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Prenatal care and infant mortality rates are crucial indicators of healthcare quality. However, millions of women in low‐income countries lack access to adequate care. Factors such as high‐risk pregnancies and unmanaged diet increase the risk of developing complications during pregnancy, highlighting the need for continuous monitoring of maternal health. The increasing burden of non‐communicable diseases represents a significant threat to fragile health systems. The lack of access to appropriate prenatal care and poor maternal and newborn health outcomes are major concerns in low‐ and middle‐income countries (LMICs). It emphasizes the need for innovative, integrative approaches to healthcare delivery, especially in pregnant women. The health services need to be reorganized holistically and effectively, focusing on factors that directly impact maternal, neonatal, and infant mortality, resulting in improved access to maternity services and survival of "at‐risk" mothers and their offspring in many LMICs. Based on the FIGO (the International Federation of Gynecology & Obstetrics) recommendations of extending preconception care to the postpartum stage, the authors of this review have developed a new model of care—PregCare—based on the triple‐intervention‐based holistic and multidisciplinary maternal and fetal medicine model for low‐risk pregnancies. This model will help transform the traditional model's high visitation frequency into a safe and reduced office visit, while increasing virtual connections, point of care and self‐care with doctors, nurses, and community‐based providers of self‐care. This shall be based on a sophisticated central PregCare call center powered by innovative technologies combined with experienced personnel in perinatal management (doctors and nurses/midwives). Digital technologies have revolutionized healthcare delivery, expanded treatment options, and improved precision in targeting specific conditions and patient types. In the realm of maternal health, there is a growing recognition of the need for a comprehensive approach encompassing prenatal care, long‐term health care, and integration with existing health programs and services. [ABSTRACT FROM AUTHOR]

Objective: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH‐related maternal deaths in France and the Netherlands. Methods: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH‐related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. Results: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non‐obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. Conclusion: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level. Synopsis: Multinational maternal death reviews provide opportunities for care improvement beyond improvable factors already identified by national maternal death enquiries, through the perspective of a different care context. [ABSTRACT FROM AUTHOR]

Objective: To investigate perceptions of early pregnancy assessment units (EPAUs) among perinatal practitioners working in Belgium, France, and Switzerland.Methods: A prospective multinational survey was conducted between September 1, 2015, and May 21, 2016. Obstetricians, gynecologists, medical doctors, radiologists, and midwives were recruited during meetings, via e-mail invitations, or through the websites of regional obstetrics and gynecology scientific societies. The survey comprised 17 questions that assessed the participants' knowledge, interest, and management of early pregnancy.Results: Of the 871 individuals invited to participate in the survey, 306 (35.1%) responded. Most of the participants were gynecologists and/or obstetricians (225 [73.5%]). A total of 258 (84.3%) participants had no or limited knowledge about EPAUs. Furthermore, 211 (69.0%) participants reported incorrect management when they visualized a gestational sac without embryo and 265 (86.6%) misinterpreted changes in serum levels of chorionic gonadotropin during early pregnancy. In all, 201 (65.7%) participants were interested in collaboration with an EPAU; however, only 125 (40.8%) had sufficient time and resources available to support a patient's psychological distress after early pregnancy loss or salpingectomy.Conclusion: Knowledge about early management of pregnancy was limited among the perinatal practitioners surveyed; however, the concept of EPAUs was welcomed by many. [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence of disrespect and abuse during childbirth and its associated factors in Peru.Methods: In an observational cross-sectional study, women were surveyed within 48 hours of live delivery at 14 hospitals located in nine Peruvian cities between April and July 2016. The survey was based on seven categories of disrespect and abuse proposed by Bowser and Hill. To evaluate factors associated with each category, prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated using adjusted Poisson models with robust variances.Results: Among 1528 participants, 1488 (97.4%) had experienced at least one category of disrespect and abuse. Frequency of abandonment of care was increased with cesarean delivery (PR 1.27, 95% CI 1.03-1.57) but decreased in the jungle region (PR 0.27, 0.14-0.53). Discrimination was associated with the jungle region (PR 5.67, 2.32-13.88). Physical abuse was less frequent with cesarean than vaginal delivery (PR 0.23, 0.11-0.49). The prevalences of abandonment of care (PR 0.42, 0.29-0.60), non-consented care (PR 0.70, 0.57-0.85), discrimination (PR 0.40, 0.19-0.85), and non-confidential care (PR 0.71, 0.55-0.93) were decreased among women who had been referred.Conclusion: Nearly all participants reported having experienced at least one category of disrespect and abuse during childbirth care, which was associated with type of delivery, being referred, and geographic region. [ABSTRACT FROM AUTHOR]

Objective: To compare perinatal outcomes between spontaneous conception and assisted reproductive technologies (ART) among patients of advanced maternal age.Methods: The present retrospective study included data from singleton pregnancies of women aged at least 40 years who delivered between January 1, 1991, and December 31, 2013, at Soroka University Medical Center, Beer Sheva, Israel. Demographic, obstetric, and perinatal data were compared between pregnancies conceived with ART (in vitro fertilization [IVF] or ovulation induction) and those conceived spontaneously. Multiple regression models were used to define independent predictors of adverse outcomes.Results: A total of 8244 singleton pregnancies were included; 229 (2.8%) following IVF, 86 (1.0%) following ovulation induction, and 7929 (96.2%) were spontaneous. Preterm delivery (P<0.001), fetal growth restriction (FGR) (P<0.001), and cesarean delivery (P<0.001) demonstrated linear associations with the conception mode; the highest rates for each were observed for IVF, with decreased rates for ovulation induction and spontaneous conception. The incidence of gestational diabetes and hypertensive disorders were highest among pregnancies following ART. No association was observed between conception mode and perinatal mortality. Multivariate logistic regression demonstrated that IVF was independently associated with increased odds of preterm delivery (P<0.001) and FGR (P=0.027) compared with spontaneous conception.Conclusions: Among patients of advanced maternal age, ART were independently associated with increased FGR and preterm delivery rates compared with spontaneous pregnancies; perinatal mortality was comparable. [ABSTRACT FROM AUTHOR]

Several Central and Eastern European countries have recently enacted retrogressive laws and policies introducing new preconditions that women must fulfill before they can obtain legal abortion services. Mandatory waiting periods and biased counseling and information requirements are particularly common examples of these new prerequisites. The present article considers these requirements in light of international human rights standards and public health guidelines, and outlines the manner in which, by imposing regressive barriers on women's access to legal abortion services, these new laws and policies undermine women's health and well-being, fail to respect women's human rights, and reinforce harmful gender stereotypes and abortion stigma. [ABSTRACT FROM AUTHOR]

Objective: To use a geographic information system (GIS) to determine accessibility to health facilities for emergency obstetric and newborn care (EmONC) and compare coverage with that stipulated by UN guidelines (5 EmONC facilities per 500 000 individuals, ≥1 comprehensive).Methods: A cross-sectional study was undertaken of all public facilities providing EmONC in 24 districts of Bangladesh from March to October 2012. Accessibility to each facility was assessed by applying GIS to estimate the proportion of catchment population (comprehensive 500 000; basic 100 000) able to reach the nearest facility within 2 hours and 1 hour of travel time, respectively, by existing road networks.Results: The minimum number of public facilities providing comprehensive and basic EmONC services (1 and 5 per 500 000 individuals, respectively) was reached in 16 and 3 districts, respectively. However, after applying GIS, in no district did 100% of the catchment population have access to these services. A minimum of 75% and 50% of the population had accessibility to comprehensive services in 11 and 5 districts, respectively. For basic services, accessibility was much lower.Conclusion: Assessing only the number of EmONC facilities does not ensure universal coverage; accessibility should be assessed when planning health systems. [ABSTRACT FROM AUTHOR]

Background: Healthcare measures to prevent maternal deaths are well known. However, effective implementation of this knowledge to change practice remains a challenge.Objectives: To assess whether strategies to promote the use of guidelines can improve obstetric practices in low- and middle-income countries (LMICs).Search Strategy: Electronic databases were searched up to February 7, 2014, using relevant terms for implementation strategies (e.g. "audit," "education," "reminder"), and maternal mortality.Selection Criteria: Randomized and non-randomized studies of implementation strategies targeting healthcare professionals within the formal health services in LMICs were included.Data Collection and Analysis: Cochrane methodological guidance was followed. Because of heterogeneity in the interventions, a narrative synthesis was completed.Main Results: Nine studies met the inclusion criteria. Moderate-to-low-quality evidence was found to show improvement in the areas of doctor-patient communication (one study), analgesic provision (one study), the management of emergencies (two studies) and maternal and late neonatal mortality (one study each). Intervention effects were not consistent across studies.Conclusions: Implementation strategies targeting health professionals could lead to improvement in obstetric care in LMICs. Future research should explore what feature of an intervention is effective in one context and how this could be translated into another context.Prospero: CRD42014010310. [ABSTRACT FROM AUTHOR]

Objective: To characterize delivery practices and factors associated with respectful, evidence-based care at a referral hospital in Western Kenya.Methods: An exploratory observational study used a standardized birth-observation form to record information on patient characteristics and healthcare practitioner behaviors during uncomplicated vaginal deliveries between June 30, 2014 and July 17, 2014. All deliveries were monitored for whether healthcare staff performed six specific evidence-based practices (three maternal and three neonatal practices).Results: In total, 75 vaginal deliveries were observed. In 48 (64%) deliveries, nursing students were the only practitioners present. The mean number of evidence-based practices performed at each delivery was 3.58. The number of evidence-based practices performed by junior practitioners was higher when a nurse educator was assessing their performance (4.47 vs 3.36, P<0.001). Lower mean respectful-care scores were recorded when delivery teams comprised three or more practitioners (1.38; 95% confidence interval 0.93-1.84 vs 2.74; 95% confidence interval 2.16-3.31, P=0.002).Conclusion: The present study found low rates of evidence-based practice and respectful maternity care; this could serve as a deterrent for women seeking care at the study facility. These findings emphasize the need for a comprehensive approach in increasing the quality of patient care to improve maternal and newborn health outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether a hospital-based mentoring program could significantly increase short- and longer-term emergency obstetrics and neonatal care (EmONC) knowledge and skills among health providers.Methods: In a prospective before-and-after study, 20 mentors were trained using a specially-created EmONC mentoring and training program at Bwaila Hospital in Lilongwe, Malawi. The mentors then trained an additional 114 providers as mentees in the curriculum. Mentors and mentees were asked to complete a test before initiation of the training (Pre-Test), immediately after training (Post-Test 1), and at least 6 months after training (Post-Test 2) to assess written and practical EmONC knowledge and skills. Mean scores were then compared.Results: Scores increased significantly between the Pre-Test and Post-Test 1 for both written (n=134; difference 22.9%, P<0.001) and practical (n=125; difference 29.5%, P<0.001) tests. Scores were still significantly higher in Post-Test 2 than in the Pre-Test for written (n=111; difference 21.0%, P<0.001) and practical (n=103; difference 29.3%, P<0.001) tests.Conclusion: A hospital-based mentoring program can result in both short- and longer-term improvement in EmONC knowledge and skills. Further research is required to assess whether this leads to behavioral changes that improve maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Background: Strengthening measurement of the quality of labor and delivery (L&D) care in low-resource countries requires an understanding of existing approaches.Objectives: To identify quantitative indicators of L&D care quality and assess gaps in indicators.Search Strategy: PubMed, CINAHL Plus, and Embase databases were searched for research published in English between January 1, 1990, and October 31, 2013, using structured terms.Selection Criteria: Studies describing indicators for L&D care quality assessment were included. Those whose abstracts contained inclusion criteria underwent full-text review.Data Collection and Analysis: Study characteristics, including indicator selection and data sources, were extracted via a standard spreadsheet.Main Results: The structured search identified 1224 studies. After abstract and full-text review, 477 were included in the analysis. Most studies selected indicators by using literature review, clinical guidelines, or expert panels. Few indicators were empirically validated; most studies relied on medical record review to measure indicators.Conclusions: Many quantitative indicators have been used to measure L&D care quality, but few have been validated beyond expert opinion. There has been limited use of clinical observation in quality assessment of care processes. The findings suggest the need for validated, efficient consensus indicators of the quality of L&D care processes, particularly in low-resource countries. [ABSTRACT FROM AUTHOR]

Objective To create a multi-site registry to enable future large-scale studies of perinatal depression among women attending obstetrics clinics in the USA. Methods A screening and recruitment registry was developed that included women aged at least 18 years who attended seven obstetric clinics in the University of Michigan Health System (Ann Arbor, MI, USA) for prenatal care between September 8, 2008, and June 9, 2011. Participants completed depression screening and research recruitment materials. Results Of 4745 women who returned a screening form, 2983 had completed it, giving an overall agreement rate of 62.9%. A total of 630 participants were enrolled into ten research studies via the registry. Among the 2982 women for whom scores on the Edinburgh Postnatal Depression Scale were available, 494 (16.6%) fell within the at-risk range or had scores suggestive of clinical depression. Conclusion The present registry could improve detection of perinatal depression symptoms and potentially serve as a model for dissemination and implementation at other sites with an interest in studying factors linked to perinatal depression. [ABSTRACT FROM AUTHOR]

Objective To evaluate differences in obstetric care between immigrant and native women in a country with free access to health care. Methods A cross-sectional study was carried out of immigrant mothers delivering in one of the four public hospitals in the Porto, Portugal, metropolitan area between February and December 2012. The comparison group included native Portuguese mothers who delivered in the same institutions. The participants (89 immigrant mothers and 188 Portuguese mothers) were recruited by telephone and completed a written questionnaire during a home visit. Results Immigrant women were more likely to have their first pregnancy appointment after 12 weeks of pregnancy (27.0% vs 14.4%, P = 0.011) and to have fewer than three prenatal visits (2.2% vs 0.0%, P < 0.001). They were also more likely to have had a cesarean delivery (48.3% vs 31.4%, P = 0.023), perineal laceration (48.8% vs 11.6%, P < 0.001), or postpartum hemorrhage (33.5% vs 12.3%, P < 0.001). Conclusion Migrants were more prone to late prenatal care and to intrapartum complications. Unsatisfactory interactions with healthcare staff may play an important role in these findings. [ABSTRACT FROM AUTHOR]

Objective: To determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali. Methods: The present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score. Results: Out of 100, the mean±SD score was 57.8±11.2 for obstetric nurses, 66.4±14.7 for midwifes, and 78.6±13.4 for physicians (P <0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers. Conclusion: Increasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine the knowledge, attitudes, and practices of obstetric care providers (OCPs) in Bugesera District, Rwanda, crucial to the delivery of safe motherhood services. Methods: A quantitative descriptive survey in Kinyarwanda targeting all OCPs in the district was implemented in November 2010 to determine demographic characteristics, safe motherhood knowledge, obstetric practices, and attitudes toward additional training. Results: The study captured 87% of OCPs, of whom 137 of 168 (82%) were A2 level nurses. Most expressed a need to improve their knowledge (60.6%) and skills confidence (72.2%) in safe motherhood. The mean percentage of correct answers of 50 questions assessing overall knowledge was 46.4%; sections on normal labor (39.3% correct) and obstetric complications (37.1% correct) were the weakest. Fundal pressure during vaginal delivery was practiced by 60.8%, and only 15.9% of providers practiced active management of the third stage of labor for all deliveries. Providers supported additional training, and 89.3% expressed willingness to participate in a 2-day workshop even if it were their day off. Conclusion: The study has identified a need to improve safe motherhood knowledge and practices of OCPs in the Bugesera District of Rwanda. OCPs support additional training as an intervention to reduce maternal mortality. [Copyright &y& Elsevier]

Objective: To examine the quality of the maternal health system in Eritrea to understand system deficiencies and its relevance to maternal mortality within the context of Millennium Development Goal (MDG) 5.Methods: A sample of 118 health facilities was surveyed. Data were collected on 5 dimensions of health system quality: availability; accessibility; management; infrastructure; and process indicators. Data on the causes of hospital admissions for obstetric patients and maternal deaths were extracted from medical records.Results: Eritrea has only 11 comprehensive emergency obstetric care (CEmOC) facilities, all of which are grossly understaffed. There is considerable pressure on the infrastructure and health providers at hospitals. Compliance with clinical care standards and availability of supplies were optimal. As a result, the case fatality rate of 0.65% was low. In total, 45.6% of obstetric admissions and 19.5% of maternal deaths were attributed to abortion complications.Conclusion: In Eritrea, critical gaps in the health system-especially those related to human resources-will impede progress toward MDG 5, and it will not be possible to reduce maternal mortality without addressing the high burden of abortion. [ABSTRACT FROM AUTHOR]

Objective: To determine the maternal and perinatal outcome for different types of placenta previa (PP).Methods: A retrospective review of 132 singleton pregnancies with PP. Outcome measures, including the incidence of obstetric hysterectomy, the neonatal Apgar score, and the neonatal weight, were evaluated by logistic regression analysis.Results: The incidence of PP was 1.0%. Of the women with PP, 51.5% had complete PP, 20.5% had incomplete PP, 5.3% had marginal PP, and 22.7% had a low-lying placenta. Most (93.9%) women were delivered by cesarean delivery. In total, 19.7% women underwent obstetric hysterectomy; of these, 92.3% had complete PP. Mothers with 2 or more previous cesarean deliveries had an increased risk for obstetric hysterectomy (P<0.01). The gestational age at delivery was a significant linear predictor of the 5-minute Apgar score. Mothers with incomplete PP delivered neonates with lower Apgar scores than did mothers with complete PP.Conclusion: A history of multiple cesarean deliveries increased the risk for obstetric hysterectomy in women with PP. The type of PP had no effect on maternal and neonatal outcome, with exception of the fact that neonates in the incomplete PP group had lower Apgar scores than neonates in the complete PP group. [ABSTRACT FROM AUTHOR]

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

Objective: To 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 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: 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]

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: 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]

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: 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: 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]

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

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

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

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

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

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

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

Unlabelled: The article summarises the baseline assessments of emergency obstetric care (EmOC) carried out in Uganda, Kenya, Southern Sudan, and Rwanda in 2003 and 2004.Objectives: Our objectives were to: (1) set up program baselines on the availability and utilization of EmOC services in these countries; (2) identify gaps and obstacles in providing EmOC services; and (3) make recommendations to governments based on evidence generated.Methods: Data were collected from clinical record reviews, provider and client interviews, observations, and focus group discussions. Either random or universal sampling was applied in the selection of health facilities assessed. Local nurses and midwives participated in the data collection and, to some extent, data processing and analysis.Results: The coverage of basic EmOC services ranged 0-1.1/500,000 population compared to the UN-recommended level of 4/500,000. The coverage of comprehensive EmOC services ranged 0.5-4.3/500,000 compared to the recommended level of 1/500,000. Between 0.6% and 8.8% of all births took place in EmOC facilities, and 2.1% and 18.5% of all expected direct obstetric complications were treated. Cesarean section as a proportion of all births was between 0.1% and 1%. Shortage of trained staff especially mid-level providers, poor basic infrastructure such as lack of electricity and water supplies, inadequate supply of drugs and essential equipment, poor working conditions and staff morale, lack of communication and referral facilities, cost of treatment, and lack of accountability and proper management were identified as the main obstacles in providing 24-h quality EmOC services especially in remote and rural areas.Conclusions: Lack of basic EmOC services limits women's access to life-saving services during obstetric complications. To reduce maternal mortality ratio the states and development partners need to focus their effort to improve the coverage, quality, and utilization of EmOC services through supportive national policy, effective program strategies, increased budget allocation to maternal health program, rural infrastructure development, and regular monitoring, and evaluation of progress. [ABSTRACT FROM AUTHOR]

Abstract: The United Nations Process Indicators for emergency obstetric care (EmOC) have been used extensively in countries with high maternal mortality ratios (MMR) to assess the availability, utilization and quality of EmOC services. To compare the situation in high MMR countries to that of a low MMR country, data from the United States were used to determine EmOC service availability, utilization and quality. As was expected, the United States was found to have an adequate amount of good-quality EmOC services that are used by the majority of women with life-threatening obstetric complications. [Copyright &y& Elsevier]

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: Our objective was to identify the frequency, causes, and avoidable factors of severe acute maternal morbidity (SAMM) in four non-specialist hospitals in rural South Africa.Method: We conducted a prospective audit using criteria for SAMM suited to the diagnostic and treatment facilities available in the primary hospital setting. For each case of SAMM, a local audit team assessed the standard of care against local management guidelines and examined avoidable factors. An external specialist also retrospectively examined avoidable factors.Result: The facility-based incidence of SAMM was 541 cases per 100,000 births (95% CI 368-767). The commonest organ systems involved were cerebral (42%), coagulation (19%), and vascular dysfunctions (16%). The commonest obstetric diagnoses were eclampsia (39%) and obstetric haemorrhage (32%). Approximately 65% of cases were avoidable.Conclusion: A qualitative case review audit of SAMM in a non-specialist rural setting appears feasible and sustainable, and provides valuable information towards improving deficiencies in maternal care. [ABSTRACT FROM AUTHOR]