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Burundi has one of the highest maternal mortality ratios (MMR) in the world, estimated at 740 maternal deaths per 100 000 live births.1 The United Nations Millennium Development Goal 5 (MDG 5) aimed to reduce the MMR by 75% between 1990 and 2015.2 This has now been replaced by Sustainable Development Goal 3 (SDG 3), which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.3 Most sub-Saharan African countries, including Burundi, are lagging far behind in achieving these desired targets.4 Two previous studies from Burundi showed that offering dedicated emergency obstetric and neonatal care (EmONC), coupled with an efficient ambulance referral network, can rapidly reduce maternal mortality in a rural district setting. This was cited as a possible way forward for achieving and sustaining MDG 5 in sub-Saharan Africa.5,6 Tayler-Smith et al. reported that over 30% of all women transferred from health centres with severe acute maternal morbidity and requiring EmONC underwent a caesarean section (C-section).5 Although a C-section is an immediate and lifesaving surgical intervention, it increases the risk of uterine rupture in future pregnancies.7–9 This risk is accentuated if the inter-pregnancy interval (IPI) is less than 24 months.10 Burundi is known to have high fertility rates of 6.2 per woman compared to 1.8/woman in a country like Belgium.11 Burundi also has very low uptakes of family planning and limited general access to EmONC services.12 These factors further contribute to the risk of uterine rupture and maternal death in a pregnancy that follows a C-section.9 While there are studies from high-income countries on maternal outcomes after a C-section,13 no study from rural Africa has prospectively assessed the status of mothers at household level and as long as 2 years after a C-section. Similarly, no studies have collectively reported on the uptake of family planning, incident pregnancies and the IPI at household-level. Existing knowledge on these issues has been limited to cohorts of women who return to hospital, and is thus subject to selection bias. As these parameters are important determinants of uterine rupture and maternal death in rural Africa, better knowledge of these would help guide maternal health strategies to reduce maternal mortality among vulnerable mothers on the African continent. We aimed to determine the maternal status of women 2 years following a C-section in a district hospital in rural Burundi. Specific objectives were to determine 1) whether complications and/or death had occurred during the post-natal phase, 2) uptake of and compliance with family planning, 3) subsequent pregnancies, 4) the IPI and 5) maternal and neonatal outcomes of subsequent pregnancies.

As neonatal care is being scaled up in economically poor settings, there is a need to know more on post-hospital discharge and longer-term outcomes. Of particular interest are mortality, prevalence of developmental impairments and malnutrition, all known to be worse in low-birthweight neonates (LBW

A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi.To describe the characteristics and in-facility mortality rates of neonates born in 2011.Descriptive study involving a retrospective review of routinely collected facility data.Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia.Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates.Un service de soins d’urgence en obstétrique et soins néonatals de Médecins Sans Frontières dans le Burundi rural, spécialisé comme centre de référence pour trois districts à l’intention des femmes encourant des complications au cours de la grossesse et de l’accouchement.Décrire les caractéristiques et la mortalité lors de l’hospitalisation chez les nouveau-nés nés en 2011.Etude descriptive impliquant une revue rétrospective des données de routine du service.Parmi 2285 femmes qui ont accouché, les complications principales ont été les suivantes:prolongement du travail 331 (14%), arrêt du travail 238 (10%), intervention utérine antérieure 203 (9%), accouchement par le siège 171 (8%) et gestation multiple 150 (7%). On a noté 175 mort-nés et 2110 nouveau-nés en vie parmi lesquels un faible poids de naissance existait chez 515 (24%), un accouchement par césarienne chez 963 (46%) et la nécessité d’une réanimation néo-natale active chez 267 (13%). Au total, il y a eu 102 décès néonatals (5%) et 453 des nouveau-nés (21%) ont été admis dans les services néonatals spécialement axés sur les bébés malades ou à faible poids de naissance. Une proportion plus élevée de ces nouveau-nés étaient nés par césarienne et avaient nécessité une réanimation active à la naissance. On a noté 67 décès néonatals (15%) dans les services spéciaux, parmi lesquels 85% étaient dus à des affections liées au faible poids de naissance ou à l’asphyxie lors de la naissance.Parmi les nouveau-nés nés de femmes ayant encouru des complications au cours de la grossesse ou de l’accouchement, les décès hospitaliers liés à un faible poids de naissance et à une asphyxie à la naissance ont été nombreux. Une attention soutenue s’impose pour réduire ces décès.Un centro de urgencias obstétricas y neonatales dirigido por Médicos Sin Fronteras, especializado como centro de referencia de las mujeres con complicaciones durante el embarazo o el parto de tres distritos rurales de Burundi.Describir las características y la mortalidad intrahospitalaria de los recién nacidos atendidos en el 2011.Fue este un estudio descriptivo que consistió en el examen retrospectivo de los datos recogidos de manera sistemática en la institución.Se atendieron 2285 partos en el período del estudio. Las complicaciones que motivaron con mayor frecuencia la remisión consistieron en: el trabajo de parto prolongado en 331 casos (14%), la detención del trabajo de parto en 238 (10%), el antecedente de cirugía uterina en 203 (9%), presentación de nalgas en 171 (8%) y el embarazo múltiple en 150 mujeres (7%). Se recibieron 175 mortinatos y 2110 recién nacidos vivos, de los cuales 515 presentaron bajo peso al nacer (24%), 963 nacieron por cesárea (46%) y 267 neonatos precisaron reanimación activa al nacimiento (13%). En general, se presentaron 102 (5%) muertes neonatales. Se admitieron 453 neonatos en los servicios neonatales especiales que atienden a los recién nacidos enfermos o con bajo peso (21%). La mayoría de estos neonatos nació por cesárea y precisó reanimación activa al nacimiento. Se presentaron 67 casos de muerte neonatal en los servicios especiales (15%), de los cuales el 85% por complicaciones derivadas del bajo peso al nacer y la asfixia del nacimiento.En los neonatos que nacieron de mujeres que presentaron complicaciones durante el embarazo o el parto fue considerable la mortalidad intrahospitalaria asociada con el bajo peso al nacer y la asfixia del nacimiento. Es preciso reforzar la atención con el fin de evitar estas situaciones.

Setting: Although neonatal mortality is gradually decreasing worldwide, 98% of neonatal deaths occur in low- and middle-income countries, where hospital care for sick and premature neonates is often unavailable. Medecins Sans Frontieres Operational Centre Brussels (MSF-OCB) managed eight specialised neonatal care units (SNCUs) at district level in low-resource and conflict-affected settings in seven countries. Objective: To assess the performance of the MSF SNCU model across different settings in Africa and Southern Asia, and to describe the set-up of eight SNCUs, neonate characteristics and clinical outcomes among neonates from 2012 to 2015. Design: Multicentric descriptive study. Results: The MSF SNCU model was characterised by an absence of high-tech equipment and an emphasis on dedicated nursing and medical care. Focus was on the management of hypothermia, hypoglycaemia, feeding support and early identification/treatment of infection. Overall, 11 970 neonates were admitted, 41% of whom had low birthweight (

Objectives To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Medecins Sans Frontieres (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. Methods The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. Results In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55–99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8–360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). Conclusion Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa. Objectifs Estimer la reduction de la mortalite maternelle associee a la prise en charge des soins obstetricaux d'urgence fournie par Medecins Sans Frontieres (MSF) et comparer cela au 5eme Objectif du Millenaire pour le Developpement dans la reduction de la mortalite maternelle. Methodes L'impact de l'intervention de MSF a ete modelise en estimant le nombre de deces evites chez les femmes transferees et traitees dans les services pour les soins obstetricaux d'urgence de MSF a Kabezi, au Burundi avec une morbidite maternelle severe aigue. Sur base de cette estimation, le taux theorique resultant de la mortalite maternelle a Kabezi a ete calcule et compare au 5eme Objectif de Developpement du Millenaire pour le Burundi. Resultats En 2011, 1385 femmes de Kabezi ont ete transferees au centre de MSF, dont 55% avec des morbidites severes aigues. Nous avons estime que l'intervention de MSF a evite 74% (intervalle 55-99%) des deces maternels dans le district de Kabezi, ce qui equivaut a un taux de mortalite maternelle du district de 208 (intervalle 8-360) deces/100.000 naissances vivantes. Cela se rapproche assez de la cible 2015 de l’OMD5 pour le Burundi (285 deces pour 100.000 naissances vivantes). Conclusion La fourniture de soins obstetricaux d'urgence de qualite combinee avec un systeme de transfert des patients fonctionnel peut etre associee a une reduction rapide et substantielle de la mortalite maternelle, et peut donc etre une voie possible pour atteindre l'Objectif 5 du Millenaire pour le Developpement en Afrique rurale. Objetivos Calcular la reduccion en la mortalidad materna asociada con las urgencias obstetricas suministradas por Medicos Sin Fronteras (MSF), y comparar estos resultados con el quinto Objetivo de Desarrollo del Milenio (ODM) de reducir la mortalidad materna. Metodos El impacto de la intervencion de MSF se modelo calculando cuantas muertes pudieron evitarse entre mujeres transferidas a y tratadas en las instalaciones para cuidados obstetricos de emergencia de MSF en Kabezi, Burundi con una gran morbilidad materna aguda. Utilizando esta estimacion, se calculo la tasa de mortalidad materna teorica en Kabezi y se comparo al ODM para Burundi. Resultados En el 2011, 1385 mujeres de Kabezi fueron transferidas a la instalacion de la MSF, y de ellas un 55% tenian una morbilidad materna aguda severa. Calculamos que la intervencion de MSF evito un 74% (rango 55-99%) de las muertes maternas en el distrito de Kabezi, igualandolas a un distrito con una tasa de mortalidad materna de 208 (rango 8–360) muertes/100,000 nacidos vivos. Esto esta muy cerca del objetivo del ODM de 2015 para Burundi (285 muertes/100,000 nacidos vivos). Conclusion La prestacion de servicios obstetricos de emergencia, combinados con un sistema funcional de transferencia de pacientes puede asociarse con una reduccion rapida y sustancial en la mortalidad materna, y puede por lo tanto ser una forma posible de alcanzar el Quinto Objetivo de Desarrollo del Milenio en Africa rural.

Background Death among premature neonates contributes significantly to neonatal mortality which in turn represents approximately 40 % of paediatric mortality. Care for premature neonates is usually provided at the tertiary care level, and premature infants in rural areas often remain bereft of care. Here, we describe the characteristics and outcomes of premature neonates admitted to neonatal services in a district hospital in rural Burundi that also provided comprehensive emergency obstetric care. These services included a Neonatal Intensive Care Unit (NICU) and Kangaroo Mother Care (KMC) ward, and did not rely on high-tech interventions or specialist medical staff. Methods A retrospective descriptive study, using routine programme data of neonates (born at

objectives In 2006, Medecins sans Frontieres (MSF) established an emergency obstetric and neonatal care (EmONC) referral facility linked to an ambulance referral system for the transfer of women with obstetric complications from peripheral maternity units in Kabezi district, rural Burundi. This study aimed to (i) describe the communication and ambulance service together with the cost; (ii) examine the association between referral times and maternal and early neonatal deaths; and (iii) assess the impact of the referral service on coverage of complicated obstetric cases and caesarean sections. methods Data were collected for the period January to December 2011, using ambulance log books, patient registers and logistics records. results In 2011, there were 1478 ambulance call-outs. The median referral time (time from maternity calling for an ambulance to the time the patient arrived at the MSF referral facility) was 78 min (interquartile range, 52–130 min). The total annual cost of the referral system (comprising 1.6 ambulances linked with nine maternity units) was € 85 586 (€ 61/obstetric case transferred or € 0.43/capita/year). Referral times exceeding 3 h were associated with a significantly higher risk of early neonatal deaths (OR, 1.9; 95% CI, 1.1–3.2). MSF coverage of complicated obstetric cases and caesarean sections was estimated to be 80% and 92%, respectively. conclusion This study demonstrates that it is possible to implement an effective communication and transport system to ensure access to EmONC and also highlights some of the important operational factors to consider, particularly in relation to minimising referral delays.