Hospitals In Senegal Research Articles

Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

BackgroundPostpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali.MethodsA cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death.ResultsAmong the 3,278 women who experienced PPH, 178 (5.4 %) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26–3.72]), living in Mali (adjusted OR = 1.84 [1.13–3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29–4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54–22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77–11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19–5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26–5.10]), transfusion (adjusted OR = 2.17 [1.53–3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20–28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35–0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC).ConclusionsOur findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.

Le syndrome d’épuisement professionnel chez les étudiants en spécialisation au Centre hospitalier universitaire de Dakar (Sénégal)

ObjectiveTo assess the burn-out syndrome among doctors in training at Dakar teaching hospital in Senegal. Materials and methodsThis was a prospective, descriptive and analytical study conducted from January 1st to June 30, 2013 at Dakar teaching hospital. A questionnaire was distributed to all doctors of 9 medical or surgical specialties. It contained two parts: One part concerned sociodemographic and occupational characteristics, and the other assessed the burn-out using the Maslach Burnout Inventory. Data were entered and analyzed using SPSS 17.0 software. ResultsThe acceptance rate was 96%. The average age of students was 31.3years with 64% of men. The students were mostly married (51.1%) and 33.9% had children. More than half (54.8%) reported spending time in a hobby. They were enrolled in a medical specialty in 60.3%. Students worked on average 38.1hours per week. Means of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA) scores were respectively 33.2±12.2 (high EE), 11.3±6.5 (moderate DP) and 46.2±6.2 (low PA). The young age (<30years) and celibacy were risk factors of burn-out. Emotional exhaustion was more common among students without dependent children than among parents. Students practicing a hobby seemed to be protected against burn-out. Medical specialties exhibit to burn-out syndrome. Students in Obstetrics and Gynecology had lowest scores of emotional exhaustion and depersonalization. ConclusionThe burnout syndrome is a reality in our hospitals with a propensity for students in medical specialization. Socialization (child, hobby…) is a mean of protection.

“Right tool,” wrong “job”: Manual vacuum aspiration, post-abortion care and transnational population politics in Senegal

The “rightness” of a technology for completing a particular task is negotiated by medical professionals, patients, state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain technologies may challenge the meaning of the “job” they are designed to accomplish. Manual vacuum aspiration (MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion, known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is legally prohibited. Although state health authorities have championed MVA as the “preferred” PAC technology, the primary donor for PAC, the United States Agency for International Development, does not support the purchase of abortifacient technologies. I conducted an ethnography of Senegal's PAC program between 2010 and 2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC. While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and digital curettage. Anxieties about MVA's capacity to induce abortion have constrained its integration into routine obstetric care. This capacity also raises questions about what the “job,” PAC, represents in Senegalese hospitals. The prioritization of MVA's security over women's access to the preferred technology reinforces gendered inequalities in health care.

Urethroplasty for male urethral strictures: Experience from a national teaching hospital in Senegal

ObjectivesTo report our experience with urethroplasties due to male urethral stricture disease and to identify factors affecting the results. Patients and MethodsBetween January 2007 and December 2010, 75 urethroplasties performed due to male urethral stricture were prospectively collected. ResultsThe mean age of patients was 52.6 years (median: 56 years) for urethroplasties by substitution and 47.3 years (median: 47.5 years) for anastomotic urethroplasties. The most common localization of urethral stricture was the bulbar urethra (63.3%). The length of the stricture averaged 1.95±0.72cm (median 2cm) in anastomotic urethroplasties and 4.40±1.54cm (median 4cm) in urethroplasties by substitution. The success rate was 69.8% (37/53) for anastomotic urethroplasties, 23.1% (3/13) for urethroplasties using Quartey's technique, 25% (1/4) for Blandy's urethroplasties. The success rate was 81% (17/21) in patients operated on by experienced surgeons, and 53.7% (29/54) in those operated on by young surgeons (p=0.02). The success of urethroplasty was more frequent for urethral strictures between 1 and 5cm (46/69) than in those greater than 5cm (0/6) (p<0.05), when the diagnosis of stricture was done within the phase of dysuria (11/13) than when it was done during the phase of progressive complications of the urethral stricture (35/62) (p<0.05). ConclusionsIn our hands, the results of anastomotic urethroplasty were better, while those of substituting urethroplasties were disappointing. These results are explained by the complexity of the strictures and the limited experience in urethral reconstruction of most surgeons.

Trends in Institutional Caesarean Delivery among Low-Risk Patients in Senegal and Mali: Secondary Analysis of a Cluster-Randomized Trial (Quarite)

Objective: To measure the trends of institutional caesarean rates in Senegal and Mali and to assess if these trends were modified by the Advances in Labour and Risk Management (ALARM) international program. Methods: We conducted a secondary analysis of the QUARITE trial to examine the trends in caesarean delivery among low-risk patients in 46 hospitals which were randomized into an intervention group (n = 23) and a control group (n = 23). ALARM combined maternal death reviews and continuous medical education to improve the quality of obstetric care. Results: Between the pre-intervention period and the post-intervention period, the institutional caesarean rate among low-risk patients increased from 17.1% to 18.6% in the intervention hospitals (adjusted OR=1.03; 95% CI =0.89-1.15) and from 16.1% to 21.1% in the control arm (adjusted OR=1.47; 95% CI=1.27-1.52). The increase was significantly higher in the control group than in the intervention group, p<0.0001. Conclusion: Caesarean delivery rates increased in referral hospitals in Senegal and Mali after the free caesarean policy was implemented. Because of potential arms for mothers and newborns associated with unnecessary caesarean delivery, ALARM international program should be considered as a promising intervention to limit excessive rise of caesareans in this context.

Lipid profile frequency and the prevalence of dyslipidaemia from biochemical tests at Saint Louis University Hospital in Senegal.

IntroductionThe aim of this study was to evaluate the frequency of lipid profile requests and the prevalence of dyslipidemia in patients at the biochemistry laboratory of St. Louis University Hospital, as well as their correlation with sex and age.MethodsThis was a retrospective study reviewing 14,116 laboratory results of patients of both sexes, over a period of six months (January-June 2013) regardless of the indication for the request. The lipid parameters included were: Total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides with normal values defined as follows: Total cholesterol (<2g/l), HDL- cholesterol (>0,40g/l), LDL- cholesterol (<1,30g/l) and Triglycerides (<1,50g/l).ResultsThe average age of our study population was 55.15 years with a female predorminance (M/F = 0.60). The age group most represented was that between 55-64 years. The frequency of lipid profile request in our sample was 9.41% (or 1,329). The overall prevalence of isolated hypercholesterolemia, hyperLDLaemia, hypoHDLaemia, hypertriglyceridaemia, and mixed hyperlipidemia were respectively 60.91%, 66.27%, 26.58%, 4.57% and 2.75%. Hypercholesterolemia, hyperLDLaemia, hypertriglyceridaemia and mixed hyperlipidaemia were higher in women with respectively 66.22%, 67.98%, 4.58%, 2.89% than in men (52.01%, 62.81%, 4.44% and 2.40% respectively). On the other hand, the prevalence of hypoHDLaemia was higher in males (32.19%) compared to females (23.76%). Hypercholesterolemia correlated significantly with age and sex.ConclusionOur study showed a relatively low request rate for lipid profile and a high prevalence of dyslipidaemia hence the importance of conducting a major study on the prevalence of dyslipidaemia and associated factors in the Senegalese population.

A Prediction Score for Maternal Mortality in Senegal and Mali

To develop and validate a maternal mortality score to identify patients at risk of in-hospital death in developing countries. We performed a prospective observational study in 46 referral hospitals in Senegal and Mali, starting October 1, 2007. Derivation of a maternal mortality score was performed, using generalized estimating equation, on patients included during the first 6 months of the study (301 deaths out of 43,624 deliveries) and validated on patients included during the next 6 months (345 deaths out of 46,328 deliveries). Nine criteria were independently associated with maternal death: severe anemia in pregnancy, malaria diagnosed during pregnancy, parity greater than 4, fewer than three antenatal visits, referral from another health facility, antepartum or postpartum hemorrhage, preeclampsia or eclampsia, uterine rupture, and genital infection or sepsis. The maternal mortality score, ranging from 0 to 100, occupies an area under the receiver operating characteristics curve of 0.89 (95% confidence interval [CI] 0.87-0.91). The low-risk group for maternal mortality, based on a score less than 10, has a negative predictive value of 99.9% (95% CI 99.8-99.9) and a negative likelihood ratio of 0.18, ruling out maternal mortality with a probability of 0.13% (95% CI 0.09-0.17). Sensitivity of the score to identify patients at risk of in-hospital death was 85.0% (95% CI 80.5-88.8). Validation of the score yielded a sensitivity of 87.8% (95% CI 83.9-91.1), a negative predictive value of 99.9% (95% CI 99.8-99.9), and a probability of maternal death of 0.12% (95% CI 0.08-0.17) in the low-risk group. : The maternal mortality score could help health care professionals to identify patients at risk of maternal mortality who need careful management. III.

Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey

BackgroundTwo years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.MethodsWe conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007–10/01/2008). Data were collected regarding women’s characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.ResultsAmong 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).ConclusionsWe confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Length of stay and mean cost of patients’ hospitalization with healthcare-associated infections acquired in a national hospital in Senegal

Economic data on healthcare-associated infections (HCAI) in resource-poor countries are practically nonexistent despite the importance of this issue. Healthcare costs are patients’ charges whereas minimum wages is of 72€ in Senegal. The objective of our study was to estimate the length of stay (LOS) and the mean cost of stays of patients who have acquired a HCAI at Hopital Principal de Dakar to increase the awareness of authorities on this issue.

Etiology and current clinical characteristics of male urethral stricture disease: experience from a public teaching hospital in Senegal

To identify the etiology and current clinical characteristics of male urethral stricture disease (USD) in Senegal. A retrospective and mono-centric study over a 10-year period (between January 1999 and December 2008) was carried out and included all male patients with USD admitted to the Urology Department of Aristide Le-Dantec Hospital (Dakar). We recorded 414 USD cases. The maximum annual incidence was observed in 2004, and from then, the incidence tended to decrease gradually. The mean age of patients was 43.7 ± 19.6 years (1-89 years), and 43% of patients were younger than 40 years old. The mean time from symptoms onset to the consultation was 20.1 ± 24.9 months (1-120 months). Most patients (42.2%) were admitted because they suffered dysuria. In 57.8% of patients, USD was diagnosed with complications. The most common site of stricture was at the bulbar urethra (72.7%). The length of the urethral stricture was smaller than 1 cm in 59.6% of patients, between 1 and 3 cm in 28.5% and between 3 and 5 cm in 7.7%. The stricture was longer than 5 cm in eight patients and was staged (multifocal) in nine patients. The etiology of urethral stricture was infectious in 63% of patients, traumatic in 13.7% and iatrogenic in 8.2%. The etiology was not identified in 14.9% of cases. The infectious etiology was urethritis in 259 cases and urogenital schistosomiasis in 12 cases. A study of the etiology according to stricture site showed that bulbar USD was infectious in 77.7% of cases and that all membranous USD cases were traumatic. Male urethral stricture in Senegal is often a sequela of gonococcal urethritis and is frequently detected because of infectious complications such as gangrene of the genitalia or urinary tract infections. Its prevention in this geographical region thus requires fighting against sexually transmitted infections and treating appropriately and effectively all urethritis.

Diaspora, faith, and science: Building a Mouride hospital in Senegal

This article examines a development initiative spearheaded by the members of a transnational diaspora – the creation of a medical hospital in the holy city of Touba in central Senegal. Although the construction of the hospital is decidedly a philanthropic project, Hôpital Matlaboul Fawzaini is better understood as part of the larger place-making project of the Muridiyya and the pursuit of symbolic capital by a particular Mouride "dahira". The "dahira's" project illuminates important processes of forging global connections and transnational localities, and underscores the importance of understanding the complex motivations behind diaspora development. The hospital's history reveals the delicate negotiations between state actors and diaspora organizations, and the complexities of public–private partnerships for development. In a reversal of state withdrawal in the neo-liberal era, a diaspora association was able to wrest new financial commitments from the state by completing a large infrastructure project. Despite this success, we argue that these kinds of projects, which are by nature uneven and sporadic, reflect particular historical conjunctures and do not offer a panacea for the failure of state-led development.

Audits de décès maternels dans les pays à faibles ressources : analyse d’implantation dans 23 établissements de santé au Sénégal et au Mali (essai QUARITE)

BackgroundIn 1990, the Society of Obstetricians and Gynaecologists of Canada joined the international movement for safe motherhood by adapting its ALARM programme to the needs of low-resource countries. The goal of the QUARITE (QUAlité des soins, gestion du RIsque et TEchniques obstétricales) trial is to evaluate the efficiency of the ALARM International programme in terms of maternal mortality reduction in 46 referral hospitals in Senegal and Mali. ObjectiveEvaluate the implementation of maternal death audits in the 23 hospitals that are part of the QUARITE trial’s intervention group. MethodTen follow-up indicators have been identified to evaluate the implementation of maternal death audits. This article describes and analyzes these follow-up indicators during a 5-month implementation period, from September 23, 2008, to January 30, 2009. Data was gathered during a supervision visit at the end of that period with a standardized follow-up questionnaire and checklist. Key participants were interviewed. The programme’s documents (procedure manual, meeting and supervision minutes, and logbook) were analyzed. An implementation score (on a scale from 1 to 10) was calculated for each centre. ResultsThe 23 centres we visited yielded a mean implementation score of 7.5 (minimum=4 and maximum=10). In each health structure, there is a multidisciplinary, functional subcommittee-maternal death audit committee whose members have been trained on the subject of maternal death audits. Overall, these subcommittees use the management tools but some of the forms are not well understood; thus, we must pinpoint the causes of this problem and eliminate them. Maternal death audit sessions had a slow start due to several factors: maternity personnel’s workload, lack of confidence of local leaders, lack of cohesion within teams and lack of personnel availability. ConclusionData analysis indicates that the process of implementing maternal death audits is slow but real and that quarterly supervision makes it possible to eliminate difficulties and to reinforce the skills of audit subcommittee members.

QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali.

BackgroundMaternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.Methods/DesignThis is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews.The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.Trial RegistrationThe QUARITE trial is registered on the Current Controlled Trials website under the number ISRCTN46950658 .

Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal

BackgroundIn sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal.MethodsThis study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches.ResultsHealth professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths.ConclusionThe identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee – particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.

Task shifting for emergency obstetric surgery in district hospitals in Senegal

Due to a long-term shortage of obstetricians, the Ministry of Health of Senegal and Dakar University Obstetric Department agreed in 1998 to train district teams consisting of an anaesthetist, general practitioner and surgical assistant in emergency obstetric surgery. An evaluation of the policy was carried out in three districts in 2006, covering trends in rates of major obstetric interventions, outcomes in newborns and mothers, and the views of key informants, community members and final year medical students. From 2001 to 2006, 11 surgical teams were trained but only six were functioning in 2006. The current rate of training is not rapid enough to cover all districts by 2015. An increase in the rate of interventions was noted as soon as a team had been put in place, but unmet need persisted. Central decision-makers considered the policy more viable than training gynaecologists for district hospitals, but resistance from senior academic clinicians, a perceived lack of career progression among the doctors trained, and lack of programme coordination were obstacles. Practitioners felt the work was valuable, but complained of low additional pay and not being replaced during training. Communities appreciated that the services saved lives and money, but called for improved information and greater continuity of care.

Survie des accidents vasculaires cérébraux comateux à Dakar (Sénégal)

Background In Dakar, stroke is the most frequent neurological disease with the highest mortality. Victims may present in a critical state of coma. The objective of this study was to evaluate survival among comatose stroke patients in Dakar, Senegal. Methods This was a longitudinal prospective study from April 2006 to July 2007 conducted in the Neurological Intensive Care Unit (NICU) of Fann University Teaching Hospital in Senegal. Were included in the study, all stroke patients confirmed by CT scan with a Glasgow coma score less than or equal to 8/15. Patients with subarachnoid hemorrhage were excluded. Results A total of 105 patients were evaluated with 54 cases of ischemic stroke among them. The mean age was 61.87 ± 14.16 years. The mean duration of hospital stay in the NICU was 10.82 ± 11 days with an estimated mortality of 82.9%; the three-month survival was 9.52%. The median overall survival was 7 ± 1 days (CI 95%: 5–9). Conclusion Comatose stroke patients have a poor prognosis, emphasizing the crucial importance of primary prevention.

Maternal mortality in Senegal

The improvement of obstetric services is one of the key components of the Safe Motherhood Programme. Reviewing maternal deaths and complications is one method that may make pregnancy safer, but there is no evidence about the effectiveness of this strategy. The objective of our before and after study is to assess the effect of facility-based maternal deaths reviews (MDR) on maternal mortality rates in a district hospital in Senegal that provides primary and referral maternity services. We included all women who were admitted to the maternity unit for childbirth, or within 24 hours of delivery. We recorded maternal mortality during a 1-year baseline period from January to December 1997, and during a 3-year period from January 1998 to December 2000 after MDR had been implemented. Effects of MDR on organization of care were qualitatively evaluated. The MDR strategy led to changes in organizational structure that improved life-saving interventions with a relatively large financial contribution from the community. Overall mortality significantly decreased from 0.83 (95% CI (confidence interval) = 0.60 -1.06) in baseline period to 0.41 (95% CI = 0.25 -0.56) per 100 women 3 years later. MDR had a marked effect on resources, management and maternal outcomes in this facility. However, given the design of our study and the local specific context, further research is needed to confirm the feasibility of MDR in other settings and to confirm the benefits of this approach for maternal health in developing countries.

Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal

To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines. Triple cohort observational time series study. A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal. All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods. To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management. The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension. There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension. While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.

Cultural response to mental illness in Senegal: Reflections through patient companions—Part I. Methods and descriptive data

Patient records from the Thiaroye mental hospital in Senegal were analyzed to see if the patterns of persons accompanying patients to the hospital could help portray the community's response to mental illness. A systematic sample of 935 records of initial out-patient visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. This article presents the study setting, methods, patient sociodemographic and clinical characteristics, and characteristics of patient companions. The second article in this series examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.

Cultural response to mental illness in Senegal: Reflections through patient companions—Part II. Statistical correlates

Patient records from the Thiaroye Psychiatric Hospital in Senegal were studied to see if analysis of patterns of persons accompanying patients to the hospital could help to portray the community's response to mental illness. A systematic sample of 935 records of initial out-patients visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. The first article in this series presented the study setting, methods, sociodemographic and clinical characteristics of the patients, and characteristics of patient companions. The current article examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.