Comprehensive Essential Obstetric Care Research Articles

Quality indicators of public maternity units in the governorate of Monastir (Tunisia)

IntroductionIncreasing access to healthcare for expectant mothers is a national goal. In Monastir, Tunisia, some Peripheral Maternity Units (PMUs) required assessment. Our goals were to describe the delivery activities in MUs (maternity units) and to assess whether some of PMUs need to have their activities replaced.MethodWe analyzed aggregate data of deliveries in Monastir from 2015 to 2020. The gouvernorate’s seven public MUs were included. Only the morning activity was allotted for obstetricians and gynecologists, in RMUs 1 and 2, whereas they were not available in all PMUs. Data was gathered from the reports of the National Perinatal Program. Both the availability of Comprehensive Essential Obstetric Care (CEOC) and Basic Essential Obstetric Care (BEOC) were calculated. Trends were calculated using Joinpoint software. The Annual Percent Change (APC) was calculated.ResultsThe number of births decreased from 2015 to 2020 (APC= -4.3%: 95%CI : -6; -2.4; p = 0.003). The largest significant decreases in APCs of deliveries were reported in PMU 2 (APC = -12.6% (95%CI : -20; -4.4; p = 0.014), in PMU 3 (APC = -29.3% (95%CI : -36.5; -21.4; p = 0.001), and in PMU 4 (APC = -32.9% (95%CI: -49.1; -11.5); p = 0.016). If PMU 3 and 4 were no longer operating as maternity facilities, BEOC and CEOC standards would still be adequat. For accessibility, both PMU 3 and PMU 2 are accessible from PMU 4 and PMU 1, respectively.ConclusionsPregnant women prefer to give birth in obstetric services with ability to perform emergency caesarean at the expense of PMU. Nowadays, it appears that accessibility is less important than the presence of qualified human resources when a pregnant woman choose a maternity hospital.

Maternal Mortality and Morbidity Will Not Reduce in Low Resource Countries without the Anaesthetists’ Involvement

Background: Maternal and foetal mortality is unacceptably high in most resource-limited countries and the practice of obstetric anaesthesia has an important influence on outcome for both mother and baby. The much needed close co-operation and collaboration between obstetricians and obstetric anaesthetist providers is crucial for the safety and comfort of parturients, particularly in low-resource environments. The current global maternal mortality is approximately 400 per 100,000 deliveries, with a range of 7 - 740 deaths per 100,000, demonstrating the inequality between the rich and poor countries. Many of the deaths could have been prevented by better essential obstetrics services including safe anaesthesia and surgery, provided such services are made available in a timely manner. Conclusion: Maternal mortality in low resource countries has its basis complex social, economic and political factors, underpinned by a lack of resources. Many of these factors are difficult and slow to resolve and are not specific to maternal health. Comprehensive essential obstetric care services at the district hospital level (first referral level) should include all the above plus safe surgery, safe anaesthesia, and blood transfusion. Government, donor agencies and all stakeholders must recognize the crucial role of anaesthesia in providing emergency obstetric care in hospitals. Advocacy by all concerned will help direct the scarce resources to the appropriate areas of need which includes provision of adequate facilities and manpower for safe anaesthesia.

Assessment of Essential Obstetric Care Services in Health Care Facilities in Benin City, Edo State

Background: In Africa healthcare service delivery is a huge challenge. This is compounded by inadequate health care facilities, poor distribution and citing of health care facilities, lack of equipments and drugs to mention a few. This study was conducted to assess the level of health care facility preparedness to render basic and comprehensive essential obstetric care services to pregnant women, with view to encourage health facility deliveries and care. Methodology: A descriptive cross sectional study design was conducted involving 114 selected Health facilities using a health facility audit tool adapted from JHPIEGO safe mother hood questionnaire. The data collected was analyzed using SPSS 16.0 statistical software with statistical significance set at p<0.05. Results: One hundred and fourteen health care facilities were assessed, comprising 36(31.6%) public and 78(68.2%) private health care facilities. Eighty eight (77.2%) of these health care facilities were well prepared, 14(12.3%), partially prepared and 12(10.5%) not prepared respectively for basic essential obstetric services while 88 (70.2%) well prepared, 30 (26.3%) partially prepared and 4(3.5%) not prepared respectively to render comprehensive essential obstetric care services. Private owned health care facilities compared to public health care facilities were significantly better prepared to render both basic essential obstetric care and comprehensive obstetric care (OR=0.111; p=0.002 and OR=0.082; p=0.01 respectively), with availability of skilled staff identified a significant predictor for basic (OR=0.042; p=0.0001) and comprehensive essential obstetric care (OR=0.015; p=0.001) respectively. Conclusion: Majority of health care facilities studied were well prepared to render essential obstetric care services but a lot more needs to be done to improve these services at the public health care facility level especially in relation to twenty four hour coverage and skilled man power needed to help improve maternal health outcome.

Maternal deaths where do they occur? A survey of health facilities in Abia state, south east Nigeria

Ascertaining the burden of maternal mortality is crucial to the improvement of maternal health for any nation. It provides basis to evolve comprehensive strategies to enhance mothers’ health. A facility-based survey was carried out in Abia State southeast Nigeria in 2003 to determine the magnitude of maternal deaths and where they occur in the State. Health facilities in the 17 local government areas of the State were enlisted. Data on births and maternal deaths in the preceding 12 months were obtained. A total of 25,081 births and 43 maternal deaths were recorded for the study period giving maternal mortality rate of 171/100,000. The public facilities had higher value of maternal mortality rate (856.8/100,000) than the private (177.2/100,000). Similarly, the Comprehensive Essential Obstetric Care facilities had lower maternal mortality rate than the Non-Essential Obstetric Care. Poor documentation may be one of the reasons for the low maternal mortality rate in this study. Enforcing proper documentation, reporting and investigation of maternal deaths is hereby recommended.

Public-sector Maternal Health Programmes and Services for Rural Bangladesh

Achieving Millennium Development Goal 5 in Bangladesh calls for an appreciation of the evolution of maternal healthcare within the national health system to date plus a projection of future needs. This paper assesses the development of maternal health services and policies by reviewing policy and strategy documents since the independence in 1971, with primary focus on rural areas where three-fourths of the total population of Bangladesh reside. Projections of need for facilities and human resources are based on the recommended standards of the World Health Organization (WHO) in 1996 and 2005. Although maternal healthcare services are delivered from for-profit and not-for-profit (NGO) subsectors, this paper is focused on maternal healthcare delivery by public subsector. Maternal healthcare services in the public sector of Bangladesh have been guided by global policies (e.g., Health for All by the Year 2000), national policies (e.g., population and health policy), and plans (e.g., five- or three-yearly). The Ministry of Health and Family Welfare (MoHFW), through its two wings-Health Services and Family Planning-sets policies, develops implementation plans, and provides rural public-health services. Since 1971, the health infrastructure has developed though not in a uniform pattern and despite policy shifts over time. Under the Family Planning wing of the MoHFW, the number of Maternal and Child Welfare Centres has not increased but new services, such as caesarean-section surgery, have been integrated. The Health Services wing of the MoHFW has ensured that all district-level public-health facilities, e.g., district hospitals and medical colleges, can provide comprehensive essential obstetric care (EOC) and have targeted to upgrade 132 of 407 rural Upazila Health Complexes to also provide such services. In 2001, they initiated a programme to train the Government's community workers (Family Welfare Assistants and Female Health Assistants) to provide skilled birthing care in the home. However, these plans have been too meagre, and their implementation is too weak to fulfill expectations in terms of the MDG 5 indicator-increased use of skilled birth attendants, especially for poor rural women. The use of skilled birth attendants, institutional deliveries, and use of caesarean section remain low and are increasing only slowly. All these indicators are substantially lower for those in the lower three socioeconomic quintiles. A wide variation exists in the availability of comprehensive EOC facilities in the public sector among the six divisions of the country. Rajshahi division has more facilities than the WHO 1996 standard (1 comprehensive EOC for 500,000 people) whereas Chittagong and Sylhet divisions have only 64% of their need for comprehensive EOC facilities. The WHO 2005 recommendation (1 comprehensive EOC for 3500 births) suggests that there is a need for nearly five times the existing national number of comprehensive EOC facilities. Based on the WHO standard 2005, it is estimated that 9% of existing doctors and 40% of nurses/midwives were needed just for maternal healthcare in both comprehensive EOC and basic EOC facilities in 2007. While the inability to train and retain skilled professionals in rural areas is the major problem in implementation, the bifurcation of the MoHFW (Health Services and Family Planning wings) has led to duplication in management and staff for service-delivery, inefficiencies as a result of these duplications, and difficulties of coordination at all levels. The Government of Bangladesh needs to functionally integrate the Health Services and Family Planning wings, move towards a facility-based approach to delivery, ensure access to key maternal health services for women in the lower socioeconomic quintiles, consider infrastructure development based on the estimation of facilities using the WHO 1996 recommendation, and undertake a human resource-development plan based on the WHO 2005 recommendation.

Quality of Obstetric Care in Public-sector Facilities and Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and Low-performing Districts of Bangladesh

This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. 'Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low-performing areas is urgently warranted.

Critical care management of eclamptics: challenges in an African setting

We conducted a retrospective study of the management and outcome for eclampsia patients in the intensive care unit (ICU) of National hospital, Abuja between November 2001 and April 2005 (42 months). The patients' case files and ICU records were used to extract the necessary data. During the study period, there were a total of 4857 deliveries, with 5051 total births (including multiple births) and 4854 live births. Forty eclamptics were admitted to the ICU, giving an ICU admission rate of 8.2/1000 live births. The records of two patients were incomplete. The average age of the patients was 28.4 years (range 17-4 years). Six patients (15.8%) were booked and 32 (84.2%) were not. The average duration of stay in ICU was 5 days. Twenty patients (52.6%) had antepartum eclampsia, 12 (31.6%) had postpartum eclampsia and six (15.8%) presented with intrapartum eclampsia. Twenty-nine (76.3%) gave birth via caesarean section and nine (23.7%) delivered per vagina augmented by oxytocin infusion. Seventeen (45%) received mechanical ventilation; 20 (53%) received oxygen via nasal prongs, nasal catheters or variable performance facemask. One patient (2%) did not receive oxygen therapy. All the patients were admitted postpartum. There were 11 maternal deaths, giving a case fatality rate of 29%. There were five (45.4%) deaths due to haemolysis, elevated liver enzymes and low platelet count syndrome and two (18.2%) due to disseminated intravascular coagulation. The remaining deaths were due to cerebrovascular accident (9.1%), lobar pneumonia (9.1%), acute renal failure (9.1%) and multiple organ failure (9.1%). All patients were admitted postpartum. This fatality rate is higher than that detailed in the reports reviewed in this study. Early referral of eclamptics or at risk patients to a tertiary care institution may help reduce morbidity and mortality. In addition, early referral to a facility providing basic essential obstetric care or comprehensive essential obstetric care is also important. Another important factor is the correct diagnosis of pre-eclampsia during antenatal and postpartum care by screening, noting blood pressure levels, performing urinalysis for protein and asking about warning signs such as headache, blurred vision, epigastric pain, etc.

Unavailability of essential obstetric care services in a local government area of south-west Nigeria.

This paper reports the findings at baseline in a multi-phase project that aimed at reducing maternal mortality in a local government area (LGA) of South-West Nigeria. The objectives were to determine the availability of essential obstetric care (EOC) services in the LGA and to assess the quality of existing services. The first phase of this interventional study, which is the focus of this paper, consisted of a baseline health facility and needs assessment survey using instruments adapted from the United Nations guidelines. Twenty-one of 26 health facilities surveyed were public facilities, and five were privately owned. None of the facilities met the criteria for a basic EOC facility, while only one private facility met the criteria for a comprehensive EOC facility. Three facilities employed a nurse and/or a midwife, while unskilled health attendants manned 46% of the facilities. No health worker in the LGA had ever been trained in lifesaving skills. There was a widespread lack of basic EOC equipment and supplies. The study concluded that there were major deficiencies in the supply side of obstetric care services in the LGA, and EOC was almost non-existent. This result has implications for interventions for the reduction of maternal mortality in the LGA and in Nigeria.

Roundtable: Making Pregnancy Safer in Myanmar: Introducing Misoprostol to Prevent Post-Partum Haemorrhage as Part of Active Management of the Third Stage of Labour

In Myanmar we carried out a successful pilot intervention with the prostaglandin misoprostol in the active management of the third stage of labour for prevention of post-partum haemorrhage. The pilot aimed to appraise the operational feasibility efficiency impact and cost-effectiveness of the intervention at family and community level and focused on a number of managerial and logistics issues in relation to scaling-up the intervention nationally and within the public sector where it proved to be successful. Myanmar is the largest country in mainland Southeast Asia geographically with over 70% of its population in rural areas. Over 60% of the population (55.4 million in December 2006) consists of mothers and children who are the most vulnerable group. Administratively there are 14 states and divisions which are sub-divided into 66 districts 325 townships and so on down to 65148 villages. Maternity care is equally spread across the whole country in both urban and rural areas but thereis still an under-served group in very remote hard-to-reach areas though their numbers are not very large. The number of facilities with functioning basic essential obstetric care in 2005 was eight per 500000 population and that of comprehensive essential obstetric care was four per 500000 population. (excerpt)

The contribution of privately owned hospitals in the provision of essential obstetric care in Nigeria.

To highlight the private sector contribution in the provision of essential obstetric care in Abia State, Southeastern Nigeria. Following two workshops a structured questionnaire was used to seek information on the type of facility, ownership, type of services, number of staff, instruments and medical consumables, deliveries and data on clients attended to in the previous twelve months. On the basis of the response the facilities were classified into not essential obstetric care, basic essential obstetric care and comprehensive essential obstetric care. Of 638 facilities visited only 378 offered antenatal and postnatal services. The 13 government hospitals and 173 primary health centers conducted 5601 deliveries. The 146 private hospitals/clinics and 46 maternity homes conducted 21,128 deliveries. Only 121 offered essential obstetric services: 42 basic with 2488 deliveries and 79 comprehensive with 14,489 deliveries. Of the basic essential obstetric facilities that were private, 84.6% were concentrated in the 6 urban local government areas (LGA) leaving 15.4% in the 11 rural LGA. Similarly 85.6% of the comprehensive essential obstetric facilities that were private are concentrated in the 6 urban LGA leaving 14.4% scattered in the 11 rural LGA CONCLUSION: The private sector, with its greater essential obstetric facilities, is concentrated mainly in the 6 urban LGA. This resulted in 14,970 deliveries as against 2007 deliveries in the government facilities. Although there is an apparent neglect of the other 11 LGA, the deliveries in the private facilities constituted over 79% within the study period. This greater contribution should be noted and considered when planning maternal and infant mortality and morbidity reforms in Nigeria.

Are Process Indicators Adequate to Assess Essential Obstetric Care at District Level?: A Case Study from Rufiji District, Tanzania

To assess coverage and quality of essential obstetric care (EOC) and the appropriateness of using processindicators, a 3-month follow-up study was done in Rufiji district, Tanzania, involving 2 hospitals, 4 health centres, 10 large dispensaries and 10 randomly selected small dispensaries. Data collection was done on process indicators as suggested by UNICEF/WHO/UNFPA (UN) and 'unmet obstetric need (UON) for major obstetric intervention (MOI)'. With standard values in (brackets), the district had two comprehensive EOC facilities, births in EOC amounted to 62% (15%), met need for EOC was 76% (100%), caesarean section (C/S) rate 4.1% (> 5%), hospital case fatality rate (CFR) 1.0% (< 1%) and successful obstetric referrals 46% (100%). MOI for absolute maternal indication in the district was 2.6% (1-2%). All four maternal deaths occurred due to transport failures. The process indicators gave contradictory impressions on the coverage and quality of care and failed to link to the outcome of delivery complications in the study.

Process indicators for safe motherhood programmes: their application and implications as derived from hospital data in Nepal.

Measuring maternal mortality ratios is fraught with problems and underestimates. Therefore process indicators have been proposed for monitoring the availability and use of obstetrics services. We report the results of process indicators for measuring the availability, use and quality of obstetric care in five districts in Nepal between 1997 and 1998. The number of comprehensive essential obstetric care (EOC) facilities was adequate for four of the five districts, but none had a minimum acceptable level of basic EOC facilities as set by UNICEF et al. The proportion of expected births in hospital was 21.5% in Rupandehi and < 5% in Baglung, Kailali, Okhaldunga and Surkhet. The minimum acceptable level is 15%. The 'met need' for obstetric care which pertains to the proportion of all women with direct obstetric complications that are treated in hospital was 14.9% in Rupandehi and < 5% in the other four districts, against the required minimum of 15%. The caesarean section rate calculated of all expected births in the population varied between 0.2% and 1.4%. The case fatality rate was 4.0% in Rupandehi Zonal Hospital. Analysis of these indicators clearly identified tremendous underuse of maternity services which has stimulated national policy discussions in Nepal with ensuing safe motherhood interventions and monitoring strategies.