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Author(s): Marion Ravit[sup.1] , Aline Philibert[sup.2] [sup.3] , Caroline Tourigny[sup.1] , Mamadou Traore[sup.4] , Aliou Coulibaly[sup.1] , Alexandre Dumont[sup.5] , Pierre Fournier[sup.1] Author Affiliations: (1) Global Health Axis, University of [...], The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

OBJECTIVE: The improvement of obstetric services is one of the key components of the Safe Motherhood Programme. Reviewing maternal deaths and complications is one method that may make pregnancy safer, but there is no evidence about the effectiveness of this strategy. The objective of our before and after study is to assess the effect of facility-based maternal deaths reviews (MDR) on maternal mortality rates in a district hospital in Senegal that provides primary and referral maternity services. METHODS: We included all women who were admitted to the maternity unit for childbirth, or within 24 hours of delivery. We recorded maternal mortality during a 1-year baseline period from January to December 1997, and during a 3-year period from January 1998 to December 2000 after MDR had been implemented. Effects of MDR on organization of care were qualitatively evaluated. FINDINGS: The MDR strategy led to changes in organizational structure that improved life-saving interventions with a relatively large financial contribution from the community. Overall mortality significantly decreased from 0.83 (95% CI (confidence interval) = 0.60 -1.06) in baseline period to 0.41 (95% CI = 0.25 -0.56) per 100 women 3 years later. CONCLUSION: MDR had a marked effect on resources, management and maternal outcomes in this facility. However, given the design of our study and the local specific context, further research is needed to confirm the feasibility of MDR in other settings and to confirm the benefits of this approach for maternal health in developing countries.

Objectives: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance‐based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply‐side intervention (PBF) combined with a demand‐side intervention (gratuité) on institutional CS rates in Burkina Faso. Methods: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility‐based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. Results: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non‐intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. Conclusion: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption. [ABSTRACT FROM AUTHOR]

Introduction Most efforts designed to reduce inequities in maternal health in low-income countries have been focused primarily on averting maternal deaths. However, in countries with poorly functioning health systems, severe [...], Objective To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mall. Methods Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them. Findings Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communaute Financiere Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits. Conclusion The poor accessibility and affordability of emergency obstetric Care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies. Objectif Etudier la frequence des depenses catastrophiques en soins obstetficaux d'urgence, explorer leurs facteurs de risque et evaluer l'effet de ces depenses sur les menages dans la region de Kayes, au Mali. Methodes Les donnees de 484 urgences obstetricales (242 deces et 242 accidents evites de justesse) ont ete recueillies sur la periode 2008-2011. Les depenses catastrophiques en soins obstetricaux d'urgence ont ete evaluees a differents niveaux, et leurs facteurs associes ont ete etudies par regression logistique. Une enquete a ensuite ete effectuee aupres d'un echantillon imbrique de 56 menages, afin de determiner comment les depenses catastrophiques les avaient affectes. Resultats Malgre la politique d'exoneration de frais pour les cesariennes et le systeme de maternite de reference, concu pour reduire la charge financiere des soins obstetricaux d'urgence, les depenses moyennes etaient de 152 dollars des Etats-Unis (equivalent a 71 535 francs de la Commu naute financiere africaine), et 20,7 a 53,5% des menages faisaient face a des depenses catastrophiques. Des depenses elevees pour les soins obstetricaux d'urgence ont force 44,6% des menages a reduire leur consommation alimentaire, et 23,2% d'entre eux etaient encore endettes, dix mois a deux ans et demi plus tard. Vivre dans des zones rurales reculees etait associe au risque de depenses catastrophiques, ce qui montre que le systeme de reference ne peut eliminer les obstacles financiers pour les menages eloignes. Les femmes ayant subi une cesarienne ont continue a faire face a des depenses catastrophiques, en particulier lorsque les medicaments prescrits n'etaient pas inclus dans les kits de cesarienne fournis par le gouvernement. Conclusion Le fait que les soins obstetricaux d'urgence soient difficilement accessibles et peu abordables a des consequences au-dela des deces maternels. Fournir gratuitement des medicaments et passer a un systeme de reference plus durable, finance au niveau national, permettrait de reduire les depenses catastrophiques pour les menages en situation d'urgence obstetricale. Objetivo Investigar la frecuencia de los gastos catastroficos en la atencion obstetrica de urgencia, examinar los factores de riesgo y evaluar el efecto de dichos gastos en los hogares de la region de Kayes en Mali. Metodos Se recogieron los datos de 484 situaciones obstetricas de urgencia (242 falledmientos y 242 errores evitados) entre 2008 y 2011. El gasto catastrofico de la atencion obstetrica de urgencia se evaluo en umbrales diferentes y los factores relacionados se examinaron por medio de una regresion logistica. Posteriormente, se realizo una encuesta en una muestra jerarquizada de 56 hogares a fin de determinar los efectos de dicho gasto catastrofico. Resultados A pesar de la politica de exencion de pago para las cesareas y el sistema de derivacion para la atencion de maternidad, disenado para reducir la carga financiera de la atencion obstetrica de urgencia, el gasto medio fue de 152 dolares estadounidenses (71 $35 francos CFA) y del 20,7 al 53,5% de los hogares incurrieron en gastos catastroficos. El gasto elevado de la atencion obstetrica de urgencia obligo al 44,6% de los hogares a reducir su consumo de alimentos, y el 23,2% seguia endeudado entre 10 meses y dos anos y medio mas tarde. Vivir en un area rural remota estuvo asociado con el riesgo de gasto catastrofico, lo que muestra la incapacidad del sistema de derivacion de eliminar los obstaculos financieros para los hogares de zonas remotas. Las mujeres que se sometieron a una cesarea continuaron acumulando gastos catastroficos, en particular en los casos en los que se prescribieron medicamentos no incluidos en los botiquines para cesareas proporcionados por el gobierno. Conclusion La mala accesibilidad y asequibilidad de la atencion obstetrica de urgencia tiene consecuencias mas alla de las muertes matemas. Suministrar medicamentos gratuitos y el cambio a un sistema de derivacion financiado a nivel nacional y mas sostenible reduciria los gastos catastroficos de los hogares en los casos de emergencias obstetricas.

Introduction Maternal mortality is a major public health problem, particularly in sub-Saharan Africa, where half (50.4%) of all maternal deaths worldwide occur. (1) One objective of the Millennium Development Goals [...], Objective To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa). Methods A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. In an uncontrolled 'before and after' study, we recorded all obstetric emergencies, major obstetric interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the intervention (P-1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression. Findings The number of women receiving emergency obstetric care doubled between P-1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P-1 to 0.46% in P2. In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30-0.76). Maternal mortality rates decreased more among women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage. Conclusion The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications. Objectif Evaluer les effets d'un systeme national d'aiguillage visant a reduire les taux de mortalite maternelle a travers une amelioration de l'accessibilite et de la qualite des soins obstetricaux d'urgence dans une region rurale du Mali (Afrique sub-saharienne). Methodes Un systeme d'aiguillage maternel, comprenant la prestation de soins obstetricaux d'urgence de base et complets, le transport dans un centre de sante dispensant des soins obstetricaux et des systemes de partage des couts dans la collectivite, a ete mis en ceuvre dans six districts sanitaires ruraux de la region de Kayes, entre decembre 2002 et novembre 2005. Dans le cadre d'une etude << avant et apres >> non controlee, nous avons en registre toutes les urgences obstetricales, les interventions obstetricales majeures et les deces maternels sur une periode d'observation de 4 ans (du 1er janvier 2003 au 30 novembre 2006), couvrant l'annee avant l'intervention (P-1), l'annee de l'intervention (P0) et les annees debutant 1 an et 2 ans apres l'intervention (P1 et P2 respectivement). La principale mesure de resultat etait le risque de deces chez les patientes presentant une urgence obstetricale, calcule a partir des taux de letalite et des odds ratios bruts. Les resultats des analyses ont ete ajustes par regression logistique pour tenir compte des facteurs de confusion. Resultats Le nombre de femmes recevant des soins obstetricaux d'urgence a double entre P-1 et P2 et le taux d'interventions obstetricales majeures (principalement des cesariennes), pratiquees pour des indications maternelles absolues, est passe de 0,13 % en P-1 a 0,46 % en P2. Pour les femmes prises en charge pour une urgence obstetricale, le risque de deces 2 ans apres l'intervention etait inferieur de moitie a celui enregistre avant l'intervention (odds ratio, OR : 0,48 ; intervalle de confiance a 95 %, IC : 0,30-0,76). Les taux de mortalite maternelie ont diminue plus fortement parmi les femmes aiguillees vers des soins obstetricaux d'urgence que parmi celles s'etant presentees dans des centres de sante de district, sans aiguillage. Pres de la moitie (47,5 %) de cette baisse de mortalite etait attribuable a la diminution des deces par hemorragie. Conclusion On a observe pour cette intervention des effets rapides, imputables a la disponibilite des interventions obstetricales majeures dans des centres de sante de district, a la reduction du temps de transport dans ces centres pour y recevoir un traitement et a la reduction des obstacles financiers a la dispensation des soins. Nos resultats montrent que les programmes nationaux sont applicables dans les pays a faible revenu sans apport financier externe majeur et qu'ils peuvent ameliorer rapidement la couverture des services obstetricaux et diminuer notablement le risque de deces associe aux complications obstetricales. Objetivo Evaluar el efecto de un sistema nacional de derivacion concebido para reducir las tasas de mortalidad materna mediante la mejora del acceso a la atencion obstetrica de urgencia y de la calidad de la misma en el Mali rural (Africa subsahariana). Metodos Entre diciembre de 2002 y noviembre de 2005 se implanto en seis distritos de salud rurales de la region de Kayes un sistema de derivacion para atencion de maternidad que incluia atencion obstetrica de urgencia basica e integral, transporte a servicios de obstetricia y planes comunitarios de participacion en la financiacion de los gastos. Mediante un estudio <> no controlado, registramos todas las urgencias obstetricas, las intervenciones obstetricas mayores y las defunciones maternas a lo largo de un periodo de observacion de 4 anos (1 de enero de 2003 a 30 de noviembre de 2006): el ano previo a la intervencion (P-1); el ano de intervencion (P0), y al cabo de 1 y 2 anos de la intervencion (P1 y P2, respectivamente). La variable principal de valoracion fue el riesgo de defuncion entre las pacientes con urgencias obstetricas, calculado mediante las tasas brutas de letalidad y las razones de posibilidades brutas. Los analisis se ajustaron por variables de confusion mediante regresion logistica. Resultados El numero de mujeres que recibieron atencion obstetrica de urgencia se duplico entre P-1 y P2, y la tasa de intervenciones obstetricas mayores (principalmente cesareas) para indicaciones maternas absolutas aumento de 0,13% en P-1 a 0,46% en P2. En las mujeres tratadas por una urgencia obstetrica, el riesgo de muerte a los 2 anos de la intervencion se redujo a la mitad respecto a antes de la intervencion (razon de posibilidades, OR: 0,48; intervalo de confianza, IC, del 95%: 0,30-0,76). Las tasas de mortalidad materna disminuyeron mas entre las mujeres derivadas para atencion obstetrica urgente que entre las que acudieron al centro de salud de distrito sin derivacion previa. Casi la mitad (47,5%) de la reduccion de la mortalidad es atribuible al menor numero de defunciones por hemorragia. Conclusion La intervencion tuvo efectos rapidos debido a la disponibilidad de intervenciones obstetricas mayores en los centros de salud de distrito, la disminucion del tiempo de transporte hasta esos centros para recibir tratamiento y la disminucion de las barreras financieras a la atencion. Nuestros resultados muestran que es posible aplicar programas nacionales en los paises de ingresos bajos sin necesidad de fondos externos importantes, y que dichos programas pueden mejorar rapidamente la cobertura de servicios obstetricos y reducir de forma considerable el riesgo de defuncion asociada a complicaciones obstetricas.

Background The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%. (1) The caesarean delivery rate in Canada increased steadily from 17.5% [...], Objective To investigate obstetricians' perceptions of clinical practice guidelines targeting management of labour and vaginal birth after previous caesarean birth, and to identify the barriers to, facilitators of and obstetricians' solutions for implementing these guidelines in practice. Methods This qualitative study was conducted in three hospitals in Montreal that represent around 10% of births in Quebec. Data was collected from 10 focus groups, followed by six semi-structured interviews. Two researchers jointly analysed the verbatim transcripts according to A manual for the use of focus groups. Findings The identified barriers to and facilitators of the implementation of guidelines can be classified into four categories: 1) the hospital level, including management and hospital policies; 2) the departmental level, including local policies, leadership, organizational factors, economic incentive, and availability of equipment and staff; 3) the health professionals' motivations and attitudes, including medico-legal concerns, skill levels, acceptance of guidelines and strategies used to implement recommendations; and 4) patients' motivations. Conclusion Identifying the barriers to and facilitators of the adoption of recommendations is an important way to guide the development of efficient strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals' perceptions are considered to make recommendations more acceptable and useful. Our findings also support the assumption that obstetricians seek to implement best practices, but require evidence tools and support to assess their practices and enhance their performance. In addition, peer review activities championed by opinion leaders have been identified by obstetricians as the most suitable strategy to improve the use of the guidelines in their practices. Resume Identification des elements empachant ou facilitant la mise en oeuvre des directives visant a reduire les taux d'accouchement par cesarienne au Quebec Objectifs Etudier la perception par les obstetriciens des directives en matiere de pratiques cliniques visant la prise en charge du travail et l'accouchement par les voies naturelles des femmes ayant anterieurement accouche par cesarienne et identifier les elements qui, dans la pratique, entravent ou facilitent la mise en ceuvre de solutions obstetricales conformes a ces directives. Methodes L'etude qualitative a ete menee dans trois hopitaux de Montreal representant environ 10 % des naissances au Quebec. On a procede a une collecte de donnees parmi 10 groupes thematiques, puis a 6 entretiens semi-structures. Deux chercheurs ont en commun analyse les transcriptions integrales de ces entretiens selon A manual for the use of focus groups. Resultats Les elements empechant ou facilitant la mise en oeuvre des directives qui ont ete identifies peuvent etre classes en trois categories : 1) niveau hospitalier (politiques de prise en charge et de l'etablissement notamment) ; 2) niveau du departement (politiques locales, facteurs lies a l'encadrement et a l'organisation, incitations economiques et disponibilites en equipements et en personnel notamment) ; 3) motivations et mentalites des professionnels de sante (preoccupations medico-legales, niveaux de competences, acceptation des directives et strategies utilisees pour appliquer les recommandations notamment) et 4) motivations des patientes. Conclusion L'identification des elements empechant ou facilitant l'adoption des directives est un moyen important pour guider le developpement de strategies efficaces. Les resultats de cette etude laissent a penser que cette adoption peut s'effectuer mieux si les perceptions des professionnels de la sante locaux sont prises en compte dans l'elaboration de recommandations plus acceptables et plus utiles. Nos resultats etayent aussi l'hypothese selon laquelle les obstetriciens cherchent a mettre en oeuvre les meilleures pratiques, mais ont besoin d'outils et d'aides reposant sur des elements factuels pour evaluer leurs pratiques et ameliorer leurs performances. En outre, le controle par des pairs des pratiques, preconise par des dirigeants politiques, a ete identifie par les obstetriciens comme la strategie la plus appropriee pour ameliorer l'application des directives dans leur activite. Resumen Identificacion de los factores que impiden o favorecen la aplicacion de protocolos orientados a reducir las tasas de cesarea en Quebec Objetivo Investigar las ideas de los obstetras acerca de los protocolos clinicos relativos al manejo del trabajo de parto y el parto vaginal tras una cesarea anterior, e identificar los factores que impiden o favorecen la aplicacion de esos protocolos en la practica y las soluciones de los obstetras a ese fin. Metodos Este estudio cualitativo se llevo a cabo en tres hospitales de Montreal que concentran alrededor del 10% de los nacimientos en Quebec. Se reunieron datos de 10 grupos de discusion, a lo que siguieron seis entrevistas semiestructuradas. Dos investigadores analizaron conjuntamente las transcripciones literales ateniendose a un manual de manejo de grupos de discusion. Resultados Los factores que impiden o favorecen la aplicacion de los protocolos pueden clasificarse en cuatro categorias: 1) el nivel hospitalario, en particular la gestion y las politicas hospitalarias; 2) el nivel departamental, con inclusion de las politicas locales, el liderazgo, los factores organizacionales, los incentivos economicos y la disponibilidad de equipo y personal; 3) las motivaciones y actitudes de los profesionales sanitarios, incluidos los problemas medico-legales, los niveles de aptitud, la aceptacion de las directrices y las estrategias usadas para poner en practica las recomendaciones, y 4) las motivaciones de las pacientes. Conclusion La identificacion de los factores que impiden o facilitan la adopcion de las recomendaciones ayuda a orientar la formulacion de estrategias eficaces. Los resultados de este estudio parecen indicar que, cuando se tienen en cuenta las impresiones de los profesionales sanitarios locales, es posible fomentar la adopcion de los protocolos. Nuestros resultados respaldan tambien la idea de que los obstetras procuran aplicar las practicas optimas, pero requieren datos probatorios y apoyo para evaluar su forma de trabajar y mejorar su desempeno. Ademas, dichos profesionales han identificado las actividades de examen por homologos preconizadas por personas de reconocida influencia como la estrategia mas apropiada para fomentar el uso de los protocolos en el ejercicio de su trabajo. [TEXT NOT REPRODUCIBLE IN ASCII]