Emergency Obstetric And Newborn Care Services Research Articles

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.

Effectiveness of a Facility-Based Health Education Intervention on Utilization of Emergency Obstetric and Newborn Care Services among Women of Reproductive Age in Nakuru County, Kenya

Purpose: Emergency obstetric and newborn care (EmONC) is the most important intervention to improve maternal survival. The study assessed facility based health education intervention on utilization of Emergency Obstetrics and Newborn care services.
 Methodology The study was a randomized control trial and utilized a mixed method. Multistage sampling was used. Key informants were purposefully selected Allocation to each study group was done on a 1:1 ratio; hence each group had 191 participants. The sample size was determined by Kelsey et al 1996 formula for calculation of sample size for randomized controlled trials and in order to take care of attrition 10% increase was done hence the sample size was 382 women. Pregnant mothers 26-32 weeks of gestation were enrolled. Structured questionnaire, focused group discussion and key informant interview schedules used. A pre-test was conducted at Kuresoi North Sub County. To ensure validity, research assistants were trained on the various research instruments. Descriptive statistics Fisher’s exact test at bivariate and odds ratio at multivariate analysis level were computed. Qualitative data was analysed using thematic content analysis. Ethical approval for the research was sought from the K.U research ethical committee, the National council for Science and Technology and Ministry of health. Informed consent was obtained from respondent prior to the study.
 Results: The intervention group had 95.93% (n =165) utilization of EmONC services in comparison to the control arm 75.29% (n = 128). There was no significance difference in the control group from base line to final survey OR 1.209, CI 0.742 to 1.969 and P-value 0.446. From the study findings the chances of EmONC services utilization after intervention was high. Those that received the intervention were seven times likely to utilize than those that did not receive the health education with an OR 7.734, 95% CI 3.363 to 17.787 and a P-value < 0.001 when we compare the intervention group and the control group.
 Unique Contribution to Theory, Practice and Policy: Administration of Health education is crucial in the utilization of EmONC services thus improving maternal mortality and morbidity. This study concurs with the Theory of Planned Behavior and the theory of Reasoned Action. Health education intervention may change the behavior intention of the client hence influencing utilization of EmONC services. It is recommended stakeholders to come up with a well-structured health education program in all regions of Kenya to improve emergency obstetric and newborn care services utilization.

Prevalence and factors associated with utilization of emergency obstetric newborn care services among women of reproductive age in Nakuru county Kenya

Background: Emergency obstetric and newborn care (EmONC) mediates maternal survival. To prevent deaths, mothers require access to quality care and utilization of health facilities where professionals can promptly diagnose and manage emergencies related to pregnancy and childbirth. The study focused on socio-demographic, social cultural and social economic factors. Methods: The study was a randomized control trial and utilized a mixed method. Pregnant mother 26 to 32 weeks gestation and aged 15-49 years totaling to 382 respondents were enrolled in the study. Allocation to each study group was done on a 1:1 ratio; hence each group had 191 participants. The study was conducted from January to July 2020. Results: The intervention group had 95.93% (n=165) utilization of EmONC services in comparison to the control arm 75.29% (n=128). There was no discrepancy in both groups from base line to final survey OR=1.209, CI=0.742 to 1.969 and p=0.446. The level of education significantly influenced utilization at χ2=40.402 and a p<0.001. Secondary education influences utilization of EmONC services at AOR=8.791, 95% CI=3.631 to 21.285 and p<0.001. Respondents with tertiary education were 2.5 times likely to utilize EmONC services. Parity was significant at χ2=43.724, p<0.001. There was no significant difference between socioeconomic factors, sociocultural factors and utilization of EmONC services at baseline level. Conclusions: There was an increase in utilization of EmONC services. The education level and parity of the woman determined the utilization of EmONC services.

Barriers and enablers to emergency obstetric and newborn care services use in Wolaita Zone, Southern Ethiopia: a qualitative case study

BackgroundGlobally, 11.4 million untreated obstetric complications did not receive Emergency Obstetric and Newborn Care (EmONC) services yearly, with the highest burden in low and middle-income countries. Half of the Ethiopian women with obstetric complications did not receive EmONC services. However, essential aspects of the problem have not been assessed in depth. This study, therefore, explored the various aspects of barriers and enablers to women’s EmONC services utilization in southern Ethiopia.MethodologyA qualitative case study research design was used in nine districts of the Wolaita Zone. A total of 37 study participants were selected using a purposive stratified sampling technique and interviewed till data saturation. Twenty-two key informant interviews were conducted among front-line EmONC service providers, managers, community leaders, and traditional birth attendants (TBAs). Individual in-depth interviews were conducted among 15 women with obstetric complications. The trustworthiness of the research was assured by establishing credibility, transferability, conformability, and dependability. NVivo 12 was used to assist with the thematic data analysis.ResultFive themes emerged from the analysis: service users’ perception and experience (knowledge, perceived quality, reputation, respectful care, and gender); community-related factors (misconceptions, traditional practices, family and peer influence, and traditional birth attendants’ role); access and availability of services (infrastructure and transportation); healthcare financing (drugs and supplies, out-of-pocket expenses, and fee exemption); and health facility-related factors (competency, referral system, waiting time, and leadership).ConclusionMany women and their newborns in the study area suffered severe and life-threatening complications because of the non-utilization or delayed utilization of EmONC services. A key policy priority should be given to enhancing women’s awareness, eliminating misconceptions, improving women’s autonomy, and ensuring traditional practices’ role in EmONC service utilization. Community awareness interventions are required to enhance service uptake. Furthermore, the health systems must emphasize improving the quality of care, inequitable distribution of EmONC facilities, and essential drugs. The financial constraints need to be addressed to motivate women from low socioeconomic status. Furthermore, intersectoral collaboration is required to maintain a legal framework to control and prohibit home deliveries and empower women.

Quality of emergency obstetric and newborn care services in Wolaita Zone, Southern Ethiopia

BackgroundGlobally, nearly 295,000 women die every year during and following pregnancy and childbirth. Emergency obstetric and newborn care (EmONC) can avert 75% of maternal mortality if all mothers get quality healthcare. Improving maternal health needs identification and addressing of barriers that limit access to quality maternal health services. Hence, this study aimed to assess the quality of EmONC service and its predictors in Wolaita Zone, southern Ethiopia.MethodologyA facility-based cross-sectional study was conducted in 14 health facilities. A facility audit was conducted on 14 health facilities, and 423 women were randomly selected to participate in observation of care and exit interview. The Open Data Kit (ODK) platform and Stata version 17 were used for data entry and analysis, respectively. Frequencies and summary statistics were used to describe the study population. Simple and multiple linear regressions were done to identify candidate and predictor variables of service quality. Coefficients with 95% confidence intervals were used to declare the significance and strength of association. Input, process, and output quality indices were created by calculating the means of standard items available or actions performed by each category and were used to describe the quality of EmONC.ResultThe mean input, process, and output EmONC services qualities were 74.2, 69.4, and 79.6%, respectively. Of the study participants, 59.2% received below 75% of the standard clinical actions (observed quality) of EmONC services. Women’s educational status (B = 5.35, 95% C.I: 0.56, 10.14), and (B = 8.38, 95% C.I: 2.92, 13.85), age (B = 3.86, 95% C.I: 0.39, 7.33), duration of stay at the facility (B = 3.58, 95% C.I: 2.66, 4.9), number of patients in the delivery room (B = − 4.14, 95% C.I: − 6.14, − 2.13), and care provider’s experience (B = 1.26, 95% C.I: 0.83, 1.69) were independent predictors of observed service quality.ConclusionThe EmONC services quality was suboptimal in Wolaita Zone. Every three-in-five women received less than three-fourths of the standard clinical actions. The health system, care providers, and other stakeholders should emphasize improving the quality of care by availing medical infrastructure, adhering to standard procedures, enhancing human resources for health, and providing standard care regardless of women’s characteristics.

Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices.

BackgroundTo address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named – Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) – in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees’ competency to provide such services in Bihar, India during 2015-2017.MethodsWe used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees’ practices. We examined changes in nurse-mentees’ knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees’ knowledge and practices after adjusting for potential confounders.ResultsOn average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees’ knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes.ConclusionThe AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions.Study registrationClinicalTrials.gov number NCT02726230.

Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices

Background To address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named - Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) - in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees' competency to provide such services in Bihar, India during 2015-2017. Methods We used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees' practices. We examined changes in nurse-mentees' knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees' knowledge and practices after adjusting for potential confounders. Results On average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees' knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes. Conclusion The AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions. Study registration ClinicalTrials.gov number NCT02726230.

Readiness of emergency obstetric and newborn care in public health facilities in Afghanistan between 2010 and 2016.

To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ2 tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (P<0.001). Fewer health facilities had amoxicillin (61% in 2016 vs 90% in 2010; P<0.001) and gentamicin (74% in 2016 vs 95% in 2010; P<0.002). The number of facilities with at least one midwife on duty 24hours a day/7days a week significantly declined (88% in 2016 vs 98% in 2010; P=0.028). Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels.

Proposing standardised geographical indicators of physical access to emergency obstetric and newborn care in low-income and middle-income countries

Emergency obstetric and newborn care (EmONC) can be life-saving in managing well-known complications during childbirth. However, suboptimal availability, accessibility, quality and utilisation of EmONC services hampered meeting Millennium Development Goal...

Maternal and Newborn Health Care Providers’ Preparedness for Provisions of Emergency Obstetric and Newborn Care

Emergency Obstetric and Newborn Care (EmONC) is a life-saving approach for mother and newborn experiencing complications during pregnancy, childbirth and or postpartum period. Like other developing countries, Ethiopia has high maternal and neonatal mortality (353/100,000 live births and 28/1000 live births respectively by 2015) where majority of them are due to lack of timely, effective, and accessible EmONC services. Even though Addis Ababa, Harar and Dire Dawa have met the WHO minimum requirements of EmONC service in terms of Availability and Accessibility unlike other regions, the report shows that the quality of care provided was highly compromised and mainly associated with poor providers’ competence. A cross-sectional study design was employed in purposively selected health care facilities in Dire Dawa city to assess providers’ level of knowledge, skills and confidence for provision of quality EmONC. The study used self-administered standardized questionnaire. Information letters, consent forms and questionnaires was handled to potential participants by research assistants. Data was coded, cleaned and entered using Epi Info 7 (7.0.9.34) and analyzed using SPSS version 20 for descriptive and inferential statistics. The finding of this study reveals that, out of 52 maternal and newborn health care providers filling questionnaires, majority (67.35%) of providers were untrained, where large numbers (38.5%) were reported from Health centers. Forty-five (86.04%) were reported of having sufficient knowledge of EmONC; while 31 (59.4%) and 46 (88.45%) reported of having adequate skills and confidence of performing major EmONC procedures, respectively. In conclusion, Even though there is a significant variation based on clinicians’ place of work and year of work experience, providers’ knowledge, skills and confidence were adequate. But, gaps in trained and specialized MNCPs were highly contributing to lack of improvements in quality of EmONC in Dire Dawa. Thus, the findings bear considerable implications for policy and local priorities.

Readiness of Health Centers to Provide Basic Emergency Obstetric and Newborn Care in Eight Districts of SNNPR, Oromia and Amhara Regions of Ethiopia, 2013

Background: The results from an Ethiopian national baseline assessment for Emergency Obstetric and Newborn Care (EmONC) Performed in 2008 clearly shows poor access and utilization of EmONC services, very low critical life-saving servicesand poor quality of health care services as evidenced by high still birth rates in most regions of the country with the exception of Addis Ababa, Gambella and Somali. Methods: An institution based cross sectional descriptive study was conducted from March to April 2013 at 48 health centers in eight districts in Ethiopia. An interviewer administered questionnaire and observation checklist was used to col- lect standardized data from participating health centers that focused specifically on maternal and newborn health services at each of the facilities. Results: The majority of health centers, 95.8% (46/48) were open to provide labor and delivery service 24 hours a day, 7 days a week. However, only 11.5% (47/410) of health workers in the study catchment area had previously received in- service training in Basic Emergency Obstetric and Newborn Care (BEmONC). The partograph was not used routinely to monitor labor in 48% (23/48) of the health centers. One fourth (12/48) of health centers had a vacuum extractor and/ or obstetric forceps for assisted delivery, but 3 health centers reported never having used this equipment. One third, 33.3% (16/48) of health centers had manual vacuum aspiration (MVA) sets to provide services related to abortion care. Magne- sium sulphate was available only in 10.4% (5/48) of health centers to treat a laboring mother with convulsions. Conclusions and recommendations: Results suggest that although the majority of the health centers participating in the study provide delivery services, quality of BEmONC services and availability of supplies and equipment were question- able. Most health centers don’t practiced administration of parenteral antibiotics, MVA, assisted vaginal delivery and other essential services. Effort should be made at all health centers across Ethiopia to increase the availability of essential drugs, equipment and supplies for the provision BEmONC service Ethiopian Journal of Reproductive Health, 2014, Volume 7(1), 11-21). Key words: Basic Emergency Obstetric and Newborn Care, Maternal health, Neonatal

Emergency obstetric and newborn care signal functions in public and private facilities in Bangladesh.

BackgroundSignal functions for emergency obstetric and newborn care (EmONC) are the major interventions for averting maternal and neonatal mortalities. Readiness of the facilities is essential to provide all the basic and comprehensive signal functions for EmONC to ensure emergency services from the designated facilities. The study assessed population coverage and availability of EmONC services in public and private facilities in Bangladesh.MethodsAn assessment was conducted in all the public and private facilities providing obstetric care in to in-patients 24 districts. Data were collected on the performance of signal functions for EmONC from the study facilities in the last three months prior to the date of assessment. Trained data-collectors interviewed the facility managers and key service providers, along with review of records, using contextualized tools. Population coverage of signal functions was assessed by estimating the number of facilities providing the signal functions for EmONC compared to the United Nations requirements. Availability was assessed in terms of the proportion of facilities providing the services by type of facilities and by district.ResultsCaesarean section (CS) delivery and blood transfusion (BT) services (the two major components of comprehensive EmONC) were respectively available in 6.4 (0.9 public and 5.5 private) and 5.6 (1.3 public and 4.3 private) facilities per 500,000 population. The signal functions for basic EmONC, except two (parental anticonvulsants and assisted vaginal delivery), were available in a minimum of 5 facilities (public and private sectors combined) per 500,000 population. A major inter-district variation in the availability of signal functions was observed in each public- and private-sector facility. Among the various types of facilities, only the public medical college hospitals had all the signal functions. The situation was poor in other public facilities at the district and sub-district levels as well as in private facilities.ConclusionsIn the public sector, CS delivery and BT services were available in the minimum required number of facilities. However, to ensure basic EmONC services, participation of the private sector is necessary. Public-private partnership should be promoted for nationwide coverage of signal functions for EmONC in Bangladesh.

Use of a geographic information system to assess accessibility to health facilities providing emergency obstetric and newborn care in Bangladesh.

To use a geographic information system (GIS) to determine accessibility to health facilities for emergency obstetric and newborn care (EmONC) and compare coverage with that stipulated by UN guidelines (5 EmONC facilities per 500000 individuals, ≥1 comprehensive). A cross-sectional study was undertaken of all public facilities providing EmONC in 24 districts of Bangladesh from March to October 2012. Accessibility to each facility was assessed by applying GIS to estimate the proportion of catchment population (comprehensive 500000; basic 100000) able to reach the nearest facility within 2hours and 1hour of travel time, respectively, by existing road networks. The minimum number of public facilities providing comprehensive and basic EmONC services (1 and 5 per 500000 individuals, respectively) was reached in 16 and 3 districts, respectively. However, after applying GIS, in no district did 100% of the catchment population have access to these services. A minimum of 75% and 50% of the population had accessibility to comprehensive services in 11 and 5 districts, respectively. For basic services, accessibility was much lower. Assessing only the number of EmONC facilities does not ensure universal coverage; accessibility should be assessed when planning health systems.

Spatial distribution of emergency obstetric and newborn care services in Ghana: Using the evidence to plan interventions.

To provide clear policy directions for gaps in the provision of signal function services and sub-regions requiring priority attention using data from the 2010 Ghana Emergency Obstetric and Newborn Care (EmONC) survey. Using 2010 survey data, the fraction of facilities with only one or two signal functions missing was calculated for each facility type and EmONC designation. Thematic maps were used to provide insight into inequities in service provision. Of 1159 maternity facilities, 89 provided all the necessary basic or comprehensive EmONC signal functions 3months prior to the 2010 survey. Only 21% of facility-based births were in fully functioning EmONC facilities, but an additional 30% occurred in facilities missing one or two basic signal functions-most often assisted vaginal delivery and removal of retained products. Tackling these missing signal functions would extend births taking place in fully functioning facilities to over 50%. Subnational analyses based on estimated total pregnancies in each district revealed a pattern of inequity in service provision across the country. Upgrading facilities missing only one or two signal functions will allow Ghana to meet international standards for availability of EmONC services. Reducing maternal deaths will require high national priority given to addressing inequities in the distribution of EmONC services.

Essential basic and emergency obstetric and newborn care: From education and training to service delivery and quality of care

Approximately 15% of expected births worldwide will result in life-threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource-poor settings. Providers have been educated to deliver high-impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiego’s programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high-quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency-based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale-up of high impact evidence-based maternal and newborn interventions in low-resource settings.

Assessment of Availability, Utilization and Quality of Emergency Obstetric Care in 2014 at Hai District, Northern Tanzania

Background: Availability of emergency obstetric and newborn care (EmOC) is one of interventions to reduce maternal and newborn deaths. Maternal and newborn mortality is a public health problem in most developing countries including Tanzania. In these settings, coverage of EmOC is low especially in rural areas, with limited information on availability and use of EmOC services. Objectives: To assess the availability, utilization and quality of emergency obstetric care in Hai district, located at Kilimanjaro region, northern Tanzania. Methods: A cross-sectional survey of 12 health facilities (2 hospitals and 10 primary health care facilities) which provide delivery services in the district was conducted in May- June 2014. Modified AMDD data collection tool was used and it assessed availability of services, supplies and equipments, infrastructure and actual performance of EmOC within the past 3 months prior to the interview. Proportions were used to summarize the data. Results: The two comprehensive EmOC facilities (CEmOC) could provide all the nine required signal functions while none of the basic EmOC facilities (BEmOC) could provide the seven required signal functions. For a population of 214,454 in the district, the total number of health facilities designated to provide EmOC services exceeded the minimum required number which was 1 for CEmOC and 2 BEmOC. The proportion of births taking place in facilities was 65.3% and the met need for emergency obstetric complications was 94.5%. Population based caesarean section rate and the still birth rate were 7.4% and 1.3% respectively. Conclusion: BEmOC facilities, which are the first level of care for majority of women and newborns with complications, need to be strengthened to offer the required medical and surgical interventions to save lives. There is a need to scale-up training of health providers especially at the lower level (dispensaries and health centres) in EmOC as well as to strength supply chain system in order to contribute in attaining the national BEmOC coverage of 70% by December 2015.

Distance to emergency obstetric services and early neonatal mortality in Ethiopia.

To assess the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality in rural Ethiopia and examine whether proximity to services contributes to socio-economic inequalities in early neonatal mortality. We linked data from the 2011 Ethiopian Demographic and Health Survey with facility data from the 2008 Ethiopian National EmONC Needs Assessment based on geographical coordinates collected in both surveys. Health facilities were classified based on the performance of nine EmONC signal functions (e.g. neonatal resuscitation, Caesarean section). We used multivariable logistic regression to assess the relationship between distance to services and early neonatal mortality. A decomposition approach was used to quantify the relative contributions of distance to EmONC services and other determinants to overall and socio-economic inequality in early neonatal mortality. In general, closer proximity to EmONC services and higher level of care were associated with lower early neonatal mortality. Living more than 80 km from the nearest comprehensive EmONC facility able to perform all nine signal functions compared to living within 10 km was associated with an increase of 14.4 early neonatal deaths per 1000 live births (95% CI: 0.1, 28.7). Closer proximity to a substandard EmONC facility compared with no facility was not associated with lower early neonatal mortality. Distance to EmONC services was an important determinant of early neonatal mortality, although it did not make a significant contribution to explaining socio-economic inequality. Our results suggest that recent initiatives by the Ethiopian government to improve geographical access to EmONC services have the potential to reduce early neonatal mortality but may not affect inequalities.

Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan

BackgroundAn evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases.MethodsA further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers.ResultsThe median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO4). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO4 should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO4 scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled.ConclusionsDrugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO4 and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.

Ethiopia's assessment of emergency obstetric and newborn care: Setting the gold standard for national facility-based assessments

Objective To describe the methods used to implement Ethiopia's 2008 emergency obstetric and newborn care services (EmONC) assessment; highlight how the collaborative process contributed to immediate integration of results into national and subnational planning; and explain how the experience informed the development of a set of tools providing best practices and guidelines for other countries conducting similar assessments. Methods A team of maternal and newborn health experts from the Federal Ministry of Health (FMOH), the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA), together with representatives from the Ethiopian Society of Obstetricians and Gynecologists, provided technical guidance for the 18-month process and facilitated demand for and use of the assessment results. Eighty-four trained data collectors administered 9 data collection modules in 806 public and private facilities. Field work and data were managed by a private firm who, together with the core team, implemented a multi-layered plan for data quality. Columbia University's Averting Maternal Death and Disability Program provided technical assistance. Results Results were published in national and regional reports and in 1-page facility factsheets informing subnational planning activities. Assessment results—which have been published in journal articles—informed water infrastructure improvements, efforts to expand access to magnesium sulfate, and FMOH and UN planning documents. The assessment also established a permanent database for future monitoring of the health system, including geographic locations of surveyed facilities. Conclusion Ethiopia's assessment was successful largely because of active local leadership, a collaborative process, ample financial and technical support, and rapid integration of results into health system planning.