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To analyze implementation of maternal and neonatal death surveillance and response (MNDSR) in Cameroon to determine to what extent monitoring objectives are being met and highlight the main obstacles and facilitating factors.Secondary analysis of a cross-sectional study using a qualitative method and routine data on maternal health. Semistructured interviews were conducted with participants involved in MNDSR at the central, regional, and district levels.Notification of maternal deaths has been incorporated into the Integrated Disease Surveillance and Response (IDSR) system since January 2014. However, maternal deaths are underreported in most hospitals and neonatal and community deaths are not recorded. Comprehensive review of maternal deaths does not occur in all hospitals despite training of providers in 2013 on how to conduct reviews.Implementation of MNDSR in Cameroon is insufficient. More commitment from the Ministry of Health is needed to develop an action plan and secure funding.

To identify barriers to the implementation of maternal death reviews in health districts in Burkina Faso.We conducted a multiple case study in seven health facilities chosen by contrasted purposive sampling. Sampling criteria were based on intrahospital maternal mortality rates and the location of the health facility. Data collection was conducted from April 27 to May 30, 2015, using structured and semistructured interviews and data extraction from source documents. Data were analyzed using a thematic approach.Barriers to quality maternal death reviews identified were primarily implementation conditions, including poor skills and motivation of healthcare personnel, low interest in quality of care, lack of suitable equipment, insufficient coordination and collaboration between health services, insufficient monitoring, and weakness in programming and conducting the reviews.Barriers to achieving quality maternal death reviews remain numerous at the operational level of the health system. Taking steps to remove these barriers is key to improving the quality of maternal death reviews and childbirth outcomes in Burkina Faso.

To analyze implementation of the maternal death surveillance and response (MDSR) strategy in Chad.Secondary data analysis of results from a cross-sectional study involving semistructured interviews with decision-makers at central, regional, and district levels, health providers, and technical and financial partners, and a document review. Data collection took place from June-July 2017.Maternal death reporting was incorporated into the Integrated Disease Surveillance and Response system but did not include neonatal deaths nor maternal and neonatal deaths in communities. Underreporting of maternal deaths owing to fear of repercussions was evident, likely associated with maternal deaths reported at monthly meetings held by the country's President with stakeholders in the health sector. Maternal death reviews were only undertaken between 2015 and 2016 in four regions of Chad and ceased in mid-August 2016. Reasons include the departure of foreign obstetricians, lack of motivation among health workers, weak accountability at all levels of the health system, organizational issues, and nonimplementation of review recommendations.Strong action is needed by the Ministry of Health to revive implementation of the MDSR system.

To assess the current system of maternal death review (MDR) in Ghana and identify the achievements, challenges, and gaps that will assist in transitioning to the maternal death surveillance and response system (MDSR).A secondary analysis of data from a cross-sectional study on MDSR implementation was conducted between September and October 2018. The MDSR cycle served as an analytical framework to measure the country's performance in implementing MDSR. Common facilitating or hindering factors were also identified.The MDR system is moderately strong at regional level with timely receipt of data and regular review meetings and reports in most regions. At district level the MDR system is less well implemented, although there is evidence of good communication with regional teams in providing timely data. Communication between districts and communities about maternal deaths seemed to be poor in general. There was no MDR committee at national level and the recommendations made were poorly implemented.MDRs in Ghana were structurally sound, but recommendations were poorly implemented. Leadership at the national level needs to be developed to ensure that the current system could transition to an MDSR system.

To assess the quality of the maternal death review (MDR) cycle in selected health facilities in Burkina Faso in accordance with national standards.A multiple case study using a qualitative approach performed in five health districts and two regional hospital centers in Burkina Faso. The facilities were chosen by contrasted purposive sampling based on hospital maternal mortality rate and urban or rural location. Structured and semistructured interviews were conducted and data analyzed thematically, horizontally, and vertically.Of the seven facilities included, six performed MDR. The MDR cycle was incomplete in five facilities because the implementation of recommendations had not been assessed. All cases of maternal death lacked vital information. Case analysis was not conducted in accordance with the national standards in most of the facilities. The action plans for implementing recommendations were not commonly used.The MDR process and its various stages did not meet quality standards. Identifying the determinants leading to lack of adherence to MDR standards will contribute to optimal choice of interventions and improving good practices in health facilities.

To evaluate the capability of high-volume comprehensive emergency obstetric care (CEmOC) health facilities on the provision of comprehensive postabortion care (PAC) in Sub-Saharan Africa and to determine the frequency of women with severe abortion-related complications in high capability facilities.A cross-sectional analysis conducted across 11 countries in Sub-Saharan Africa, using facility-level information from the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity (MCS-A) between 2017 and 2018. PAC signal functions were adapted to assess facilities' capability to deliver comprehensive PAC through infrastructure, standard comprehensive capability, and extended comprehensive capability to provide PAC. The percentage of facilities with each signal function and distribution of facilities by number of signal functions were calculated for the three capability categories. Distribution of severe abortion complications by facility capability score was assessed.Of 210 high-volume CEmOC facilities included, 47.9% (n = 100) had capability to provide all facility infrastructure signal functions, 54.4% (n = 105) for standard comprehensive PAC, reducing to 17.7% (n = 34) for extended comprehensive PAC capability. Overall, there were gaps in extended capabilities including availability of a functioning ICU (available in 37.3% of facilities) and providers 24/7 (65.5% of facilities reported an obstetrician available 24/7 dropping to 41.3% for anesthesiologists). Facilities' PAC capability varied across regions. Overall, 34.6% (n = 614) of women with severe abortion-related complications were treated in facilities with the maximum capability score for extended comprehensive PAC.Although high levels of capability to provide abortion-related care for most signal functions were evident, significant gaps that impact on the management of severe abortion-related complications remain, particularly related to extended facility capabilities including specialized human resources and ICU.

In the post-conflict context of the Central African Republic, underreporting of maternal deaths in health facilities has occurred. There are no guidelines in place for operational or intermediate levels. There are no review or audit committees within the health facilities, districts, or regions, or at the national level. Only three hospitals have an informal review committee. Implementing the MDSR system is not an easy task, especially in Africa, which has surveillance systems that remain fragile and inefficient. Conflict situations have affected the system, and the lack of optimal funding does not enable ideal implementation of these intervention strategies.

Objective To identify the factors associated with home births in the Kaya health district in Burkina Faso, where child delivery was free of charge between 2007 and 2011. Methods Both qualitative and quantitative data were collected from the Kaya Health and Demographic Surveillance System (Kaya HDSS) among women who delivered at home or in a health facility between January 2008 and December 2010. Multilevel logistic regression was applied to quantitative data, while the qualitative data were analyzed thematically based on emerging themes, subthemes, and patterns across group and individual cases. Results The findings indicate that 12% (n = 311) of childbirths occurred at home (n = 2560). Key factors associated with home birth were age, distance from the household to the primary health center, and prenatal visits. The qualitative analysis showed that immediate child delivery, previous experience of giving birth at home, negative experiences with health centers, fear of cesarean delivery, and lack of transport are key predictors of home births. Conclusion Though relevant, addressing the financial barrier to health care is not enough. Additional measures are necessary to further reduce the rate of home births.

Objective To determine the prevalence of cesarean deliveries in Burkina Faso, analyze the indications for them and the outcomes, and identify factors associated with non-absolute maternal indications for the procedure, as opposed to major obstetric interventions performed to save a woman’s life. Methods In a cross-sectional study, we selected and analyzed cesarean deliveries among those most recently performed between May 2009 and April 2010 in all facilities in Burkina Faso. To identify the factors associated with non-absolute maternal indications, we used generalized estimating equations to take into account the clustering of data at the hospital level. Results The proportion of births by cesarean delivery was 1.5%, with regional variations ranging from 0.8% to 4.5%. They were performed mainly for absolute maternal indications (54.8%). Cesarean deliveries for non-absolute maternal indications were statistically more frequent in private hospitals (OR 2.2; 95% CI, 1.2–4.0), among women in urban areas (OR 1.6; 95% CI, 1.0–2.4), during scheduled cesareans, and in the absence of use of the partogram. Conclusion This study confirms the small proportion of cesarean deliveries in Burkina, the disparity between urban and rural areas, and the relative preponderance of absolute maternal indications for cesarean delivery.

Objective To understand the role of transportation in accessing health care during pregnancy, delivery, and the postpartum period among women in rural Bangladesh and Burkina Faso. Methods An exploratory mixed methods study was conducted in Mymensingh district in Bangladesh and Kaya district in Burkina Faso. We recruited 300 women from Bangladesh and 340 from Burkina Faso with a delivery outcome within one year of interview. Key informant interviews were conducted with 19 participants and 12 focus group discussions took place with attendees in selected community clinics. Results Of the interviewees, 45.7% in Bangladesh and 73.2% in Burkina Faso reported having had health complications during their last pregnancy, delivery, or postpartum period. Of all women, 42.7% in Bangladesh and 67.4% in Burkina Faso sought facility care for their complications. Facility-based delivery was much higher in Burkina Faso (87.7%) than Bangladesh (38.2%). Literacy, transport availability, transportation costs, and travel time were associated with care seeking behavior. Conclusion Lack of reliable transportation was reported as a significant barrier to accessing care during pregnancy, delivery, and postpartum by women in Bangladesh and Burkina Faso. Effort should be made to improve access to emergency obstetric care, and transport intervention should be strengthened.

Objective To assess the implementation and effects of the strategy, introduced in June 2011, of making obstetric kits readily available in health facilities in the Adamaoua region of Cameroon. Methods We conducted a quasi-experimental study using an interrupted time series to assess the effects of the strategy, and a case study to evaluate its implementation. The reviewed data were gathered from 13 health facilities over a period from January 2008 to December 2014. Qualitative data were collected from in-depth interviews. Results The provision of obstetric kits was effective in the intervention health facilities, although some challenges existed and included lack of staff motivation and rampant illegal practices. The number of deliveries and cesareans increased. Conclusion There is a need to rethink this strategy, given its gaps and shortcomings.

Objective To describe the various local initiatives to access emergency obstetric and neonatal care in Burkina Faso. Methods An existing framework was used to review the three processes for local initiatives: emergence, formulation, and implementation. Multiple case studies were conducted, followed by literature review and semi-structured interviews with key informants. Results Sixteen districts had implemented local initiatives, including cost sharing, free care for women and children, and free care for delivery and cesareans. Most districts (n = 10) had implemented the cost-sharing intervention. These initiatives were initiated by local actors as well as nongovernmental organizations. The profile of those involved led to different ways of handling the emergence and formulation processes. At implementation, these initiatives faced many issues including late payment of contributions, low involvement of local governments, and equity in participation. Conclusion There are some issues in the implementation and sustainability of the local initiatives. Although many initiatives exist, these are unable to fully address the financial barriers to care. However, these initiatives highlight context-based financial barriers that must be taken into account to accelerate universal access to health care.

Objective To identify the factors associated with non-medically indicated cesarean deliveries (NMIC) in Burkina Faso in centers where user fees for cesarean delivery were partially removed. Methods We carried out a criteria-based audit in 22 referral hospitals, using data from a 6-month prospective observational study, to assess the proportion of NMIC. Multivariate logistic regression analyses were used to identify factors associated with NMIC. Results The decision of cesarean delivery was not medically indicated in 24% of cases. The factors independently associated with NMIC were urban residence (adjusted OR 1.55; 95% CI, 1.12–2.12; P=0.006), spouse’s occupation other than breeder or farmer (aOR varying from 1.77 [95% CI, 1.19–2.62] to 2.15 [95% CI, 1.38–3.32] according to the profession), and cesarean decided by a general practitioner (aOR 1.61; 95% CI, 1.13–2.30; P=0.009). Conclusion The high percentage of unnecessary cesarean deliveries is in contrast to the unmet needs of women who still deliver outside health facilities. NMIC is associated with both socioeconomic determinants and medical factors. Hence, interventions are needed to improve the skills of healthcare professionals and awareness of women concerning the risks associated with unnecessary cesarean delivery.

To investigate trends and changes in home deliveries in northern Ghana following the implementation of interventions targeting common barriers to utilization of health services.Data collected through repeated cross-sectional surveys conducted in the Kassena-Nankana east and west districts from 2003-2009 were used in a secondary analysis. All childbirths that occurred in this period were included. Univariate time series were used to describe trends in home deliveries. Significant trends were investigated using the χA total of 25 539 deliveries were recorded, of which 58.1% occurred at home. The incidence of home deliveries declined from 69.1% in 2003 to 36.5% in 2009 (P0.001). This declining pattern was consistently observed within all subgroups defined by wealth index, and educational and residential status. Larger declines were observed in poor and rural residents compared with rich and urban residents (P0.001).The incidence of home deliveries halved during the study period and there was a significant reduction in previous inequalities.

Objective To assess the availability, utilization, and quality of emergency obstetric and neonatal care (EmONC) in Togo. Methods A cross-sectional study of EmONC services in all public and private health facilities in the territory of Togo conducted from July to December, 2012. The generic tools developed by the Averting Maternal Death and Disability program were used as the basic tools for this evaluation. Results The survey involved 1019 health facilities including 864 potential EmONC facilities that constituted the final sample. The results showed that there was low availability of functional EmONC health facilities (8 basic EmONC and 24 comprehensive EmONC) with a large urban/rural variation. Among the 24 current CEmONC, 22 were in urban areas and half were from the private sector. The national ratio of availability was 3 EmONC health facilities per 500 000 inhabitants. Nationally, the cesarean delivery rate was 3.5%. The lethality rate of direct obstetric causes was estimated at 1.3%. Conclusion Needs assessment for EmONC showed low availability of EmONC services and underutilization of the available services.

Objective To identify the risk factors associated with very early neonatal death in Burkina Faso. Methods A matched case–control study including newborns born between May 2009 and April 2010. Cases comprised newborns that died within 24 hours of birth, whereas controls were those of a similar birth weight to the cases who survived the first 24 hours. Potential risk factors related to mothers, neonates, and healthcare provision were assessed from medical records and via interviews. Conditional logistic regression was used to estimate odds ratios. Results Data from 470 cases and 470 controls were analyzed. Multivariate analysis showed that Apgar score at 4–7 or 1–3 (aOR 6.27; 95% CI, 3.10–12.68 and aOR 72.26; 95% CI, 14.07–371.26, respectively); bradycardia at the last heart sound recorded before delivery (aOR 5.72; 95% CI, 1.42–23.03); inadequacy or lack of prenatal care (aOR 2.39; 95% CI, 1.15–4.97); resuscitation of newborns (aOR 2.07; 95% CI, 1.01–4.27); and referral of the newborn (aOR 5.29; 95% CI, 1.44–19.43) were associated with increased odds of neonatal mortality. However, being a primigravid mother (aOR 0.51; 95% CI, 0.29–0.89) was associated with decreased odds of neonatal mortality. Conclusion Very early neonatal mortality is closely related to the condition of the newborn at birth, the monitoring of the pregnancy, and medical procedures.

Objective To propose a rationale to improve maternal postpartum care in reproductive, maternal, newborn, and child health (RMNCH) services. Methods We conducted a cross-sectional mixed study in the Kaya health district in Burkina Faso based on two data collection exercises conducted between December 2012 and May 2013. A household survey of 757 mothers in their first year after delivery was processed. It was complemented with a qualitative analysis using in-depth interviews with key informants, focus group discussions with mothers, and participant observation. Results Postpartum services showed serious weaknesses. Overall, 52% (n=384) of mothers did not receive any maternal postpartum care; however among them, 47% (n= 349) received infant postpartum care. Conclusion We suggest the integration of maternal postpartum care in RMNCH services as a key step to improving postpartum care. The intervention would require the overcoming of challenges related to the quality and cost of services, and to reaching the poor populations with low education and a high parity.

Micronutrients powder (MNP) can prevent anaemia amongst children 6-23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron-containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6-23 months and the effect of sustained use of MNP on morbidity in a malaria-endemic area. Child feeding practises and nutritional status were assessed through cross-sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (-0.7% [-6.8, 5.3] points; p = .805), stunting (+4.6% [-2.9, 12.0] points; p = .201), or mean length-for-age z-score and weight-for-length z-score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.

Objective To assess the risks of uterine rupture, maternal and perinatal outcomes associated with a trial of labour (TOL) after one previous caesarean were compared with having an elective repeated caesarean section (ERCS) without labour in low-resource settings. Design A prospective 4-year observational study. Setting Senegal and Mali. Sample A cohort of 9712 women with one previous caesarean delivery. Methods Maternal and perinatal outcomes were compared between 8083 women who underwent a TOL and 1629 women who had an ERCS. Perinatal and maternal outcomes were then stratified according to the presence or absence of risk factors associated with vaginal birth after caesarean section. These outcomes were adjusted on maternal, perinatal and institutional characteristics. Main outcome measuresThe risks of uterine rupture, maternal complication and perinatal mortality associated with TOL after one previous caesarean as compared with ERCS, ResultsThe risks of hospital-based maternal complication [adjusted odds ratio (OR) 1.52; 95% CI 1.09-2.13; P = 0.013] and perinatal mortality (adjusted OR 4.53; 95% CI 2.30-9.92; P < 0.001) were significantly higher in women with a TOL compared with women who had an ERCS. However, when restricted to low-risk women, these differences were not significant (adjusted OR 0.90, 95% CI 0.55-1.46, P = 0.68, and adjusted OR 1.13; 95% CI 0.75-1.86; P = 0.53, for each outcome, respectively). Uterine rupture occurred in 25 (0.64%) of 3885 low-risk women compared with 70 (1.66%) of 4198 women with unfavourable risk factors. Conclusion Low-risk women have no increased risk of maternal complications or perinatal mortality compared with women with one or more unfavourable factors. Tweetable abstractLow-risk women have a lower risk of maternal complications or perinatal mortality compared with high-risk women. Tweetable abstract Low-risk women have a lower risk of maternal complications or perinatal mortality compared with high-risk women.

The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.