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Abstract: This paper aims to highlight the importance of aspiring to achieve universal reporting of maternal deaths as a part of taking responsibility for these avoidable tragedies. The paper first discusses the reasons for reporting maternal deaths, distinguishing between individual case notification and aggregate statistics. This is followed by a summary of the status of reporting at national and international levels, as well as major barriers and facilitators to this process. A new framework is then proposed — the REPORT framework, designed to highlight six factors essential to universal reporting. Malaysia is used to illustrate the relevance of these factors. Finally, the paper makes a Call to Action by FIGO to promote REPORT and to encourage health professionals to play their part in improving the quality of reporting on all maternal deaths — not just those directly in their care. [Copyright &y& Elsevier]

Objective: To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries.Methods: Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized.Results: Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided.Conclusion: The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools. [ABSTRACT FROM AUTHOR]

Objective: 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]

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]

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

The aim of this paper is to describe different approaches to make emergency obstetric care (EmOC) accessible to women in Mozambique. The definitions of basic (BEmOC) and comprehensive EmOC (CEmOC), proposed by the UN agencies, were adopted by FIGO and by the Mozambican Ministry of Health as a general strategy to reduce maternal mortality. Four projects are presented: (1) Jose´ Macamo and (2) Mavalane Hospitals in Maputo city, (3) Manhic¸a District in Maputo Province and (4) Sofala Province. Jose´ Macamo was staffed by physicians 24 h a day; other hospitals by non-physicians trained in surgical and anesthesiology techniques, as well as nurse-midwives. Jose´ Macamo Hospital provided CEmOC to the city of Maputo and the southern area of Maputo Province. In 2001, this hospital attended 32% of deliveries and 38% of cesarean sections in the city, up from 14 and 2.5%, respectively, in 1998. The Mavalane Hospital failed to provide CEmOC; however, the number of deliveries per year almost doubled. The Manhic¸a hospital carried out 31% of the District's C-sections in 2001, up from 9% in 1998. In Sofala Province, one additional CEmOC and four BEmOCs were installed and case fatality rates decreased. In conclusion, the strategy for ensuring provision of EmOC is feasible even in countries with minimal resources and a scarcity of physicians, such as Mozambique. [Copyright &y& Elsevier]

Abstract: The Millennium Development Goals (MDGs) set very high targets for women''s reproductive health through reductions in maternal and infant mortality, among other things. Reductions in maternal mortality and morbidity can be achieved through various different approaches, such as the confidential review of maternal deaths, use of evidence-based treatments and interventions, using a health systems approach, use of information technology, global and regional partnerships, and making pregnancy safer through initiatives that increase the focus on human rights. A combination of these and other approaches can have a synergistic impact on reductions in maternal mortality. This paper highlights some of the current global efforts on safer pregnancy with a focus on reproductive rights. We encourage readers to do more in every corner of the world to advocate for women''s reproductive rights and, in this way, we may achieve the MDGs by 2015. [Copyright &y& Elsevier]

Abstract: In the last few years there have been several critical milestones in acknowledging the centrality of human rights to sustainably addressing the scourge of maternal death and morbidity around the world, including from the United Nations Human Rights Council. In 2012, the Council adopted a resolution welcoming a Technical Guidance on rights-based approaches to maternal mortality and morbidity, and calling for a report on its implementation in 2years. The present paper provides an overview of the contents and significance of the Guidance. It reviews how the Guidance can assist policymakers in improving women''s health and their enjoyment of rights by setting out the implications of adopting a human rights-based approach at each step of the policy cycle, from planning and budgeting, to ensuring implementation, to monitoring and evaluation, to fostering accountability mechanisms. The Guidance should also prove useful to clinicians in understanding rights frameworks as applied to maternal health. [Copyright &y& Elsevier]

Task shifting-moving tasks to healthcare workers with a shorter training-for emergency obstetric care (EmOC) can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without significant increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC and the role of this approach in improving maternal and newborn health in the short and long term. [ABSTRACT FROM AUTHOR]

Abstract: Unsafe abortion is one of the main causes of maternal mortality and severe morbidity in countries with restrictive abortion laws. In 2007, the International Federation of Gynecology and Obstetrics (FIGO) created a Working Group on the Prevention of Unsafe Abortion and its Consequences (WGPUA). This led to a FIGO initiative with that aim which has the active participation of 43 FIGO member societies. The WGPUA has recommended that the plans of action of the countries participating in the initiative consider several levels of prevention shown to have the potential to successfully reduce unsafe abortions: (1) primary prevention of unintended pregnancy and induced abortion; (2) secondary prevention to ensure the safety of an abortion procedure that could not be avoided; (3) tertiary prevention of further complications of an unsafe abortion procedure that has taken place already, through high-quality postabortion care; and (4) quaternary prevention of repeated abortion procedures through postabortion family planning counseling and contraceptive services. This paper reviews these levels of prevention and the evidence that they can be effective. [Copyright &y& Elsevier]

Objectives: To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia.Methods: The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008.Results: Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively.Conclusion: Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion. [ABSTRACT FROM AUTHOR]

Objectives: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services.Methods: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities.Results: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2 hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions.Conclusions: GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services. [ABSTRACT FROM AUTHOR]

Background: Forty years of safe motherhood programming has demonstrated that isolated interventions will not reduce maternal mortality sufficiently to achieve MDG 5. Although skilled birth attendants (SBAs) can intervene to save lives, traditional birth attendants (TBAs) are often preferred by communities. Considering the value of both TBAs and SBAs, it is important to review strategies for maximizing their respective strengths.Objectives: To describe mechanisms to integrate TBAs with the health system to increase skilled birth attendance and examine the components of successful integration.Method: A systematic review of interventions linking TBAs and formal health workers, measuring outcomes of skilled birth attendance, referrals, and facility deliveries.Results: Thirty-three articles met the selection criteria. Mechanisms used for integration included training and supervision of TBAs, collaboration skills for health workers, inclusion of TBAs at health facilities, communication systems, and clear definition of roles. Impact on skilled birth attendance depended on selection of TBAs, community participation, and addressing barriers to access. Successful approaches were context-specific.Conclusions: The integration of TBAs with formal health systems increases skilled birth attendance. The greatest impact is seen when TBA integration is combined with complementary actions to overcome context-specific barriers to contact among SBAs, TBAs, and women. [ABSTRACT FROM AUTHOR]

Objective: To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia.Methods: The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia.Results: Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers.Conclusion: The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services. [ABSTRACT FROM AUTHOR]

Objective: To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia.Methods: All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths-and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices.Results: Too few facilities provided EmONC to meet the UN standards of 5 per 500,000 population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related).Conclusion: None of the indicators met UN standards. Ethiopia faces many challenges--not least geography--with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions. [ABSTRACT FROM AUTHOR]

Objective: To review the use of evidence-based practices in the care of mothers who died or had severe morbidity attending public hospitals in two Latin American countries.Methods: This study is part of a multicenter intervention to increase the use of evidence-based obstetric practice. Data on maternal deaths and women admitted to intensive care units whose deliveries occurred in 24 hospitals in Argentina and Uruguay were analyzed. Primary outcomes were use rates of effective interventions to reduce maternal mortality (MM) and severe maternal morbidity (SMM).Results: A total of 106 women were included: 26 maternal deaths and 80 women with SMM. Some effective interventions for severe acute hemorrhage had a high use rate, such as blood transfusion (91%) and timely cesarean delivery (75%), while active management of the third stage of labor (25%) showed a lower rate. The overall use rate of effective interventions was 58% (95% CI, 49%-67%). This implies that 42% of the women did not receive one of the effective interventions to reduce MM and SMM.Conclusion: This study shows a low use of effective interventions to reduce MM and SMM in public hospitals in Argentina and Uruguay. Dissemination and implementation of evidence-based practices must be guaranteed to effectively achieve progress on maternal health. [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]

Objective: The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance.Methods: The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected.Results: Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.Conclusion: Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program. [ABSTRACT FROM AUTHOR]

Objective: To document an innovative public-private partnership between the government of Gujarat, India and private obstetricians in rural areas that provides delivery care to the poor.Methods: This is a descriptive analysis of the scheme and analysis of secondary data. We estimate the lives of mothers and newborns potentially saved because of the scheme.Results: More than 800 obstetricians have joined the scheme and more than 269000 poor women have delivered in private facilities in 2 years. We estimate that the percentage of institutional deliveries among poor women increased from 27% to 48% between April 2007 and September 2008. In addition, there are fewer reported maternal and newborn deaths among the beneficiaries compared with the number of deaths expected in the absence of the scheme.Conclusions: This innovative program shows that, at least in some areas of India, it is possible to develop a large scale partnership with the private sector to provide skilled birth attendance and emergency obstetric care to poor women at a relatively low cost. This is one way of addressing the human resource deficit in the public sector in rural areas of low-income countries to achieve Millennium Development Goals 4 and 5. We also conclude that the skilled care thus provided can reduce maternal and neonatal mortality among the poor. [ABSTRACT FROM AUTHOR]

Objective: We assessed the effect of prenatal and peripartum antibiotics on maternal morbidity and mortality among HIV-infected and uninfected women.Methods: A multicenter trial was conducted at clinical sites in 4 Sub-Saharan African cities: Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. A total of 1558 HIV-infected and 271 uninfected pregnant women who were eligible to receive both the prenatal and peripartum antibiotic/placebo regimens were enrolled. Pregnant women were interviewed at 20-24 weeks of gestation and a physical examination was performed. Women were randomized to receive either antibiotics or placebo. At the 26-30 week visit, participants were given antibiotics or placebo to be taken every 4 hours beginning at the onset of labor and continuing after delivery 3 times a day until a 1-week course was completed. Logistic regression and Cox proportional hazards models were used.Results: There were no significant differences between the antibiotic and placebo groups for medical conditions, obstetric complications, physical examination findings, puerperal sepsis, and death in either the HIV-infected or the uninfected cohort.Conclusion: Administration of study antibiotics during pregnancy had no effect on maternal morbidity and mortality among HIV-infected and uninfected pregnant women. [ABSTRACT FROM AUTHOR]

Introduction: It is unlikely that some low-income countries will achieve Millennium Development Goal 5 (MDG5) unless governments find new approaches. One possibility is through government partnerships with mission hospitals and other faith-based organizations (FBOs), but this would require overcoming historic reservations.Methods: We review the limited literature on mission hospitals and other FBO health services providing maternity care.Conclusion: The management and the clinical care provided by FBOs are often of higher quality than that provided by government hospitals. Mission hospitals have several advantages including more resources (especially foreign exchange), greater access to expatriate staff especially for training, and more flexibility in hiring and managing staff and in procuring and managing medicines and supplies.Recommendation: Increased collaboration between governments and mission hospitals, particularly in underserved and rural areas, could improve availability and quality of obstetric services enough to meet MDG5 targets. Delegating responsibilities to mission hospitals, exchanging information, and collaboration in projects and training could accelerate progress toward MDG5. Bilateral and multilateral funding institutions and International NGOs should encourage more effective partnerships between governments and FBOs. [ABSTRACT FROM AUTHOR]

Objective: Findings from 4 studies conducted by the Women's Dignity Project and partners on the subjects of obstetric fistula, maternal mortality and morbidity, and health inequities are presented.Methods: The studies include qualitative and quantitative research, a survey, and an analysis of secondary data that examine women's experiences of fistula; constraints in service delivery for fistula treatment; factors shaping women's access to delivery care and constraints health workers face in providing care; and health inequities.Results: Findings from the studies are being used to improve fistula prevention and management, strengthen access to and provision of quality maternity care, and redress the health inequities that so adversely affect the poor.Conclusion: The studies provide policy makers, program managers, and service providers with evidence and the impetus to re-equilibrate policies, financial and human resources, and services in the interest of those in greatest need: women living in poverty. [ABSTRACT FROM AUTHOR]

Objective: We describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali.Methods: Project planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts.Results: By the end of 2004, despite many health systems' challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively.Discussion: Although useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed.Conclusion: Save the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community. [ABSTRACT FROM AUTHOR]

Introduction: The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. Methods: The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. Results: In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. Discussion: While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women. [ABSTRACT FROM AUTHOR]

Purpose: We report on assessments of the needs for emergency obstetric care in 3 West African countries.Methods: All (or almost all) medical facilities were visited to determine whether there are sufficient facilities of adequate quality to manage the expected number of obstetric emergencies.Results: Medical facilities able to provide emergency obstetric care were poorly distributed and often were unable to provide needed procedures. Too few obstetricians and other providers, lack of on-the-job training and supervision were among the challenges faced in these countries. [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]

Abstract: Objective: CARE''s work in Rwanda was designed to improve the functional capacity of health facilities for the delivery of EmOC services. Objective: The project supported a comprehensive package of focused interventions that included hospital renovations, provision of essential equipment, training of staff and improvement of management systems at the Kabgayi regional referral hospital. Results: There was an increased level of preparedness for emergencies and ability to manage common obstetric complications according to evidence-based practices. These changes ultimately led to increased availability, quality and use of services as demonstrated by an increase in the demand for care of obstetric complications at the facility. The met need increased from 16% at the start of the project (2001) to 25% in 2004, while the cesarean rate remained essentially the same (1.9% and 3.2%) over the same time period. There were progressive declines in the case fatality rates from 2.2% in 2001 to 1.2% in 2004. Conclusion: CARE''s experience indicates that progress towards reducing maternal mortality requires specific efforts that support and strengthen existing health systems to provide skilled care that can save women''s lives. [Copyright &y& Elsevier]

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

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 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]

Abstract: This article presents a tool that can be used to assess the readiness of a health facility to provide emergency obstetric care. The ‘walk-through’ tool is a checklist that follows the physical path that a woman and her caregivers might follow. The items on the checklist are critical to an enabling environment in which skilled providers can save lives. The article explains how the tool can be used and by whom, and it describes several experiences in the field. [Copyright &y& Elsevier]

Objective: To monitor changes in the utilization and need for obstetric care between 1995 and 1998 at three hospitals in the highlands of Guatemala.Methods: We collected data on 5300 obstetric admissions from maternity registries and selected 10 indicators to measure intermediate outcomes.Results: Utilization of services increased at some or all hospitals as measured by the number of obstetric admissions, proportion of births in facilities, and cesarean deliveries as a proportion of all births. We observed increases in the proportion of women expected to have obstetric complications who were treated at each hospital and in the proportion of women with obstetric complications who were referrals. The changes in patient profile reflect increased service utilization and accessibility among women who traditionally used the health system the least.Conclusions: Positive changes in these indicators are likely to be associated with a reduction in maternal mortality. Without a control area, we cannot be sure of a cause and effect relationship between outcomes and interventions, nevertheless, maternity registry data offer an inexpensive source of information for facilities to monitor changes. [ABSTRACT FROM AUTHOR]

Purpose: To improve the quality and accessibility of emergency obstetric care (EmOC) at district level.Methods: As the availability of safe and reliable blood transfusion services is a critical component of EmOC, financial and management support was provided to the blood transfusion service centers in the 3 project's Phase 1 districts.Evaluation: An evaluation after 3 years showed that, with modest financial outlays and the development of supportive district level partnerships, substantial improvements in quality and management of services had been achieved. The evaluation also identified limitations imposed by lack of legal frameworks and central support; although the Nepal Red Cross Society has a government mandate to supply the national blood needs, the operating procedures and guidelines have no legal base. The evaluation report was widely circulated, and the findings used in national policy discussions.Results: Following this a task force was commissioned to develop a legal policy framework to ensure standardized quality blood services with defined management and monitoring roles and responsibilities. [ABSTRACT FROM AUTHOR]

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

Objective: To identify, from the best available evidence, underutilized and promising technologies that may reduce maternal mortality from obstructed labor.Methods: The author sought systematic reviews of randomized trials, individual randomized trials, and, in the absence of randomized data, non-randomized studies and clinical consensus. Data were presented according to the level of the evidence.Results: Obstructed labor causes approximately 8% of maternal deaths, and indirectly contributes to a greater percentage. Proven or widely accepted technologies that help reduce mortality from obstructed labor include contraception, external cephalic version, the partogram, augmentation of labor, selective amniotomy, selective episiotomy, vacuum extraction, caesarean section, symphysiotomy, and destructive procedures for non-viable fetuses. Technologies of uncertain usefulness include maternal height and shoe size, vaginal cleansing, upright posture for delivery and vaginal lubrication. Unuseful technologies include pelvimetry, estimating fetal weight, early labor induction, routine amniotomy and augmentation, routine episiotomy, and starvation during labor.Conclusion: Access to well-established technologies, particularly safe caesarean section, can reduce maternal mortality in resource-poor countries. [ABSTRACT FROM AUTHOR]

Little progress has been made in preventing the more than 500 000 maternal deaths that occur each year. Many new and underutilized technologies can be used to reduce these deaths. In July 2003, maternal health experts from around the world gathered in Bellagio, Italy, to develop a set of priority actions for reducing maternal mortality using proven and promising technologies. To reduce maternal mortality, immediate efforts are needed to accelerate the appropriate use of technologies and to reduce their inequitable distribution. Organizations are called on to commit the necessary human and financial resources to evaluate and document the effectiveness of promising technologies and to scale up and put proven technologies into widespread use to save women''s lives. [Copyright &y& Elsevier]

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

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

Objectives: We present an evaluation of the Community Capacity Building and Empowerment initiative, undertaken by the Community-Based Reproductive Health Project (CBRHP), designed to address high maternal morbidity and mortality.Methods: Qualitative data from group interviews and program data from CBRHP were used to assess progress in development and use of community level transport systems and support for the village health workers (VHWs).Results: Project activities increased community participation in maternal health. An increase was seen in knowledge of danger signs, birth planning, timely referrals, and transport of pregnant women to hospitals, as well as in support and retention of VHWs. More women with obstetrical problems are using the community-based transport system to get to hospitals.Conclusions: Community participation and support for VHW activities and the transport systems have led to better care for pregnant women and sustained links between the communities and health facilities, which may reduce maternal and infant morbidity and mortality. [ABSTRACT FROM AUTHOR]

Abstract: The Woman Friendly Hospital Initiative is part of the overall strategy aimed at overcoming a situation of high maternal mortality in Bangladesh. It has evolved from the reality of 14% of maternal deaths being associated with violence. A key of the initiative is the management of violence against women. Training courses for doctors developed through a process of multi‐sectoral consultation. The focus is on effecting a change in the perceptions, emotions, attitude, knowledge and skills of providers and nurturing leadership. [ABSTRACT FROM AUTHOR]