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Background: Ethiopia has one of the highest maternal mortality ratios in Africa. Few have examined the quality of labour and delivery (L&D) care in the country. This study evaluated the quality of routine L&D care and identified patient-level and hospital-level factors associated with the quality of care in a subset of government hospitals. Materials and methods: This was a facility-based, cross-sectional study using direct non-participant observation carried out in 2016. All mothers who received routine L&D care services at government hospitals (n = 20) in one of the populous regions of Ethiopia, Southern Nations Nationalities and People's Region (SNNPR), were included. Mixed effects multilevel linear regression modeling was employed in two stages using hospital as a random effect, with quality of L&D care as the outcome and selected patient and hospital characteristics as independent variables. Patient characteristics included woman's age, number of previous births, number of skilled attendants involved in care process, and presence of any danger sign in current pregnancy. Hospital characteristics included teaching hospital status, mean number of attended births in the previous year, number of fulltime skilled attendants in the L&D ward, whether the hospital had offered refresher training on L&D care in the previous 12 months, and the extent to which the hospital met the 2014 Ethiopian Ministry of Health standards regarding to resources available for providing quality of L&D care (measured on a 0–100% scale). These standards pertain to availability of human resource by category and training status, availability of essential drugs, supplies and equipment in L&D ward, availability of laboratory services and safe blood, and availability of essential guidelines for key L&D care processes. Results: On average, the hospitals met two-thirds of the standards for L&D care quality, with substantial variation between hospitals (standard deviation 10.9 percentage points). While the highest performing hospital met 91.3% of standards, the lowest performing hospital met only 35.8% of the standards. Hospitals had the highest adherence to standards in the domain of immediate and essential newborn care practices (86.8%), followed by the domain of care during the second and third stages of labour (77.9%). Hospitals scored substantially lower in the domains of active management of third stage of labour (AMTSL) (42.2%), interpersonal communication (47.2%), and initial assessment of the woman in labour (59.6%). We found the quality of L&D care score was significantly higher for women who had a history of any danger sign (β = 5.66; p-value = 0.001) and for women who were cared for at a teaching hospital (β = 12.10; p-value = 0.005). Additionally, hospitals with lower volume and more resources available for L&D care (P-values < 0.01) had higher L&D quality scores. Conclusions: Overall, the quality of L&D care provided to labouring mothers at government hospitals in SNNPR was limited. Lack of adherence to standards in the areas of the critical tasks of initial assessment, AMTSL, interpersonal communication during L&D, and respect for women's preferences are especially concerning. Without greater attention to the quality of L&D care, regardless of how accessible hospital L&D care becomes, maternal and neonatal mortality rates are unlikely to decrease substantially. [ABSTRACT FROM AUTHOR]

Problem Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress. Approach We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intra partum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services. Local setting Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals. Relevant changes Significant improvements in quality of intrapartum care were detected from baseline (June-July 2015) to follow-up (February-March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001). Lessons learnt The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries. Qualite de ses hopitaux depuis plus de dix ans, et cet outil a ete integre aux mecanismes existants d'amelioration de la qualite de ces hopitaux principaux, avec la perspective de l'etendre eventuellement a tous les hopitaux gouvernementaux. Changements significatifs Des ameliorations considerables de la qualite des soins intrapartum ont ete constatees entre les donnees initiales (juin a juillet 2015) et les donnees de suivi (fevrier a mars 2016) dans les hopitaux cibles. Le score global moyen de la qualite est passe de 65,6 (ecart type, ET: 10,5) a 91,2 (ET: 12,4) pour les 110 elements evalues (P < 0,05). Lecons tirees La methode etait realisable, necessitant pour chaque visite troisjours et entre deux ettrois collecteurs de donnees experimentes. Elle a permis d'obtenir des donnees refletant les changements importants survenus en huit mois d'efforts d'amelioration de la qualite des hopitaux nationaux. Moyennant des etudes de reiteration complementaires, cet outil pourrait etre utile dans d'autres regions a revenu faible et intermediaire. Probleme La mortalite maternelle et la mortalite neonatale restent elevees dans les pays a revenu faible et intermediaire, oU la qualite insuffisante des soins pratiques pendant l'accouchement constitue un frein a la progression dans ce domaine. Approche Nous avons concu et teste une methode pour evaluer la qualite des soins dispenses aux meres et aux nouveau-nes, qui pourrait etre integree a une initiative nationale de gestion des performances de plus grande envergure. Grace a des observations directes et a l'examen des registres medicaux, notre outil a permis d'attribuer un score de qualite dans neuf domaines de soins intrapartum. Nous avons applique et teste notre outil dans le cadre de la visite des 18 hopitaux principaux ayant chacun la responsabilite de promouvoir et de coordonner les efforts d'amelioration de la qualite au sein d'un groupement d'hopitaux en Ethiopie. Entre les evaluations de depart et les evaluations ulterieures de suivi, le personnel d'une alliance nationale de collaboration pour la qualite a dispense des formations dans les hopitaux sur les services realises pendant le travail et l'accouchement. Environnement local L'Ethiopie investit dans l'amelioration de la integrado a los mecanismos existentes de mejora de la calidad en los hospitales mas importantes, con potencial para llegar a todos los hospitales publicos. Cambios importantes Se detectaron mejoras significativas en la calidad de la atencion durante el parto desde el principio (junio-julio de 2015) hasta el seguimiento (febrero-marzo de 2016) en los hospitales estudiados. La calidad media general obtuvo una puntuacion de 65,6 (desviacion estandar, DE: 10,5) a 91,2 (DE: 12,4) de 110 elementos (P < 0,05). Lecciones aprendidas El metodo fue viable, necesitando un total de tres dias y de dos a tres recopiladores de datos con formacion por visita hospitalaria. Se generaron datos que detectaron grandes cambios durante los ocho meses de trabajos de mejora de la calidad de los hospitales. Con otros estudios de reproduccion, esta herramienta podria resultar util en otros paises con ingresos bajos y medios. Situacion La mortalidad materna y neonatal sigue siendo alta en paises con ingresos bajos y medios, siendo la escasa calidad de atencion durante el parto un impedimento para hacer progresos. Enfoque Se desarrollo y probo un metodo de calculo de la calidad de la atencion materna y neonatal que podria aplicarse en una gran iniciativa nacional de gestion del rendimiento. La herramienta utilizo observaciones directas y revisiones de historiales medicos para puntuar la calidad en nueve dominios de atencion durante el parto. La herramienta se piloto y evaluo en visitas a los 18 hospitales mas importantes con responsabilidad para fomentar y coordinar esfuerzos de mejora de la calidad de un conglomerado de hospitales en Etiopia. Entre las primeras evaluacionesy las de seguimiento, el personal de una colaboracion nacional de calidad proporciono formacion hospitalaria sobre el parto. Marco regional Etiopia ha invertido en mejoras de la calidad de los hospitales durante mas de una decada y esta herramienta se ha, Introduction Maternal mortality remains high in most low-and middle-income countries, and poor quality of intrapartum care limits further progress. (1, 2) Pregnancy- or childbirth-related complications lead to more than 380 [...]

Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector's readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government's vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort--rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders. De nombreux pays s'efforcent d'elaborer et de mettre en oeuvre des strategies pour controler les hopitaux a l'echelle nationale. C'est un defi de taille, en particulier pour les pays a faible revenu, qui disposent de peu de ressources pour effectuer des mesures et des comptes-rendus. Nous avons analyse l'experience qui a consiste a elaborer et mettre en oeuvre un systeme national de controle des performances de 130 hopitaux publics en Ethiopie. Des observations participatives ont revele que ce systeme de controle a entraine une communication plus systematique des donnees sur les performances aux bureaux regionaux de la sante et au gouvernement federal de la part des hopitaux, a ameliore la transparence concernant les performances de ces derniers et a permis d'elaborer plusieurs projets d'amelioration de la qualite, ^elaboration et la mise en oeuvre de ce systeme, qui ont necessite des investissements et des soutiens techniques et politiques, n'auraient pas ete possibles sans d'importantes capacites de gestion dans les hopitaux. Il peut etre utile, aux premiers stades de la conception et de la mise en oeuvre, d'evaluer de maniere approfondie l'ouverture au changement du secteur de la sante ainsi que son souhait de placer au premier plan la qualite des services hospitaliers. Cette evaluation peut s'appuyer sur des entretiens avec des informateurs cles, sur la collecte de donnees au sujet des etablissements de sante et des ressources humaines, ou encore sur une discussion avec des partenaires universitaires. Le fait d'associer des partenaires et des donateurs a l'objectif d'amelioration de la qualite vise par le gouvernement peut permettre de renforcer son acceptabilite ainsi que le soutien politique en la matiere. Cela peut permettre de faire converger les ressources de facon strategique vers un meme effort national, plutot que de les eparpiller dans des dizaines de projets potentiellement concurrents. Au cours des premieres phases, il est benefique d'avoir des objectifs modestes et de faire preuve de souplesse afin de permettre des modifications et une amelioration continues, par le biais d'un engagement actif aupres de l'ensemble des parties prenantes. Muchos paises tienen dificultades para desarrollar e implementar estrategias a nivel nacional para monitorizar los hospitales. El reto es especialmente complicado en paises de ingresos bajos donde los recursos para la medicion y la notificacion son escasos. Se examino la experiencia a la hora de desarrollar e implementar un sistema nacional para monitorizar el rendimiento de 130 hospitales del gobierno en Etiopia. Haciendo uso de una observacion participativa, se observo que el sistema de monitorizacion se tradujo en una notificacion de datos de rendimiento de los hospitales mas coherente a las oficinas de salud regionales y al gobierno federal, asi como un incremento en la transparencia sobre el rendimiento de los hospitales y el desarrollo de diferentes proyectos para la mejora de la calidad. El desarrollo y la implementacion de dicho sistema, que requeria de inversiones y soporte tanto tecnico como en materia de inversion, no hubieran sido posibles sin una fuerte habilidad de gestion a nivel hospitalario. Una meticulosa valoracion de la disposicion del sector sanitario a cambiar y del deseo de este a priorizar la calidad hospitalaria podria ser de gran ayuda en las primeras fases del diseno y la implementacion. Esta evaluacion podria incluir entrevistas con informadores clave, una recopilacion de datos sobre instalaciones sanitarias, recursos humanos y debates con asociados del mundo academico. Poner en consonancia la vision del gobierno sobre la mejora de la calidad con los asociados y contribuyentes puede hacer aumentar la aceptacion y el apoyo politico. Dicho alineamiento puede permitir una focalizacion estrategica de los recursos respecto a un solo esfuerzo nacional, antes que esparcirlo en docenas de proyectos potencial mente conflictivos. Las fases iniciales son las principales beneficiadas de tener objetivos modestos y flexibilidad para modificar y mejorar de forma continua, a traves de un compromiso activo con todos los accionistas., Introduction Improvement in the quality of hospital care is a fundamental aspect of health system strengthening (1-4) that is directly linked to the service delivery dimension of the World Health [...]

Objective To conduct a cross-national comparative study of the prevalence and correlates of female genital cutting (FGC) practices and beliefs in western Africa. Methods Data from women who responded to the Multiple Indicator Cluster Surveys between 2005 and 2007 were used to estimate the frequencies of ever having been circumcised, having had a daughter circumcised, and believing that FGC practices should continue. Weighted logistic regression using data for each country was performed to determine the independent correlates of each outcome. Findings The prevalence of FGC was high overall but varied substantially across countries in western Africa. In Sierra Leone, Gambia, Burkina Faso and Mauritania, the prevalence of FGC was 94%, 79%, 74% and 72%, respectively, whereas in Ghana, Niger and Togo prevalence was less than 6%. Older age and being Muslim were generally associated with increased odds of FGC, and higher education was associated with lower odds of FGC. The association between FGC and wealth varied considerably. Burkina Faso was the only country in our study that experienced a dramatic reduction in FGC prevalence from women (74%) to their daughters (25%); only 14.2% of the women surveyed in that country said that they believe the practice should continue. Conclusion The prevalence of FGC in western Africa remains high overall but varies substantially across countries. Given the broad range of experiences, successful strategies from countries where FGC is declining may provide useful examples for high-prevalence countries seeking to reduce their own FGC practices. [TEXT NOT REPRODUCIBLE IN ASCII.] Mutilations genitales feminines: pratiques et croyances actuelles en Afrique de l'Ouest Objectif Realiser une etude comparative transnationale de la prevalence et des indicateurs des pratiques et croyances en matiere de mutilations genitales feminines (MGF) en Afrique de l'Ouest. Methodes Les donnees fournies par des femmes ayant repondu aux enquetes en grappes a indicateurs multiples entre 2005 et 2007 ont servi a estimer la frequence avec laquelle elles avaient ete excisees, avaient fait exciser une ou plusieurs de leurs filles et pensaient que les pratiques de MGF devaient se poursuivre. Une regression logistique ponderee a ete realisee afin de determiner les indicateurs autonomes de chaque resultat. Resultats La prevalence des MGF etait generalement elevee mais variait de maniere significative d'un pays d'Afrique de l'Ouest a l'autre. En Sierra Leone, Gambie, Burkina Faso et Mauritanie, la prevalence des MGF etait de 94%, 79%, 74% et 72%, respectivement, alors qu'au Ghana, Niger et Togo, cette prevalence etait inferieure a 6%. Un age plus avance et le fait d'etre musulmane constituaient des facteurs generalement associes a des risques accrus de MGF et un degre d'education plus eleve etait associe a des risques plus faibles. L'association entre MGF et aisance financiere variait considerablement. Le Burkina Faso etait le seul pays de notre etude a avoir note une diminution spectaculaire des MGF des femmes (74%) a leurs filles (25%); seules 14,2% des femmes interrogees dans ce pays ont declare penser que cette pratique devait se poursuivre. Conclusion La prevalence des MGF en Afrique de l'Ouest reste generalement elevee mais varie de maniere significative d'un pays a l'autre. Compte tenu du large eventail d'experiences, des strategies reussies dans des pays ou les MGF sont en baisse peuvent fournir des exemples utiles a des pays a forte prevalence desireux de diminuer leurs propres pratiques de MGF. [TEXT NOT REPRODUCIBLE IN ASCII.] Mutilacion genital femenina: practicas actuales y creencias en Africa occidental Objetivo Llevar a cabo un estudio comparativo entre paises de artica occidental sobre la prevalencia y correlacion de las practicas de mutilacion genital femenina (MGF) y las creencias relacionadas. Metodos Se emplearon los datos procedentes de las mujeres que respondieron a las Encuestas de Indicadores Multiples por Conglomerados entre 2005 y 2007 para calcular el porcentaje de mujeres que habian sido sometidas a una ablacion, el de hijas de dichas mujeres que habian sido sometidas a una ablacion y la creencia de que las practicas de MGF deberian mantenerse. Se realizo una regresion logistica ponderada empleando los datos procedentes de cada pais para determinar las correlaciones independientes de cada resultado. Resultados La prevalencia de la MGF fue alta en general, si bien variaba de manera sustancial en los diversos paises de africa occidental. En Sierra Leona, Gambia, Burkina Faso y Mauritania, la prevalencia de la MGF fue de un 94%, 79%, 74% y 72%, respectivamente, mientras que en Ghana, Niger y Togo la prevalencia fue inferior al 6%. Una edad mas avanzada y la condicion de musulmana se asociaron generalmente a una mayor probabilidad de haber sufrido una MGF, mientras que se asocio una educacion superior a una menor probabilidad de MGF. La asociacion entre MGF y riqueza variaba ostensiblemente. Burkina Faso fue el unico pais dentro del estudio que experimento una reduccion drastica en la prevalencia de la MGF entre las madres (74%) y las hijas (25%). Solo el 14,2% de las mujeres encuestadas en dicho pais afirmaron considerar que debia continuarse con dicha practica. Conclusion La prevalencia de la MGF en affica occidental sigue siendo elevada en general, si bien varia sustancialmente entre los diversos paises. Teniendo en consideracion la amplia variedad de experiencias, las estrategias fructiferas en paises donde la MGF esta descendiendo podrian servir de ejemplo util a los paises con una mayor prevalencia que deseen reducir sus practicas de MGF., Introduction More than 100 million girls and women have undergone female genital cutting (FGC, also known as 'female circumcision'), and more than 3 million female infants and children are at [...]