Quality Of Emergency Obstetric Care Research Articles

Optimization of the emergency obstetric and neonatal care network in Benin through expert-based sub-national prioritizations.

To reduce maternal mortality by 2030, Benin needs to implement strategies for improving access to high quality emergency obstetric and neonatal care (EmONC). This study applies an expert-based approach using sub-national travel specificities to identify and prioritize a network of EmONC maternities that maximizes both population coverage and functionality. We conducted a series of workshops involving international, national, and department experts in maternal health to prioritize a set of EmONC facilities that meet international standards. Geographical accessibility modeling was used together with EmONC availability to inform the process. For women in need of EmONC, experts provided insights into travel characteristics (i.e., modes and speeds of travel) specific to each department, enabling more realistic travel times estimates modelled with the AccessMod software. The prioritization approach resulted in the selection of 109 EmONC maternities from an initial group of 125 designated maternities. The national coverage of the population living within an hour's drive of the nearest EmONC maternity increased slightly from 92.6% to 94.1% after prioritization. This increase in coverage was achieved by selecting maternities with sufficient obstetrical activities to be upgraded to EmONC maternities in the Plateau and Atlantique departments. The prioritization approach enabled Benin to achieve the minimum EmONC availability, while ensuring very good geographical accessibility to the prioritized network. Limited human and financial resources can now be targetted towards a smaller number of EmONC facilities to make them fully functioning in the medium-term. By implementing this strategy, Benin aims to reduce maternal mortality rates and deliver effective, high-quality obstetric and neonatal care, especially during emergencies.

Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis

BackgroundIn 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.MethodsAn interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention’s effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the “itsa’ command in STATA.ResultsDuring the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (− 8.86; p < 0.001), delayed care (− 8.76; p < 0.001) and substandard care (− 5.58; p < 0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: − 6.95 to − 2.54, p < 0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: − 0.37 to − 0.14, p < 0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: − 4.74 to − 2.26, p < 0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: − 0.28 to − 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: − 9.28 to − 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.ConclusionsOur findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Evaluation of the Emergency Obstetric and Newborn Care training in Gondar, Ethiopia; a mixed methods study.

In Ethiopia maternal and perinatal morbidity and mortality remains high. Timely access to quality emergency obstetric and neonatal care is essential for the prevention of adverse outcomes. Training healthcare providers can play an important role in improving quality of care, thereby reducing maternal and perinatal mortality and morbidity. The aim of this study was to evaluate change of knowledge, skills and behaviour in health workers who attended a postgraduate Emergency Obstetric and Newborn Care training in Gondar, Ethiopia. A descriptive study with before-after approach, using a mix of quantitative and qualitative data, based on Kirkpatrick's model for training evaluation was conducted. The evaluation focussed on reaction, knowledge, skills, and change in behaviour in clinical practice of health care providers and facilitator's perspectives on performance. A 'lessons learned approach' was included to summarize facilitators' perspectives. Health care providers reacted positively to the Emergency Obstetric and Newborn Care training with significant improvement in knowledge and skills. Of the 56 participants who attended the training, 44 (79%) were midwives. The main evaluation score for lectures was 4,51 (SD 0,19) and for breakout sessions was 4,52 (SD 0.18) on scale of 1-5. There was a statistically significant difference in the pre and post knowledge (n = 28, mean difference 13.8%, SD 13.5, t = 6.216, p<0.001) and skills assessments (n = 23, mean difference 27.4%, SD 22.1%, t = 5.941, p<0.001). The results were the same for every component of the skills and knowledge assessment. Overall, they felt more confident in performing skills after being trained. Local sustainability, participant commitment and local context were identified as challenging factors after introducing a new training program. In Gondar Ethiopia, the Emergency Obstetric and Newborn Care training has the potential to increase skilled attendance at birth and improve quality of care, both vital to the reduction of maternal and perinatal mortality and morbidity.

BARRIERS IN ACCESSING EMERGENCY OBSTETRIC SERVICE: A PROSPECTIVE OBSERVATIONAL STUDY AT A TERTIARY CARE CENTRE

Introduction: Despite a drastic reduction in maternal mortality rate, India still contributes to 12% of global maternal deaths. Multiple factors influence access to quality emergency obstetric care that is timely, effective, efficient, equitable, evidence, and client-centric. The present study was carried out to determine the factors influencing access to emergency services by obstetric patients using the Three Delay Model. Methods: This was a prospective, observational, single-center study conducted in the Department of Obstetrics and Gynaecology at a tertiary care hospital from June 1st, 2021 to 31st July 2021. All Pregnant and Postpartum patients admitted from the emergency room were included. A predesigned proforma was used to record the reasons for the delay in receiving emergency care at the time of admission. Results: More than three-fourths of women (75.64%) had a delay of more than four hours from the onset of symptoms to the arrival at the emergency room. Out of these, the majority had Level 1 delay, i.e., there was a delay in deciding to seek care, most commonly due to unawareness of danger signs. The most common reason for level 2 delay, i.e., delay in reaching the facility was the refusal of admission/care at a center visited before reaching our facility. Conclusion: Three-delay model is an effective bottleneck assessment tool for understanding the reasons for delay in receiving emergency obstetric care. For minimizing level 1 delays, strengthening patient education and counseling in the antenatal clinics and engagement of family members in the counseling about the danger signals is important.

Observation of Demographic Factors, Labor Characteristics, and Outcomes in Vesicovaginal Fistula

Introduction: Vesicovaginal fistula (VVF) is a significant public health issue, particularly in areas with inadequate access to quality emergency obstetric care. This study aimed to examine the demographic and obstetric factors associated with VVF in a specific population and to evaluate the outcomes of VVF surgery. Methods: This cross-sectional study was conducted at the Dhaka Medical College Fistula Centre from April to July 2013. From a total of 47 admissions, 27 patients were selected based on specific inclusion criteria. Data were collected on demographic factors, obstetric history, cause of VVF, and surgery-related characteristics. The primary outcome was the success or failure of VVF surgery. Result: The study included women with an average age of 33.78 years and an average height of 144.67 cm. Majority were classified as poor (66.67%). Most had primary education (62.96%) and were housewives (92.59%). Vaginal deliveries were most common (59.26%). Stillbirths accounted for the majority of outcomes (77.78%). Obstetrical causes were the primary reason for vesicovaginal fistula (VVF) (70.37%). Local repair was the most common mode of surgical repair (59.26%), and the majority of surgeries were successful (85.19%). Conclusion: The study highlights the significant burden of VVF among women of lower socioeconomic status and educational level. It underscores the need for improved surgical techniques and decision-making in obstetric and gynecological care, and the importance of access to quality obstetric care. Further research is needed to develop and implement effective strategies to prevent and treat VVF, particularly in resource-limited settings.

MATERNAL DEATHS IN PUNJAB: A 3-YEAR AUDIT FROM A TERTIARY LEVEL GOVERNMENT INSTITUTE

Objective: This study aims to recognize the most common causes and delays in maternal death. Methods: This is an observational study from Government Medical College Amritsar from the period December 2017 to November 2020 which included all cases of maternal death irrespective of gestational age and up to 42 days postpartum. Results: Maternal mortality ratio in our institute during 3-year study period (2018–2020) was 1081 per 100,000 live births. About 90.9% of the maternal deaths were unregistered emergency cases, 11.7% were brought dead, and 33.8% deaths took place within 24 h of admission. Direct obstetric causes were the most common causes of maternal death (49%), while indirect causes were responsible for 42.8% deaths. Hypertensive disorders and hemorrhage were responsible for almost one third cases and severe anemia was an aggravating factor in 31.5%. Maternal deaths were associated with type 1 delay in 57.6%, type 2 delay in 9% cases, and type 3 delay in 21.2%. Conclusion: Hypertensive disorders of pregnancy and obstetric hemorrhage continue to be the leading threats to maternal lives. Improvement in public health services and special campaigns focusing on prevention of viral hepatitis and other infectious diseases can be helpful in decreasing maternal death due to indirect causes. Need of the hour is quality intrapartum and emergency obstetric care at first referral units. Indirect causes of maternal death are a significant public health issue which needs to be addressed.

“We know it is not good, but we are constrained”: A study on quality of emergency obstetric and newborn care in Northern Ghana

ObjectiveTo explore the quality of emergency obstetric and newborn care provided to newly delivered women in rural Ghana. MethodsA multiple case study design, involving in-depth face to face interviews, was deployed to draw evidence from essential health providers, clients and caretakers. Data were further derived from non-participant observation by means of an observation guide and analysis of physical artifacts using the room-by-room walk-through tool. Data analysis followed Yin’s five phase process to case study analysis. ResultsQuality of care was compromised by non-adherence to standard practices, inadequate monitoring, crude treatment procedures, lack of basic care needs and poor health providers' relational behaviours. Limited supplies of drugs, equipment and essential care providers further weakened the provision of quality emergency obstetric and newborn care. ConclusionInadequate supply of essential logistics and skill gaps on the part of health providers in some maternal and newborn care components adversely produced poor maternal and neonatal outcomes in rural Ghana. Elements of disrespectful care for women suggest violations of their rights in the maternal and newborn care encounter.

Travel scenario workshops for geographical accessibility modeling of health services: A transdisciplinary evaluation study.

Limited geographical access to quality Emergency Obstetric and Newborn Care (EmONC) is a major driver of high maternal mortality. Geographic access to EmONC facilities is identified by the global community as a critical issue for reducing maternal mortality and is proposed as a global indicator by the Ending Preventable Maternal Mortality (EPMM) initiative. Geographic accessibility models can provide insight into the population that lacks adequate access and on the optimal distribution of facilities and resources. Travel scenarios (i.e., modes and speed of transport) used to compute geographical access to healthcare are a key input to these models and should approximate reality as much as possible. This study explores strategies to optimize and harmonize knowledge elicitation practices for developing travel scenarios. Knowledge elicitation practices for travel scenario workshops (TSW) were studied in 14 African and South-Asian countries where the United Nations Population Fund supported ministries of health and governments in strengthening networks of EmONC facilities. This was done through a mixed methods evaluation study following a transdisciplinary approach, applying the four phases of the Interactive Learning and Action methodology: exploration, in-depth, integration, and prioritization and action planning. Data was collected in November 2020-June 2021 and involved scoping activities, stakeholder identification, semi-structured interviews (N = 9), an evaluation survey (N = 31), and two co-creating focus group discussions (N = 8). Estimating realistic travel speeds and limited time for the workshop were considered as the largest barriers. The identified opportunities were inclusively prioritized, whereby preparation; a favorable composition of attendees; validation practices; and evaluation were anticipated to be the most promising improvement strategies, explaining their central place on the co-developed initial standard operating procedure (SOP) for future TSWs. Mostly extensive preparation-both on the side of the organization and the attendees-was anticipated to address nearly all of the identified TSW challenges. This study showed that the different identified stakeholders had contradicting, complementing and overlapping ideas about strategies to optimize and harmonize TSWs. Yet, an initial SOP was inclusively developed, emphasizing practices for before, during and after each TSW. This SOP is not only relevant in the context of the UNFPA EmONC development approach, but also for monitoring the newly launched EPMM indicator and even in the broader field of geographic accessibility modeling.

Factors Associated with Postpartum Haemorrhage amongst Primigravidae Women; the Case of Two Hospitals within the Bamenda Health District

Background: Approximately 830 women die from pregnancy-related conditions daily with 99% of these maternal deaths occurring in low resource countries. Primary postpartum haemorrhage (PPH) accounts for 25.7% of maternal deaths in Africa. In Cameroon, postpartum hemorrhage remains the leading cause of maternal death, with little information on the primigravidae population compared to multigravida or multiparity. Objective: The aim of this study was to assess the factors associated with postpartum haemorrhage amongst primigravidae women giving birth in two hospitals within the Bamenda Health District. Methods: This study was a multicentric, non-randomized cross-sectional descriptive and analytic study. Of the 221 women interviewed regarding their willingness to participate in the study, 197 consented. Quantification of blood loss was done by visual estimate and with the assistance of the pathfinder international wall chart for visual estimation of blood loss. Data was collected using a structured questionnaire and analyzed using SPSS version 23. A P-value of sidered statistically significant. Results: The prevalence of postpartum hemorrhage in primigravidae was 7.1%. The risk factors of postpartum hemorrhage were: induction of labour (P-value (P-value macrosomia (P-value ny and obstetrical lacerations (P value Conclusion: The prevalence of postpartum hemorrhage amongst primigravidae was high. The main causes of post-partum hemorrhage were uterine atony and obstetric lacerations. PPH was associated with uterine hypotonia, retained products and genital lacerations. No maternal mortality was recorded. These findings highlight the pressing need for good quality em ergency obstetric care and the availability of more accurate techniques of postpartum blood loss measurement. Secondly, hospitals need blood banks to manage patients with severe hemorrhage.

Assessment of Accessibility and Quality of Emergency Obstetric Care services: A cross sectional study in rural Varanasi

Background: Emergency Obstetrics care is an integrated strategy developed by the WHO, UNFPA and UNICEF that aims to equip health facilities with the capacity to provide evidence based, cost effective interventions to attend the leading causes of maternal mortality. Methods: A community based cross sectional study was conducted between April 2019 - July 2020. A total of 201 women who delivered in the last 6 months and had complications during their pregnancy were interviewed to find out accessibility and quality emergency obstetric Care (EmOC) services. Facility assessment was also done at two health facilities of Chiraigaon block for the assessment EmOC. Results: Findings show that only 41.8% respondents were able to reach the government health facilities in less than half-an-hour. Out of the total respondents who utilized government health facilities for EmOC, only 19% were attended by the health providers within 1 hour. Conclusion: Low percentage of respondents with complications were reaching the health facility within 30 minutes. Therefore, there is a strong need for strengthening of basic EmOC services at health facilities .

Health facility capacity to provide postabortion care in Afghanistan: a cross-sectional study

BackgroundAfghanistan has one of the highest burdens of maternal mortality in the world, estimated at 638 deaths per 100,000 live births in 2017. Infections, obstetric hemorrhage, and unsafe abortion are the three leading causes of maternal death. Contraceptive prevalence rate has fluctuated between 10 and 20% since 2006. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment evaluated facility readiness to provide quality routine and emergency obstetric and newborn care, including postabortion care services.MethodsAccessible public health facilities with at least five births per day (n = 77), a nationally representative sample of public health facilities with fewer than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Assessment components examining postabortion care included a facility inventory and record review tool to verify drug, supply, equipment, and facility record availability, and an interview tool to collect information on skilled birth attendants’ knowledge and perceptions.ResultsMost facilities had supplies, equipment, and drugs to manage postabortion care, including family planning counseling and services provision. At public facilities, 36% of skilled birth attendants asked to name essential actions to address abortion complications mentioned manual vacuum aspiration (23% at private facilities); fewer than one-quarter mentioned counseling. When asked what information should be given to postabortion clients, 73% described family planning counseling need (70% at private facilities). Nearly all high-volume public health facilities with an average of five or more births per day and less than 5% of low volume public health facilities with an average of 0–4 deliveries per day reported removal of retained products of conception in the past 3 months. Among the 77 high volume facilities assessed, 58 (75%) reported using misoprostol for removal of retained products of conception, 59 (77%) reported using manual vacuum aspiration, and 67 (87%) reported using dilation and curettage.ConclusionsThis study provides evidence that there is room for improvement in postabortion care services provision in Afghanistan health facilities including post abortion family planning. Access to high-quality postabortion care needs additional investments to improve providers’ knowledge and practice, availability of supplies and equipment.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border.

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick’s framework for assessment of education effectiveness included: qualitative data on participants’ reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick’s framework for assessment of education effectiveness included: qualitative data on participants’ reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

Performance Measurement of Comprehensive Emergency Neonatal Obstetric Servant (PONEK) in Dr. Moh. Hoesin Palembang with a Balanced Scorecard to Improve the Quality of Midwifery Services

A B S T R A C TIntroduction Maternal Mortality Rate (MMR) and Neonatal Mortality Rate (IMR)in Indonesia are the highest among ASEAN countries, namely 307 / 100.000 livebirths for MMR and 20/1000 live births for IMR. This situation can actually beprevented through early detection approaches and appropriate management ofmothers and babies through the Comprehensive Obstetric Neonatal EmergencyServices (PONEK) program as one of the important elements of good hospitalservice performance. The performance of a hospital is of course determined by theperformance of each unit and team which requires relevant multi-dimensionalmeasurement standards. Basic Score Card (BSC) is a method developed byKaplan and Norton (1996) to measure performance comprehensively, so it ishoped that this method can help improve the quality of obstetric emergencyservices, especially in Palembang. Methods: This descriptive analytic study wasconducted at Dr. Mohammad Hoesin (RSMH) Palembang by looking for factorsthat affect the quality of emergency obstetric care and analyzing the performanceof the PONEK team in providing PONEK services. Primary data is obtainedthrough questionnaires with direct interviews with respondents or by directobservation in the field to see the real obstacles that occur during service. Thedata were analyzed qualitatively and quantitatively. Results: During the periodOctober 2014 - March 2015 there were 1219 total hospitalized patients. Based onthe Financial Perspective, the effectiveness ratio for achieving the performance ofthe RSMH PONEK team still meets the target of 1.3 for vaginal and has not metthe target of 0.5 for SC with a financial perspective score of +2. Based on theCustomer Perspective, the total score is +2 with the patient satisfaction index is5957 (satisfied) and the Gross Death Rate (GDR) figure for PONEK RSMH servicesis 14 (meets GDS MOH standards). Based on the Internal Business Perspectivethe total score is +1, with the level of compliance with the clinical pathwaystandard = 92%, the level of compliance for the National Fornas PONEK = 100%,while the response time is &gt; 1 hour. Based on the perspective of learning andgrowth, the total score = +1, with the number of PONEK trained personnel &lt;50%,neonatal resuscitation and lactation management &lt;10%, employee workmotivation is very high, and facilities and infrastructure are classified as good.Based on these four perspectives, the BSC score for RSMH PONEK performanceis +0.6 with an interval scale of -1 to +1. Conclusion: Based on the BSCmeasurement results of the PONEK team at RSMH Palembang, it can beconcluded that the PONEK team's performance is good.

The influence of travel time to health facilities on stillbirths: A geospatial case-control analysis of facility-based data in Gombe, Nigeria.

Access to quality emergency obstetric and newborn care (EmONC); having a skilled attendant at birth (SBA); adequate antenatal care; and efficient referral systems are considered the most effective interventions in preventing stillbirths. We determined the influence of travel time from mother's area of residence to a tertiary health facility where women sought care on the likelihood of delivering a stillbirth. We carried out a prospective matched case-control study between 1st January 2019 and 31st December 2019 at the Federal Teaching Hospital Gombe (FTHG), Nigeria. All women who experienced a stillbirth after hospital admission during the study period were included as cases while controls were consecutive age-matched (ratio 1:1) women who experienced a live birth. We modelled travel time to health facilities. To determine how travel time to the nearest health facility and the FTHG were predictive of the likelihood of stillbirths, we fitted a conditional logistic regression model. A total of 318 women, including 159 who had stillborn babies (cases) and 159 age-matched women who had live births (controls) were included. We did not observe any significant difference in the mean travel time to the nearest government health facility for women who had experienced a stillbirth compared to those who had a live birth [9.3 mins (SD 7.3, 11.2) vs 6.9 mins (SD 5.1, 8.7) respectively, p = 0.077]. However, women who experienced a stillbirth had twice the mean travel time of women who had a live birth (26.3 vs 14.5 mins) when measured from their area of residence to the FTHG where deliveries occurred. Women who lived farther than 60 minutes were 12 times more likely of having a stillborn [OR = 12 (1.8, 24.3), p = 0.011] compared to those who lived within 15 minutes travel time to the FTHG. We have shown for the first time, the influence of travel time to a major tertiary referral health facility on the occurrence of stillbirths in an urban city in, northeast Nigeria.

Perceptions of midwives on the quality of emergency obstetric care at hospitals in Ethiopia: A qualitative explanatory study

BackgroundIn Ethiopia, maternal mortality remains an important public health concern. High maternal mortality is attributed in part to the poor quality of obstetric care. This study was designed to investigate perceptions of midwives about the quality of emergency obstetric care provided at hospitals in the Harari region of Ethiopia. MethodsAn explanatory qualitative study was conducted from December 2018 to February 2019 at public and private hospitals in the Harari region, Ethiopia. The data were obtained through in-depth interviews with 12 midwives working in maternity units. The interviewers took notes and audio-recorded the respondents’ descriptions. Braun and Clarke's thematic analysis method was employed to analyse the data using Nvivo 12 qualitative data analysis software. ResultsPoorly designed infrastructure, including a scarcity of beds, rooms and ambulances challenged the provision of quality obstetric services. Midwives working at hospitals were inadequate in number and training opportunities were scarce. Language barriers affected effective communication between patients and caregivers. Frequent disruptions to medical supplies resulted in the provision of suboptimal obstetric care as it created an inability to provide appropriate medications. A lack of treatment protocols, poor supportive supervision, and poor staff motivation impaired the provision of quality obstetric care at hospitals, although disparities were observed among hospitals in this regard. ConclusionsSeveral interdependent factors limited the quality of emergency obstetric care at hospitals in the region. Quality improvement initiatives and equitable resource distribution for hospitals need to be enhanced while the existing health infrastructure, resources and service delivery management need to be strengthened.

Perceived Causes of Obstetric Fistula and Predictors of Treatment Seeking among Ugandan Women: Insights from Qualitative Research.

Many obstetric fistula patients remain untreated or present late to treatment despite increasing surgical availability in Uga nda. We explored women's perceptions of the cause of their obstetric fistula and their treatment seeking behaviours, including barriers and facilitators to timely care access. In-depth interviews and focus group discussions were conducted from June-August 2014 among 33 women treated for obstetric fistula at Mulago Hospital, Kampala. Data were analysed to describe dimensions and commonalities of themes identified under perceived causes and treatment seeking experiences, and their intersection. Perceived obstetric fistula causes included delays in deciding on hospital delivery, lengthy labour, injury caused by the baby, health worker incompetence, and traditional beliefs. Treatment seeking timing varied. Early treatment seeking was facilitated by awareness of treatment availability through referral, the media, community members, and support by partners and children. Barriers to early treatment seeking included inadequate financial and social support, erroneous perceptions about fistula causes and curability, incorrect diagnoses, and delayed or lack of care at health facilities. Our study supports broad educational and awareness activities, facilitation of social and financial support for accessing care, and improving the quality of emergency obstetric care and fistula treatment surgical capacity to reduce women's suffering.

Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study

Background: In India, emergency obstetric care (EmOC) services were started under RCH-II program (2004) with the goal to reduce maternal mortality ratio <100/lakh live births and increase institutional deliveries to at least 80% by 2010. Implemented strategy was to enhance availability and accesses to EmOC services. Objective: This study was conducted in one of the blocks of Wardha district in Maharashtra to understand the accessibility for providing EmOC services at primary health center and rural hospital in the last 1 year. Materials and Methods: This cross-sectional qualitative study was conducted from May 2018 to October 2018. Data were collected by key informant interviews of service providers. Notes were transcribed and then translated into English. Respondents' verbatim that is significant and illustrative as per the theme of the study was used for analysis. Results: Equipment and drugs essential for EmOC were available; however, most of these were underutilized due to lack of skill in selected facilities. Basic EmOC training pattern was found inadequate in duration and practical skill. Training and recruitment of staff constantly were observed challenging for higher stakeholders. Of all EmOC signal functions, only parental antibiotics, oxytocics, and assisted vaginal delivery (episiotomy) were provided. Conclusion: Although building infrastructure, drugs, equipment, and transportation facilities were accessible, needy women may fail to receive timely and quality EmOC, due to lack of trained staff, low confidence, and lack of motivation in managing obstetric emergencies.

Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms

BackgroundThe Demographic and Health Survey 2013–14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC.MethodsA cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson’s chi-squared test using an alpha significance level of 0.05.ResultsA total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines.ConclusionsThe distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.