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Objective: To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC.Methods: All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined.Results: Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma.Conclusion: AMOs carried most of the burden of life-saving EmOC-particularly cesarean deliveries-in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%. [ABSTRACT FROM AUTHOR]

Objective: To conduct a needs assessment for emergency obstetric care (EmOC) to address the unacceptably high maternal and newborn mortality indices in Sierra Leone 8 years after the end of the civil war.Methods: From June to August 2008, a cross-sectional survey was conducted of health facilities in Sierra Leone offering delivery services. Assessment tools were local adaptations of tools developed by the Averting Maternal Death and Disability program at Columbia University, New York, USA.Results: There were enough comprehensive EmOC (CEmOC) facilities in the country but they were poorly distributed. There were no basic EmOC (BEmOC) facilities. Few facilities (37% of hospitals and 2% of health centers) were able to perform assisted vaginal delivery (AVD), and 3 potentially BEmOC facilities did not meet the standard only because they did not perform AVD. Severe shortages in staff, equipment, and supplies, and unsatisfactory supply of utilities severely hampered the delivery of quality EmOC services. Demand for maternity and newborn services was low, which may have been related to the poor quality and the high/unpredictable out-of-pocket cost of such services.Conclusion: Significant increases in the uptake of institutional delivery services, the linkage of remote health workers to the health system, and the recruitment of midwives, in addition to rapid expansion in the training of health workers (including training in midwifery and obstetric surgery skills), are urgently needed to improve the survival of mothers and newborns. [ABSTRACT FROM AUTHOR]

Objective: To assess the availability and coverage of emergency obstetric care (EmOC) services in Zambia.Methods: Reported provision of EmOC signal functions in the Zambian Health Facility Census and additional criteria on staffing, opening hours, and referral capacity were used to classify all Zambian health facilities as providing comprehensive EmOC, basic EmOC, or more limited care. Geographic accessibility of EmOC services was estimated by linking health facility data with data from the Zambian population census.Results: Few Zambian health facilities provided all basic EmOC signal functions and had qualified health professionals available on a 24-hour basis. Of the 1131 Zambian delivery facilities, 135 (12%) were classified as providing EmOC. Zambia nearly met the UN EmOC density benchmarks nationally, but EmOC facilities and health professionals were unevenly distributed between provinces. Geographic access to EmOC services in rural areas was low; in most provinces, less than 25% of the population lived within 15 km of an EmOC facility.Conclusion: A national Health Facility Census with geographic information is a valuable tool for assessing service availability and coverage at national and subnational levels. Simultaneously assessing health worker density and geographic access adds crucial information. [ABSTRACT FROM AUTHOR]

Objective: To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries.Methods: Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized.Results: Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided.Conclusion: The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools. [ABSTRACT FROM AUTHOR]

Objective: To determine risk factors for perinatal mortality among hospital-based deliveries in Nigeria.Methods: The WHO Global Maternal and Perinatal Health Survey was implemented in Nigeria as a first step in establishing a global system for monitoring maternal and perinatal health. Twenty-one health facilities with more than 1000 deliveries annually were selected by a stratified multistage cluster sampling strategy. Information was recorded on all women who delivered and their neonates within a 3-month period.Results: Overall, there were 9208 deliveries, comprising 8526 live births, 369 fresh stillbirths, 282 macerated stillbirths, 70 early neonatal deaths, and 721 perinatal deaths. The stillbirth and perinatal mortality rates were, respectively, 71 and 78 per 1000 deliveries; the early neonatal death rate was 8 per 1000 live births. Approximately 10% of all newborns weighed less than 2500 g, and 12.3% were born at less than 37 weeks of gestation. Predictors of perinatal mortality were mother's age, lack of prenatal care, unbooked status, prematurity, and birth asphyxia.Conclusion: The perinatal mortality rate remains unacceptably high in Nigeria. Fresh stillbirth accounted for most perinatal deaths. Interventions to improve the utilization and quality of prenatal care, in addition to the quality of intrapartum care, would considerably reduce perinatal death. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence of vitamin D deficiency among pregnant women in Karachi, Pakistan; correlate maternal and cord blood vitamin D deficiency; and assess possible predictors of vitamin D deficiency.Methods: This observational, analytical, cross-sectional study was conducted with 50 consecutive women in labor presenting with a singleton term pregnancy at a large tertiary center in Karachi. Data were recorded on a special form, maternal blood was taken before delivery and cord blood was taken at delivery. All blood samples were analyzed for 25-hydroxy vitamin D levels. Comparisons were made using the Χ(2) test.Results: The mean vitamin D levels were 24 ng/mL for the participants and 20 ng/mL for the newborns. Vitamin D sufficiency was noted in 11 (22%), insufficiency in 16 (32%), and deficiency in 23 (46%) of the 50 participants whereas sufficiency and deficiency, respectively, were noted in 6 (12%) and 44 (88%) of the newborns. There was a positive correlation between the vitamin D levels in maternal and cord blood (r=0.03; P<0.003). Maternal vitamin D levels were significantly affected by sunlight exposure (P<0.007) and quality of diet P<0.01).Conclusion: Vitamin D deficiency is high among pregnant urban Pakistani women and their newborns. This public health problem needs urgent attention. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of intermittent preventive treatment with sulfadoxine and pyrimethamine (IPT-SP) on placental parasitemia and maternal and perinatal outcome.Methods: We compared placental malaria parasitemia during pregnancy and pregnancy outcome in 2 groups of women receiving antenatal care at University of Benin Teaching Hospital. One group was prophylactically treated with IPT-SP and the other was not treated.Results: The parasitemia rates for peripheral, placental, and cord blood were 11.9%, 11.4%, and 2.7% in the IPT-SP group (n=370) and 19.1%, 22.6%, and 6.2% in the control group (n=371) (P=0.006, P=0.002, and P=0.02, respectively). The treatment reduced the odds of placental parasitemia by 37% (OR 0.63; 95% CI, 0.48-0.81). Peripheral (P=0.002) and placental (P=0.001) parasitemia were significantly reduced in the subgroup of women who took 2 or 3 doses of SP. Fewer women (16.2%) in the IPT-SP group than the control group (23.7%) had symptomatic malaria. Anemia at delivery was significantly lower in the IPT-SP group (10.8 vs 1.6%). The risks of abortion, preterm delivery, and low birth weight were also significantly lower in the IPT-SP group.Conclusion: IPT-SP is effective in preventing placental parasitemia, and reduces rates of malaria, maternal anemia, abortion, preterm delivery and low birth weight among pregnant women. [ABSTRACT FROM AUTHOR]

Objective: To assess maternal mortality and its association with accessibility to obstetric care in the metropolitan region of Rio de Janeiro, Brazil.Methods: Maternal mortality was assessed from 2 national databases, one administrative and the other designed for epidemiologic purposes. Distances traveled from residence to hospital via the transit network were calculated using a specialized information system. Deaths were grouped by area of residence, and maternal mortality ratios (number of deaths per 100,000 live births) as well as death incidence ratios (deaths/live births in 2 regions or hospital types) were calculated for these areas.Results: We identified 236 deaths and estimated under-reporting at 30%. The most common causes of death were hypertension-related disorders, "other obstetric conditions," and complications from abortion; the longest traveled distance was 66.43 km (mean, 13.65 km); and maternal mortality ratios varied between 25.54% and 56.45%, the highest values being for areas with the lowest municipal human development index. The highest death incidence ratios were found at general hospitals without specialized obstetric care.Conclusion: Maternal mortality is still a serious problem in the studied region. The wide variations among areas of different socioeconomic conditions suggest the need for a better allocation of health care resources. [ABSTRACT FROM AUTHOR]

Objective: To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province.Methods: The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care.Results: The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%-40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor.Conclusion: Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement. [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 examine the impact of a national intervention to improve the postabortion care (PAC) content of midwifery education in Nigeria.Methods: A 3-part quantitative assessment was carried out during and post-intervention. The first baseline component developed and examined the intervention to improve teaching capacity and improve the PAC curriculum among 6 midwifery schools that were to become regional training centers. The second survey was a pre- and post-assessment conducted among midwifery instructors from all schools of midwifery in the country. In the third component, 149 midwives graduating from the 6 regional midwifery schools were interviewed once 3-9 months after graduation to evaluate whether the intervention had improved their knowledge of PAC and clinical practice, and the likelihood that they would provide PAC after graduation.Results: Data from 6 schools of midwifery in 2003 showed that none offered PAC or had educators trained in PAC prior to the intervention. Incorporation of PAC content and teaching capacity increased in all 6 study schools during the 3 years after a national intervention. Midwifery instructors demonstrated statistically significant improvements in knowledge of and exposure to PAC and manual vacuum aspiration (MVA) after the intervention. A follow-up interview with 149 student midwives post graduation showed increased knowledge, exposure to, and use of MVA in the workplace.Conclusion: Significant changes in graduate midwives' exposure, practice, and provision of PAC services resulted from a national intervention to improve the training environment and skills of midwifery instructors and students in the 6 schools of midwifery selected for evaluation. [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]

Objectives: To improve obstetric care and reduce the incidence of uterine rupture through the use of audits.Methods: Data were collected from medical records and from questioning women who sustained uterine rupture over a 12-month period in Thyolo District Hospital, Malawi. Audit sessions were performed every 2-3 weeks for the first 3 months with relevant members of the hospital staff, after which an extended audit was held with input from two external expert obstetricians. Cases were also audited by the principal investigator for delays in referral, diagnosis, and treatment.Results: Thirty-five cases of uterine rupture were diagnosed at the facility during the study period. Sixteen ruptures were diagnosed during the first 3 months, an incidence of 19.2 per 1000 deliveries. Following audit and implementation of recommendations, the incidence of uterine rupture decreased by 68% (OR 0.32; 95% CI, 0.16-0.63) to 6.1 per 1000 deliveries over the next 9 months. The overall case fatality rate was 11.4%, and the perinatal mortality rate was 829 per 1000 live births.Conclusions: Audit is an inexpensive, appropriate, and effective intervention to improve the quality of facility-based maternal care and decrease the incidence of uterine rupture in low-resource settings. Ensuring constructive self-criticism, continuous professional learning, and good participation by district health managers in audit sessions may be important requirements for their success. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality continues to be high in rural India. Chief among the reasons for this is a severe shortage of obstetricians to perform cesarean delivery and other skills required for emergency obstetric care (EmOC). In 2006, the Government of India and the Federation of Obstetric and Gynecological Societies of India (FOGSI) with technical assistance from Jhpiego, instituted a nationwide, 16-week comprehensive EmOC (CEmOC) training program for general medical officers (MOs). This program is based on an earlier pilot project (2004-2006).Objective: To evaluate the pilot project, and identify lessons learned to inform the nationwide scale-up.Methods: The lead author (CE) visited trainees and their facilities to evaluate the project. Eight data collection tools were created, which included interviews with informants (program/government staff, regional/international experts, trainees and trainers), facility observation, and facility-based data collection of births and maternal/newborn deaths during the study period.Results: More trainees performed each of the basic EmOC skills after the training than before. After training, 10 of 15 facilities to which trainees returned could provide all signal functions for basic EmOC whereas only 2 could do so before. For comprehensive EmOC, 2 facilities with obstetricians were providing all functions before and 2 were doing so after, even though the specialists had left those facilities and services were being provided by CEmOC trainees. Barriers to providing, or continuing to provide, EmOC for some trainees included insufficient training for cesarean delivery, lack of anesthetists, equipment and infrastructure (operating theater, blood services, forceps/vacuum, manual vacuum aspiration syringes).Conclusion: Although MOs can be trained to provide CEmOC (including cesarean delivery), without proper selection of facilities and trainees, adequate training, and support, this strategy will not substantially improve the availability of comprehensive EmOC in India.Recommendations: To implement a successful nationwide scale-up, several steps should be taken. These include, selecting motivated trainees, implementing the training as it was designed, improving support for trainees, and ensuring appropriate staff and infrastructure for trainees at their facilities before they return from training. [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: To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities.Methods: Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity.Results: Median cesarean delivery rate was 8.8% among 83439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity--probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths.Conclusion: Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths. [ABSTRACT FROM AUTHOR]

Objective: To investigate inequalities in cesarean delivery rates in Brazil according to ethnic group and level of access to hospital delivery.Methods: Cross-sectional analysis of data for primiparous women with singleton deliveries between 2003 and 2004 from the National Information System of Live-Births (6,064,799 live births). Robust Poisson regression modeling was applied to estimate prevalence ratios of cesarean deliveries for ethnic group and level of access to hospital delivery according to residence.Results: There were 2,438,180 primiparous deliveries and the cesarean rate was 45.8%. Ethnic inequalities in cesarean delivery rates showed lower rates for all ethnic groups compared with white women, with the lowest rates recorded for indigenous women. The association between ethnicity and cesarean delivery was higher in states with lower access to hospital (P<0.001). Multiple regression models showed that this association was, in part, explained by older maternal age and higher levels of education and prenatal care.Conclusions: Overuse of cesarean delivery and strong evidence of ethnic inequalities in cesarean rates exist in Brazil. The inequalities are greater in states with lower access to hospital and were partially explained by socioeconomic factors and prenatal care, suggesting a misuse of medical technology at birth. [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]

Objective: To assess women's satisfaction with traditional birth attendants (TBAs) in rural Tanzania.Method: A population-representative sample of households in Kasulu district was used to collect data on demographics, childbirth history, and perception of TBAs and doctors/nurses from women who had recently had a child and from their partners.Results: Two-thirds of women who gave birth in a health facility reported being very satisfied with the experience, compared with 21.2% of women who delivered at home with TBAs. A sizeable proportion of women felt that TBAs had poor medical skills (23.1%), while only 0.3% of women felt the same about doctors' and nurses' skills. Of women who delivered with a TBA, 16.0% reported that TBAs had poor medical skills whereas 0.5% stated the same for doctors and nurses.Conclusion: Although many women delivered at home in this rural study district, women and their partners reported higher confidence in doctors and nurses than in TBAs. Policymakers and program managers should not assume that women prefer TBAs to trained professionals for delivery but should consider system barriers to facility delivery in interventions aimed at reducing maternal mortality. [ABSTRACT FROM AUTHOR]

Objective: To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.Methods: A case series study of 42 obstetric fistula patients seeking services at the Provincial Hospital of Maroua, Cameroon, between May 2005 and August 2007. Structured interviews were conducted prior to surgical intervention.Results: Among obstetric fistula patients, 60% had lived with obstetric fistula for more than 5 years at the time of surgery. Eighty-one percent of patients had received no formal education and 86% were teenagers at their first delivery. Regarding the pregnancy and delivery preceding the occurrence of the fistula, 50% of women reported that they had received no prenatal care and 76% were in labor for more than 12 hours. The majority (83%) of women delivered a stillborn baby.Conclusions: Obstetric fistula patients in the Far North Province of Cameroon had a low level of education, were married at a young age, and had poor access to quality maternal healthcare services. [ABSTRACT FROM AUTHOR]

Abstract: Two decades have passed since the global community agreed in Nairobi to the Safe Motherhood Initiative to reduce maternal deaths. However, every year 536000 pregnant women are dying. There is no ambiguity about why most of these women are dying. These tragedies are avoidable if women have timely access to quality essential obstetric and emergency care. Rural and poor women are mostly excluded from accessing skilled and emergency care. Quality facility-based care is the best option to reduce maternal mortality. Scaling up essential interventions and services—particularly for those who are excluded—is a substantial and challenging undertaking. We need to challenge our policy makers and program managers to refocus program content; to shift focus from development of new technologies toward development of viable organizational strategies to provide access to essential and emergency obstetric care 24 hours a day 7 days a week, and account for every birth and every death. [Copyright &y& Elsevier]

Abstract: The health of mothers and their children is of critical importance, both as a reflection of the current health status of a large segment of the world''s population and as a predictor of the health of the next generation. A range of indicators of maternal and neonatal health exist—those primarily affecting pregnant and postpartum women, and those affecting the health and survival of infants. Pregnancy outcome may be affected by toxicant exposure, maternal habits, occupational hazards, psychosocial factors, socioeconomic status, racial disparity, chronic stress, and infections. An increase in obstetric pathologies related to lifestyle, environment, aging, and diet has been seen in Western countries. Large segments of the population are obese and this factor is associated with a great number of adverse reproductive health outcomes. In other countries, the most important objective is to reduce the incidence of infectious diseases and their transmission from mother to fetus. AIDS remains the leading cause of death of children worldwide. [Copyright &y& Elsevier]

Objective: WHO, UNICEF, and UNFPA with other development partners have supported African Ministries of Health to institutionalize maternal death review (MDR) since 2003. To evaluate the program, its status, lessons learned, and the challenges to success were reviewed in 2007.Methods: A standard self-administered questionnaire was sent to Ministries of Health in 46 Sub-Saharan African countries in May 2007. Completed questionnaires were returned by e-mail, processed, and analyzed.Results: Thirty countries completed the survey questionnaire. Maternal death is a notifiable condition in 21 (67%) counties. A national committee has been set up to plan, coordinate, and implement MDR activities in 7 countries. Fifteen countries stated that facility-based MDR is the main method selected for conducting reviews of the causes of maternal death. Fourteen (47%) countries reported that national MDR guidelines had been developed and 12 (40%) had implemented the guidelines. Fifteen (50%) countries reported that maternal deaths were reviewed and analyzed. Only 7 countries reported that the government had allocated a budget for MDR. Implementation of MDR has led to local policy changes and improvement in quality of maternal health services in several countries. Ten of the 15 countries in which analysis has been conducted reported that recommendations have been implemented at least at the health facility level.Conclusion: Although use of MDR is increasing in African countries, effective coverage is still low. The institutionalization of MDR requires political commitment, legal and administrative back-up, financial support, capacity development, simplified reporting forms and procedures, coordinated support of development partners, involvement of professional bodies, and regular supportive follow-up. [ABSTRACT FROM AUTHOR]

Objective: Factors contributing to the limited use of confidential inquiries into maternal deaths include the negative focus and demotivating effect of such inquiries, perceptions of unavailability of sufficient documentation of events, and lack of time and resources. To ascertain whether these problems can be overcome, variations to confidential inquiries into maternal deaths were introduced in Ghana and Indonesia.Methods: Clinical review panels were set up as part of the usual process of confidential inquiries, and modifications to the confidential inquiries were introduced. In Ghana, the traditional confidential inquiry process focusing on health facility care was modified to introduce the assessment of positive factors. In addition to the assessment of positive factors, adaptations in Indonesia consisted of including cases of obstetric complications, as well as deaths, and the use of interview testimonials as data sources. Information about resource and time needs for conducting confidential inquiries was collected.Results: The introduction of positive aspects to the process provided a balanced and more motivating setting for the inquiry. The data obtained from case notes in district hospitals and interview testimonials provided sufficient information to assess why maternal deaths and severe complications occurred. The costs of conducting the inquiries ranged from US $4000 to US $11000 (per study), and the estimated time required for a panel member to review each case was more than 3 hours.Conclusion: This study introduced practical ways to encourage the implementation of maternal death reviews, inquiries, and audits that are context specific and, therefore, acceptable to local practitioners. [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]

Objective: The Yemen is a signatory of the Millennium Development Goals (MDGs) and one of 10 countries chosen for the UN Millennium Project. However, recent MDG progress reviews show that it is unlikely that the maternal health goal will be reached by 2015 and Yemen still has an unacceptably high maternal mortality of 365 per 100000 live births. Because 82% of deaths happen intrapartum, the purpose of this needs assessment was to identify and prioritize constraints in delivery of emergency obstetric care (EmOC).Methods: Four district hospitals and 16 health centers in 8 districts were assessed for functional capacity in terms of infrastructure; availability of essential equipment and drugs; EmOC technical competency and training needs; and Health Management Information System.Results: We found poor obstetric services in terms of structure (staffing pattern, equipment, and supplies) and process (knowledge and management skills).Conclusion: The data argue for strengthening the 4 interlinked health system elements-human resources, and access to, use, and quality of services. The Government must address each of these elements to meet the Safe Motherhood MDG. [ABSTRACT FROM AUTHOR]

Objective: To investigate Sri Lankan maternal deaths due to heart disease and to consider low-cost interventions to reduce these deaths.Methods: A qualitative study based on retrospective audit of all maternal deaths and late maternal deaths in Sri Lanka caused by cardiac disease in 2004.Results: A total of 145 maternal deaths were recorded in 2004, for a maternal mortality rate of 38 per 100,000. There were 42 indirect deaths, 25 of which were due to cardiac disease; 23 deaths had a specific cardiac cause listed. Standard care was identified in prepregnancy counseling, contraception, and prenatal community and specialist care.Conclusion: Cardiac disease is a major cause of maternal mortality in Sri Lanka, second only to postpartum hemorrhage. Rheumatic mitral valve disease is responsible for more than a third of maternal deaths from cardiac disease. Substandard care was identified in all cases; strategies to improve care could allow a reduction in maternal cardiac deaths. [ABSTRACT FROM AUTHOR]

Objective: To develop, implement, and evaluate an evidence-based multidisciplinary teaching program to improve maternal and infant health in remote Vietnam.Methods: Needs assessments identified prevention of infection, neonatal resuscitation, and prevention of postpartum hemorrhage as primary targets. A 3-day workshop based on the small group, interactive, skills-based SCORPIO method was developed. Participants underwent formative written and performance-based assessments. Qualitative and quantitative evaluation of course content and teaching method was conducted.Results: Two annual workshops were conducted for 58 health professionals, all of whom demonstrated skills acquisition to an adequate standard on completion. The workshops were rated as good or excellent overall by 100% of the participants, who reported that the content would help with their clinical work and that the teaching method was acceptable and easy to understand.Conclusion: We demonstrated the SCORPIO method can be adapted to teach knowledge and clinical skills in remote Vietnam. Further work is needed to demonstrate an effect on health outcomes. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of a comprehensive intervention (staff training, equipment, internal clinical audits, cost sharing system, patients-providers meetings) in improving cesarean delivery access and quality in an urban district of Burkina Faso.Methods: We conducted a before-after study in the health district sector 30 in Ouagadougou between 2003 and 2006. We measured cesarean delivery quality (accessibility, diagnosis, procedure, postoperative follow-up) and maternal and neonatal health in 1371 sections.Results: The number of cesarean deliveries performed increased each year, from 42 in 2003 to 630 in 2006. This increase happened without increase in maternal and perinatal post-cesarean mortality (respectively 1.1% and 3.6% in 2006). The cesarean delivery rate for women of the district increased from 1.9% to 3.3% of expected births between 2003 and 2005.Conclusion: To improve access to quality cesarean delivery, we have shown that it was necessary to have a systemic approach combining technical, operational, sociocultural, and political factors. [ABSTRACT FROM AUTHOR]

Abstract: About a third of anencephalic fetuses are born alive, but they are not conscious or viable, and soon die. This neural tube defect can be limited by dietary consumption of foliates, and detected prenatally by ultrasound and other means. Many laws permit abortion, on this indication or on the effects of pregnancy and prospects of delivery on a woman''s physical or mental health. However, abortion is limited under some legal systems, particularly in South America. To avoid criminal liability, physicians will not terminate pregnancies, by induced birth or abortion, without prior judicial approval. Argentinian courts have developed means to resolve these cases, but responses of Brazilian courts are less clear. Ethical concerns relate to late-term abortion, meaning after the point of fetal viability, but since anencephalic fetuses are nonviable, many ethical concerns are overcome. Professional guidance is provided by several professional and institutional codes on management of anencephalic pregnancies. [Copyright &y& Elsevier]

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: Since the Department of Health and Human Services chose Rabia Balkhi Hospital (RBH) in Kabul, Afghanistan, as a site for intervention in 2002, the status of women's health there has been of interest. This study created a tool to assess accessibility and quality of care of women admitted from May to July, 2005.Methods: A 39-item questionnaire was created in English and translated into Dari. Hospital staff administered the survey to 292 women admitted to RBH for obstetric and gynecological complaints.Results: Approximately 40% of the women traveled between 1 and 5 hours to reach RBH. Only 54% (158/292) of women reported having their blood pressure monitored during their pregnancy. About one-third of women reported that they had never received an immunization.Conclusions: This survey tool ascertained that women who received care at RBH traveled great lengths to reach the facility. Preventative measures such as blood pressure checks and immunizations are areas that need improvement. [ABSTRACT FROM AUTHOR]

Objective: To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi.Methods: A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care.Results: Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies.Conclusion: Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the stillbirth rates in 4 cities at different altitudes in Peru. Methods: The stillbirth rates from a sample of 22,662 births recorded in the Perinatal Information System database were analyzed between 2005 and 2006 for the cities of Lima (150 m), Huancayo (3280 m), Cuzco (3430 m), and Puno (3850 m). Results: Stillbirths were higher at high altitude (>3000 m) (OR 4.82; CI, 3.05–7.72) compared with low altitude. The effect of altitude was observed after controlling for socioeconomic (OR 4.29; CI, 2.61–6.93), demographic and biological (OR 4.18; CI, 2.65–6.77), maternal health care (OR 4.72; CI, 2.96–7.61), and fetal factors (OR 3.96; CI, 2.48–6.45). Inhabitants from the southern Andes demonstrated a protective effect on stillbirth rate compared with the central Andes, which may be due to an ancestry effect with longer multigenerational residence in the southern Andes population. Conclusion: Stillbirth rate is higher at high altitude compared with low altitude. [Copyright &y& Elsevier]

Objective: To assess the quality of partograms used to monitor labor in Dar es Salaam hospitals, Tanzania.Methods: The study team reviewed the records of the parameters of labor, and maternal and fetal conditions in 367 partograms, and interviewed 20 midwives.Results: All midwives interviewed had been previously trained to use the partogram. Of all partograms reviewed, 50% had no records of duration of labor. Although cervical dilation and fetal heart rates were recorded in 97% and 94% of the partograms respectively, 63% and 91% of these were judged to be substandard. Substandard monitoring of fetal heart rates was strongly associated with poor fetal outcome (P<0.001). Blood pressure, temperature, and pulse rates were not recorded in 47%-76% of partograms.Conclusion: These findings reflect poor management of labor and indicate urgent in-service training to address the importance of documentation and regular partogram audit in order to reduce maternal and perinatal deaths. [ABSTRACT FROM AUTHOR]

Objective: As part of the global Campaign to End Fistula, the Fistula Fortnight, a 2-week mass obstetric fistula treatment project, was organized in northern Nigeria to contribute to reducing the backlog of untreated fistulas and raise awareness regarding obstetric fistulas and safe motherhood.Methods: An array of partners joined forces to provide free surgical treatment, strengthen the capacity of existing facilities to manage obstetric fistulas, and utilize media strategies to raise awareness.Results: The Fistula Fortnight took place from February 21 to March 6, 2005, at 4 established fistula repair centers in the northern Nigeria states of Kano, Katsina, Kebbi, and Sokoto. A total of 569 women received treatment, with an 87.8% rate of successful closures. The highly publicized event also raised awareness on the issue of obstetric fistula and helped put a face to maternal deaths.Conclusion: The Fortnight, which required extensive and thoughtful planning involving many persons cognizant of health system and quality of care issues, was effective in drawing attention to the vast fistula problem and contributed to reducing the backlog of patients. [ABSTRACT FROM AUTHOR]

Abstract: It is estimated that more than 2 million women are living with obstetric fistulas (OFs) worldwide, particularly in Africa and Asia, and yet this severe morbidity remains hidden. As a contribution to the global Campaign to End Fistula, the World Health Organization (WHO) published Obstetric fistula: Guiding principles for clinical management and programme development, a manual intended as a practical working document. Its 3 main objectives are to draw attention to the urgency of the OF issue and serve as an advocacy document for prompt action; provide policy makers and health professionals with brief, factual information and principles that will guide them at the national and regional levels as they develop strategies and programs to prevent and treat OFs; and assist health care professionals as they acquire better skills and develop more effective services to care for women treated for fistula repair. [Copyright &y& Elsevier]

Objective: Findings from 4 studies conducted by the Women's Dignity Project and partners on the subjects of obstetric fistula, maternal mortality and morbidity, and health inequities are presented.Methods: The studies include qualitative and quantitative research, a survey, and an analysis of secondary data that examine women's experiences of fistula; constraints in service delivery for fistula treatment; factors shaping women's access to delivery care and constraints health workers face in providing care; and health inequities.Results: Findings from the studies are being used to improve fistula prevention and management, strengthen access to and provision of quality maternity care, and redress the health inequities that so adversely affect the poor.Conclusion: The studies provide policy makers, program managers, and service providers with evidence and the impetus to re-equilibrate policies, financial and human resources, and services in the interest of those in greatest need: women living in poverty. [ABSTRACT FROM AUTHOR]

Introduction: The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries.Methods: In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity.Results: 95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered.Conclusion: This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost. [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]

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: To obtain descriptive measures of maternal and perinatal health in the Ba Men Region of Inner Mongolia, China.Methods: Data collected from the Examination Chart for Pregnant Women for approximately 22,000 pregnancies in a three-county area of Inner Mongolia, China from December 1, 1996 through December 31, 1999 were analyzed for maternal, perinatal, and neonatal outcomes.Results: Compared to selected developing countries, a higher percentage of women (99%) in this region received at least one prenatal care visit. This region was also characterized by a low percentage of low birthweight (<2.5 kg) infants (1%) and neonatal mortality rate (5 deaths per 1000 live births).Conclusions: Maternal and neonatal health outcomes in this region of Inner Mongolia were better than those in selected developing countries. [ABSTRACT FROM AUTHOR]

Purpose: We conducted a survey to determine availability of emergency obstetric care (EmOC) and to provide data for advocating for improved maternal and newborn health in Uganda.Methods: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions, documented maternal deaths and the related causes. Three levels of health facilities were covered.Findings: Few health units had running water; electricity or a functional operating theater. Yet having these items had a protective effect on maternal deaths as follows: theater (OR 0.56, P<0.0001); electricity (OR 0.39, P<0.0001); laboratory (OR 0.71, P<0.0001) and staffing levels (midwives) OR 0.20, P<0.0001. The availability of midwives had the highest protective effect on maternal deaths, reducing the case fatality rate by 80%. Further, most (97.2%) health facilities expected to offer basic EmOC, were not doing so. This is the likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda.Conclusion: Addressing health system issues, especially human resources, and increasingaccess to EmOC could reduce maternal mortality in Uganda and enable the country to achieve the Millennium Development Goal (MDG). [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]

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]

Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998-2003.Method: Records of public hospitals and state pathologists were reviewed to identify pregnancy-related deaths within 12 months of delivery and determine their underlying causes.Results: Maternal mortality declined (p=0.023) since surveillance began in 1981-83. The fall in direct mortality (p=0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p=0.057), moving to 31% of maternal deaths from 17% in 1993-95.Interpretation: Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases. [ABSTRACT FROM AUTHOR]

Purpose: We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda.Methods: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services.Findings: A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly.Conclusion: An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda. [ABSTRACT FROM AUTHOR]

Should we give prophylactic antibiotics routinely after operative vaginal delivery?Delivering better maternity care experiences across public health systems in low‐ and middle‐income countriesPROLONG Study shows no benefit from 17‐hydroxyprogesterone in preventing recurrent spontaneous preterm birth. [ABSTRACT FROM AUTHOR]

Abstract: The lack of human resources is one of the main bottlenecks to achieving the Millennium Development Goals on maternal and child health. A coherent national policy, recognized across government, needs to be in place to overcome this especially in countries severely affected by HIV/AIDS. Such a policy should cover selection of pre-service students, the qualifications of trainers and training sites, supportive supervision, career path development, a package of carefully thought-out incentives for the retention of staff, strategies for interaction with communities, and an agreed-upon health staff HIV/AIDS policy. Without such coherent human resource planning, a large number of countries will fail to reduce maternal and newborn mortality. [Copyright &y& Elsevier]