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

Background: The 1990-2008 estimates for the maternal mortality associated with unsafe abortion require a re-examination.Objective: To provide the latest estimates of the mortality associated with unsafe abortion and to examine trends within the framework of new maternal mortality estimates.Search Strategy: Extensive search of databases and websites for country- and region-specific data on unsafe abortion.Selection Criteria: Reports, papers, and websites with data on unsafe abortion incidence and mortality.Data Collection and Analysis: Earlier published estimates for the unsafe-abortion-related mortality were recalculated by country for 1990, 1997, 2000, and 2003 to harmonize with the new maternal mortality estimates. The resulting estimates were aggregated to give subregional, regional, and global figures, including those recently estimated for 2008.Main Results: In 2008, unsafe abortions accounted for an estimated 47000 maternal deaths, down from 69000 in 1990. Globally, the unsafe-abortion mortality ratio has declined from 50 in 1990 to 30 in 2008. The overall burden of unsafe abortion mortality continues to be the highest in Africa.Conclusions: Important gains have been made in reducing maternal deaths attributable to unsafe abortion. However, 1 in 8 maternal deaths globally and 1 in 5 maternal deaths in Eastern Africa continue to be attributable to unsafe abortion. Averting these preventable deaths can contribute to achieving Millennium Development Goal number 5 of improving maternal health. [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: 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]

Abstract: Of the 4 million neonatal deaths and 500,000 maternal deaths that occur annually worldwide, almost 99% are in developing countries and one-third are associated with infections. Implementation of proven interventions and targeted research on a select number of promising high-impact preventative and curative interventions are essential to achieve Millennium Development Goals for reduction of child and maternal mortality. Feasible, simple, low-cost interventions have the potential to significantly reduce the mortality and severe morbidity associated with infection in these settings. Studies of chlorhexidine in developing countries have focused on three primary uses: 1) intrapartum vaginal and neonatal wiping, 2) neonatal wiping alone, and 3) umbilical cord cleansing. A study of vaginal wiping and neonatal skin cleansing with chlorhexidine, conducted in Malawi in the 1990s suggested that chlorhexidine has potential to reduce neonatal infectious morbidity and mortality. A recent trial of cord cleansing conducted in Nepal also demonstrated benefit. Although studies have shown promise, widespread acceptance and implementation of chlorhexidine use has not yet occurred. This paper is derived in part from data presented at a conference on the use of chlorhexidine in developing countries and reviews the available evidence related to chlorhexidine use to reduce mortality and severe morbidity due to infections in mothers and neonates in low-resource settings. It also summarizes issues related to programmatic implementation. [Copyright &y& Elsevier]

Objective: This paper describes the package of interventions undertaken by the CARE/AMDD program collaboration to increase the availability and quality of emergency obstetric care for 3 high maternal mortality countries in Africa.Methods: Project implementation over 4 years focused on enhancing the capacity of 10 district hospitals in 3 countries - Tanzania, Rwanda and Ethiopia. Interventions were designed to create functional health facilities with trained and competent staff, working in an enabling environment supporting EmOC service delivery.Results: By keeping a clear focus on EmOC, the project achieved modest improvements in services, even in the face of the considerable constraints of rural district hospitals. Availability and utilization of EmOC increased in Tanzania; the met need for EmOC increased slightly from 14% in year 1 to 19% in year 4, while in Rwanda it increased from 16% to 25% over 4 years. Case fatality rates (CFR) declined by 30-50% in all 3 countries. While still well below UN recommendations, in all 3 countries there was also a progressive increase in the cesarean section rates, a life saving obstetric intervention.Conclusions: The increases in met need and decreases in case fatality suggest that project interventions improved the quality and use of EmOC, a critical component for saving women's lives. [ABSTRACT FROM AUTHOR]

Objective: This paper examines the association between birth intervals and infant and child mortality and nutritional status.Methods: Repeated analysis of retrospective survey data from the Demographic and Health Surveys (DHS) program from 17 developing countries collected between 1990 and 1997 were used to examine these relationships. The key independent variable is the length of the preceding birth interval measured as the number of months between the birth of the child under study (index child) and the immediately preceding birth to the mother, if any. Both bivariate and multivariate designs were employed. Several child and mother-specific variables were used in the multivariate analyses in order to control for potential bias from confounding factors. Adjusted odds ratios were calculated to estimate relative risk.Results: For neonatal mortality and infant mortality, the risk of dying decreases with increasing birth interval lengths up to 36 months, at which point the risk plateaus. For child mortality, the analysis indicates that the longer the birth interval, the lower the risk, even for intervals of 48 months or more. The relationship between chronic malnutrition and birth spacing is statistically significant in 6 of the 14 surveys with anthropometric data and between general malnutrition and birth spacing in 5 surveys. However, there is a clear pattern of increasing chronic and general undernutrition as the birth interval is shorter, as indicated by the averages of the adjusted odds ratios for all 14 countries.Conclusion: Considering both the increased risk of mortality and undernutrition for a birth earlier than 36 months and the great number of births that occur with such short intervals, the author recommends that mothers space births at least 36 months. However, the tendency for increased risk of neonatal mortality for births with intervals of 60 or more months leads the author to conclude that the optimal birth interval is between 36 and 59 months. This information can be used by health care providers to counsel women on the benefits of birth spacing. [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]

Vesico-vaginal fistula remains a major public health issue in the developing world. Over 80% of cases result from neglected obstructed labour, and the condition may follow 1–2 per 1000 deliveries, with an annual worldwide incidence of up to 500 000 cases. The principles of investigation and treatment are reviewed in this paper, although national and international strategies aimed at prevention are much more important to the ultimate eradication of this devastating condition. Such strategies much include government recognition of fistulae as a major public health concern, improvement in the status of women in society, the extension of primary education particularly for girls, and affordable, accessible and acceptable services for all pregnant women. [Copyright &y& Elsevier]

Background: Infertility/subfertility could be a formerly unrecognized risk factor for intimate partner violence (IPV).Objectives: To review the evidence on the association between infertility/subfertility in women and the risk of IPV.Search Strategy: Seven databases were searched for articles published in English or Spanish between January 2000 and July 2015.Selection Criteria: Studies were included if they analyzed the relationship between infertility/subfertility and IPV in a quantitative manner.Data Collection and Analysis: A systematic search was completed by one author, and articles meeting the inclusion/exclusion criteria were chosen by two authors. It was not possible to pool the data because of heterogeneity in the study design, the methods, and the definitions of IPV and infertility/subfertility found across the studies. Instead, a narrative report was completed.Main Results: Twenty-one papers met the inclusion/exclusion criteria. The available evidence indicated that infertility/subfertility is associated with IPV in low- and middle-income countries (LMICs).Conclusions: Infertility/subfertility is associated with an increased risk of experiencing IPV in LMICs. Future research should focus on studies with a homogenous design, rigorous methodology, and appropriately selected study and control groups. Qualitative research would also be invaluable to assess the impact of relevant social variables on outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background: In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. Objectives: To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. Results: Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%–38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. Conclusion: The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care. [Copyright &y& Elsevier]

Objective: To evaluate the evidence for prenatal corticosteroid use in low- and middle-income countries and to make recommendations regarding implementation and further research.Methods: Studies and meta-analyses on prenatal corticosteroids relevant to low- and middle-income countries were identified and reviewed at the Maternal and Child Health Integrated Project (MCHIP) Antenatal Corticosteroid Conference held in Washington on October 19, 2010.Results: There is strong evidence regarding the effectiveness of prenatal corticosteroid use in hospitals in high- and middle-income countries, usually in settings with high-level newborn care. For births occurring in hospitals in low-income countries without high-level neonatal care or for births outside hospitals, no studies have been conducted to evaluate prenatal corticosteroid use. The efficacy and safety of prenatal corticosteroid use in these settings must be evaluated.Conclusions: The conference working group recommended expanding the use of prenatal corticosteroids in hospitals with high-level newborn care in low-income countries. For other low-income country settings, further research regarding efficacy and safety should precede the widespread introduction of prenatal corticosteroids. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate pre-eclampsia/eclampsia-associated maternal mortality in high-income countries to understand better the potential improvements in pre-eclampsia/eclampsia-related mortality in low-income countries.Methods: We searched Medline, PubMed, and the Cochrane Database (1900-2010) using relevant search terms. Studies of the incidence of pre-eclampsia/eclampsia and case fatality rates in various geographic regions were included. The incidence of pre-eclampsia/eclampsia and the pre-eclampsia/eclampsia-associated case fatality rates are presented by location and year.Results: Most declines in maternal mortality associated with pre-eclampsia/eclampsia in high-income countries occurred between 1940 and 1970 and were associated with a 90% reduction in the incidence of eclampsia and a 90% reduction in the case fatality rate in women with eclampsia. The most important interventions were widespread use of prenatal care with blood pressure and urine protein measurement, and increased access to hospital care for timely induction of labor or cesarean delivery for women with severe pre-eclampsia or seizures.Conclusions: A substantial reduction in pre-eclampsia/eclampsia-related mortality could be made in low-income countries by widespread hypertension and proteinuria screening and early delivery of women with severe disease. Magnesium sulfate may reduce mortality, but should not be the cornerstone of maternal mortality reduction programs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the quality of costing studies of post-abortion care from low- and middle-income countries and to describe costs in various settings.Methods: A systematic review identified unit costs. Descriptive statistical analysis and univariate regression analysis identified drivers of unit costs of post-abortion care.Results: There are few cost studies from Asia or Eastern Europe. Data indicate that the cost (in 2007 international dollars) of post-abortion care in Africa and Latin America is $392 and $430, respectively, per case.Conclusion: Differences in post-abortion care costs were associated with region, procedure, facility level, case severity, and whether the study was operations research. Methods varied between studies, and efforts should be made in future research to improve consistency. Additional data are needed from Asia and Eastern Europe, as well as the costs of medical methods of uterine evacuation. These data justify improved access to contraception and safe, legal abortion. [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]

Abstract: The brain drain of health workers occurs mostly from low- and low/middle-income countries to resource-rich countries and from rural to urban areas. Shortage and uneven distribution of healthcare workers aggravated by the brain drain from Africa, Asia, and Pacific countries has contributed to impaired reproductive and sexual health services and the high rate of maternal and newborn mortality and morbidity in these counties. Brain drain impedes maternal, neonatal, and child health and the fight against HIV/AIDS, and translates into loss of potential employers, teachers, and role models. Source countries spend US$ 500 million each year to educate health workers who leave their home countries for North America, Western Europe, and South Asia. A code of practice on international recruitment of health personnel is needed. Improving the health workforce database, wages, health resources and working conditions, task shifting, pay-back from recipient countries and migrant health professionals, securing additional investment in the health workforce, and the development of locally relevant medical training and research are useful measures to combat this problem. [Copyright &y& Elsevier]

Abstract: Infertility is a central issue in the lives of many couples who suffer from it. In resource-poor countries the problem of childlessness is even more pronounced compared with Western societies owing to different sociocultural circumstances. It often leads to severe psychological, social, and economic suffering, and access to infertility treatment is often limited to certain procedures and certain costumers. The issue of infertility in resource-poor countries is underestimated and neglected, not only by local governments but also by the international nonprofit organizations. Simplification of the diagnostic and therapeutic procedures, minimizing the complication rate, and incorporating fertility centers into existing reproductive healthcare programs are essential measures to take in resource-poor countries if infertility treatment is to be accessible for a large part of the population. For reasons of social justice, a search for strategies to implement simplified methods of infertility diagnosis and treatment in resource-poor countries is urgently warranted. [Copyright &y& Elsevier]

Abstract: The plight of women in poor nonindustrialized countries who have incurred catastrophic childbirth injuries, such as vesico-vaginal and recto-vaginal fistulas, from prolonged obstructed labor is receiving increased attention from the world medical community. While the good intentions that have prompted this greater concern are not in doubt, intentions by themselves are insufficient guarantees of ethical conduct in programs developed to repair these injuries. Clinical proposals put forward to deal with the problem of fistula must undergo critical analysis to insure that basic ethical requirements are met. This article emphasizes the vulnerability to exploitation of women with obstetric fistulas and reviews the basic principles of medical ethics relevant to fistula care. [Copyright &y& Elsevier]

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]

Objective: Maternal mortality and stillbirths are important adverse pregnancy outcomes, especially in developing countries. Because underlying causes of both outcomes appeared similar, the relationship between maternal mortality, stillbirth and three measures of obstetrical care were studied.Methods: Using data provided by the World Health Organization from 188 developed and developing countries, correlations and linear regression analyses between maternal mortality and stillbirth rates and cesarean section rates, skilled delivery attendance, and >or=4 prenatal visits) were developed.Results: Stillbirth and maternal mortality rates were strongly correlated, with about 5 stillbirths for each maternal death. However, the ratio increased from about 2 to 1 in least developed countries to 50 to 1 in the most developed countries. In developing countries, as the cesarean section rates increased from 0 to about 10%, both maternal mortality and stillbirth rates decreased sharply. Skilled delivery attendance was not associated with significant reductions in maternal mortality or stillbirth rates until coverage rates of about 40% were achieved. Four or more antenatal visits were not associated with significant reductions in maternal deaths until about 60% coverage was achieved. The same measure was associated with only modest decreases in stillbirth.Conclusion: Across countries, stillbirth was significantly associated with maternal mortality. Both stillbirth and maternal mortality were similarly related to all three measures of obstetric care. An increase in cesarean section rates from 0 to 10% was associated with sharp decreases in both maternal mortality and stillbirths. [ABSTRACT FROM AUTHOR]

Objective: To conduct a systematic review of the literature on stillbirths in developing countries.Method: Review of the English literature for all articles related to stillbirth in developing countries published from 1975 to 2005.Results: Because almost half of the deliveries in developing countries occur at home, under-reporting of stillbirths is a huge problem, and reliable data about rates and causes are difficult to obtain. Hospital stillbirth data are often subject to substantial bias and the ability to generalize from these data is unknown. Nevertheless, at least 4 million stillbirths occur yearly, the vast majority in developing countries, with rates in many developing countries ten-fold higher than elsewhere. Prolonged and obstructed labor, preeclampsia and various infections, all without adequate treatment, account for the majority of stillbirths.Conclusion: Despite the large number of stillbirths worldwide, the topic of stillbirths in developing countries has received very little research, programmatic or policy attention. Better access to appropriate obstetric care, especially during labor, should reduce developing country stillbirth rates dramatically. [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: With support from the Averting Maternal Death and Disability (AMDD) Program, CARE began the FEMME Project in 2000 to increase access and utilization of emergency obstetric care (EmOC) services for the approximately 48,000 pregnant women in the northern provinces of Ayacucho.Methods: The project targeted 5 facilities with a comprehensive package of interventions designed to improve capacity to provide quality EmOC services and to promote a human rights approach in health care. Key program activities included improvements in infrastructure, human resources capacity development, development of service standards and protocols, quality improvement activities, and promoting a rights-based approach to health.Results: By the end of the project, northern Ayacucho had 6 functioning EmOC facilities: 3 comprehensive (including a non-FEMME project facility) and 3 basic. This exceeds the UN minimum recommendation of 5 EmOC facilities per 500,000 population. Other changes in the UN process indicators indicate an increase in quality and utilization of EmOC services. Met need for EmOC increased significantly from 30% in 2000 to a high of 84% in 2004. Case fatality rates declined and the number of maternal deaths in the entire region declined.Conclusion: CARE's work in Ayacucho made an impact on policies and programs related to EmOC throughout the region. Within CARE, project experiences have supported maternal health programs particularly in the Latin American/Caribbean region. [ABSTRACT FROM AUTHOR]

Abstract: Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject™ have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth. [Copyright &y& Elsevier]

Objective: To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh.Method: From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum.Result: Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions.Conclusion: A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed. [ABSTRACT FROM AUTHOR]

Cervical cancer is a significant health problem among women in developing countries. Contributing to the cervical cancer health burden in many countries is a lack of understanding and political will to address the problem. Broad-based advocacy efforts that draw on research and program findings from developing-country settings are key to gaining program and policy support, as are cost-effectiveness analyses based on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken advocacy efforts at the international, regional, national, and local levels to raise awareness and understanding of the problem (and workable solutions), galvanize funders and governments to take action, and engage local stakeholders in ensuring program success. ACCP experience demonstrates the role that evidence-based advocacy efforts play in the ultimate success of cervical cancer prevention programs, particularly when new screening and treatment approaches-and, ultimately, radically new approaches such as a human papillomavirus vaccine-are available. [ABSTRACT FROM AUTHOR]

Abstract: The goals of any cervical cancer prevention program should be threefold: to achieve high coverage of the population at risk, to screen women with an accurate test as part of high-quality services, and to ensure that women with positive test results are properly managed. This article focuses on the experiences of the Alliance for Cervical Cancer Prevention (ACCP) in delivery of screening and treatment services as part of cervical cancer prevention projects in Africa, Latin America, and Asia. Research and experience show that cervical cancer can be prevented when strategies and services are well planned and well managed and when attention is paid to program monitoring and evaluation. Coordination of program components, reduction of the number of visits, improvement of service quality, and flexibility in how services are delivered are all essential features of an effective service. [Copyright &y& Elsevier]

Objective: To identify the extent of demand for birth spacing, according to age and parity among married women of reproductive age (MWRA) in developing countries.Methods: Secondary analysis of data from the Demographic and Health Surveys (DHS) using cross-tabulations. Data collected from nationally representative samples of MWRA in selected developing countries between 1990 and 2004.Results: Demand for birth spacing is the most prevalent reason for an interest in family planning among married women aged 15-29 years in the majority of developing countries examined. In the 15-19-year age cohort, the demand for spacing is proportionally the most prevalent reason for a demand for family planning. A demand for spacing even exists among young, zero-parity married women in each country examined. Findings on the demand for spacing among zero-parity married women quantifies the expressed desire of some married women in developing countries to postpone a first birth or the timing of a first pregnancy.Conclusion: The substantial demand for birth spacing among young, low- and zero-parity women suggests that family planning programs in developing countries may need to reevaluate how accessible services are for this cohort of potential contraception users. Currently, many service-delivery protocols, counseling practices and service provider training may not fully address the needs of younger, low- or zero-parity clients. [ABSTRACT FROM AUTHOR]

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

Objective: To identify information and service delivery needs for obstetric/gynecologic uses of misoprostol in developing countries.Methods: The study included a survey of reproductive health providers in 23 countries and a qualitative study of misoprostol use in four developing countries. Researchers used purposive sampling methods for the survey and qualitative study and conducted a descriptive statistical analysis of survey data and computer-assisted text-based content analysis of qualitative data.Results: In some developing countries, women frequently access misoprostol through pharmacies and self-medicate to induce early abortion. Some clinicians expressed concern about this use of misoprostol, but many stated that its availability had reduced serious complications resulting from unsafe abortions.Conclusion: Although misoprostol is routinely used for a range of off-label obstetric/gynecologic indications, evidence-based, up-to-date information about safety, effectiveness, and appropriate regimens is not widely available. This information is requested by providers, including pharmacists. Women need information and guidance about its use. [ABSTRACT FROM AUTHOR]

Objective: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia.Method: One intervention (St. Catherine) and two control (St. Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system.Results: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13-0.27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved.Conclusion: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy and acceptability of a patient-held pictorial card aimed at raising awareness and appropriate health seeking behavior in response to prodromal symptoms of imminent eclampsia.Method: Pictorial cards (and posters) were issued to antenatal clinics and used to focus instruction and advice to pregnant women. Mothers were surveyed before and after the cards were introduced to assess maternal likelihood of seeking care if edema was seen, and of attending hospital if so advised. We monitored the eclampsia rate. Health workers were interviewed 6 months after cards and posters were issued to determine the acceptability of using the cards as part of routine antenatal care.Results: The card was seen as widely acceptable by health professionals, and increased their own awareness of the prodromal symptoms of eclampsia and their discussion of these symptoms with antenatal mothers. Mothers' awareness and response to symptoms improved significantly and there was a marked drop in eclampsia incidence. Suggested improvements to the card were made by mothers and health workers.Conclusion: The cost of providing a card for every pregnant mother is likely to be offset by health service delivery savings. [ABSTRACT FROM AUTHOR]

Abstract: International research partnerships bring together some of the best and the brightest in an effort to tackle global health problems. Such collaborations also pose complex challenges, such as maintaining ethical principles in the conduct of research in developing nations. In implementing a randomized clinical trial to reduce postpartum hemorrhage (PPH) during childbirth in rural India, U.S. and Indian collaborators addressed three such issues: the appropriateness of an ethical randomized controlled trial in the developing world, the inclusion of a placebo arm, and the relevance of informed consent in a semiliterate rural population. [Copyright &y& Elsevier]

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers'' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided. [Copyright &y& Elsevier]

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

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

We describe the iterative process of developing a locally-appropriate quality of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. We describe the context of maternal health issues in Nepal, the rationale for developing a quality of care approach within a model to improve EmOC, and outline the outcomes and catalytic effects of the process. The lessons learned during the development of this approach are detailed. The program developed and implemented a quality of care approach at three district hospitals in Nepal. This resulted in improvements in the structure, process and outcomes of EmOC in these institutions. The process also resulted in improved understanding of quality of care approaches on both local and national levels and the creation of a Nepalese quality of care evaluation framework for maternity services. While the theoretical concept of quality of care is difficult to translate into a concrete approach, we used a process in rural hospitals in Nepal that created highly motivated teams and improved the overall functioning of these hospitals. [ABSTRACT FROM AUTHOR]

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: To identify new and underutilized technologies that may assist in reducing maternal mortality due to obstetric hemorrhage.Methods: Review of published and unpublished literature, including systematic reviews of randomized trials and individual clinical studies.Results: Hemorrhage, primarily postpartum, accounts for approximately 25% of maternal deaths globally. Uterotonic drugs offer great promise for both prevention and management of postpartum hemorrhage (PPH). Other technologies--such as anti-shock garments, umbilical vein injection of oxytocin, and simple anemia detection methods--represent potential new opportunities to reduce PPH-related mortality.Conclusions: Clinical and operational research is needed to answer remaining questions about misoprostol, the anti-shock garment, and umbilical vein injection of oxytocin for retained placenta. Efforts are needed to ensure the availability of technologies with proven value, such as oxytocin in Uniject prefilled injection devices. Equally important, technologies and techniques with proven efficacy--such as active management of third-stage labor and aortic compression--must be translated into general use by disseminating the evidence for them, incorporating them into national guidelines and training curricula, and ensuring the availability of supportive supplies and equipment. [ABSTRACT FROM AUTHOR]

Objective: To identify new and underutilized technologies to reduce maternal mortality related to puerperal sepsis in developing countries.Method: Review of current medical literature.Result: The literature indicates that infection-control protocols and evidence-based procedures--including prophylactic antibiotics for cesarean section or preterm rupture of membranes, and updated antibiotic regimens--should be widely adopted. Devices such as hand rubs, needle-disposal systems, and rapid microbiological diagnostic tests can improve compliance and efficiency. Operational research on promising developments like vaginal cleansing with antiseptics, vitamin A supplementation, and prophylactic antibiotics in high-risk women is needed.Conclusion: Sepsis management continues to depend on good implementation of established technologies. Program-based approaches are required to improve uptake. [ABSTRACT FROM AUTHOR]

Objectives: To review the evidence on appropriate transport and communications technologies for obstetrical referrals in developing countries.Methods: Review of articles published in peer-reviewed journals and gray literature, supplemented by email and telephone consultations with key informants and field programmers.Results: A wide range of transportation options have been attempted. Initial approaches--such as those relying on ambulances owned and operated by health systems--have evolved into recommendations that emphasize community-based solutions. There are fewer options within the realm of communications technologies, and the recommendations are more consistent. Public health researchers are only beginning to evaluate the cost and effectiveness of different options.Conclusions: One of the greatest barriers to effective use of transport and communications for obstetric emergencies is the short time interval necessary for action, which limits options for obstetric referrals more than for other medical referrals. Although evidence is still scarce, experience suggests that motorized transport is likely to be the most acceptable and effective transportation option. More sophisticated communications technologies such as cell phones are both practical and effective, and are increasingly becoming the technologies of choice for low-resource settings. [ABSTRACT FROM AUTHOR]

Objectives: To identify and describe constraints facing the development and dissemination of technologies appropriate for public health care challenges and solutions in the developing world.Methods: Review of lessons learned in development and introduction of numerous health technologies as experienced by a non-profit organization working on technologies for 25 years.Results: Many obstacles prevent appropriate technologies from reaching widespread use and acceptance. These include low profit margins in developing world markets, regulatory constraints, and the need for systems changes. Strong public/private-sector partnerships and realistic approaches to working in these environments make a difference.Conclusions: There is a growing awareness of the need for new technologies and experience with strategies that can make them happen. Some technologies with documented value for maternal care in developing world settings appear to be stuck short of widespread acceptance and use. Understanding the factors impeding their progress can enable the public sector and its collaborators to organize and facilitate their progress more effectively. [ABSTRACT FROM AUTHOR]