Search

Background: Cervical cancer incidence is high among women living with HIV due to high-risk HPV persistence in the cervix. In low-income countries, cervical cancer screening is based on visual inspection with acetic acid. Implementing human papilloma virus (HPV) screening through self-sampling could increase women's participation and screening performance. Our study aims to assess the preintervention acceptability of HPV screening among HIV-infected women in Abidjan, Côte d'Ivoire.Methods: Applying the Health Belief Model theoretical framework, we collected qualitative data through in-depth interviews with 21 HIV-infected women treated in an HIV-dedicated clinic. Maximum variation sampling was used to achieve a diverse sample of women in terms of level of health literacy. Interviews were recorded and transcribed with the participants' consent. Data analysis was performed using NVivo 12.Results: Screening acceptability relies on cervical cancer representations among women. Barriers were the fear of diagnosis and the associated stigma disregard for HIV-associated health conditions, poor knowledge of screening and insufficient resources for treatment. Fees removal, higher levels of knowledge about cervical cancer and of the role of HIV status in cancer were found to facilitate screening. Healthcare providers are obstacle removers by their trusting relationship with women and help navigating through the healthcare system. Self-confidence in self-sampling is low.Conclusions: Free access to cervical screening, communication strategies increasing cervical cancer knowledge and healthcare provider involvement will foster HPV screening. Knowledge gathered through this research is crucial for designing adequate HPV-based screening interventions for women living with HIV in this setting. [ABSTRACT FROM AUTHOR]

Background: Since 2006, Burkina Faso has subsidized the cost of caesarean sections to increase their accessibility. Caesareans are performed by obstetricians, general practitioners, and nurses trained in emergency surgery. While the national caesarean rate is still too low (only 2 % in 2010), 12 to 24 % of caesareans performed in hospital are, in fact, not medically indicated. The objective of this study is to evaluate the effectiveness and analyze the implementation of a multi-faceted intervention to lower the rate of non-medically indicated caesareans in Burkina Faso. Methods: This study combines a multicentre cluster randomized controlled trial with an implementation analysis in a mixed-methods approach. The evidence-based intervention will consist of three strategies to improve the competencies of maternity teams: 1) clinical audits based on objective criteria; 2) training of personnel; and 3) decision-support reminders of indications for caesareans via text messages. The unit of randomization and of intervention is the public hospital equipped with a functional operating room. Using stratified randomization on hospital type and staff qualifications, 11 hospitals have been assigned to the intervention group and 11 to the control group. The intervention will cover 1 year. Every patient who delivered by caesarean during a 6-month period in the year preceding the intervention and the 6 months following its end will be included in the trial. The change in the rate of non-medically indicated caesareans is the main criterion by which the intervention's impact will be assessed. To analyze the intervention process, a longitudinal qualitative study consisting of deliberative workshops and individual in-depth interviews will be conducted. The target outcome is a 50 % reduction in the rate of non-medically indicated caesareans. Discussion: This study will provide evidence regarding the effectiveness of a multi-faceted intervention for reducing non-medically indicated caesareans in a low-income country. By combining qualitative and quantitative methods, the study's findings will allow understanding the factors that could influence the intervention process and ultimately the intended outcomes. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women's characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali.Methods: A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death.Results: Among the 3,278 women who experienced PPH, 178 (5.4%) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26-3.72]), living in Mali (adjusted OR = 1.84 [1.13-3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29-4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54-22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77-11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19-5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26-5.10]), transfusion (adjusted OR = 2.17 [1.53-3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20-28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35-0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC).Conclusions: Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality. [ABSTRACT FROM AUTHOR]

Background: Despite a global increase in contraception use, its prevalence remains low in low- and middle-income countries. One strategy to improve uptake and use of contraception, as an essential complement to policies and supply-side interventions, is demand generation. Demand generation interventions have reportedly produced positive effects on uptake and use of family planning services, but the evidence base remains poorly documented. To reduce this knowledge gap, we will conduct a systematic review on the impact of demand generation interventions on the use of modern contraception. The objectives of the review will be as follows: (1) to synthesize evidence on the impacts and costs of family planning demand generation interventions and on their effectiveness in improving modern contraceptive use and (2) to identify the indicators used to assess effectiveness, cost-effectiveness, and impacts of demand generation interventions. Methods/design: We will systematically review the public health and health promotion literature in several databases (e.g., CINAHL, Medline, EMBASE) as well as gray literature. We will select articles from 1970 to 2015, in French and in English. The review will include studies that assess the impact of family planning programs or interventions on changes in contraception use. The studied interventions will be those with a demand generation component, even if a supply component is implemented. Two members of the team will independently search, screen, extract data, and assess the quality of the studies selected. Different tools will be used to assess the quality of the studies depending on the study design. If appropriate, a meta-analysis will be conducted. The analysis will involve comparing odd ratios (OR) Discussion: The systematic review results will be disseminated to United Nations Population Fund program countries and will contribute to the development of a guidance document and programmatic tools for planning, implementing, and evaluating demand generation interventions in family planning. Improving the effectiveness of family planning programs is critical for empowering women and adolescent girls, improving human capital, reducing dependency ratios, reducing maternal and child mortality, and achieving demographic dividends in low- and middle-income countries. Systematic review registration: This protocol is registered in PROSPERO (CRD 42015017549). [ABSTRACT FROM AUTHOR]

Background: In sub-Saharan Africa, lack of motivation and job dissatisfaction have been cited as causes of poor healthcare quality and outcomes. Measurement of health workers, satisfaction adapted to sub-Saharan African working conditions and cultures is a challenge. The objective of this study was to develop a valid and reliable instrument to measure satisfaction among health professionals in the sub-Saharan African context. Methods: A survey was conducted in Senegal and Mali in 2011 among 962 care providers (doctors, midwives, nurses and technicians) practicing in 46 hospitals (capital, regional and district). The participation rate was very high: 97% (937/962). After exploratory factor analysis (EFA), construct validity was assessed through confirmatory factor analysis (CFA). The discriminant validity of our subscales was evaluated by comparing the average variance extracted (AVE) for each of the constructs with the squared interconstruct correlation (SIC), and finally for criterion validity, each subscale was tested with two hypotheses. Two dimensions of reliability were assessed: internal consistency with Cronbach,s alpha subscales and stability over time using a test-retest process. Results: Eight dimensions of satisfaction encompassing 24 items were identified and validated using a process that combined psychometric analyses and expert opinions: continuing education, salary and benefits, management style, tasks, work environment, workload, moral satisfaction and job stability. All eight dimensions demonstrated significant discriminant validity. The final model showed good performance, with a root mean square error of approximation (RMSEA) of 0.0508 (90% CI: 0.0448 to 0.0569) and a comparative fit index (CFI) of 0.9415. The concurrent criterion validity of the eight dimensions was good. Reliability was assessed based on internal consistency, which was good for all dimensions but one (moral satisfaction < 0.70). Test-retest showed satisfactory temporal stability (intra class coefficient range: 0.60 to 0.91). Conclusions: Job satisfaction is a complex construct; this study provides a multidimensional instrument whose content, construct and criterion validities were verified to ensure its suitability for the sub-Saharan African context. When using these subscales in further studies, the variability of the reliability of the subscales should be taken in to account for calculating the sample sizes. The instrument will be useful in evaluative studies which will help guide interventions aimed at improving both the quality of care and its effectiveness. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality in referral hospitals in Mali and Senegal surpasses 1% of obstetrical admissions. Poor quality obstetrical care contributes to high maternal mortality; however, poor care is often linked to insufficient hospital resources. One promising method to improve obstetrical care is maternal death review. With a cluster randomized trial, we assessed whether an intervention, based on maternal death review, could improve obstetrical quality of care. Methods: The trial began with a pre-intervention year (2007), followed by two years of intervention activities and a post-intervention year. We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit (CBCA). We collected data from 32 of the 46 trial hospitals (16 in each trial arm) and included 658 patients admitted to the maternity unit with a trial of labour. The CBCA questionnaire measured 5 dimensions of care- patient history, clinical examination, laboratory examination, delivery care and postpartum monitoring. We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material resources affect quality of care differences associated with the intervention. Results: For all women, the mean percentage of care criteria met was 66.3 (SD 13.5). There were significantly greater mean CBCA scores in women treated at intervention hospitals (68.2) compared to control hospitals (64.5). After adjustment, women treated at intervention sites had 5 points' greater scores than those at control sites. This difference was mostly attributable to greater clinical examination and post-partum monitoring scores. The association between the intervention and quality of care was the same, irrespective of the level of resources available to a hospital; however, as resources increased, so did quality of care scores in both arms of the trial. Conclusions: Patients treated at hospitals with maternal death review had greater CBCA scores suggesting that the intervention improves quality of care. Results indicate that the intervention mostly improves clinical examination at admission and post-partum monitoring. They also indicate that quality of care scores can be maximized by increasing the availability of human and material resources to hospitals in the region. [ABSTRACT FROM AUTHOR]

Introduction: Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain. Methods: A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both. Results: Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%. Conclusions: First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain. [ABSTRACT FROM AUTHOR]

Background: Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali. Methods: We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007-10/01/2008). Data were collected regarding women's characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model. Results: Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]). Conclusions: We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context. [ABSTRACT FROM AUTHOR]

Background: In Mali and Senegal, over 1% of women die giving birth in hospital. At some hospitals, over a third of infants are stillborn. Many deaths are due to substandard medical practices. Criterion-based clinical audits (CBCA) are increasingly used to measure and improve obstetrical care in resource-limited settings, but their measurement properties have not been formally evaluated. In 2011, we published a systematic review of obstetrical CBCA highlighting insufficient considerations of validity and reliability. The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity. This work was conducted as a sub-study within a cluster randomized trial known as QUARITE. Methods: Criteria were selected based on extensive literature review and expert opinion. Early 2010, two auditors applied the CBCA to identical samples at 8 sites in Mali and Senegal (n = 185) to evaluate inter-rater reliability. In 2010-11, we conducted CBCA at 32 hospitals to assess construct validity (n = 633 patients). We correlated hospital characteristics (resource availability, facility perinatal and maternal mortality) with mean hospital CBCA scores. We used generalized estimating equations to assess whether patient CBCA scores were associated with perinatal mortality. Results: Results demonstrate substantial (ICC = 0.67, 95% CI 0.54; 0.76) to elevated inter-rater reliability (ICC = 0.84, 95% CI 0.77; 0.89) in Senegal and Mali, respectively. Resource availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores. Poor CBCA scores, adjusted for hospital and patient characteristics, were significantly associated with perinatal mortality (OR 1.84, 95% CI 1.01-3.34). Conclusion: Our CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory. Trial registration: Current Controlled Trials ISRCTN46950658 [ABSTRACT FROM AUTHOR]

Background: Despite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility.Methods: A cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics.Results: Despite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their "remuneration" and "work environment" and most satisfied with the "morale" and "job security" facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with "remuneration" and "task" satisfaction, actively job searching was associated with being dissatisfied with job "security" and voluntary quitting was associated with dissatisfaction with "continuing education".Conclusions: This study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education. [ABSTRACT FROM AUTHOR]

Background: Since 2001, a referral system has been operating in Kayes (Mali) to reduce maternal and perinatal deaths. Normal deliveries are managed in community health centers (CHC). Complicated cases are referred to a district health center (DHC) or the regional hospital (RH). Women with obstetric emergencies can directly access the DHC and the RH. Objective: To assess, in women presenting with an obstetric complication: 1) the effects of the point of entry into the referral system on joint mother-newborn survival; and 2) the effects of the configuration of healthcare team at the CHCs on joint mother-newborn survival. Method: Cross-sectional study of 7,214 women users of the referral system in the region of Kayes in 2006-2009. Bivariate probit equations were fitted to estimate joint mother-newborn survival. The marginal effects of the point of entry into the referral system and of the configuration of the healthcare team at the CHCs were evaluated with a probit bivariate regression. Results: Entering the referral system at the RH was associated with the best joint mother-newborn survival; the most qualified the CHCs team was, the best was mother-newborn survival. Distance traveled interacts with the point of entry and the configuration of the CHCs team. For women coming from far (over 50 km), going directly to the RH increased the probability of joint mother-newborn survival by 11.90% (p < 0.001) as compared with entry at the CHC. Entry at the CHC while coming from a distance of less than 5 km increased the likelihood of joint survival by 8.50% (p < 0.001). Among women who go first to a CHC, physician presence increased joint mother-newborn survival, compared with having no physician and fewer than three professionals. The size of the healthcare team at the CHC is significantly associated with mother-newborn survival only when distance traveled is 5 km or less. Conclusion: Mother-newborn survival in the Kayes maternal referral system is influenced by combined effects of the point of care, the skill configuration of CHC personnel and distance traveled. [ABSTRACT FROM AUTHOR]

Background: Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.Methods/design: This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews. The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background: In April 2016, Burkina Faso introduced a free health care policy for women. Instead of reimbursing health facilities, as many sub-Saharan countries do, the government paid them prospectively for covered services to avoid reimbursement delays, which are cited as a reason for the persistence of out-of-pocket (OOP) payments. This study aimed to (i) estimate the direct expenditures of deliveries and covered obstetric care, (ii) determine the OOP payments, and (iii) identify the patient and health facility characteristics associated with OOP payments., Methods: A national cross-sectional study was conducted in September and October 2016 in 395 randomly selected health facilities. A structured questionnaire was administered to women (n = 593) who had delivered or received obstetric care on the day of the survey. The direct health expenditures included fees for consultations, prescriptions, paraclinical examinations, hospitalization and ambulance transport. A two-part model with robust variances was performed to identify the factors associated with OOP payments., Results: A total of 587 women were included in the analysis. The median direct health expenses were US$5.38 [interquartile range (IQR):4.35-6.65], US$24.72 [IQR:16.57-46.09] and US$136.39 [IQR: 108.36-161.42] for normal delivery, dystocia and cesarean section, respectively. Nearly one-third (29.6%, n = 174) of the women reported having paid for their care. OOP payments ranged from US$0.08 to US$98.67, with a median of US$1.77 [IQR:0.83-7.08]). Overall, 17.5% (n = 103) of the women had purchased drugs at private pharmacies, and 11.4% (n = 67) had purchased cleaning products for a room or equipment. OOP payments were more frequent with age, for emergency obstetric care and among women who work. The women's health region of origin was also significantly associated with OOP payments. For those who made OOP payments, the amounts paid decreased with age but were higher in urban areas, in hospitals, and among the most educated women. The amounts paid were lower among students and were associated with health region., Conclusion: The policy is effective for financial protection. However, improvements in the management and supply system of health facilities' pharmacies could further reduce OOP payments in the context of the free health care policy in Burkina Faso.

Objective: Acute pelvic pain is a common reason for emergency room visits that can indicate a potentially life-threatening emergency (PLTE). Our objective here was to develop a triage process for PLTE based on a self-assessment questionnaire for gynecologic emergencies (SAQ-GE) in patients experiencing acute pelvic pain., Methods: In this multicenter prospective observational study, all gynecological emergency room patients seen for acute pelvic pain between September 2006 and April 2008 completed the SAQ-GE after receiving appropriate analgesics. Diagnostic procedures were ordered without knowledge of questionnaire replies. Laparoscopy was the reference standard for diagnosing PLTE; other diagnoses were based on algorithms. In two-thirds of the population, SAQ-GE items significantly associated with PLTEs (P < 0.05) by univariate analysis were used to develop a decision tree by recursive partitioning; the remaining third served for validation., Results: Of 344 derivation-set patients and 172 validation-set patients, 96 and 49 had PLTEs, respectively. Items significantly associated with PLTEs were vomiting, sudden onset of pain, and pain to palpation. Sensitivity of the decision tree based on these three features was 87.5% (95% confidence interval (95% CI), 81%-94%) in the derivation set and 83.7% in the validation set. Derivation of the decision tree provided probabilities of PLTE of 13% (95% CI, 6%-19%) in the low-risk group, 27% (95% CI, 20%-33%) in the intermediate-risk group and 62% (95% CI, 48%-76%) in the high-risk group, ruling out PLTE with a specificity of 92.3%; (95% CI, 89%-96%). In the validation dataset, PLTE probabilities were 16.3% in the low-risk group, 30.6% in the intermediate-risk group, and 44% in the high-risk group, ruling out the diagnosis of PLTE with a specificity of 88.6%., Conclusion: A simple triage model based on a standardized questionnaire may assist in the early identification of patients with PLTEs among patients seen in the gynecology emergency room for acute pelvic pain.

Background: In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal., Methods: This study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches., Results: Health professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths., Conclusion: The identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee--particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.