Improving Emergency Obstetric Care Research Articles

Strengthening Health Systems in Conflict: Evidence-Based Policies for Quality Care in Yemen

Yemen’s health system has faced formidable obstacles due to the enduring conflict since 2014, resulting in compromised infrastructure, disrupted services, and exacerbated vulnerabilities. This discourse meticulously analyzes the primary health system challenges in Yemen within the framework of the World Health Organization’s six pillars. It subsequently presents evidence-based policy recommendations to enhance Yemen’s health system and ensure the provision of high-quality and equitable care. In terms of service delivery, it suggests augmenting the presence of community health workers, leveraging mobile health technology, rehabilitating facilities, and improving emergency obstetric care. Regarding the health workforce, it proposes financing mechanisms for adequate remuneration, task-shifting strategies, embracing telemedicine, and fostering partnerships with universities. To strengthen information systems, it advocates for the enhancement of facility reporting, the implementation of national surveys, the utilization of mobile phone surveys, and the adoption of robust health information software. Regarding essential medicines, it recommends reorganizing regulations pertaining to selection, procurement, storage, and distribution. For health financing, it highlights the importance of increasing domestic budget allocation, implementing user fee exemptions, adopting performance-based financing mechanisms, and strengthening financial management systems. Last, in terms of governance, it emphasizes the need for transparent and accountable leadership, effective coordination mechanisms, and inclusive policy-making processes. Yemen requires sustained political commitment and adequate resources to facilitate the comprehensive reconstruction of its health system.

Challenges of rural women living with obstetric fistula: A phenomenological study

BackgroundObstetric fistula is a devastating complication caused by a prolonged and obstructed labor. It is estimated that about 2 million girls and women continue to live with obstetric fistula while between 50,000–100,000 women worldwide develop obstetric fistula each year. This condition continues to persist and remains a major problem in Ghana and other developing countries. AimTo explore the challenges and post-surgery integration needs among rural women living with obstetric fistula. MethodA critical exploratory research methodology based on phenomenology was used to conduct in-depth one-on-one interviews. A non-probability and purposive sampling were done to identify thirty-six (36) women between the ages of 25 and 65. The interviews were recorded electronically and transcribed verbatim. A systematic analysis of data was then done to identify and categorize emerging themes. ResultsThe results from the study showed that those who lived with obstetric fistulae experienced psychosocial, physical and economic challenges. Dominant among the psychological challenges identified were disruptions in social relations, divorce and loss of baby through neonatal death. Physical challenges include rashes and sores, foot drop, incontinence of urine. Economically, these women lost their source of livelihood and were heavily dependent on other family members. Support from family was also found to be key towards the post-surgery integration of the women. ConclusionObstetric fistula is a dilapidating condition that needs to be addressed at the micro, mezzo and macro level. Based on the findings of the study, recommendations were made to improve emergency obstetric care for women especially for women living in rural communities.

Improving emergency obstetric care and reversing the underutilisation of vacuum extraction: a qualitative study of implementation in Tete Province, Mozambique

BackgroundMaternal and perinatal mortality in Mozambique were declining at a slow pace, despite progress in coverage of institutional childbirth. Implementation of quality emergency obstetric care including vacuum extraction remained inadequate. In 2015–2017, Tete Province achieved remarkable progress in improving emergency obstetric care and reversing the underutilisation of vacuum extraction, with encouraging results for maternal and perinatal outcomes, despite severe resource constraints. This paper presents the experience of Tete Province, generating a rich, contextualised understanding, which might provide generalizable insights and lessons.MethodsThis qualitative study design is used to present Tete’s experience in improving emergency obstetric care and reversing the underutilisation of vacuum extraction, drawing on principles from implementation science and applying a systems thinking approach. Sources include routine data, documents, social media messages, and the lived experience of the authors, all intimately involved in the implementation process during 2014–2017. Iterative learning and analysis, involving all authors, led to the final interpretations.ResultsWithin a context of severe resource constraints, Tete applied 4 interventions (training, accreditation, audit, monitoring and evaluation with feedback) to improve the implementation of emergency obstetric care. Considerable progress was achieved in vacuum extraction and other signal functions of emergency obstetric care and in the decision-making process for caesarean sections, contributing to important reductions in the provincial institutional maternal mortality and stillbirth rates. Facilitating factors include attributes of the vacuum extraction itself, of the structural and organisational environments in which it was introduced, of the people involved in implementation, and of the process through which the implementation was rolled-out.ConclusionsThe lessons from implementation science and systems thinking can contribute to surprising results in the improvement of emergency obstetric care including the use of vacuum extraction, even in a severely resource-constrained setting. The creation of conditions for real change, with empowerment of the staff and managers at the front-line of day-to-day practice in Tete may inspire others in similar conditions and circumstances. The underutilisation of vacuum extraction in middle- and low-income countries is indeed a missed opportunity. Its reversion is possible and provides a good chance to make considerable difference in maternal and perinatal outcomes.

АНАЛИЗ КРИТИЧЕСКИХ СЛУЧАЕВ, УГРОЖАЮЩИХ ЖИЗНИ ЖЕНЩИН: ОТ ВНЕДРЕНИЯ МЕТОДОЛОГИИ ДО ИЗВЛЕЧЕНИЯ УРОКОВ

Objective: Examining the results of implementing a new methodology of analysis of critical cases in the work of an obstetric hospital in order to prevent the occurrence of deadly conditions in the maternity obstetric services and to improving emergency obstetric care. Methods: The comparative analysis of 20 cases of critical states is conducted – exchange cards, childbirth and neonatal histories, critical case analysis (CCA) cards and women’s interviews: 14 cases of massive obstetric haemorrhage and 6 cases of severe hypertensive disorders with complications. Results: The country supported by the WHO initiative on the analysis of critical states in obstetrics aimed at reducing maternal morbidity and mortality (2008). Experts trained the specialists from maternity obstetric service, including the staff of the Tajik Scientific Research Institute of Obstetrics, Gynecology and Perinatology. Using the proposed methodologies, a number of critical cases were examined at the meeting of the working group on the CCA from among specialists of the above-mentioned institution. Each individual subsequent audit session included the implementation report on the previously provided recommendations. The direct case study consisted of a discussing of the interview report and identifying the positive aspects of the patient’s vision, as well as missed opportunities of 20 cases of critical conditions – exchange cards, childbirth and neonatal histories. The study of critical cases of life-threatening women during pregnancy, childbirth and after delivery resulting from massive obstetric haemorrhage (14) and complications of severe pre-eclampsia (6). It turned out that positive moments of assisting in critical situations are the availability of necessary drugs and equipment institution, the introduction of guidelines and standards for the management of obstetric haemorrhage and hypertensive complications, as well as teamwork. Along with the positive moments, the missed opportunities were revealed – insufficient counselling, defects of antenatal and inpatient surveillance need to optimize the existing guidelines in the field of emergency conditions in obstetrics. Based on the decisions taken by the participants of the critical cases and the working group on the CCA, conducted 15 sessions as a senior secondary medical staff on various aspects of emergency obstetric care, prepared 4 draft orders, further signed by the administration and aimed at improving the work of organization and improving the quality of the rendered services. Based on the experience gained, a number of organizational measures aimed at prevention of possible complications were introduced. Conclusion: Based on the results of the audit sessions, conclusions were drawn on the main directions in which the activity should be improved by: adapting some order manuals, orders and standards for the institutions, the establishment of a series of orders, continuously raising the level of knowledge improvement. Keywords: Analysis of critical conditions, maternal mortality, severe hypertensive disorders, obstetric haemorrhages.

Stagnating maternal mortality in Tanzania: what went wrong and what can be done

Background: This paper presents and analyses the trend of maternal mortality ratio in Tanzania against major events, policy, economic and political decisions which may have influenced this trend. The impact of several initiatives related to Health Systems Strengthening are discussed and alternative strategies for effective maternal mortality reduction in Tanzania are proposed.Methods: We reviewed data and information published on maternal mortality and relevant political decisions, policies programmes and guidelines on maternal and new-born for Tanzania from 1990 to 2016. We examined the timeline of economic development, political decisions and other major events going back 5-10 years before the possible stagnation of maternal mortality decline.Results: This period coincides with the Health Sector Reforms which included among other things the introduction of user fees, reintroduction of private practice, staff retrenchment, widening inequalities and growing poverty. Health service factors include persistent low coverage and utilization of basic emergency obstetric care services. To address these gaps, we propose strengthening rights-based approaches in maternal health programming with political, financial and performance accountabilities at all levels. Introducing these will themselves help with improvement of the quality of care and address the issues of equity by reaching even the poorest households. We further propose application of process indicators to monitor maternal care services. Skilled care should be adopted as the single most important indicator for improving emergency obstetric care. There is need to review the legal and policy framework on task shifting to allow nurses to deliver the seven signal functions and Assistant Medical Officers to deliver Comprehensive Emergency Obstetric Care.Conclusion: We conclude that greater effort needs to be put in designing heath strengthening systems that address more the demand side of health systems strengthening as opposed to current efforts which are largely supply oriented.

Trends and Causes of Maternal Mortality at the Wa Regional Hospital, Ghana: 2005-2010

Maternal mortality has been a health concern for many developing countries. The study undertook a comprehensive maternal mortality audit at the Wa Regional Hospital in order to discover the trends and causes of maternal mortality at the hospital, and suggest ways of improving the situation. The study involved a retrospective examination of maternal mortality cases from January 1, 2005 to December 31, 2010. It included all pregnancy related deaths at the hospital within this period. A gynecologist and midwives served as key informants who provided primary data to augment the secondary data collected. Results showed a total of 73 maternal deaths occurred out of 14027 live births, giving a maternal mortality ratio of 520.4 per 100,000 live births. The yearly maternal mortality ratios saw an undulating scenario. On the specific causes of death, direct causes accounted for 60%, while indirect causes were 40%. Medically, haemorrhage (19%), Eclampsia (15%), Sepsis (11%), abortion related difficulties (8%) and obstructed labour (7%) were the main causes of mortality. Indirect causes include malaria, aneamia, sickle cell, HIV-Aids and TB. The trends of maternal mortality in the Upper West Regional Hospital over the period have seen a decline, but the decline is not significant enough. The number of women still dying from trying to bring life is unacceptably high. Key recommendations include the need to: improve emergency obstetric care by ensuring that there are enough personnel, logistics and facilities to attend to women who are in labour, especially 12 hours prior to delivery and after delivery.

A hospital-centered approach to improve emergency obstetric care in South Sudan

ObjectiveTo assess provision of emergency obstetric care (EmOC) in Greater Yirol, South Sudan, after implementation of a hospital-centered intervention with an ambulance referral system. MethodsIn a descriptive study, data were prospectively recorded for all women referred to Yirol County Hospital for delivery in 2012. An ambulance referral system had been implemented in October 2011. Access to the hospital and ambulance use were free of charge. ResultsThe number of deliveries at Yirol County Hospital increased in 2012 to 1089, corresponding to 13.3% of the 8213 deliveries expected to have occurred in the catchment area. Cesareans were performed for 53 (4.9%) deliveries, corresponding to 0.6% of the expected number of deliveries in the catchment area. Among 950 women who delivered a newborn weighing at least 2500g at the hospital, 6 (0.6%) intrapartum or very early neonatal deaths occurred. Of 1232 women expected to have major obstetric complications in 2012 in the catchment area, 472 (38.3%) received EmOC at the hospital. Of 115 expected absolute obstetric indications, 114 (99.1%) were treated in the hospital. ConclusionA hospital-centered approach with an ambulance referral system effectively improves the availability of EmOC in underprivileged remote settings.

Reducing maternal mortality: better monitoring, indicators and benchmarks needed to improve emergency obstetric care. Research summary for policymakers

Several limitations of emergency obstetric care (EmOC) indicators and benchmarks are analysed in this short paper, which synthesises recent research on this topic. A comparison between Sri Lanka and Zambia is used to highlight the inconsistencies and shortcomings in current methods of monitoring EmOC. Recommendations are made to improve the usefulness and accuracy of EmOC indicators and benchmarks in the future.

MATERNAL DEATH REVIEW TO KNOW THE DETERMINANTS OF MATERNAL MORTALITY IN A DISTRICT HOSPITAL OF CENTRAL INDIA

Background: Avoiding maternal deaths is possible even in resource-limited countries, but r correct information on which to base maternal health programmes is required. Knowing the level of maternal mortality is not enough to prevent further deaths; there is need to understand the underlying factors that led to the deaths. Maternal death review is one of the oldest and the most documented methods that can be effective in improving emergency obstetric care and maternal outcomes. Objectives: To study the maternal deaths in a District level tertiary health care unit so as to find the determinants of maternal mortality and suggest local solutions. Methods: Maternal deaths occurring in a tertiary care district hospital were analysed using maternal death review form. Socio demographic profile, antenatal care, labour and delivery parameters and cause of death was studied. Analysis was done using computer software stata. Results: In the present study there were 12 maternal deaths among 4953 deliveries giving a Maternal Mortality ratio of 242.27 per 1,00,000 live births. Pulmonary embolism was the leading cause of death complicating obstetric disorders of pregnancy induced hypertension and eclampsia. Most of the women died in the postpartum period. The affected population was rural, illiterate and belonged to the 19-29 years age group. Conclusions: Maternal death review is an important tool for delineating the causes of maternal deaths and finding cause specific and need based local solutions for curtailing maternal mortality.

A systematic review of the effectiveness of training in emergency obstetric care in low‐resource environments

Training of healthcare workers can play an important role in improving quality of care, and reducing maternal and perinatal mortality and morbidity. To assess the effectiveness of training programmes aimed at improving emergency obstetric care in low-resource environments. We searched Pubmed, Embase, Popline and selected websites, and manually searched bibliographies of selected articles. Language was not an exclusion criterion. All papers describing postgraduate training programmes aimed at improving emergency obstetric care in low-resource environments were included. Two reviewers independently extracted the data and classified these according to the level of the measured effects (reaction of participants, improved knowledge and skills, changes in behaviour and outcomes in practice). Any disagreements were resolved by discussion with a third author until agreement was reached. A total of 38 papers were selected. Training programmes vary considerably in length, content and design. The evaluation of effects is often hampered by inadequate study design and the use of non-validated measuring instruments. Most papers describe positive reactions, increased knowledge and skills, and improved behaviour after training. Outcome is assessed less frequently, and positive effects are not always demonstrated. Measures that can contribute to a positive effect of training programmes include hands-on practise, team approaches and follow-up on training efforts. Training programmes may improve quality of care, but strong evidence is lacking. Policymakers need to include evaluation and reporting of effects in project budgets for new training programmes.

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 .

The challenges of improving emergency obstetric care in two rural districts in Mali

ObjectiveWe describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali. MethodsProject planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts. ResultsBy the end of 2004, despite many health systems’ challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively. DiscussionAlthough useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed. ConclusionSave the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community.

Improving Emergency Obstetric Care in a Context of Very High Maternal Mortality: The Nepal Safer Motherhood Project 1997–2004

The Nepal Safer Motherhood Project (1997–2004) was one of the first large-scale projects to focus on access to emergency obstetric care, covering 15% of Nepal. Six factors for success in reducing maternal mortality are applied to assess the project. There was an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004. Infrastructure and equipment to achieve comprehensive-level care were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia, were greater challenges. In three districts, 70% of emergency procedures were managed by nurses, with additional training. However, major shortages of skilled professionals remain. Enhancement of the weak referral system was beyond the project’s scope. Instead, it worked to increase information in the community about danger signs in pregnancy and delivery and taking prompt action. A key initiative was establishing community emergency funds for obstetric complications. Efforts were also made to develop a positive shift in attitudes towards patient-centred care. Supply-side interventions are insufficient for reducing the high level of maternal deaths. In Nepal, this situation is complicated by social norms that leave women undervalued and disempowered, especially those from lower castes and certain ethnic groups, a pattern reflected in use of maternity services. Programming also needs to address the social environment.RésuméLe projet népalais pour une maternité à moindre risque (1997–2004) a été l’un des premiers grands projets à se centrer sur l’accès aux soins obstétricaux d’urgence, couvrant 15% du Népal. Six facteurs de réduction de la mortalité maternelle ont été choisis pour évaluer le projet. La satisfaction des besoins en soins obstétricaux d’urgence a augmenté en moyenne de 1,3% par an, atteignant 14% en 2004 dans les centres publics visés par le projet. L’infrastructure et les équipements se sont améliorés, mais le fonctionnement, la disponibilité d’un médecin qualifié, de sang et d’anesthésie demeuraient problématiques. Dans trois districts, 70% des procédures d’urgence étaient pratiquées par des infirmières ayant suivi une formation complémentaire. Néanmoins, les professionnels qualifiés continuent de manquer cruellement. L’amélioration du système d’aiguillage n’entrait pas dans le champ du projet qui a préféré apprendre à la communauté à reconnaître les signes de danger pendant la grossesse et l’accouchement et à y réagir rapidement. La création de fonds communautaires pour les complications obstétricales constitue une initiative clé. Le projet a également encouragé un changement de comportement en faveur de soins à l’écoute des patientes. Les interventions centrées sur l’offre ne suffisent pas à réduire le niveau élevé de décès maternels. Au Népal, cette situation est compliquée par des normes sociales défavorables aux femmes – particulièrement quant elles appartiennent à des castes inférieures ou à certains groupes ethniques – qui se reflètent dans beaucoup de services de maternité. La programmation doit aussi agir sur l’environnement social.ResumenEl proyecto de Maternidad más segura (1997–2004), en Nepal, fue uno de los primeros proyectos de gran escala que se centró en el acceso a los cuidados obstétricos de emergencia, y abarcó el 15% de Nepal. A fin de evaluar el proyecto se aplican seis factores para lograr disminuir la tasa de mortalidad materna. En 2004, hubo un aumento anual promedio de un 1.3% para cubrir la necesidad de cuidados obstétricos de emergencia, y se alcanzó el 14% en establecimientos del sector público, en distritos del proyecto. Se mejoraron la infraestructura y el equipo para lograr el nivel de atención integral, pero resultó más difícil lograr funcionamiento continuo, así como disponibilidad de un médico calificado, sangre y anestesia. En tres distritos, el 70% de los procedimientos de emergencia eran manejados por enfermeras, con capacitación adicional. Sin embargo, aún existe una gran escasez de profesionales calificados. Quedó fuera del alcance del proyecto mejorar el sistema de referencia deficiente. En vez, se trabajó para aumentar la información de la comunidad respecto a los signos de alarma del embarazo y el parto, y la toma de medidas con prontitud. Una iniciativa importante fue establecer fondos comunitarios de emergencia para complicaciones obstétricas. Además, se realizaron esfuerzos por fomentar un cambio positivo en actitudes hacia la atención centrada en la paciente. Las intervenciones relacionadas con los suministros son insuficientes para disminuir el alto índice de muertes maternas. En Nepal, esta situación se complica por las normas sociales que dejan a las mujeres subvaloradas y sin poder, especialmente aquéllas de clases más bajas y determinados grupos étnicos, un patrón reflejado en el uso de los servicios de maternidad. Los programas deben tener en cuenta el ambiente social.

Improving emergency obstetric care in Mozambique: The story of Sofala

Objective: The 5-year project in the province of Sofala was designed to improve access, quality and utilization of emergency obstetric care (EmOC) by strengthening rural hospitals and health centers and ultimately the health system's capacity to respond to emergencies more quickly and effectively. Methods: Implementation consisted of attention to infrastructure, human resource development, transportation and communication systems, and management. Specific management aspects that were targeted for improvement included: supportive supervision, logistics for supplies, equipment and drugs, record keeping, monitoring and evaluation, and quality improvement techniques such as maternal death audits. Results: Access to EmOC improved with an increase in the number of fully functional EmOC facilities from 4 to 18. The number of women with obstetric complications who were admitted for treatment in participating facilities tripled, and the proportion of those women dying declined by half. Conclusions: Close collaboration and partnership with the provincial health directorate make the sustainability of many results likely while the replication of much of the Sofala model to other provinces is promising for the national strategy to reduce maternal mortality.

The evolution of a quality of care approach for improving emergency obstetric care in rural hospitals in Nepal

We describe the iterative process of developing a locally-appropriate quality of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. We describe the context of maternal health issues in Nepal, the rationale for developing a quality of care approach within a model to improve EmOC, and outline the outcomes and catalytic effects of the process. The lessons learned during the development of this approach are detailed. The program developed and implemented a quality of care approach at three district hospitals in Nepal. This resulted in improvements in the structure, process and outcomes of EmOC in these institutions. The process also resulted in improved understanding of quality of care approaches on both local and national levels and the creation of a Nepalese quality of care evaluation framework for maternity services. While the theoretical concept of quality of care is difficult to translate into a concrete approach, we used a process in rural hospitals in Nepal that created highly motivated teams and improved the overall functioning of these hospitals.

Monitoring obstetric services: putting the ‘UN Guidelines’ into practice in Malawi: 3 years on

The maternal mortality ratio is difficult to use for monitoring short-term progress in safe motherhood programs. UNICEF/WHO/UNFPA have proposed alternative process indicators monitoring the availability, utilization and quality of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in developing countries. The Malawi Safe Motherhood Project, which covers a population of over 5 million, was one of the first large projects to implement the new process indicators. At the end of 2000 data were available from the new monitoring system for 3 consecutive years. In 1998, availability of comprehensive emergency obstetric care was adequate but availability of basic emergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesarean section rate was only 1.6%. The mean case fatality rate in District hospitals was nearly 5%. By the end of 2000, improvements in availability, utilization and quality of obstetric care were observed. Participation in developing the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged from routine use of the process indicators. In particular, it has been difficult to be certain that obstetric complications have been recorded correctly. The results confirm that a focus on improving emergency obstetric care in Malawi was justified and that process indicators for obstetric care can be successfully introduced in developing countries. The monitoring system has provided data that are of immediate relevance to service providers, managers, and policy makers and provide many lessons useful for similar programs in other settings.

Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone

Preliminary studies: A facility review and focus group discussions revealed poor capacity to manage obstetric complications. Interventions: In response, a physician with obstetric skills was posted, and a second physician was trained. Courses in life-saving obstetric skills were held for nurses and midwives. An unused operating theater was made functional with simple modifications. A generator and blood bank were installed. Drugs and supplies were made available through a revolving fund. Subsequently, community interventions focused on improving utilization. Results: The number of women seeking treatment for major obstetric complications at the district hospital increased from 31 in 1990 to 98 in 1995, while the case fatality rate (CFR) among these women dropped from 32% to 5%. Cesarean sections increased from two in 1990 to 38 in 1995. In 1995, 444 abortion-related procedures were performed — almost all of them for unwanted pregnancy — compared with only 22 in 1990. Costs: The cost of material improvements and training was approximately US$39 000, of which 46% was from project funds, 41% from non-governmental organizations and 13% from government. Conclusions: Women with obstetric complications will seek hospital care if services are available. Government hospital services can be improved by building on existing resources. Obstetric CFR can be dramatically reduced. The need for safe abortion services, which are currently illegal in Sierra Leone, is demonstrated.© 1997 International Federation of Gynecology and Obstetrics

Improving emergency obstetric care at a state referral hospital, Kebbi State, Nigeria

Preliminary studies: An inventory at Birnin Kebbi Specialist Hospital in Nigeria revealed poor capacity in emergency obstetric care and excessive delays. Focus group discussions among community members emphasized poor services as a reason for not seeking care. Interventions: During 1992–1993, several specialist obstetricians visited the hospital. They provided training to general physicians and midwives and care to patients, and stayed approximately five weeks each. An obstetric first-aid box with essential drugs and supplies was introduced. Midwives were trained in recognition and management of obstetric complications. Subsequent community interventions focused on improving access and reducing delay in seeking care. Results: The number of cesarean sections performed increased from 101 in 1990 to 131 in 1995. The case fatality rate among women with complications dropped from 22% to 5% over the same period. The number of women with complications seeking treatment in the hospital increased from 200 in 1990 to 227 in 1994, and then declined to 152 in 1995. Costs: The cost of improvements at the hospital was approximately US$12 300, with 10% contributed from government sources. Conclusion: Improving hospital obstetric services is feasible and affordable. Better services, however, may not be sufficient to reverse declining hospital utilization related to worsening economic conditions.© 1997 International Federation of Gynecology and Obstetrics