapted for local use.ResultsOnly 7.6 % of the health facilities qualified as functioning basic EmONC (Emergency Obstetric and Neonatal Care) facilities and 9 % were comprehensive EmONC facilities. Twenty-eight percent were partially performing basic EmONC and the remaining 55.7 % were not providing EmONC. Neonatal resuscitation was performed in 80 % of the hospitals and only 17.4 % of the other health facilities that were surveyed. Based on World Health Organisation (WHO) criteria, the study revealed a gap of 20 % for minimum provision of EmONC facilities per 500,000 population. The met need at national level (proportion of women with major direct obstetric complications treated in a health facility providing EmONC) was only 33.1 % in the 12 months preceding the survey. The study found that there was limited availability of human resources in all visited health facilities, particularly for the higher cadres, as per Zanzibar minimum staff requirements.ConclusionThere is a need to strengthen human resource capacity at primary health facilities through training of health care providers to improve EmONC services, as well as provision of necessary equipment and supplies to reduce workload at the higher referral health facilities and increase geographic access.