National Emergency Obstetric Research Articles

Health care professionals\u2019 adherence to partograph use in Ethiopia: analysis of 2016 national emergency obstetric and newborn care survey

BackgroundThe period around childbirth and the first 24 hours postpartum remains a perilous time for both mother and newborn. Health care providers’ compliance to the World Health Organization modified partogram across the active first stage of labor is a graphic representation of a mother’s condition that is used as a guide in providing quality obstetrics care. However, little evidence is documented on the health providers’ adherence to the use of the partograph in Ethiopia, which limits health care providers’ ability to improve quality care services. Therefore, this study assessed the adherence of partograph use and associated factors in Ethiopia.MethodsData from the Ethiopian 2016 National Emergency Obstetric and Newborn Care survey of 3,804 health facilities that provided maternity services were used. We extracted 2611 partograph charts over a 12 months period prior to the survey to review the proper recording of each component. Data analyses were performed using SPSS version 22.0 software. A logistic regression analyses was used to identify the association of explanatory variables with the outcome variable. A p-value of <0.05 was considered as cut off point to declare the significance association in the multivariable analysis.ResultsOf the total 2611 partographs reviewed, 561(21.5%) of them were fully recorded as per the WHO guideline. Particularly, molding in 50%, color of liquor in 70.5%, fetal heart beat in 93.3%, cervical dilation in 89.6%, descent in 63.2%, uterine contraction in 94.5%, blood pressure in 80.5%, pulse rate in 70.5%, and temperature in 53% were accurately recorded. The odds of adherence to partograph use were 1.4 in rural health facilities when compared to their counterparts (AOR=1.44; 95% CI: 1.15, 1.80, P- 0.002).ConclusionThis study revealed a poor level of adherence in partograph use in Ethiopia. Molding, maternal temperature and decent were the least recorded parameters of the partograph. The odds of completion of partograph were high in rural facilities. Strong supporting supervision and mentoring the health workers to better record and use of partograph are needed mainly in urban health facilities. Moreover in the future, interventional research should be conducted to improve the current rate of adherence.

Exploring Factors Influencing Practice of Neonatal Resuscitation with Bag and Mask in Ethiopia: Analysis from 2016 National Emergency Obstetric and Newborn Care Survey.

BackgroundGlobally, more than 7 million children die under the age of five and the highest proportion of death is during the first 28 days of life. For babies who do not breathe at birth, neonatal resuscitation is critical in reducing intra-partum related neonatal deaths by 30%. Yet, there is a dearth of studies on the provision of neonatal resuscitation in Ethiopia. So, this study aimed to assess health facilities provision of neonatal resuscitation with bag and mask and its factors among asphyxiated newborns.Materials and MethodsData used were from the Ethiopian 2016 Emergency Obstetric Newborn Care survey, conducted in 3,804 health facilities providing maternal and newborn health services. The analysis included neonatal resuscitation with bag and mask in the previous 3 months before the survey. Descriptive statistics, simple and multivariable regression analyses were performed using SPSS-21 version.ResultsThe analysis findings show that 72.2% of the health facilities were providing neonatal resuscitation with bag and mask. The result showed that hospitals (adjusted odds ratio (AOR): 3.90; 95% confidence interval (CI) [2.05, 7.49]), health-care providers not trained in neonatal resuscitation (AOR: 0.64; 95% CI [0.42, 0.99]) and availability of essential equipment (AOR: 1.32; 95% CI [1.15, 1.51]) were more likely to practice neonatal resuscitation.ConclusionOverall practice of health facilities on neonatal resuscitation with bag and mask was at 72.2%. Type of facility, providers trained in neonatal resuscitation and availability of essential equipments were independently affecting the practice of neonatal resuscitation. Incorporating competency-based training, refresher training, and clinical mentorship will improve the practice.

Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system

BackgroundTriangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women.MethodsThis paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system.ResultsA maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10–27%) and severe preeclampsia/eclampsia (10–24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7–33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics.ConclusionThe facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

Healthcare workers\u2019 clinical knowledge on maternal and newborn care in Ethiopia: findings from 2016 national EmONC assessment

BackgroundImproving maternal and newborn health indicators are key if Ethiopia is to achieve the Sustainable Development Goals. To do so, women need access to skilled attendance at birth and emergency obstetric and newborn care. To maximize their impact, understanding gaps in workers’ knowledge is required to remedy the weakness. This assessment determines knowledge levels of clinical management of maternal and newborn healthcare and factors that influence knowledge.MethodsThis study used data from the National Emergency Obstetric and Neonatal Care assessment conducted in 2016. Provider knowledge for MNH was assessed by interviewing providers. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible answers, and standardizing this to a scale of 100. Mixed linear regression was used to determine individual and contextual factors associated with the score.ResultsA total of 3800 interviews with complete data were included in this study. Most respondents were diploma midwives (73%), BSc midwives (11%) and diploma nurses (10%). On average, midwives scored 60 out of 100 on the question regarding the primary aspects of focused antenatal care and elements of a birth plan. Half of the midwives and health officers, and one-third of nurses knew to provide a loading dose of magnesium sulphate. Midwives scored 90% on the steps of active management of third stage of labor. In the mixed linear regression, working in a private for profit facility, health center/clinic, rural area, or in a facility with a protocol on referral/counter referral predicted lower knowledge scores. More positive scores were associated with work environments that had a computer, internet, and protocols on safe abortion care, management of selected obstetric topics, integrated management of pregnancy, childbirth, postnatal, and newborn, care for low birth weight including kangaroo mother care, and treatment of infection in young infants.ConclusionWith regard to most knowledge related questions, health officers and midwives scored similarly. Providers scored substantially better on routine intrapartum and newborn care than on aspects related to care for complications. A substantial proportion of providers indicated that they would never give a loading dose of magnesium sulphate.

Quality of Kangaroo Mother Care services in Ethiopia: Implications for policy and practice

BackgroundProviding high-quality kangaroo mother care (KMC) is a strategy proven to improve outcomes in premature babies. However, whether KMC is consistently and appropriately provided in Ethiopia is unclear. This study assesses the quality of KMC services in Ethiopia and the factors associated with its appropriate initiation among low birth weight neonates.MethodsWe used data from the 2016 national Emergency Obstetric and Newborn Care (EmONC) assessment which contains data on all health facilities providing delivery care services in Ethiopia (N = 3,804). We described the quality of KMC services provided to low-birth weight (LBW) babies in terms of infrastructure, processes and outcomes (survival status at discharge). We also explored the factors associated with appropriate KMC initiation using multivariable logistic regression models.ResultsThe quality of KMC services in Ethiopia was poor. The facilities included scored only 59.0% on average on a basic index of service readiness. KMC was initiated for only 46.4% of all LBW babies included in the sample. Among those who received KMC, 66.7% survived, 13.3% died and 20.4% had no data on survival status at discharge. LBW babies born in health centers were twice more likely to receive KMC compared to those born in hospitals (AOR = 2.0, 95% CI: 1.3–3.0). Public facilities, those with a staff rotation policy in place for newborn care, and those with separate newborn corners were also more likely to initiate KMC for LBW babies.ConclusionsWe found low levels of appropriate KMC initiation, inadequate infrastructure and staffing, and poor survival among LBW babies in Ethiopia. Efforts must be made to improve the adoption of this life saving technique, particularly in hospitals and in the private sector where KMC remains underutilized. Facilities should also dedicate specific spaces for newborn care that enables mothers to provide KMC. In addition, improving record keeping and data quality for routine health data is a priority.

Healthcare Professionals' Knowledge of Neonatal Resuscitation in Ethiopia: Analysis from 2016 National Emergency Obstetric and Newborn Care Survey.

Background Birth asphyxia, which accounts for 31.6% of all neonatal deaths, is one of the principal causes of neonatal mortality in Ethiopia. Adequate knowledge of newborn resuscitative procedures plays an important role in early diagnoses and suitable management. However, there are limited data on healthcare professionals' knowledge about neonatal resuscitation. Thus, this study aimed to determine the knowledge of healthcare professionals about neonatal resuscitation and factors affecting it. Methods Data from the Ethiopian 2016 national Emergency Obstetric and Newborn Care survey of 3,804 health facilities that provided maternal and newborn health services were analyzed. We have included 3804 healthcare providers, who attended the largest number of deliveries in the last month prior to the survey, and assessed their knowledge of neonatal resuscitation. It was also determined whether certain factors were associated with healthcare providers' knowledge through linear regression method. Result The overall knowledge score of the healthcare providers about neonatal resuscitation ranged from 12 to 24 out of 37 items (with mean score of 18.4 (±5.47) and mean score percentage of 49%). The findings showed that providers trained on neonatal resuscitation (β=2.65, 95% CI: 0.65, 4.62; p <0.00), facilities that had guideline of neonatal resuscitation (β=2.50, 95% CI: 0.60, 3.52; p =0.01), and availability of essential equipment (β=0.95, 95% CI: 0.44, 1.45; p =0.02) were significantly associated with sufficient knowledge of neonatal resuscitation in Ethiopia. Conclusion Overall knowledge of neonatal resuscitation was insufficient. Trained healthcare providers, having guideline on neonatal resuscitation, and availability of essential equipment were significantly associated with knowledge of neonatal resuscitation. Competency and simulation-based in-service training and refresher training complemented by supportive supervision and mentorship are helpful ways to put up providers capability to perform neonatal resuscitation.

Prevalence and associated factors of pre-eclampsia among pregnant women attending anti-natal care at Mettu Karl referal hospital, Ethiopia: cross-sectional study

BackgroundPreeclampsia is leading causes of maternal and perinatal morbidity and mortality worldwide and it is a hypertensive disorder which usually occurs after 20 weeks of gestation. In Ethiopia, according to Ethiopian National Emergency Obstetric and Newborn Care about 10% of all maternal mortality (direct and indirect) were due to preeclampsia. Despite this condition has adverse effects on the maternal and child health, its prevalence is still significant especially in developing countries including Ethiopia.ObjectivesThe aim of the study is to assess the prevalence and associated factors of preeclampsia among pregnant women attending antenatal care at Mettu Karl referral hospital.MethodThe study was conducted at Mettu Karl referral hospital using institutional based cross sectional study design among women whose age was greater or equal to eighteen from March to April 2018. Data were collected from 129 participants by face to face interview technique using structured and pretested questionnaire. Logistic regression analysis was used to identify the factors associated with preeclampsia development.ResultA total of 129 participants were enrolled in the study with the mean age of 25.87 [SD ± 4.757]. Prevalence of preeclampsia among the current pregnant women who attend ANC in Mettu Karl Hospital were 16 (12.4%) with 95% CI (7, 18). Predictor variables like respondents age (AOR = .009, 95% CI = [.000, .317]), current multiple pregnancy (AOR = .071, 95% CI = [.007, .773]) and history of diabetes mellitus (AOR = .058, 95% CI = [.007–.465]) were significantly associated with the current preeclampsia.ConclusionThe finding of this study showed that a considerable proportion of women had preeclampsia. Health seeking behavior towards pregnant women’s should be encouraged for both urban and rural residents, which provide a chance to diagnose preeclampsia as early as possible and to prevent the coming complication towards preeclampsia.

Distribution of maternity waiting homes and their correlation with perinatal mortality and direct obstetric complication rates in Ethiopia

BackgroundEthiopia has been expanding maternity waiting homes to bridge geographical gaps between health facilities and communities in order to improve access to skilled care. In 2015, the Ministry of Health revised its national guidelines to standardize the rapid expansion of waiting homes. Little has been done to document their distribution, service availability and readiness. This paper addresses these gaps as well as their association with perinatal mortality and obstetric complication rates.MethodsWe utilized data from the 2016 national Emergency Obstetric and Newborn Care assessment, a census of 3804 public and private health facilities. Data were collected between May and December 2016 through interviews with health care workers, record reviews, and observation of infrastructure. Descriptive statistics describe the distribution and characteristics of waiting homes and linear regression models examined the correlation between independent variables and institutional perinatal and peripartum outcomes.ResultsNationally, about half of facilities had a waiting home. More than two-thirds of facilities in Amhara and half of the facilities in SNNP and Oromia had a home while the region of Gambella had none. Highly urbanized regions had few homes.Conditions were better among homes at hospitals than at health centers. Finished floors, electricity, water, toilets, and beds with mattresses were available at three (or more) out of four hospital homes. Waiting homes in pastoralist regions were often at a disadvantage.Health facilities with waiting homes had similar or lower rates of perinatal death and direct obstetric complication rates than facilities without a home. The perinatal mortality was 47% lower in hospitals with a home than those without. Similarly, the direct obstetric complication rate was 49% lower at hospitals with a home compared to hospitals without.ConclusionsThe findings should inform regional maternal and newborn improvement strategies, indicating gaps in the distribution and conditions, especially in the pastoralist regions. The impact of waiting homes on maternal and perinatal outcomes appear promising and as homes continue to expand, so should efforts to regularly monitor, refine and document their impact.

Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana

IntroductionCountries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities’ readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral.MethodsThe National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression.ResultsLower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport.DiscussionUnderstanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.

Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis

BackgroundMaternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers’ and households’ practices.MethodsPCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010–January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program’s average treatment effects (ATEs) on women’s care seeking behavior, providers’ service provision behavior and households’ newborn care practices.ResultsThe ATEs of PCQI were statistically significant (p < 0.05) for two care seeking behaviors — four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively — and one service provision behavior — complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider.ConclusionsNational BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.

Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study.

BackgroundComplications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.MethodsA national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.ResultsThe average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.ConclusionsWhile designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.

Using direct clinical observation to assess the quality of cesarean delivery in Afghanistan: an exploratory study.

BackgroundAs part of a National Emergency Obstetric and Newborn Care (EmONC) Needs Assessment, a special study was undertaken in July 2010 to examine the quality of cesarean deliveries in Afghanistan and examine the utility of direct clinical observation as an assessment method in low-resource settings.MethodsThis cross-sectional assessment of the quality of cesareans at 14 facilities in Afghanistan included a survey of surgeons regarding their routine cesarean practices, direct observation of 29 cesarean deliveries and comparison of observations with facility records for 34 additional cesareans conducted during the 3 days prior to the observation period at each facility. For both observed cases and record reviews, we assessed time intervals between specified points of care-arrival to the ward, first evaluation, detection of a complication, decision for cesarean, incision, and birth.ResultsAll time intervals with the exception of “decision to skin incision” were longer in the record reviews than in observed cases. Prior cesarean was the most common primary indication for all cases. All mothers in both groups observed survived through one hour postpartum. Among newborns there were two stillbirths (7%) in observed births and seven (21%) record reviews. Although our sample is too small to show statistical significance, the difference is noteworthy. In six of the reviewed cesareans resulting in stillbirth, a fetal heart rate was recorded in the operating theater, although four were recorded as macerated. For the two fresh stillbirths, the cesarean surgeries were recorded as scheduled and not urgent.ConclusionsDirect observation of cesarean deliveries enabled us to assess a number of preoperative, postoperative, and intraoperative procedures that are often not described in medical records in low resource settings. Comparison of observations with findings from provider interviews and facility records allowed us to infer whether observed practices were typical of providers and facilities and detect potential Hawthorne effects.