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Purpose: This paper focuses attention on declining rates of instrumental (vacuum or forceps) delivery. The decline often means that women must travel further to deliver in hospitals with capacity for cesarean delivery.Background: The paper illustrates recent trends in the use of vacuum extraction and forceps in low- and high-income countries. It describes some of the obstacles to the use of instrumental delivery and why the techniques, especially vacuum extraction, should be reintroduced. Over the past two decades, many countries have observed a decline in instrumental delivery rates while cesarean rates have increased. Objections to instrumental delivery are largely due to the potential harm it causes newborns. Some medical schools no longer train their professionals to perform instrumental delivery. Elsewhere, only specialists are permitted to perform the procedures.Methods and Results: As this is a policy paper rather than a research report, the methods and results sections are not applicable.Conclusions: Vacuum extraction can be taught to midlevel practitioners (midwives, nurse practitioners and general physicians), thereby increasing access to emergency obstetric care especially at the periphery. This allows women to give birth closer to home in midlevel facilities when hospitals are not easily accessible or are overcrowded. Where instrumental and cesarean delivery are both available, instrumental delivery could potentially reduce the risks associated with cesarean delivery and reduce the costs of obstetric care. [ABSTRACT FROM AUTHOR]

Introduction: As countries are designing and implementing strategies to address maternal and newborn mortality and morbidity (Millennium Development Goals 5 and 4), it appears that a large number of evidence-based obstetric practices are not used in many settings, and this is a major obstacle to the improvement of quality obstetric care.Objectives: To remind readers of the existing, relatively easy-to-implement, evidence-based interventions that are currently not being universally applied in obstetric care and, second, to foster research to expand the evidence base further for obstetric care practices and devices, especially those that could be used in resource-poor settings.Methods: We review possible reasons why changes into practices are difficult to obtain, and we list the key evidence-based interventions known to effectively deal with the main obstetric complications, with supporting references and sources of documentation. We also list some promising interventions that require more research before being recommended.Conclusion: Professionals and health services managers have a crucial role in producing the best quality obstetric and neonatal care through implementing the listed evidence-based interventions and make them accessible to all pregnant women and their newborns without delay, even in poor settings. Reasons for which progress is slow should be addressed. One of these reasons being the lack of access to scientific knowledge from the part of professionals in developing countries, we give the key references and also websites which are freely accessible through the Internet. It is hoped that this paper will stimulate the discussion on the dissemination and use of good obstetric practices, and contribute to better maternal and newborn health. [ABSTRACT FROM AUTHOR]

Objective: This paper examines the frequency with which a set of life-saving interventions or signal functions was performed to treat major obstetric complications.Methods and Results: The basic signal functions include parenteral antibiotics, anticonvulsants and oxytocics, and the procedures of manual removal of the placenta, removal of retained uterine products, and assisted vaginal delivery. Comprehensive functions include the six basic functions, cesarean delivery, and blood transfusions. Data from 1906 health facilities in 13 countries indicate that the most likely functions to be reported are oxytocics and antibiotics. The basic function least likely to be reported is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure to perform operations or provide blood transfusions.Conclusions: These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur. [ABSTRACT FROM AUTHOR]

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross-country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy. [ABSTRACT FROM AUTHOR]

Objective: Save the Children/USA and the Ministry of Health of Vietnam undertook a project between 2001 and 2004 to improve the availability of, access to, quality and utilization of emergency obstetric care (EmOC) services at district and provincial hospitals in two provinces in Vietnam.Methods: The project improved the functional capacity of 3 provincial and 1 district hospitals providing comprehensive EmOC services, and upgraded 1 district hospital providing basic EmOC into a comprehensive EmOC facility through training, infrastructure and quality improvement.Results: Data presented in this paper focus on only the 2 district hospitals even though the UN process indicators showed increases in utilization of EmOC in all 5 hospitals. In the case of Hai Lang, the proportion of births increased from 13% at baseline to 31% at the end of 2004, and met need increased significantly from 16% to 87% largely due to increased capacity of the hospital and staff. Met need in Hoang Hoa hospital more than doubled (17% at baseline versus 54% in 2004) and the proportion of births increased slightly from 19% in 2001 to 22% in 2004. Case fatality rates for the two hospitals remarkably remained at zero. Lessons from this project have been incorporated into national policy and guidelines.Conclusion: Improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth can be realized in a relatively short period of time and is an essential element in reducing maternal mortality. [ABSTRACT FROM AUTHOR]

Objective: The paper reviews the experience with the EmOC process indicators, and evaluates whether the indicators serve the purposes for which they were originally created - to gather and interpret relatively accessible data to design and implement EmOC service programs.Method: We review experience with each of the 6 process indicators individually, and monitoring change over time, at the level of the facility and at the level of a region or country. We identify problems encountered in the field with data collection and interpretation.Result: While they have strengths and weaknesses, the process indicators in general serve the purposes for which they were developed. The data are easily collected, but some data problems were identified. We recommend several relatively minor modifications to improve data collection, interpretation and utility.Conclusions: The EmOC process indicators have been used successfully in a wide variety of settings. They describe vital elements of the health system and how well that system is functioning for women at risk of dying from major obstetric complications. [ABSTRACT FROM AUTHOR]

Abstract: Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003. [Copyright &y& Elsevier]

Objective: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC.Methods and Results: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential.Conclusion: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries. [ABSTRACT FROM AUTHOR]

Objective: This paper argues for an additional indicator for measuring progress of the Millennium Development Goal for maternal health-the availability of emergency obstetric care.Methods: MDG monitoring will be based on two indicators: the maternal mortality ratio and the proportion of births attended by skilled personnel. Strengths and weaknesses of a third indicator are discussedResults: The availability of EmOC measures the capacity of the health system to respond to direct obstetric complications. Benefits to using this additional indicator are its usefulness in determining an adequate distribution of services and showing management at all levels what life-saving interventions are not being provided, and stimulate thought as to why. It can reflect programmatic changes over a relatively short period of time and data requirements are not onerous.Conclusion: A measure of strength of the health system is important since many interventions depend on the health system for their implementation. [ABSTRACT FROM AUTHOR]

Objectives: The study documented facility-based obstetric practices for normal labor in Egypt for the first time, to determine their relationship to evidence-based medicine. This paper describes the labor augmentation pattern observed.Methods: 176 cases of normal labor were observed by medically-trained observers using a checklist. Ward activities were also documented. Observed women were interviewed postpartum and all findings were shared with the providers for their feedback.Results: Labor was augmented in 91% (165) of the labors observed; this was inappropriate for 93% or 154 women. Reasons for inappropriateness were: oxytocin ordered at the first vaginal exam (41%); in spite of intact membranes (36%), at the time of membrane rupture (42%), in spite of good progress (24%), or a combination of these. The monitoring of oxytocin-receiving women and their babies was inadequate.Conclusions: Labor augmentation and monitoring deviated from evidence-based guidelines. Obstacles to implementing protocols need to be explored. [ABSTRACT FROM AUTHOR]

The death of hundreds of thousands of women due to pregnancy-related complications casts a shadow over the modern obstetrical world. This paper examines the potential roles and responsibilities of professional obstetrical and midwifery associations in addressing this tolerated tragedy of maternal deaths. We examine the successes and challenges of obstetrical and midwifery associations and encourage the growth and development of active associations to address maternal mortality within their own borders. Professional associations can play a vital role in the reduction of maternal mortality worldwide. Their roles include lobbying for women''s health and rights, setting standards of practice, raising awareness and team building. Associations from developed countries can influence and strengthen their colleagues within developing countries; for example, the FIGO Save the Mothers initiative. Professional associations should be encouraged to play an active role in reducing maternal mortality within their own country and abroad. [Copyright &y& Elsevier]

Abstract: Access to Emergency obstetric care (EmOC) remains a challenge for women. This paper presents a summary of issues and suggestions from one of the working groups at the FIGO precongress workshop on access of sexual and reproductive health care in November, 2006, in Kuala Lumpur. [Copyright &y& Elsevier]

Abstract: Background: The present paper describes the implementation of a novel, web-based, comprehensive national information hub for trainees in obstetrics and gynecology in Ireland. This was a unique development in the context of an entire medical specialty and was aligned with the communication strategy of the governing professional body. To date, trainee doctors working in Ireland undergo an incoherent and inconsistent new-staff induction and handover. In the healthcare setting, staff integration can have a major impact on the quality of patient care. Methods: A free wiki software platform (PBworks) was used for the website, and freely available software (Google Analytics) was used to determine user interaction and level of engagement. Results: In the first year, 442 user visits were recorded. The average duration of site visits was 4minutes 39seconds, which compared favorably with the 4-minute duration for visits to Wikipedia. Conclusion: The project was successful as a proof concept and in practice. Other medical faculties have expressed an interest in adopting the concept and developing it for their trainees. The concept is widely applicable to other countries, with the negligible cost relevant to resource-poor areas. [Copyright &y& Elsevier]

Abstract: Obstetric fistula is a complication of childbirth that often follows obstructed labor and is almost exclusive to low-resource countries. The original Global Burden of Disease Study (GBD 1990 Study) reported an incidence of 8.68 per 100000 and a prevalence of 51.35 per 100 000 for women aged 15–44years in low-resource regions. The most cited global prevalence estimate is 2 million women. Although the global burden of obstetric fistula remains unclear, the number of women suffering from the condition is increasing, while surgical treatment remains limited. There are few experienced fistula surgeons and past surgical training approaches have been inconsistent. The Global Competency-Based Fistula Surgery Training Manual developed by FIGO and partners contains a set curriculum and, to ensure its implementation, a global strategy and training program have been developed. This paper describes key elements of the training program and its implementation. The anticipated impact of the training program is a reduction in global morbidity caused by obstetric fistula. [Copyright &y& Elsevier]

Abstract: Reducing maternal mortality within significant margins is a global imperative that reflects attainment of development goals. Progress in reducing maternal mortality, in particular among countries with notably high maternal mortality ratios (MMRs), has been substantially slower than the Millennium Development Goal target of an annual rate of 5.5% decline. The latest UN maternal mortality estimates show a reduction in MMR in a number of countries between 1990 and 2008. Understanding the factors associated with progress in countries that have reduced maternal mortality provides other countries and development partners with opportunities to consider and implement policies and interventions that could help accelerate progress. This paper reviews 6 countries that have demonstrated marked progress. The policies that have been effective include innovative financing measures; investment in human resources both in terms of strengthening pre-service education and emphasizing in-service training for healthcare providers; strengthening obstetric care by enhancing infrastructure and upgrading equipment, as well as improving quality of services; and investing in the broader determinants of maternal mortality, particularly family planning and women''s education and socioeconomic empowerment. This range of actions, which includes a combination of facility and community-based approaches, provides a list of potentially effective strategies that could be considered when developing programs in other countries with slower progress. Strong political will and multistakeholder involvement and interventions are key in the development and implementation of these policies and actions. [Copyright &y& Elsevier]

This short paper describes some early findings from an overview of the maternal death or severe morbidity “near-miss” reviews that have been undertaken to improve clinical care by the eight societies participating in the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health aimed at strengthening the role of professional obstetric associations. While it is expected that each will publish its own report, generalizable lessons emerged and valuable solutions were implemented that will help others planning such reviews and audits in future. [ABSTRACT FROM AUTHOR]

The global burden of complications from unsafe abortion is thought to be high, but difficult to measure. A systematic review was conducted to describe the prevalence and type of complications of abortion among women hospitalized for treatment of abortion complications in settings where abortion is generally considered unsafe. There were 43 hospital-based studies reporting on severity and type of complications of abortions, but definitions varied substantially. The proportion of women treated in facilities for severe complications ranged from a median of 1.6% (range, 0.1%-10.8%) for renal failure to 7.2% (range, 0.1%-43.9%) for severe trauma. Heterogeneity of study designs and definitions makes comparisons difficult. Therefore, it is recommended that standardized designs and definitions are used in future studies of abortion complications. © 2012 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. [ABSTRACT FROM AUTHOR]

Background: Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped.Objectives: A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa.Search Strategy: MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa.Results: Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better.Conclusion: Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5. [ABSTRACT FROM AUTHOR]

Objective: To describe our experience of a complex training intervention to introduce effective perinatal care, evidence-based medicine, national confidential enquiries into maternal deaths, and facility-based near-miss case reviews in the Central Asian Republics.Methods: We describe our experiences from training sessions and report on findings from data extraction from patient records, patient interviews, discussions with healthcare staff, and observation of health care during our follow-up visits.Results: Many outdated practices in perinatal care have been abandoned, and several recommended approaches have been adopted in pilot facilities. Familiarity with the concept of evidence-based medicine has increased among participants. National confidential enquiries into maternal deaths are being prepared and facility-based near-miss case reviews piloted.Conclusion: The experience of the complex training intervention to improve maternal and perinatal health care in the Central Asian Republics is encouraging, but roll-out will be challenging. The quality of care and the attitudes of healthcare providers will have to be monitored continuously. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of an instructional DVD on the anatomy and repair of anal sphincter lacerations to improve postgraduate trainees' understanding.Methods: A total of 71 obstetrics and gynecology trainees completed a pretest of third- and fourth-degree lacerations to assess baseline knowledge and perceptions. Question categories included anatomy, antibiotics, anesthesia, repair methods, complications, postoperative care, and risk factors. After 1 year of clinical experience, 67 trainees (94%) were randomly assigned into DVD (intervention) and non-DVD (control) groups. A post-test was administered 4 weeks later.Results: In the DVD group (n=34), mean scores on the pretest versus the post-test were 65% vs 74% for postgraduate year (PGY)-1 (P=0.09); 72% vs 83% for PGY-2 (P=0.06); 67% vs 83% for PGY-3 (P=0.01); and 75% vs 87% for PGY-4 (P<0.001). In the non-DVD group (n=33), mean scores did not change significantly for any year level. The increase in score from pretest to post-test was significantly different between the 2 groups, independent of year (P<0.001). DVD group scores improved significantly over non-DVD group scores in anatomy (P=0.005) and repair methods (P=0.042) subscales.Conclusion: An educational video is an effective tool for improving understanding of third- and fourth-degree lacerations for physicians-in-training. [ABSTRACT FROM AUTHOR]

Objective: To assess the worldwide availability of misoprostol. Documenting the extent of misoprostol use in obstetrics-gynecology is difficult because the drug typically is unregistered for such indications.Methods: Data for 2002-2007 on annual sales (measured in weight) to hospitals and retail pharmacies, plus manufacturer prices per 200-microg misoprostol, were analyzed for medications containing misoprostol alone or combined with a nonsteroidal anti-inflammatory drug (NSAID); regional and country-specific trends were identified. Consumer prices per pill are documented for all formulations of registered medications.Results: Of the misoprostol sold worldwide, 70% was misoprostol-NSAID-combination drugs; of this, 91% was sold in North America and Western Europe. Asia sold the most misoprostol-only drugs; sales increased dramatically in Bangladesh (by 128%) and India (646%), where various low-price brands are sold. Misoprostol sales decreased in Latin America but increased in the Middle East-North Africa and Sub-Saharan Africa; these regions generally had low amounts sold per population.Conclusion: Availability is improving in some low-income regions where misoprostol could significantly reduce maternal deaths due to postpartum hemorrhage and unsafe abortion. [ABSTRACT FROM AUTHOR]

Objective: To investigate the use of beneficial maternal and perinatal healthcare practices in a network of public maternity hospitals in Argentina.Method: A multicenter, prospective, descriptive study of 6661 deliveries in 9 hospitals. The use of 5 obstetric care practices that reduce maternal and perinatal morbidity and mortality was evaluated.Results: Median use rates for the selected practices were: continuous support for women during childbirth (17.9%); corticosteroids for preterm birth (35.3%); avoidance of episiotomy in primiparous women (41.2%); iron and folate supplementation (52.5%); active management of third stage of labor (93.5%).Conclusion: There is limited use of the selected evidence-based maternal and perinatal practices in public hospitals in Argentina and a large variation in their use among and within hospitals. Efforts should be made to increase the use of these evidence-based practices. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether motorcycle ambulances placed at rural health centers are a more effective method of reducing referral delay for obstetric emergencies than a car ambulance at the district hospital, and to compare investment and operating costs with those of a 4 wheel drive car ambulance at the district hospital.Methods: Motorcycle ambulances were placed at 3 remote rural health centers in Malawi. Data were collected over a 1-year period, from October 2001 to September 2002, using logbooks, cashbooks, referral forms, and maternity registers.Results: Depending on the site, median referral delay was reduced by 2-4.5 hours (35%-76%). Purchase price of a motorcycle ambulance was 19 times cheaper than for a car ambulance. Annual operating costs were US dollars 508, which was almost 24 times cheaper than for a car ambulance.Conclusions: In resource-poor countries motorcycle ambulances at rural health centers are a useful means of referral for emergency obstetric care and a relatively cheap option for the health sector. [ABSTRACT FROM AUTHOR]

Abstract: The rates of HIV infection among women are rising at a higher rate than among men. After citing the reasons for women''s vulnerability, this report argues the potential role of gynecologists and obstetricians through integration of HIV/AIDS into sexual and reproductive health services to strengthen the response to the epidemic. [Copyright &y& Elsevier]

Background: In view of the disappointing progress made in the last 20 years in reducing maternal mortality in low-income countries and before going to scale in implementing the new evidence-based strategies, it is crucial to review and assess the progress made in pilot countries where maternal mortality reduction programs focused on emergency obstetric care.Objective: To review the process indicators recommended for monitoring emergency obstetric care and their application in field situations, examining the conditions under which they can be used to assess the progress of maternal mortality reduction programs.Methods: Five of the six UN recommended process indicators were monitored annually for 5 years in selected districts of Morocco, Mozambique, India and Nicaragua. Trends are presented and discussed.Results: With specific variations due to different local situations in the four countries and in spite of variations in quality of data collection, all indicators showed a consistent positive trend, in response to the inputs of the programs.Conclusions: The UN process indicators for emergency obstetric care should continue to be promoted, but with two important conditions: (1) data collection is carefully checked for quality and coverage; (2) efforts are made to match process and outcome indicators (maternal and perinatal mortality, incidence of complications). [ABSTRACT FROM AUTHOR]

Purpose: The Dinajpur SafeMother Initiative (DSI) was designed to test the impact of several interventions on use of obstetric services in government health facilities in Northwestern Bangladesh during 1998-2001.Intervention: Facility-based interventions included upgrading health facilities. The sub-district hospitals or Upazila Health Centers (UHCs) had earlier been upgraded to provide basic emergency obstetric care (BEmOC). This project undertook activities designed to improved the quality of care in the facilities which included team-building among providers, case reviews and a stakeholders' committee. CARE introduced a community mobilization intervention, which included birth planning, community support systems for funding, transportation, blood donation etc. for care of women with complications.Methods: The intervention area received all interventions. The only intervention in the comparison area was the upgrading of the health facilities to provide basic EmOC. There were no interventions in the control area.Results: Met need increased by 13% in comparison area but nearly 24% in intervention area. There was no substantial change in the control area. At the end of the project, knowledge of obstetric danger signs was much greater in intervention area than in the other 2 areas.Conclusion: We conclude, therefore, that the best results are achieved through a combination of facility improvement, quality of care activities and targeted community mobilization activities. [ABSTRACT FROM AUTHOR]

Objective: The Government of Bangladesh has implemented safe motherhood programs throughout the country supported by the United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) aimed at reducing maternal morbidity and mortality. The objective of this study is to assess the effect of the interventions on the UN emergency obstetric care (EmOC) process indicators in Khulna division, Bangladesh.Methods: Of the 71 government health facilities in Khulna division, 32 were providing comprehensive and 20 were providing basic EmOC services. Another 4 facilities were providing comprehensive or basic EmOC services during the first three-quarters but became non-functional during the last quarter. EmOC data, from January to December 2002, were collected from all these 56 facilities to determine the levels of EmOC process indicators relative to the UN guidelines and compared with baseline data from 1998 to 1999.Results: There were 1.04 and 0.64 comprehensive and basic EmOC facilities respectively per 500,000 population. When compared with the baseline data, the coverage of comprehensive EmOC services was substantially increased from 0.23 to 1.04 per 500,000 population, which achieves the minimum UN standards but the coverage of basic EmOC services remained the same. The data also showed that, compared with the baseline survey, the proportion of births at the EmOC facilities increased 119% from 5.3% to 11.7% (p<0.001), met need increased 141% from 11.1% to 26.6% (p<0.001), and cesarean section as a proportion of all expected births, increased 151% from 0.5% to 1.3% (p<0.001), while the overall case fatality rate (CFR) decreased by 51% (p<0.001).Conclusion: With the exception of coverage of basic EmOC after the interventions, there was significant improvement in all the EmOC process indicators in Khulna division. However, most of the process indicators are still far from the minimum recommended UN standards.Recommendations: Efforts should continue to keep the EmOC facilities functional 24/7 while increasing the number of basic EmOC facilities, and improving utilization of services to reach the minimum UN standards. Community mobilization should be directed to understand the danger signs and utilization of services at functional facilities when necessary. Further research to identify the factors influencing utilization of EmOC services and continuous monitoring and periodical assessment of the process indicators are recommended to evaluate the overall situation from time to time. [ABSTRACT FROM AUTHOR]

Objective: To improve the quality of clinical care for women with severe pre-eclampsia.Methods: A criteria-based audit was conducted in a large government hospital in Uganda. Management practices were evaluated against standards developed by an expert panel by retrospectively evaluating 43 case files. Results of the audit were presented, and recommendations developed and implemented. A re-audit was conducted 6 months later.Results: The initial audit showed that most standards were rarely achieved. Reasons were discussed. Guidelines were produced, additional supplies were purchased following a fundraising effort, labor ward procedures were streamlined, and staffing was increased. In the re-audit there were significant improvements in diagnosis, monitoring, and treatment.Conclusion: Criteria-based audit can improve the quality of maternity care in countries with limited resources. [ABSTRACT FROM AUTHOR]

Purpose: To establish a baseline for the availability, utilization, and quality of EmOC, and to help develop an operational strategy based on the findings.Methods: A needs assessment of emergency obstetric care (EmOC) was carried out in 197 health facilities in 19 out of 56 districts in Uganda, covering 38% of the total population.Findings: There were a large number of missing signal functions at health facilities and an urgent need to improve the availability of EmOC.Conclusion: By using the data from the assessment, it was possible to influence national policy through the health sector-wide approach (SWAp) and place EmOC high on the national agenda. A national strategy and roll out plan to strengthen EmOC is now in place. [ABSTRACT FROM AUTHOR]

Objective: To identify, survey and review randomized controlled studies of the use of complementary and alternative medicine (CAM) for obstetric treatment or health promotion.Methods: The MEDLINE database was searched to identify randomized controlled trials of CAM treatment and therapies in obstetrics. Studies examining modalities for treatment or improvement of health status were reviewed.Results: Fifty-four articles assessing a variety of health modalities met the criteria for inclusion. Acupressure and ginger for prenatal nausea and vomiting, moxibustion for version of breech presentation, sterile water injections for back pain relief in labor, and perineal massage to prevent perineal trauma have three or more studies demonstrating beneficial effect. Other interventions have been studied less, and evidence for them is limited.Conclusions: Some CAM interventions have evidence of effectiveness for use in obstetric patients, while others require further investigation before they can be considered for use in practice. [ABSTRACT FROM AUTHOR]

Objective: To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces.Method: Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts (n=19); were randomly selected; all public health facilities providing EmOC services (n=170) were included.Results: The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab.Conclusion: Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality. [ABSTRACT FROM AUTHOR]

Purpose: We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.Methods: We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register.Results: The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality. [ABSTRACT FROM AUTHOR]

In resource-poor countries, substantial sums of money from governments and international donors are used to purchase equipment for health facilities. WHO estimates that 50–80% of such equipment remains non-functional. This article is based on experience from various projects in developing countries in Asia and Africa. The key issues in the purchase, distribution, installation, management and maintenance of equipment for emergency obstetric care (EmOC) services are identified and discussed. Some positive examples are described to show how common equipment management problems are solved. [Copyright &y& Elsevier]

Objective: Our study assesses Pakistani obstetricians knowledge of the prevalence of domestic violence in clinical practice and attitudes towards instituting screening protocols during routine antenatal care.Methods: One hundred obstetricians, all Karachi residents, were randomly drawn from a stratified sampling list taken from membership lists. A structured questionnaire assessing prevalence, attitudes, and beliefs on training and domestic violence screening protocols was administered.Results: Nearly 70% of obstetricians reported that more than 30% of Pakistani women are victims of domestic abuse. Sixty-two obstetricians specified that they had identified a physically abused woman within the past year. Almost half of the respondents were favorably inclined to screen patients. Professional, personal and patient-related barriers were identified as the main hurdles preventing instituting screening.Conclusions: The desire for instituting routine screening despite the recognition of major hurdles by Pakistani obstetricians should propel reproductive health stakeholders to raise awareness about appropriately modifying standard antenatal care protocols. [ABSTRACT FROM AUTHOR]

The objective of this review is to present the findings and lessons learned over the first 4 years (1999–2002) of implementation of postabortion care (PAC) services outside of major urban centers in Nepal, where a significant proportion of services are provided by nurses. The contributions made by a national Safe Motherhood project to the establishment of the National Postabortion Care Program including the promotion of nurse providers within an integrated program of emergency obstetric care services are highlighted. Clinical competency assessments and service utilization data from three district hospital-based postabortion service sites supported by the Nepal Safer Motherhood Project are analyzed. The relationship between the findings of this assessment and two previous assessments, one covering two districts and one nationwide, are discussed. This review found that nurses are at least as competent as physicians in providing postabortion care services. The inclusion of postabortion care into the emergency treatment of obstetric complications provided the environment needed for successful introduction of nurse-led PAC services. Competency-based training of nurse providers is the key to making life-saving postabortion care services accessible and affordable in Nepal. Ensuring that these nurse providers are able to implement services requires strategic planning, careful advocacy and support from physician colleagues as well as the presence of adequate infrastructure and equipment. The successful introduction of postabortion care services into three district hospitals also offering emergency obstetric care provides an example of how a nurse-led service can be integrated into an emergency obstetric care support project. The project''s learning has influenced national policy on the expansion of the postabortion care program throughout Nepal. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]