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Abstract: This paper aims to highlight the importance of aspiring to achieve universal reporting of maternal deaths as a part of taking responsibility for these avoidable tragedies. The paper first discusses the reasons for reporting maternal deaths, distinguishing between individual case notification and aggregate statistics. This is followed by a summary of the status of reporting at national and international levels, as well as major barriers and facilitators to this process. A new framework is then proposed — the REPORT framework, designed to highlight six factors essential to universal reporting. Malaysia is used to illustrate the relevance of these factors. Finally, the paper makes a Call to Action by FIGO to promote REPORT and to encourage health professionals to play their part in improving the quality of reporting on all maternal deaths — not just those directly in their care. [Copyright &y& Elsevier]

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]

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]

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: Introduction: Worldwide, 13% of maternal deaths are caused by complications of spontaneous or induced abortion, 29% in Uruguay and nearly half (48%) in the Pereira Rossell Hospital. Purpose: This paper describes a risk reduction strategy for unsafe abortions in Montevideo, Uruguay, where over one-fourth of maternal deaths are caused by unsafe abortion. Methods: Although abortion is not legal in Uruguay, women desiring abortions can be counseled before and immediately after to reduce the risk of injury. Women contemplating abortion were invited to attend a “before-abortion” and an “after-abortion” visit at a reproductive health polyclinic. At the “before-abortion” visit, gestational age, condition of the fetus and pathologies were diagnosed and the risks associated with the use of different abortion methods (based on the best available scientific evidence) were described. The “after-abortion” visit allowed for checking for possible complications and offering contraception. Results: From March 2004 through June 2005, 675 women attended the “before-abortion” and 495 the “after-abortion” visit, the number increasing over time. Some women (3.5%) decided not to abort, others were either not pregnant, the fetus/embryo was dead or the woman had a condition that permitted legal termination of pregnancy in the hospital (7.5%). Most women, however, aborted. All women used vaginal misoprostol in the doses recommended in the medical literature. There were no serious complications (one mild infection and two hemorrhages not requiring transfusion). Conclusion: The strategy is effective in reducing unsafe abortions and their health consequences. [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]

The aim of this paper is to describe different approaches to make emergency obstetric care (EmOC) accessible to women in Mozambique. The definitions of basic (BEmOC) and comprehensive EmOC (CEmOC), proposed by the UN agencies, were adopted by FIGO and by the Mozambican Ministry of Health as a general strategy to reduce maternal mortality. Four projects are presented: (1) Jose´ Macamo and (2) Mavalane Hospitals in Maputo city, (3) Manhic¸a District in Maputo Province and (4) Sofala Province. Jose´ Macamo was staffed by physicians 24 h a day; other hospitals by non-physicians trained in surgical and anesthesiology techniques, as well as nurse-midwives. Jose´ Macamo Hospital provided CEmOC to the city of Maputo and the southern area of Maputo Province. In 2001, this hospital attended 32% of deliveries and 38% of cesarean sections in the city, up from 14 and 2.5%, respectively, in 1998. The Mavalane Hospital failed to provide CEmOC; however, the number of deliveries per year almost doubled. The Manhic¸a hospital carried out 31% of the District's C-sections in 2001, up from 9% in 1998. In Sofala Province, one additional CEmOC and four BEmOCs were installed and case fatality rates decreased. In conclusion, the strategy for ensuring provision of EmOC is feasible even in countries with minimal resources and a scarcity of physicians, such as Mozambique. [Copyright &y& Elsevier]

Objectives: To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia.Methods: The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008.Results: Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively.Conclusion: Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion. [ABSTRACT FROM AUTHOR]

Objectives: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services.Methods: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities.Results: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2 hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions.Conclusions: GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services. [ABSTRACT FROM AUTHOR]

Objective: To analyze the data available on obstetric complications, maternal deaths, and types of admission in 7 tertiary maternity centers in Cameroon.Methods: A descriptive retrospective study of all obstetric complications and maternal deaths that occurred in 7 tertiary level maternity hospitals between January 2005 and December 2006. Data were collected using the same registers, file records, and standardized questionnaires.Results: During the study period there were 34898 deliveries and 4069 cesareans were performed. There were 11014 obstetric complications and 249 maternal deaths were recorded, giving an MMR of 713 per 100000 deliveries. The risk of mortality among women referred to the tertiary level facilities was higher compared with women who were directly admitted to the facilities (odds ratio 3; 95% CI, 2.2-4.0).Conclusion: The high rates of maternal mortality recorded in tertiary maternity centers among women who were referred reveal the urgent need for interventions to improve the referral system. [ABSTRACT FROM AUTHOR]

Objective: To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia.Methods: The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia.Results: Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers.Conclusion: The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services. [ABSTRACT FROM AUTHOR]

Objective: To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia.Methods: All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths-and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices.Results: Too few facilities provided EmONC to meet the UN standards of 5 per 500,000 population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related).Conclusion: None of the indicators met UN standards. Ethiopia faces many challenges--not least geography--with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions. [ABSTRACT FROM AUTHOR]

Objective: To investigate the efficacy of oral nucleosides in preventing hepatic failure during pregnancy (HFP) caused by hepatitis B virus (HBV) infection.Methods: Besides receiving standard treatment, 70 women with HFP caused by HBV infection joined a study group (n = 40) or a control group (n = 30) according to their preference. In the study group, 14 women were given lamivudine in the third trimester and an antiviral treatment was continued postpartum. The 26 remaining patients were treated postpartum only, with lamivudine (n = 16) or entecavir (n = 10).Results: In the study group, the values for serum HBV DNA and hepatitis B envelope antigen were markedly lower at 1 and 2 months than they were at baseline (P < 0.001 and P < 0.001, respectively). Moreover, the HBV DNA values at 1 and 2 months were significantly lower in the study than in the control group (P < 0.05). Overall mortality and incidence of intrauterine infection were also significantly lower in the study group (P < 0.05). No newborns had any apparent abnormalities in either group.Conclusion: Treatment with nucleosides suppressed the replication of HBV DNA and led to biochemical improvement. It also reduced maternal mortality and safely decreased mother-to-child HBV transmission. [ABSTRACT FROM AUTHOR]

Objective: To review the use of evidence-based practices in the care of mothers who died or had severe morbidity attending public hospitals in two Latin American countries.Methods: This study is part of a multicenter intervention to increase the use of evidence-based obstetric practice. Data on maternal deaths and women admitted to intensive care units whose deliveries occurred in 24 hospitals in Argentina and Uruguay were analyzed. Primary outcomes were use rates of effective interventions to reduce maternal mortality (MM) and severe maternal morbidity (SMM).Results: A total of 106 women were included: 26 maternal deaths and 80 women with SMM. Some effective interventions for severe acute hemorrhage had a high use rate, such as blood transfusion (91%) and timely cesarean delivery (75%), while active management of the third stage of labor (25%) showed a lower rate. The overall use rate of effective interventions was 58% (95% CI, 49%-67%). This implies that 42% of the women did not receive one of the effective interventions to reduce MM and SMM.Conclusion: This study shows a low use of effective interventions to reduce MM and SMM in public hospitals in Argentina and Uruguay. Dissemination and implementation of evidence-based practices must be guaranteed to effectively achieve progress on maternal health. [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 impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage.Methods: A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss >or=1000 mL and/or >or=1 sign of shock [systolic blood pressure <100 mm Hg or pulse >100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO.Results: Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P<0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85).Conclusion: The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO. [ABSTRACT FROM AUTHOR]

Objective: To test the safety, acceptability, feasibility, and effectiveness of community-based education and distribution of misoprostol for prevention of postpartum hemorrhage at home birth in Afghanistan.Methods: A nonrandomized experimental control design in rural Afghanistan.Results: A total of 3187 women participated: 2039 in the intervention group and 1148 in the control group. Of the 1421 women in the intervention group who took misoprostol, 100% correctly took it after birth, including 20 women with twin pregnancies. Adverse effect rates were unexpectedly lower in the intervention group than in the comparison group. Among women in the intervention group, 92% said they would use misoprostol in their next pregnancy. In the intervention area where community-based distribution of misoprostol was introduced, near-universal uterotonic coverage (92%) was achieved compared with 25% coverage in the control areas.Conclusion: In Afghanistan, community-based education and distribution of misoprostol is safe, acceptable, feasible, and effective. This strategy should be considered for other countries where access to skilled attendance is limited. [ABSTRACT FROM AUTHOR]

Objective: The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance.Methods: The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected.Results: Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.Conclusion: Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program. [ABSTRACT FROM AUTHOR]

Objective: To document an innovative public-private partnership between the government of Gujarat, India and private obstetricians in rural areas that provides delivery care to the poor.Methods: This is a descriptive analysis of the scheme and analysis of secondary data. We estimate the lives of mothers and newborns potentially saved because of the scheme.Results: More than 800 obstetricians have joined the scheme and more than 269000 poor women have delivered in private facilities in 2 years. We estimate that the percentage of institutional deliveries among poor women increased from 27% to 48% between April 2007 and September 2008. In addition, there are fewer reported maternal and newborn deaths among the beneficiaries compared with the number of deaths expected in the absence of the scheme.Conclusions: This innovative program shows that, at least in some areas of India, it is possible to develop a large scale partnership with the private sector to provide skilled birth attendance and emergency obstetric care to poor women at a relatively low cost. This is one way of addressing the human resource deficit in the public sector in rural areas of low-income countries to achieve Millennium Development Goals 4 and 5. We also conclude that the skilled care thus provided can reduce maternal and neonatal mortality among the poor. [ABSTRACT FROM AUTHOR]

Objective: We assessed the effect of prenatal and peripartum antibiotics on maternal morbidity and mortality among HIV-infected and uninfected women.Methods: A multicenter trial was conducted at clinical sites in 4 Sub-Saharan African cities: Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. A total of 1558 HIV-infected and 271 uninfected pregnant women who were eligible to receive both the prenatal and peripartum antibiotic/placebo regimens were enrolled. Pregnant women were interviewed at 20-24 weeks of gestation and a physical examination was performed. Women were randomized to receive either antibiotics or placebo. At the 26-30 week visit, participants were given antibiotics or placebo to be taken every 4 hours beginning at the onset of labor and continuing after delivery 3 times a day until a 1-week course was completed. Logistic regression and Cox proportional hazards models were used.Results: There were no significant differences between the antibiotic and placebo groups for medical conditions, obstetric complications, physical examination findings, puerperal sepsis, and death in either the HIV-infected or the uninfected cohort.Conclusion: Administration of study antibiotics during pregnancy had no effect on maternal morbidity and mortality among HIV-infected and uninfected pregnant women. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure <100 mm Hg or pulse >100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5±93.9 mL, compared with 340.4±248.2 mL pre-intervention (P <0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock. [Copyright &y& Elsevier]

Objective: To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.Methods: A cost-effectiveness analysis depicted three hypothetical cohorts of 10,000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 microg of misoprostol in the third stage of labor.Results: Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.Conclusion: Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the Chinese maternal mortality surveillance system in an inland province and identify how it can be improved.Methods: The review process and Chinese Maternal Deaths Reporting Form were compared with standards recommended by the UK Confidential Enquiry into Maternal and Child Health using interviews with key personnel, field observations, and reports and audits from 2003-2005.Results: The Chinese Maternal Deaths Reporting Form does not provide anonymity for the deceased woman, the health workers, or hospitals. The information collected is often insufficient to identify substandard care. The Review Committee was not multidisciplinary and the review was not confidential. The review findings were only available to the Review Committee.Conclusion: Confidentiality should be a requirement in the maternal mortality surveillance system. The anonymous findings should be available to health workers, and be used to improve the system and inform the community about performance. [ABSTRACT FROM AUTHOR]

Introduction: It is unlikely that some low-income countries will achieve Millennium Development Goal 5 (MDG5) unless governments find new approaches. One possibility is through government partnerships with mission hospitals and other faith-based organizations (FBOs), but this would require overcoming historic reservations.Methods: We review the limited literature on mission hospitals and other FBO health services providing maternity care.Conclusion: The management and the clinical care provided by FBOs are often of higher quality than that provided by government hospitals. Mission hospitals have several advantages including more resources (especially foreign exchange), greater access to expatriate staff especially for training, and more flexibility in hiring and managing staff and in procuring and managing medicines and supplies.Recommendation: Increased collaboration between governments and mission hospitals, particularly in underserved and rural areas, could improve availability and quality of obstetric services enough to meet MDG5 targets. Delegating responsibilities to mission hospitals, exchanging information, and collaboration in projects and training could accelerate progress toward MDG5. Bilateral and multilateral funding institutions and International NGOs should encourage more effective partnerships between governments and FBOs. [ABSTRACT FROM AUTHOR]

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

Introduction: The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. Methods: The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. Results: In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. Discussion: While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women. [ABSTRACT FROM AUTHOR]

Introduction: To determine the outcomes of vaginal deliveries in three study hospitals in Lhasa, Tibet Autonomous Region (TAR), People's Republic of China (PRC), at high altitude (3650 m).Methods: Prospective observational study of 1121 vaginal deliveries.Results: Pre-eclampsia/gestational hypertension (PE/GH) was the most common maternal complication 18.9% (n=212), followed by postpartum hemorrhage (blood loss > or = 500 ml) 13.4%. There were no maternal deaths. Neonatal complications included: low birth weight (10.2%), small for gestational age (13.7%), pre-term delivery (4.1%) and low Apgar (3.7%). There were 11 stillbirths (9.8/1000 live births) and 19 early neonatal deaths (17/1000 live births).Conclusion: This is the largest study of maternal and newborn outcomes in Tibet. It provides information on the outcomes of institutional vaginal births among women delivering infants at high altitude. There was a higher incidence of PE/GH and low birth weight; rates of PPH were not increased compared to those at lower altitudes. [ABSTRACT FROM AUTHOR]

Purpose: We report on assessments of the needs for emergency obstetric care in 3 West African countries.Methods: All (or almost all) medical facilities were visited to determine whether there are sufficient facilities of adequate quality to manage the expected number of obstetric emergencies.Results: Medical facilities able to provide emergency obstetric care were poorly distributed and often were unable to provide needed procedures. Too few obstetricians and other providers, lack of on-the-job training and supervision were among the challenges faced in these countries. [ABSTRACT FROM AUTHOR]

Summary: Maternal mortality reduction has been a focus of major international initiatives for the past two decades. Widespread provision of emergency obstetric care (EmOC) has been shown to be an important strategy for addressing many of the complications that might otherwise lead to maternal death. However, unsafe abortion is one of the major causes of pregnancy-related deaths, and will be only partially addressed by EmOC. This manuscript presents a comprehensive approach to measuring whether abortion-related needs are met.Proposed Methods: We propose a set of indicators for monitoring the implementation of safe abortion care (SAC) interventions. We build on the model developed for monitoring the availability and use of Emergency Obstetric (EmOC) services. We describe the critical elements ("signal functions") of SAC - including treatment of abortion complications, legal, induced abortion and postabortion contraception - and define the indicators necessary to assess the availability, utilization and quality of abortion-related services.Sample Evidence: Data from 5 countries suggest there are sufficient service delivery points to provide decentralized abortion care, but that the full range of necessary abortion care services may not be provided at all these sites. Studies from several countries also show that many women receiving services for the treatment of abortion complications accept contraceptive methods when offered prior to discharge. This is an important strategy for reducing unwanted pregnancy, repeat unsafe abortion and risk for abortion-related mortality. Both findings suggest there are considerable opportunities within the present facilities to improve the delivery of abortion care services.Conclusion: This article recommends that the proposed model undergo field-testing on its own or in conjunction with the EmOC indicators, and encourages increased support for this important but often neglected aspect of pregnancy-related health. [ABSTRACT FROM AUTHOR]

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]

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 monitor changes in the utilization and need for obstetric care between 1995 and 1998 at three hospitals in the highlands of Guatemala.Methods: We collected data on 5300 obstetric admissions from maternity registries and selected 10 indicators to measure intermediate outcomes.Results: Utilization of services increased at some or all hospitals as measured by the number of obstetric admissions, proportion of births in facilities, and cesarean deliveries as a proportion of all births. We observed increases in the proportion of women expected to have obstetric complications who were treated at each hospital and in the proportion of women with obstetric complications who were referrals. The changes in patient profile reflect increased service utilization and accessibility among women who traditionally used the health system the least.Conclusions: Positive changes in these indicators are likely to be associated with a reduction in maternal mortality. Without a control area, we cannot be sure of a cause and effect relationship between outcomes and interventions, nevertheless, maternity registry data offer an inexpensive source of information for facilities to monitor changes. [ABSTRACT FROM AUTHOR]

Purpose: To improve the quality and accessibility of emergency obstetric care (EmOC) at district level.Methods: As the availability of safe and reliable blood transfusion services is a critical component of EmOC, financial and management support was provided to the blood transfusion service centers in the 3 project's Phase 1 districts.Evaluation: An evaluation after 3 years showed that, with modest financial outlays and the development of supportive district level partnerships, substantial improvements in quality and management of services had been achieved. The evaluation also identified limitations imposed by lack of legal frameworks and central support; although the Nepal Red Cross Society has a government mandate to supply the national blood needs, the operating procedures and guidelines have no legal base. The evaluation report was widely circulated, and the findings used in national policy discussions.Results: Following this a task force was commissioned to develop a legal policy framework to ensure standardized quality blood services with defined management and monitoring roles and responsibilities. [ABSTRACT FROM AUTHOR]

Objectives: The study describes normal labor practices in an Egyptian teaching hospital for the first time, where postpartum hemorrhage is the leading cause of maternal mortality. Third-stage management patterns are described and compared to evidence-based medicine. Reasons for third-stage practices observed are explored.Study Design: 176 normal births were directly observed. Women were interviewed postpartum and study findings were shared with providers.Results: Third-stage active management was correctly done for 15% of women observed. Most common deviations for the remaining 85% were: giving uterotonic drugs after placental delivery (65%) and without cord traction (49%). Passive management was not done for any observed delivery.Conclusions: The preventive role actively managing the third stage can provide against postpartum hemorrhage was lost to the majority of the deliveries observed. Obstacles to adopting protocols shown to reduce hemorrhage should be explored, given the contribution of postpartum hemorrhage to maternal deaths in Egypt. [ABSTRACT FROM AUTHOR]

Little progress has been made in preventing the more than 500 000 maternal deaths that occur each year. Many new and underutilized technologies can be used to reduce these deaths. In July 2003, maternal health experts from around the world gathered in Bellagio, Italy, to develop a set of priority actions for reducing maternal mortality using proven and promising technologies. To reduce maternal mortality, immediate efforts are needed to accelerate the appropriate use of technologies and to reduce their inequitable distribution. Organizations are called on to commit the necessary human and financial resources to evaluate and document the effectiveness of promising technologies and to scale up and put proven technologies into widespread use to save women''s lives. [Copyright &y& Elsevier]

Objectives: We present an evaluation of the Community Capacity Building and Empowerment initiative, undertaken by the Community-Based Reproductive Health Project (CBRHP), designed to address high maternal morbidity and mortality.Methods: Qualitative data from group interviews and program data from CBRHP were used to assess progress in development and use of community level transport systems and support for the village health workers (VHWs).Results: Project activities increased community participation in maternal health. An increase was seen in knowledge of danger signs, birth planning, timely referrals, and transport of pregnant women to hospitals, as well as in support and retention of VHWs. More women with obstetrical problems are using the community-based transport system to get to hospitals.Conclusions: Community participation and support for VHW activities and the transport systems have led to better care for pregnant women and sustained links between the communities and health facilities, which may reduce maternal and infant morbidity and mortality. [ABSTRACT FROM AUTHOR]