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In Ethiopia maternal and perinatal morbidity and mortality remains high. Timely access to quality emergency obstetric and neonatal care is essential for the prevention of adverse outcomes. Training healthcare providers can play an important role in improving quality of care, thereby reducing maternal and perinatal mortality and morbidity. The aim of this study was to evaluate change of knowledge, skills and behaviour in health workers who attended a postgraduate Emergency Obstetric and Newborn Care training in Gondar, Ethiopia. A descriptive study with before-after approach, using a mix of quantitative and qualitative data, based on Kirkpatrick's model for training evaluation was conducted. The evaluation focussed on reaction, knowledge, skills, and change in behaviour in clinical practice of health care providers and facilitator's perspectives on performance. A 'lessons learned approach' was included to summarize facilitators' perspectives. Health care providers reacted positively to the Emergency Obstetric and Newborn Care training with significant improvement in knowledge and skills. Of the 56 participants who attended the training, 44 (79%) were midwives. The main evaluation score for lectures was 4,51 (SD 0,19) and for breakout sessions was 4,52 (SD 0.18) on scale of 1-5. There was a statistically significant difference in the pre and post knowledge (n = 28, mean difference 13.8%, SD 13.5, t = 6.216, p<0.001) and skills assessments (n = 23, mean difference 27.4%, SD 22.1%, t = 5.941, p<0.001). The results were the same for every component of the skills and knowledge assessment. Overall, they felt more confident in performing skills after being trained. Local sustainability, participant commitment and local context were identified as challenging factors after introducing a new training program. In Gondar Ethiopia, the Emergency Obstetric and Newborn Care training has the potential to increase skilled attendance at birth and improve quality of care, both vital to the reduction of maternal and perinatal mortality and morbidity., Competing Interests: The authors have declared that they have no competing interest exists., (Copyright: © 2023 Hulsbergen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers' views on EWS' acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. Health workers reported that the EWS helped them cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use and that scores consistently correlated with the clinical picture of patients. Identified challenges included rotation of clinical staff, low staffing numbers and reduced availability of monitoring equipment. The implementation of EWS improved the frequency of patient monitoring, but a larger study will be required to explore the effect on health outcomes. The EWS is a feasible and acceptable tool in low-resource settings with implementation modifications. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2022 Umar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Globally, low and middle-income countries bear the greatest burden of maternal and newborn mortality. To reduce these high levels, the quality of care provided needs to be improved. This study aimed to develop a patient reported outcome measure for use in maternity services in low and middle-income countries, to facilitate improvements in quality of care. Semi-structured interviews and focus groups discussions were conducted with women who had recently given birth in selected healthcare facilities in Malawi and Kenya. Transcripts of these were analysed using a thematic approach and analytic codes applied. Draft outcomes were identified from the data, which were reviewed by a group of clinical experts and developed into a working copy of the Maternity Patient Reported Outcome Measure (MPROM). A further sample of new mothers were asked to evaluate the draft MPROM during cognitive debriefing interviews, and their views used to revise it to produce the final proposed measure. Eighty-three women were interviewed, and 44 women took part in 10 focus group discussions. An array of outcomes was identified from the data which were categorised under the domains of physical and psychological symptoms, social issues, and baby-related health outcomes. The draft outcomes were configured into 79 questions with answers provided using a five-point Likert scale. Minor revisions were made following cognitive debriefing interviews with nine women, to produce the final proposed MPROM. In conjunction with women from the target population and clinical experts, this study has developed what is believed to be the first condition-specific PROM suitable for assessing care quality in maternity services in low and middle-income countries. Following further validation studies, it is anticipated that this will be a useful tool in facilitating improvements in the quality of care provided to women giving birth in healthcare facilities in these settings., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Charles Ameh is an academic editor for PLoS ONE. The remaining authors have declared that no competing interests exist., (Copyright: © 2022 Dickinson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population., Methods and Findings: A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0-9.3% and still birth (SB) rates ranged from 1.9-6.8%., Conclusions: Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.