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Objective To describe Ethiopian national population-based and institutional cesarean delivery rates by sector, and to describe indications for cesarean delivery, fetal and maternal outcomes, and aspects of quality of care. Methods The data source was the national baseline assessment of emergency obstetric and newborn care—a cross-sectional, facility-based survey of 797 facilities. Two instruments were used to collect the data for the present paper: a retrospective record review of 267 cesarean deliveries based on the last 3 performed in each facility; and a 12-month summary of each facility's statistics on vaginal and abdominal deliveries. Results The national population-based cesarean delivery rate was 0.6%, with regional rates varying from 0.2% to 9%. The overall institutional rate was 18%, which varied between 46% in the private for- profit sector and 15% in the public sector. Maternal indications accounted for 66% of the cesareans reviewed, and fetal indications for 34%. Three-quarters of the cesareans were recorded as emergencies, but only 12% of these had their labor monitored with a partograph. The interval between decision and delivery was within 30 minutes for 36% of the women, 31–60 minutes for 23%, and more than 5 hours for 19%. Antibiotics were given in 94% of the reviewed cases; nevertheless, 12% of the cases reported wound infection. There were 2 maternal deaths and 14% of the newborns were stillbirths or died shortly after birth. Conclusion The study showed little progress in the proportion of all births delivered by cesarean and a high rate of cesarean among women attended in the private sector—indicating a need to monitor the appropriateness of obstetric care in all sectors and to increase access in rural areas. Clinical management protocols for obstetric and newborn care are needed, and audits of cesareans should be performed at all institutions, especially in the private sector. The importance of improving record keeping is crucial for informed local decision-making.

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

The question of cesarean section by choice (that is, cesarean delivery in the absence of medical indications) has been hotly debated by the obstetrical profession in recent years. The debate has focused around questions of risks and benefits, and has revolved around questions of obstetrical practice. In this paper, the question will be framed in a reproductive rights context. How does the phenomenon of CSBC (cesarean section by choice) impact women's empowerment? Which reproductive rights might be affected by this question, and what policies are related to its use? FIGO's 1998 statement "Ethical Aspects regarding Cesarean Delivery for Non-Medical Reasons" is revisited, and, in light of these considerations, its contents are endorsed once again.

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

Depression is a ubiquitous disorder in childbearing women with up to 10% of women experiencing depression in pregnancy. Postpartum depression occurs in 12-16% of pregnancies making it a common complication. Moreover, these illnesses are frequently underdiagnosed in obstetric settings, and a recent report of the Surgeon General's Office confirms that many women do not access services, or receive treatment of inadequate intensity or duration. This paper provides current treatment guidelines to aid in appropriate diagnosis and treatment of depression in pregnancy and postpartum. Review of current literature on psychotropic medication use in pregnancy is also provided.

The authors wish to clarify that analyses in the paper are based on the full-analysis set (FAS), excluding patients for whom data wereunavailable.FortherevisedAmericanFertilitySociety(rAFS)score,datawereunavailablein9.5%ofpatientsinthe2-mggroupgroupat24 weeks.The columns in Fig. 2 are adjusted to 100%, after excluding these missing data. Histologic examination at 24 weeks in the 2-mg and 4-mg groupsidentified endometriosis in 33.3% and 46.7%, and no endometriosis in 28.6% and 30.0% of women, with data unavailable in 38.1% and 23.3%,respectively.

Although there is little understanding of what causes pre-eclampsia / eclampsia there is an effective treatment for this condition. In 1994 WHO recommended magnesium sulfate as the standard treatment for pre-eclampsia and eclampsia and within 2 years it was placed on WHO’s Essential Medicines List. Treatment of pre-eclampsia with magnesium sulfate has been shown to significantly lower the risk of eclampsia (by 58%) and the risk of mortality (by 45%). Despite its known efficacy this inexpensive drug is often underused partly because the diffusion of an innovation takes time but also because it requires a strong and effective referral system often a challenge in under-resourced health systems. Although the treatment of eclampsia seems simple -- introduce magnesium sulfate into the woman’s blood stream and deliver the fetus as soon as possible -- doing so in time and correctly is complicated and involves many steps and many players. In 2007 the MacArthur Foundation began funding a series of grants to expand the use of magnesium sulfate for pre-eclampsia / eclampsia in Nigeria. The impact of this work on maternal mortality was significant: the case fatality rate due to eclampsia dropped from 20.9% to 2.3% and the findings encouraged the government to scale up the intervention to other states. In 2014 the Foundation commissioned a process evaluation of this work to help to determine what factors facilitated uptake and expansion of magnesium sulfate services the challenges encountered while implementing the projects and existing opportunities for future scaling up of the services across the country. The present paper reports on the findings of that process evaluation. (Excerpts) © 2016 International Federation of Gynecology and Obstetrics. Open Access.

Cervical cancer is known to be a preventable disease through the detection of cervical cancer precursors, historically using cytology of the cervix as the primary screening test. Over 85% of cervical cancer cases and deaths occur in low-resource countries. Alternatives to cytology have been investigated with the strongest possibilities being visual inspection with acetic acid (VIA) and HPV DNA testing. HPV DNA testing has been shown in randomized trials to be significantly more sensitive for the detection of cervical cancer precursors than either cytology or VIA. In this paper we argue that prevention really does cost less than cure, or that prevention and treatment of cancer costs less than no prevention, in effect just treatment, of cancer. The true cost savings of prevention will include a more difficult assessment of the socioeconomic savings associated with longer, healthier lives for women in their prime who have a major role in supporting their families.