Current evidence on basic emergency obstetric and newborn care services in Addis Ababa, Ethiopia; a cross sectional study

Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries

Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.

Audit as a tool for improving obstetric care in low- and middle-income countries

Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities.

Knowledge and practice of health workers towards maternal and child health in the Democratic Republic of the Congo: a cross-sectional study

BACKGROUND

The burden of maternal and child mortality is high in the Democratic Republic of the Congo (DRC). While health workers (HWs) with adequate knowledge and practice of maternal and child health (MCH) are crucial to reduce this burden, the skill level of HWs in charge of MCH in the DRC is currently insufficient. This study aimed to assess the knowledge and practice of HWs towards MCH in Kasai and Maniema, two DRC provinces with very high maternal mortality ratios and under-5 mortality rates.

METHODS

This cross-sectional study was conducted in 96 health facilities of Kasai and Maniema provinces in 2019. All HWs in charge of MCH were eligible for the study. Data were collected using a structured questionnaire containing 76 questions on knowledge and practice of MCH. Analyses were performed using the Wilcoxon-Mann-Whitney test, Kendall's correlation test, and a multivariate linear mixed regression model.

RESULTS

Among participating HWs, 42.6% were A2 nurses (lowest qualification), 81.9% had no up-to-date training in MCH, and 48.4% had only 1-5 years of experience in MCH. In the two provinces combined, about half of HWs had poor knowledge (50.6%) and poor practice (53.3%) of MCH. Knowledge and practice scores were higher in Maniema than in Kasai (P < 0.001). Good knowledge and practice scores were significantly associated with high qualification (P = 0.001), continuing up-to-date training in MCH (P = 0.009), and 6 years of experience or more in MCH (P = 0.01).

CONCLUSION

In Maniema and Kasai provinces, about half of HWs had poor knowledge and poor practice of MCH. The conversion of A1 nurses into midwives as well as the provision of up-to-date training in MCH, supervision, and mentorship could improve the skill level of HWs and could thus reduce the burden of MCH in the DRC.

Geographical distribution of emergency obstetric and neonatal care signal functions in Ethiopian health facilities: 2021-2022 Ethiopian service Provision Assessment (SPA)

BACKGROUND

The maternal mortality ratio in Ethiopia is still high, with an estimate of 412 deaths per 100,000 live births in 2016. Signal functions for emergency obstetric and neonatal care must be accessible and usable in order to successfully prevent maternal deaths. It is an important strategy to reduce maternal and newborn morbidity and mortality in countries with limited resources. Hence, an assessment of the availability of fully functioning EmONC services and their coverage per 500,000 people in Ethiopia is crucial.

METHODS

This study is a retrospective analysis of data from the Ethiopian Service Provision Assessment Survey (ESPA), a national-level survey data source. Data collection for the survey took place from August 11, 2021, to February 4, 2022. For this investigation, 905 healthcare facilities in total were evaluated for the availability of emergency obstetric and new-born care (EmONC) services at all hospitals, selected health centers, and private clinics were evaluated. Descriptive data analysis was done by the using statistical package for social science version 26 (SPSS) to run frequency and cross-tabs. Global Positioning System (GPS) (arc map 10.8) Software was used for spatial distribution in order to locate the physical accessibility of EmONC providing health facilities on flat map surfaces. It was projected based on Ethiopia's geographic coordinate system at Adindan UTM zone 370N.

RESULTS

Of 905 health facilities, only 442 (49%) could provide fully functioning BEmONC, and 250 (27.6%) health facilities have been providing fully functioning CEmONC. The overall coverage of BEmONC ratios in Ethiopia is 1.5-3.77 per 500,000 population and CEmONC (0.83-2.1) per 500,000 populations. Regions such as Amhara, SNNPR and Addis Ababa had found to have high BEmONC ratio. The geographical distribution of the EmONC showed that the central areas of the country, such as southwest Shewa and east Shewa, the Oromia region, the northern areas of the South Nation, nationalities, and peoples regions (SNNPR), including the Gurage zone and the Wolaita-Soddo zone, and the middle areas in the Amhara region (west Gojjam or around Bahir Dar town), and the southern areas, Debra Tabor and Debre Birhane zones, all had greater access to facilities offering complete EmONC services.

CONCLUSION

Comprehensive emergency obstetrics and neonatal care (CEmONC) in Ethiopia met WHO recommendations, despite basic emergency obstetric and neonatal care (BEmONC) falling below those standards in Ethiopia. There are extremely large disparities in the accessibility of both basic and comprehensive emergency obstetrics and neonatal care in Ethiopia. Thus, Strategic planning is needed to improve infrastructures and inputs for EmONC services, particularly in remote areas of the country. Additionally, private facilities ought to place a priority on the provision of these services.

The Journey Toward Establishing Inpatient Care for Small and Sick Newborns in Ethiopia, India, Malawi, and Rwanda

BACKGROUND

Limited information is available about the approaches used and lessons learned from low- and middle-income countries that have implemented inpatient services for small and sick newborns. We developed descriptive case studies to compare the journeys to establish inpatient newborn care across Ethiopia, India, Malawi, and Rwanda.

METHODS

A total of 57 interviews with stakeholders in Ethiopia (n=12), India (n=12), Malawi (n=16), and Rwanda (n=17) informed the case studies. Our heuristic data analysis followed a deductive organizing framework approach. We informed our data analysis via targeted literature searches to uncover details related to key events. We used the NEST360 Theory of Change for facility-based care, which reflects the World Health Organization (WHO) Health Systems Framework as a starting point and added, as necessary, in an edit processing format until data saturation was achieved.

FINDINGS

Results highlight the strategies and innovation used to establish small and sick newborn care by health system building block and by country. We conducted a gap analysis of implementation of WHO Standards for Improving Facility-Based Care. The journeys to establish inpatient newborn care across the 4 countries are similar in terms of trajectory yet unique in their implementation. Unifying themes include leadership and governance at national level to consolidate and coordinate action to improve newborn quality of care, investment to build staff skills on data collection and use, and institutionalization of regular neonatal data reviews to identify gaps and propose relevant strategies.

CONCLUSION

Efforts to establish and scale inpatient care for small and sick newborns in Ethiopia, India, Malawi, and Rwanda over the last decade have led to remarkable success. These country examples can inspire more nascent initiatives that other low- and middle-income countries may undertake. Documentation should give voice to lived country experience, not all of which is fully captured in existing, peer-reviewed published literature.

Place of death and associated factors among reviewed maternal deaths in Ethiopia: a generalised structural equation modelling

OBJECTIVE

The study aims to determine the magnitude and factors that affect maternal death in different settings.

DESIGN, SETTING AND ANALYSIS

A review of national maternal death surveillance data was conducted. The data were obtained through medical record review and verbal autopsies of each death. Generalised structural equation modelling was employed to simultaneously examine the relationships among exogenous, mediating (urban/rural residence) and endogenous variables.

OUTCOME

Magnitude and factors related to the location of maternal death.

PARTICIPANTS

A total of 4316 maternal deaths were reviewed from 2013 to 2020.

RESULTS

Facility death constitutes 69.0% of maternal deaths in the reporting period followed by home death and death while in transit, each contributing to 17.0% and 13.6% of maternal deaths, respectively. Educational status has a positive direct effect on death occurring at home (β=0.42, 95% CI 0.22 to 0.66), obstetric haemorrhage has a direct positive effect on deaths occurring at home (β=0.41, 95% CI 0.04 to 0.80) and death in transit (β=0.68, 95% CI 0.48 to 0.87), while it has a direct negative effect on death occurring at a health facility (β=-0.60, 95% CI -0.77 to -0.44). Moreover, unanticipated management of complication has a positive direct (β=0.99, 95% CI 0.34 to 1.63), indirect (β=0.05, 95% CI 0.04 to 0.07) and total (β=1.04, 95% CI 0.38 to 1.70) effect on facility death. Residence is a mediator variable and is associated with all places of death. It has a connection with facility death (β=-0.70, 95% CI -0.95 to -0.46), death during transit (β=0.51, 95% CI 0.20 to 0.83) and death at home (β=0.85, 95% CI 0.54 to 1.17).

CONCLUSION

Almost 7 in 10 maternal deaths occurred at the health facility. Sociodemographic factors, medical causes of death and non-medical causes of death mediated by residence were factors associated with the place of death. Thus, factors related to the place of death should be considered as an area of intervention to mitigate preventable maternal death that occurred in different settings.

Evidence-informed framework for gender transformative continuing education interventions for midwives and midwifery associations

INTRODUCTION

Continuing education for midwives is an important investment area to improve the quality of sexual and reproductive health services. Interventions must take into account and provide solutions for the systemic barriers and gender inequities faced by midwives. Our objective was to generate concepts and a theoretical framework of the range of factors and gender transformative considerations for the development of continuing education interventions for midwives.

METHODS

A critical interpretive synthesis complemented by key informant interviews, focus groups, observations and document review was applied. Three electronic bibliographic databases (CINAHL, EMBASE and MEDLINE) were searched from July 2019 to September 2020 and were again updated in June 2021. A coding structure was created to guide the synthesis across the five sources of evidence.

RESULTS

A total of 4519 records were retrieved through electronic searches and 103 documents were included in the critical interpretive synthesis. Additional evidence totalled 31 key informant interviews, 5 focus groups (Democratic Republic of Congo and Tanzania), 24 programme documents and field observations in the form of notes. The resulting theoretical framework outlines the key considerations including gender, the role of the midwifery association, political and health systems and external forces along with key enabling elements for the design, implementation and evaluation of gender transformative continuing education interventions.

CONCLUSION

Investments in gender transformative continuing education for midwives, led by midwifery associations, can lead to the improvement of midwifery across all United Nations' target areas including governance, health workforce, health system arrangements and education.

Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis

BACKGROUND

In approximately 15% of all pregnancies, a potentially fatal complication that necessitates medical attention arises, requiring a significant obstetrical intervention for the pregnant women to survive. Between 70% and 80% of maternal life-threating complication have been treated through emergency obstetric and newborn services. This study investigates women's satisfaction with emergency obstetric and newborn care services in Ethiopia and factors associated with their satisfaction.

METHODS

In this systematic review and meta-analysis, we searched electronic databases, such as PubMed, Google Scholar, HINARI, Scopus, and Web of Sciences for primary studies. A standardized data collection measurement tool was used to extract the data. STATA 11 statistical software was used to analyze the data, and I² tests were used to evaluate heterogeneity. The pooled prevalence of maternal satisfaction was predicted using a random-effects model.

RESULTS

Eight studies were included. The pooled prevalence of maternal satisfaction with emergency obstetric and neonatal care services was 63.15% (95% confidence interval: 49.48-76.82). Age (odds ratio = 2.88, 95% confidence interval: 1.62-5.12), presence of birth companion (odds ratio = 2.66, 95% confidence interval: 1.34-5.29), satisfaction with health workers' attitudes (odds ratio = 4.02, 95% confidence interval: 2.91-5.55), educational status (odds ratio = 3.59, 95% confidence interval: 1.42-9.08), length of stay at health facility (odds ratio = 3.71, 95% confidence interval: 2.79-4.94), and antenatal care visits (odds ratio = 2.22, 95% confidence interval: 1.52-3.24) were associated with maternal satisfaction with emergency obstetric and neonatal care service.

CONCLUSION

This study found a low level of overall maternal satisfaction with emergency obstetric and neonatal care services. To increase maternal satisfaction and utilization, the government should focus on improving the standards of emergency maternal, obstetric, and newborn care by identifying gaps in maternal satisfaction regarding the services provided by healthcare professionals.

Effective Coverage of Emergency Obstetric and Newborn Care Services in Africa: A Scoping Review

Objective

This scoping review aimed to map the evidence of effective coverage (EC) of EmONC (Emergency Obstetric and Neonatal Care) services and associated factors in Africa.

Methodology

The review used PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) checklist to select, appraise, and report the findings. We searched four databases (PubMed, Web of Science, Google Scholar, and Scopus) and grey literature published between Jan 01, 2011 - Dec 31, 2020. The search terms included "emergency", "obstetric", "newborn", "effective coverage", and "quality" with Boolean terms, AND and OR. The review was conducted using title, abstract, and full-article screenings. The results were analyzed thematically using NVivo v12 qualitative research data analysis software.

Results

Of the 1811 searched studies, 32 met the eligibility criteria for review. The majority of the studies were from East (56.3%) and Western (28.1%) Africa. Most studies were cross-sectional, had targeted health facilities, and combined two or more data collection techniques. The thematic analysis yielded three themes: EmONC service utilization, quality of EmONC service, and factors associated with the quality of EmONC services. The review showed a scarcity of evidence and variations regarding the crude coverage, quality of care, and factors affecting the quality of EmONC services in Africa.

Conclusion

The review reported that the utilization of EmONC services was below the WHO-recommended 100% in all studies, though some reported improvements over time. Disparities in EmONC services quality were paramount across studies and contexts. However, the methodological and analytical incongruity across studies brought difficulties in tracing and comparing the progress made in EmONC services utilizations.

Registration

This scoping review protocol was first registered on the Open Science Framework (OSF) on Aug 27, 2021 (https://osf.io/khcte/).

Too busy to care? Analysing the impact of system-related factors on maternal mortality in Zanzibar's Referral Hospital

This study analyses the contribution of system-related factors to maternal mortality in the low-resource setting of Mnazi Mmoja Hospital in Zanzibar, Tanzania. It is a retrospective cohort study including all maternal deaths (MD, n = 139) and maternal near-misses (MNM, n = 122) in Mnazi Mmoja Hospital with sufficient documentation during 2015 to 2018 (MD) and 2017 to 2018 (MNM). The number of admissions and surgical interventions per health care provider on the day of admission and the number of times vital signs were monitored per day were compared between MNM and MD cases using logistic regression. The mean number of times vital signs were monitored per day was associated with reduced odds of mortality (aOR 0.75, 95% CI 0.64-0.89), after adjustment for confounding factors such as severity of illness. The numbers of admissions or surgical procedures per health care provider were not associated with mortality. Concluding, the degree of monitoring of patients with life-threatening complications of pregnancy or childbirth is associated with the risk of mortality independent of the degree of severity. Preventing maternal mortality requires going beyond availability of essential interventions to tackle system-related factors that have a direct impact on the capacity to provide comprehensive care.Impact StatementWhat is already known on this subject? Root cause analyses of maternal deaths have identified many system-related factors, such as availability of health care providers, adequate training, and motivation to sustain high intensity monitoring (Madzimbamuto et al. 2014; Mahmood et al. 2018).What do the results of this study add? This is the first study to attempt to quantify the contribution of these system-related factors by comparing cases of maternal death with cases of maternal near-miss. We show that the degree of monitoring of patients with life-threatening complications is associated with the odds of mortality independent of the degree of severity. Even though this relation should not be regarded as causative, monitoring of vital signs can be seen as reflective of many system-related factors which hamper or facilitate comprehensive care.What are the implications of these findings for clinical practice and/or further research? This study helps increase general understanding of the factors leading to progression from severe disease to death in a high-volume low-income setting.

Structural quality of labor and delivery care in government hospitals of Ethiopia: a descriptive analysis

Background

Ethiopia has low skilled birth attendance rates coupled with low quality of care within health facilities contributing to one of the highest maternal mortality rates in Sub-Saharan Africa, at 412 deaths per 100,000 live births. There is lack of evidence on the readiness of health facilities to deliver quality labor and delivery (L&D) care. This paper describes the structural quality of routine L&D care in government hospitals of Ethiopia.

Methods

A facility-based cross-sectional study design, involving census of all government hospitals in Southern Nations Nationalities and People’s Region (SNNPR) (N = 20) was conducted in November 2016 through facility audit using a structured checklist. Data collectors verified the availability and functioning of the required items through observation and interview with the heads of labor and delivery case team. An overall mean score of structural quality was calculated considering domain scores such as general infrastructure, human resource and essential drugs, supplies, equipment and laboratory services. Summary statistics such as proportion, mean and standard deviation were computed to describe the degree of adherence of the hospitals to the standards related to structural quality of routine labor and delivery care.

Results

One third of hospitals had low readiness to provide quality routine L&D care, with only two approaching near fulfilment of all the standards. Hospitals had fulfilled 68.2% of the standards for the structural aspects of quality of L&D care. Of the facility audit criteria, the availability of essential equipment and supplies for infection prevention scored the highest (88.8%), followed by safety, comfort and woman friendliness of the environment (76.4%). Availability skilled health professionals and quality management practices scored 72.5% each, while availability of the required items of general infrastructure was 64.6%. The two critical domains with the lowest score were availability of essential drugs, supplies and equipment (52.2%); and laboratory services and safe blood supply (50%).

Conclusion

Substantial capacity gaps were observed in the hospitals challenging the provision of quality routine L&D care services, with only two thirds of required resources available. The largest gaps were in laboratory services and safe blood, and essential drugs, supplies and equipment. The results suggest the need to ensure that all public hospitals in SNNPR meet the required structure to enable the provision of quality routine L&D care with emphases on the identified gaps.

Assessment of Availability and Quality of Emergency Obstetric and Newborn Care Service in Southwestern Oromia, Ethiopia, 2017

Background. Emergency obstetrics and newborn care (EmONC) is an important lifesaving function which can avert the death of women facing obstetrics-related complications. It is a cost-effective, significant intervention to decrease maternal and neonatal morbidity and mortality in poor resource settings, including Ethiopia. Objective. The aim of this study was to assess the availability and quality of the EmONC services in southwestern Oromia, Ethiopia, in 2017. Methods. An institutional-based cross-sectional study was implemented from April to May 2017. Data were collected using checklists and questionnaires developed from different studies. Data were analyzed using EPI-info and exported to SPSS version 20 for further analysis. Each descriptive statistic was summarized using frequency, percentage, and tables for categorical variables. Results. Despite the fact that the overall coverage of fully functioning basic emergency obstetric and newborn care (BEmONC) facilities was greater than 5 per 500,000 people, nearly one-fourth (25.64%) provided less than expected signal functions, indicating that these facilities were nonfunctional. There were only 0.24 comprehensive emergency obstetric and newborn care (CEmONC) facilities per 500,000 people. The result of this study also revealed that the quality of EmONC facilities in all health-care settings was poor. Conclusion and Recommendation. There were gaps in performance signal functions as well as the availability and quality of EmONC in the study area. Availability and quality of EmONC necessitate improvements through enhancing health-care providers’ skills by training and mentoring as well as enabling facilities accessible for utilization of EmONC. Further research is needed to identify factors that could be barriers to the performance quality and coverage of EmONC services.

Clinical decision making in basic emergency obstetric and newborn care among nurses and midwives: the role of the safe delivery mhealth application_pre-post-intervention study (research protocol)

Most maternal and newborn deaths in low-income countries, including Rwanda, are attributable to preventable causes. Timely access to Basic Emergency Obstetric and Newborn Care (BEmONC) guidelines to support clinical decisions could lead to better obstetric care thus reduction of maternal and newborn deaths. Besides, innovative methods such as the usage and reference to healthcare guidelines using mobile devices (mhealth) may support clinical decision making. However, there is little evidence about mhealth that focuses on the clinical decision support process. This proposal aims to investigate the effect of the Safe Delivery mhealth Application(SDA) on nurses' and midwives' clinical decision making, so as to inform mhealth interventions for work in specific contexts. The study adopts a quasi-experimental design. Convergent parallel mixed - methods will be used to collect, analyze and interpret data. A pre-intervention assessment of the BEmONC outcomes: Apgar score and PPH progressions, and related knowledge, skills, and perceptions of nurses and midwives will be conducted. The intervention will take place in two district hospitals in Rwanda and entails the implementation of the SDA for six months. Six months' post-intervention, the effect of the SDA on BEmONC outcomes and the nurses' and midwives' knowledge and skills will be evaluated.

Assessment of integration of emergency obstetric and newborn care in maternal and newborn care in healthcare facilities in Osun State, Nigeria

The integration of emergency obstetric and newborn care (EmONC) into maternal and newborn care is essential for its effectiveness to avert preventable maternal and newborn deaths in healthcare facilities. This study used a theory-oriented quantitative approach to document the reported extent of EmONC integration, and its relationship with EmONC training, guidelines availability and level of healthcare facility. A descriptive cross-sectional study was conducted among five hundred and five (505) healthcare providers and facility managers across the three levels of healthcare delivery. An adapted questionnaire from NoMad instrument was used to collect data on the integration of EmONC from the study participants. Ethical approval was obtained and informed consents taken from the participants. Both descriptive (frequency, percentage, mean and median) and inferential analyses (Kruskal Wallis and Mann Whitney tests) were done with statistical significance level of p<0.05 using STATA 14. The mean age of respondents was 38.68±8.27. The results showed that the EmONC integration median score at the three levels of healthcare delivery was high (77 (IQR = 83–71)). The EmONC integration median score were 76 (IQR = 84–70), 76 (IQR = 80–68) and 78 (IQR = 84–74) in the primary, secondary and tertiary healthcare facilities respectively. Integration of EmONC was highest (83 (IQR = 87–78)) among healthcare providers who had EmONC training and also had EmONC guidelines made available to them. There were significant differences in EmONC integration at the three levels of healthcare delivery (p = 0.046), among healthcare providers who had EmONC training and those with EmONC guidelines available in their maternity units (p = 0.001). EmONC integration was reportedly high and significantly associated with EmONC training and availability of guidelines. However, the congruence of reported and actual extent of integration of EmONC at the three levels of healthcare delivery still need validation as such would account for the implementation success and maternal-neonatal outcomes.

Essential Newborn Care Service Readiness and Barriers in Northwest Ethiopia: A Descriptive Survey and Qualitative Study

Background

Despite the efforts put forth in improving neonatal survival, there is still a high rate of neonatal morbidity and mortality in northwest Ethiopia. Therefore, this study aimed to determine the essential newborn care service readiness scores and explore the health facility-related barriers in North Gondar Zone, Northwest Ethiopia.

Methods

A cross-sectional survey of 16 health facilities (14 health centers and two hospitals) and twelve in-depth interviews were included in the study in three randomly selected districts of North Gondar Zone. A pretested health facility inventory questionnaire customized from the World Health Organization (WHO) service readiness assessment tool was used for a facility audit. Basic emergency and essential obstetric and newborn care (BEmONC), and child immunization service readiness scores were determined using unweighted averages according to the WHO guideline. Descriptive statistics were done for the quantitative data, and thematic content analysis was employed using NVivo 12 software for the qualitative data.

Results

All the surveyed health facilities had no specialist medical doctors, and 50% (8/16) of them had no inpatient beds. The overall BEmONC service readiness score was 62.7% (10/16) (95% CI: 34.8, 83.8) and only one facility had all the tracer items. Trained staff and guidelines had a 27.5% (4/16) readiness score, followed by 71.9% (12/16) readiness score for equipment, and 88.6% (14/16) readiness score for medicine and commodities. The overall child immunization service readiness score was 90.3% (15/16) (95% CI: 51.4, 94.7) and eleven facilities (68.8%) had all the tracer items. The immunization service readiness score was higher; 84.4% (14/16) for trained staff and guidelines, 92.8% (15/16) for equipment, and 93.8% (15/16) for medicines and commodities. Unavailability of equipment, shortage of supplies, and lack of respectful and compassionate healthcare practices were the key facility-related barriers compromising essential newborn care service readiness.

Conclusions for Practice

The survey revealed that the essential newborn care service readiness score of the health facilities was low, and it calls for improving BEmONC service readiness in particular. Provision of timely training for newly recruited staff, fulfilling essential equipment, and steady supply is imperative.

Perspectives of health workers on the referral of women with obstetric complications: a qualitative study in rural Sierra Leone

OBJECTIVES

Sierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric complications. This study describes factors affecting timely and adequate referral of women with obstetric complications in rural areas of Sierra Leone as viewed by health workers in rural health facilities.

DESIGN

Qualitative research with semi-structured interviews using open-ended questions. Data were analysed by systematic text condensation.

SETTING

Interviews were held in nine peripheral health units in rural Sierra Leone.

PARTICIPANTS

19 health workers including nurses, midwives and clinical health officers participated in nine interviews.

RESULTS

From the interviews, four major themes describing possible factors of delay in referral of women in need of emergency obstetric care emerged: (1) communication between healthcare workers; (2) underlying influences on decision-making; (3) women's compliance to referral and (4) logistic constraints.Several factors in rural Sierra Leone are perceived to complicate timely and adequate referral of women in need of emergency obstetric care. Notable among these factors are fear among women for being referred and fear among healthcare workers for having maternal deaths or severe obstetric complications occurring at their own facilities. Furthermore, decision-making of healthcare workers whether to refer a woman or not is negatively influenced by a hierarchical culture with high power distance between healthcare workers.

CONCLUSION

Factors identified that complicate timely and adequate referral of women in need of emergency obstetric care must be considered in efforts to reduce maternal mortality. Possible interventions that may reduce delay in referral include increased communication by mobile phones between health workers for advice and feedback regarding referrals, involvement of influential stakeholders to increase women's compliance to referral, and consistent use of standardised management protocols.

Basic neonatal resuscitation skills of midwives and nurses in Eastern Ethiopia are not well retained: An observational study

BACKGROUND

Neonatal resuscitation is a life-saving intervention for birth asphyxia, a leading cause of neonatal mortality. Worldwide, four million neonate deaths happen annually, and birth asphyxia accounts for one million deaths. Improving providers' neonatal resuscitation skills is critical for delivering quality care and for morbidity and mortality reduction. However, retention of these skills has been challenging in developing countries, including Ethiopia. Hence, this study aimed to assess neonatal resuscitation skills retention and associated factors among midwives and nurses in Eastern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted using a pre-tested, structured, observational checklist. A total of 427 midwives and nurses were included from 28 public health facilities by cluster sampling and simple random sampling methods. Data were collected on facility type, availability of essential resuscitation equipment, socio-demographic characteristics of participants, current working unit, years of professional experience, whether a nurse or midwife received refresher training, and skills and knowledge related to neonatal resuscitation. Binary logistic regression was used to analyse the association between neonatal resuscitation skill retention and independent variables.

RESULTS

About 11.2% of nurses and midwives were found to have retention of neonatal resuscitation skills. Being a midwife (AOR, 7.39 [95% CI: 2.25, 24.24]), ever performing neonatal resuscitation (AOR, 3.33 [95% CI: 1.09, 10.15]), bachelor sciences degree or above (AOR, 4.21 [95% CI: 1.60, 11.00]), and good knowledge of neonatal resuscitation (AOR, 3.31 [95% CI: 1.41, 7.73]) were significantly associated with skill retention of midwives and nurses.

CONCLUSION

Basic neonatal resuscitation skills of midwives and nurses in Eastern Ethiopia are not well retained. This could increase the death of neonates due to asphyxia. Being a midwife, Bachelor Sciences degree or above educational status, ever performing neonatal resuscitation, and good knowledge were associated with skill retention. Providers should be encouraged to upgrade their educational level to build their skill retention and expose themselves to NR. Further, understanding factors affecting how midwives and nurses gain and retain skills using high-level methodology are essential.

Knowledge of Basic Neonatal Resuscitation and Associated Factors Among Midwives and Nurses in Public Health Institutions in Eastern Ethiopia

Background

Neonatal resuscitation is a means to restore life to a baby from the state of asphyxia. It is a single intervention of birth asphyxia. Over 1.2 million African babies are supposed to die in the first four weeks of their life and many of them in the first 24 hours of birth in Sub-Saharan Africa. The major cause of early neonatal death is neonatal asphyxia, which can be prevented by neonatal resuscitation. However, there is limited evidence on midwives’ and nurses’ knowledge of neonatal resuscitation in the study area. Therefore, this study aimed to assess the knowledge of midwives and nurses about neonatal resuscitation and its associated factors.

Methods

This facility-based cross-sectional study was done on 427 midwives and nurses, who were selected using simple random sampling technique. Data were collected on facility type, availability of essential equipment, socio-demographic characteristics, working unit, professional experience, in-service training, and knowledge of neonatal resuscitation. First-degree holder midwives collected the data using a pre-tested face-to-face interviewer-administered questionnaire. Bivariate and multivariate logistic regression was used to analyze the association between the dependent and independent variables.

Results

The study showed that 9.8% of the study participants had good knowledge about neonatal resuscitation. Factors significantly associated with knowledge of neonatal resuscitation were being trained on newborn resuscitation (AOR = 3.79, 95% CI: 1.73, 8.32), being unmarried (AOR = 2.36, 95% CI: 1.11, 5.02), holding bachelor sciences degree or above (AOR = 2.67, 95% CI: 1.11, 6.47), and working under West Hararghe health institutions (AOR = 0.30, 95% CI: 0.10, 0.88).

Conclusion

The study participants had low knowledge of neonatal resuscitation. Being unmarried, holding bachelor sciences degree or above, being trained on neonatal resuscitation, and working under West Hararghe health institutions were factors associated with the knowledge of the study participants on neonatal resuscitation.

Determinants of birth asphyxia among newborns in Ethiopia: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to estimate the pooled magnitude of birth asphyxia and its determinants in Ethiopia.

METHODS

The databases, including PubMed, Medline, CINAHL, EMBASE, and other relevant sources, were used to search relevant articles. Both published and unpublished studies, written in English and carried out in Ethiopia, were included in the study. Quality of evidence was assessed by the relevant of the Joanna Briggs Institute tool. RevMan v5.3 statistical software was used to undertake the meta-analysis using a Mantel-Haenszel random-effects model. Heterogeneity was evaluated using the Cochran Q test, and I2 statistics was considered to assess its level. The outcome was measured using a 95% confidence interval (CI).

RESULTS

The pooled prevalence of birth asphyxia was 22.8% (95% CI: 13-36.8%]. Illiterate mothers (adjusted odds ratio [AOR]; 1.96, 95% CI: 1.44-2.67), antepartum hemorrhage (APH) (AOR; 3.43, 95% CI: 1.74-6.77), cesarean section (AOR; 3.66, 95% CI: 1.35-9.91), instrumental delivery (AOR; 2.74, 95% CI: 1.48-5.08), duration of labor (AOR; 3.09, 95% CI: 1.60-5.99), pregnancy induced hypertension (AOR; 4.35, 95% CI: 2.98-6.36), induction of labor (AOR; 3.69, 95% CI: 2.26-6.01), parity (AOR; 1.29, 95% CI: 1.03-1.62), low birth weight (LBW) (AOR; 5.17, 95% CI: 2.62-10.22), preterm (AOR; 3.98, 95% CI: 3.00-5.29), non-cephalic presentation (AOR; 4.33, 95% CI: 1.97-9.51), and meconium staining (AOR; 4.59, 95% CI: 1.40-15.08) were significantly associated with birth asphyxia.

CONCLUSION

The magnitude of birth asphyxia was very high. Maternal education, APH, mode of delivery, prolonged labor, induction, LBW, preterm, meconium-staining, and non-cephalic presentation were determinants of birth asphyxia. Hence, to reduce birth asphyxia and associated neonatal mortality, attention should be directed to improve the quality of intrapartum service and timely communication between the delivery team. In addition, intervention strategies aimed at reducing birth asphyxia should target the identified determinants.

Healthcare workers' clinical knowledge on maternal and newborn care in Ethiopia: findings from 2016 national EmONC assessment

Background

Improving maternal and newborn health indicators are key if Ethiopia is to achieve the Sustainable Development Goals. To do so, women need access to skilled attendance at birth and emergency obstetric and newborn care. To maximize their impact, understanding gaps in workers’ knowledge is required to remedy the weakness. This assessment determines knowledge levels of clinical management of maternal and newborn healthcare and factors that influence knowledge.

Methods

This study used data from the National Emergency Obstetric and Neonatal Care assessment conducted in 2016. Provider knowledge for MNH was assessed by interviewing providers. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible answers, and standardizing this to a scale of 100. Mixed linear regression was used to determine individual and contextual factors associated with the score.

Results

A total of 3800 interviews with complete data were included in this study. Most respondents were diploma midwives (73%), BSc midwives (11%) and diploma nurses (10%). On average, midwives scored 60 out of 100 on the question regarding the primary aspects of focused antenatal care and elements of a birth plan. Half of the midwives and health officers, and one-third of nurses knew to provide a loading dose of magnesium sulphate. Midwives scored 90% on the steps of active management of third stage of labor. In the mixed linear regression, working in a private for profit facility, health center/clinic, rural area, or in a facility with a protocol on referral/counter referral predicted lower knowledge scores. More positive scores were associated with work environments that had a computer, internet, and protocols on safe abortion care, management of selected obstetric topics, integrated management of pregnancy, childbirth, postnatal, and newborn, care for low birth weight including kangaroo mother care, and treatment of infection in young infants.

Conclusion

With regard to most knowledge related questions, health officers and midwives scored similarly. Providers scored substantially better on routine intrapartum and newborn care than on aspects related to care for complications. A substantial proportion of providers indicated that they would never give a loading dose of magnesium sulphate.

Referral linkage among public health facilities in Ethiopia: A qualitative explanatory study of facilitators and barriers for emergency obstetric referral in Addis Ababa city administration

BACKGROUND

In developing countries including Ethiopia, maternal mortality ratio remains unacceptably high. During pregnancy and childbirth, a woman may acquire one or more of obstetric complications including hemorrhage, sepsis, hypertension and obstructed labor. Early diagnosed and referral of women who experienced obstetric complications to a specialty center can save the life of women and babies. However, several factors might affect the referral procedures of these women. Therefore, this study was aimed at assessing the facilitators and barriers of obstetric referral in selected public health facilities of Addis Ababa city administration, Ethiopia.

METHODS

A qualitative study design was employed to obtain the narratives of 12 healthcare workers and three recently referred mothers. The study included a regional health bureau, a lead hospital and a health center. Thematic analysis was employed to present to present the findings of the study and open code software was used to code and generate the themes.

RESULTS

This study revealed several barriers and some facilitators of obstetric referral. Early identification of complications, exercising teamwork, availability of referral protocol, availability of ambulance and effective communication system were the major reported factors which enhanced obstetric referral. Several themes including poor perception of clients, poor supportive supervision, lack of staff motivation and shortage of beds and medical equipment, lack of competence among the staffs and shortage of ambulance at health center were emerged as barriers of obstetric referral.

CONCLUSIONS

This study revealed several barriers of obstetric referral in the Addis Ababa city administration although a number of facilitators of obstetric referral exist. All of the reported barriers are related to the existing health system that need a collective action of all the actors to eliminate the barriers while enhancing the facilitators of obstetric referral.

Immediate newborn care of knowledge, practice and associated factors among health care providers in Northwestern Zonal health facilities Tigray, Ethiopia, 2018

Objective

The aim of this study was to assess the immediate newborn care of knowledge, practice and associated factors among healthcare providers in Northwestern Zonal health facilities Tigray, Ethiopia, 2018.

Results

Among the total healthcare providers, who participated in this study, 64.8% had good knowledge and 59.8% of the respondents had a good level of essential newborn care practice. Unavailability of adequate materials (like guidelines, drug, etc.) and training status were significant variables with knowledge and practice of newborn care.

Knowledge of intrapartum care among obstetric care providers in rural Kenya

BACKGROUND

Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya.

METHODS

This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications.

RESULTS

Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care.

CONCLUSIONS

Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival.

Health workers' experiences with the Safe Delivery App in West Wollega Zone, Ethiopia: a qualitative study

Background

Health workers in many low-income countries are not adequately trained to deliver pregnant women safely. In response to this, the Safe Delivery App (SDA) has been developed, which provides animated clinical instruction videos in basic emergency obstetric and neonatal care. The SDA aims to improve knowledge and skills of health workers located in the periphery of the health system in order to improve quality of care and potentially save the lives of mothers and newborns. The objective of this qualitative study was to explore the users’ experiences with using the SDA and in which ways the SDA influences their work situation and their perceived ability to conduct safe deliveries.

Methods

Eleven focus group discussions and four individual interviews were conducted with a total of 56 midwives, nurses and health extension workers from five districts in West Wollega Zone, Oromiya region of Ethiopia. The data further include observations and informal conversations. All interviews were recorded, transcribed verbatim, checked for corrections and analysed using systematic text condensation.

Results

The findings indicate that health workers perceive the SDA as a useful tool, which helps them memorize and update knowledge and skills, and improves their confidence. User patterns follow the relevancy of the tool to the health workers’ work situation - those who conduct many deliveries have more often used the app in emergency situations, whereas those who conduct few deliveries more often use it to improve their knowledge and to provide health education to pregnant women. Thus, the SDA is used in varying ways depending on internal and external factors such as own competencies, availability of equipment and frequency of births attended. Health workers experienced that community members showed more recognition and trust in their abilities and ascribed this to their increased confidence in assisting in deliveries. The increased recognition from communities may also be associated to a medical technology.

Conclusion

The health workers perceive the SDA as having improved their ability to manage complications during childbirth and have gained increased recognition and trust from the communities.

Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria

BACKGROUND

Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria.

METHODS

This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses.

RESULTS

Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012.

CONCLUSION

The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.

Epidemiology of ambulance utilized patients in Addis Ababa, Ethiopia

Background

Well organized and appropriately utilized pre-hospital emergency services play a critical role in augmenting emergency care systems. The primary objective of this study was to understand the demographic and clinical profile of patients who used ambulances in Addis Ababa. The secondary objectives were to assess ambulance response time, transport time and reasons for referral amongst inter-facility transported patients in Addis Ababa.

Methods

The study was designed as a cross-sectional retrospective chart review of ambulance transported patients using ambulance station records from Addis Ababa Fire and Emergency Prevention and Control Authority. With IRB approval, simple random sampling and manual review of six months of clinical records was performed. Data were collected by trained data collectors and descriptive analysis was done using SPSS version 20.

Results

Female patients used ambulance services more often than males (female to male ratio of 3:1) and the mean age of the patients was 26 years. The most commonly transported age group was 16–30 years, followed by 31–50 years and neonatal patients (i.e. < 1 month). The majority of the patients had pregnancy related illnesses (n = 492, 61.4%), followed by general medical issues (n = 210, 26.2%) and injury secondary to trauma (n = 99, 12.3%). Most patients (n = 702, 87.6%) were transported for inter-facility transfers, while only 12.4% (n = 99) were primary responses (i.e. from the scene). Prolonged labor was the most common reason (n = 103, 23.4%) for inter-facility transfer of pregnant patients, followed by premature rupture of the amniotic membrane (n = 60, 13.6%). The mean dispatch to scene time interval was 10.1 min, and mean scene to facility time interval was 17.2 min.

Conclusion

Inter-facility transfers accounted for the largest proportion of ambulance utilization and dispatch in Addis Ababa. Ambulance transport time was twice as long compared to international recommendations of less than eight minutes for emergent transports. The most common reasons for ambulance dispatch were Obstetric. We recommend urgent action to decrease the transport times and to dedicate further pre-hospital resources to address the high burden of inter-facility transfers.

Nursing knowledge of essential maternal and newborn care in a high-mortality urban African setting: A cross-sectional study

Aims

To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya.

Background

The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low‐resource settings.

Design

Cross‐sectional survey.

Methods

Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015–2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed.

Results

Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case‐load facilities had lower average knowledge scores compared with better‐resourced and busier facilities.

Conclusion

Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6).

Relevance to clinical practice

Focus on periodic training, ensuring retention of knowledge and skills among health workers in low‐case load setting, and bridging the know‐do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature

BACKGROUND

Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.

METHODS

Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.

RESULT

The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.

CONCLUSIONS

A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102.

Assessing the competence of midwives to provide care during labor, childbirth and the immediate postpartum period - A cross sectional study in Tigray region, Ethiopia

Background

The availability of a skilled birth attendant is widely recognized as a critical factor in reducing maternal and newborn mortality. Competence of maternal healthcare providers directly affects quality of care and health outcomes. This study assessed competence of midwives and associated factors in provision of care during labor, and the immediate postpartum period at public health facilities in Tigray, Ethiopia.

Methods

A cross-sectional study design was employed to collect data through direct observation of the performance of 144 midwives selected from 57 health facilities. Data were collected from January to February 2015 by 12 experienced midwives who were trained on basic emergency obstetric care and had previous experience with data collection. Using a standardized competence checklist, adapted from International confederation of midwives, data collectors interviewed and directly observed the performance of midwives from admission of laboring mothers to six hours after delivery. Multivariable linear regression was used to identify predicators associated with overall clinical competence of midwives.

Result

The mean competence score of midwives was found to be 51%. In multivariable linear regression, male midwifery professionals (p = 0.022), availability of up to date job aids in work place (p = 0.04) and being recognized for improved performance (p = 0.005) were significantly associated with competence of midwives in the provision of care during labor, childbirth and immediate postpartum period.

Conclusion

Competence of midwives was found to be low to provide safe and quality maternity care in the region. Male gender, availability of complete job aids and receiving recognition/awards for better performance were predicted competence. This requires attention and investment from Tigray regional health bureau and health development partners working on maternal and child health. Competence based in-service training, on-the-job mentoring, availing up to dated standard job aids, recognition of high performing midwives are recommended to improve the quality of maternity care in public health facilities of the region. Moreover, affirmative actions including on-the-job training and supervision are needed to improve the competence of female midwives.

Assessment of the quality of neonatal care in the Solomon Islands

AIM

To identify strengths and obstacles for improving the quality of newborn care in the Solomon Islands. Improving the quality of newborn care is a priority in the Sustainable Development Goals and the Action Plan for Healthy Newborns in the Western Pacific. The neonatal mortality rate in the Solomon Islands, a lower-middle-income country, has improved slower than overall child mortality. In 2013, neonatal mortality (13.2/1000) constituted 44% of under-5 deaths (30.1/1000).

METHODS

A cross-sectional study of newborn care in five provincial hospitals using a World Health Organization assessment tool for hospital quality of care. Twelve months of neonatal records of the National Referral Hospital (NRH) labour ward and nursery were audited.

RESULTS

Essential medications and basic equipment were generally available. Challenges included workforce shortages and lack of expertise, high costs, organisation and maintenance of equipment, infection control and high rates of stillbirth. Over 12 months at the NRH labour ward, there were 5412 live births, 65 (1.2%) 'fresh' stillbirths and 96 (1.8%) 'macerated' stillbirths. Over the same period, there were an associated 779 nursery admissions, and the main causes of mortality were complications of prematurity, birth asphyxia, congenital abnormalities and sepsis. Total neonatal mortality at NRH was 16 per 1000 live births, and 77% of deaths occurred in the first 3 days of life.

CONCLUSIONS

Infrastructure limitations, technical maintenance and equipment organisation were obstacles to newborn care. Greater health-care worker knowledge and skills for early essential newborn care, infection control and management of newborn complications is needed.

Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia

BACKGROUND

Despite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia's plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period.

METHODS

A cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests.

RESULTS

A total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training.

CONCLUSIONS

Although our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.

Knowledge and practice of immediate newborn care among health care providers in eastern zone public health facilities, Tigray, Ethiopia, 2016

Background

According to WHO (2013) report the number of under five-year mortality in Ethiopia was 195,504, out of this 84,437 was from neonatal death and this mortality is related to immediate obstetric and newborn care of babies provided by health care providers; But little was known about the level of knowledge and practice related to immediate newborn care and their associated factors among health care providers generally in Tigray region and specifically in the Eastern Zone so the aim of this study was to assess knowledge and practice of immediate newborn care and associated factors among health care providers in the Eastern zone public health facilities, Tigray, Ethiopia.

Methods

A cross-sectional study was conducted from December 2015 to February 2016. A total of 16 health care facilities were selected for study using simple random sampling techniques and all health care providers in the selected health care facilities who participated in immediate newborn care were involved in the study. Data were entered, cleaned and analyzed using SPSS version 20.0. Ethical clearance was obtained from Adigrat University institutional ethical review board and Tigray regional health bureau. Consent was obtained from participants to conduct the study.

Result

In this study 215 participants were contacted, with a response rate of 99.1%. Generally, from the health care providers who participated in this study, 74.65% had adequate knowledge on newborn care and overall 72.77% of the participants were having good newborn care practice. Among the health care providers participated in the study, 151 (70.9%) were getting access to newborn care national guideline and only 99 (46%) of the health care providers get training in newborn care within the past two years before the study. Availability of national guideline, having adequate materials, the period of taking training and type of health facility were significant predictors for the health care providers newborn care practice.

Conclusion

Even though some improvement observed in the knowledge and practice of health care providers on newborn care, but still this study identified knowledge and practice gap. Regional health bureau and district health offices should provide refreshment training on immediate newborn care regularly, equipping all health facilities with necessary materials and national guideline of newborn care and there should be sharing experience between hospital and health center staffs working on newborn care through mentoring.

Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review

BACKGROUND

Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.

RESULTS

One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.

CONCLUSION

Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2014 CRD42014015549.

Healthcare workers' behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review

BACKGROUND

Healthcare workers may affect the utilization of sexual and reproductive healthcare (SRH) services, and quality of care thereof, for example by their behaviours or attitudes they hold. This can become a hindrance to accessing and utilizing SRH services, particularly by young people, and thus a better understanding of these behaviours and associated factors is needed to improve access to and utilization of SRH services.

METHODS

A systematic review of literature was conducted to identify studies focusing on healthcare workers' behaviors and personal determinants associated with providing adequate SRH services in sub-Saharan Africa (January 1990 - October 2015). Five databases were searched until 30th October 2015, using a search strategy that was adapted based on the technical requirements of each specific database. Articles were independently screened for eligibility by two researchers. Of the 125-screened full-text articles, 35 studies met all the inclusion criteria.

RESULTS

Negative behaviours and attitudes of healthcare workers, as well as other personal determinants, such as poor knowledge and skills of SRH services, and related factors, like availability of essential drugs and equipment are associated with provision of inadequate SRH services. Some healthcare workers still have negative attitudes towards young people using contraceptives and are more likely to limit access to and utilization of SRH by adolescents especially. Knowledge of and implementation of specific SRH components are below optimum levels according to the WHO recommended guidelines.

CONCLUSIONS

Healthcare workers' negative behaviours and attitudes are unlikely to encourage women in general to access and utilize SRH services, but more specifically young women. Knowledge of SRH services, including basic emergency obstetric care (EmOC) is insufficient among healthcare workers in SSA.

TRIAL REGISTRATION

A protocol for this systematic review was registered with PROSPERO and the registration number is: CRD42015017509 .

Trends and causes of maternal mortality in Ethiopia during 1990-2013: findings from the Global Burden of Diseases study 2013

Background

Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013.

Methods

We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths.

Results

In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20–29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was -1.6 (95% UI: -2.8 to -0.3).

Conclusion

The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period.

Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011

Background

While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi.

Methods

This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards.

Results

The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one.

In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities.

Conclusion

Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1224-9) contains supplementary material, which is available to authorized users.

Equipment for neonatal resuscitation in a middle-income country: a national survey in Vietnam

BACKGROUND

Interventions to improve neonatal resuscitation are considered a priority for reducing neonatal mortality. In addition to training programs for health caregivers, the availability of adequate equipment in all delivery settings is crucial. In this study, we assessed the availability of equipment for neonatal resuscitation in a large sample of delivery rooms in Vietnam, exploring regional differences.

METHODS

In 2012, a structured questionnaire on 2011 neonatal resuscitation practice was sent to the heads of 187 health facilities, representing the three levels of hospital-based maternity services in eight administrative regions in Vietnam, allowing national and regional estimates to be calculated.

RESULTS

Overall the response rate was an 85.7 % (160/187 hospitals). There was a limited availability of equipment considered as "essential" in the surveyed centres: stethoscopes (68.0 %; 95 % CI: 60.3-75.7), clock (50.3 %; 42.0-58.7), clothes (29.5 %; (22.0-36.9), head covering (12.3 %; 7.2-17.4). The percentage of centres equipped with polyethylene bags (2.2 %; 0.0-4.6), pulse oximeter (9.4 %; 5.2-13.6) and room air source (1.9 %; 0.1-3.6) was very low.

CONCLUSION

Adequate equipment for neonatal resuscitation was not available in a considerable proportion of hospitals in Vietnam. This problem was more relevant in some regions. The assessment strategy used in this study could be useful for organizing the procurement and distribution of supplies and equipment in other low and/or middle resource settings.

Availability and Quality of Emergency Obstetric and Newborn Care in Bangladesh

Bangladesh's maternal mortality and neonatal mortality remain unacceptably high. We assessed the availability and quality of emergency obstetric care (EmOC) and emergency newborn care (EmNC) services at health facilities in Bangladesh. We randomly sampled 50 rural villages and 50 urban neighborhoods throughout Bangladesh and interviewed the director of eight and nine health facilities nearest to each sampled area. We categorized health facilities into different quality levels (high, moderate, low, and substandard) based on staffing, availability of a phone or ambulance, and signal functions (six categories for EmOC and four categories for EmNC). We interviewed the directors of 875 health facilities. Approximately 28% of health facilities did not have a skilled birth attendant on call 24 hours per day. The least commonly performed EmOC signal function was administration of anticonvulsants (67%). The quality of EmOC services was high in 33% and moderate in 52% of the health facilities. The least common EmNC signal function was kangaroo mother care (7%). The quality of EmNC was high in 2% and moderate in 33% of the health facilities. Approximately one-third of health facilities lack 24-hour availability of skilled birth attendants, increasing the risk of peripartum complications. Most health facilities offered moderate to high quality services for EmOC and low to substandard quality for EmNC.

Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care

Background

Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria’s high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care.

Methods

We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000–2014. A ‘best-fit’ framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score.

Results

Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services.

Conclusions

Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

The effect of prenatal and intrapartum care on the stillbirth rate among women in rural Ethiopia

OBJECTIVE

To determine whether community-based prenatal and intrapartum care in Ethiopia results in a lower stillbirth rate.

METHODS

Between May and December 2014, a randomly selected sample of women in northern and eastern Ethiopia who had delivered a neonate in the preceding 12months completed a face-to-face survey about their experiences of maternal services and the fetal outcome for each delivery. The stillbirth rates among women delivering at home and at health facilities were compared.

RESULTS

Overall, 4442 women completed surveys. Stillbirth was reported by 42 (1.7%) of the 2437 women who had received prenatal care and 53 (2.8%) of the 1921 women who did not receive prenatal care (P=0.01). The stillbirth rate was similar among women who delivered in a health center (27/1417 [1.9%]), in a hospital (6/126 [4.8%]), and at home (62/2725 [2.3%]; P=0.13). However, women experiencing an intrapartum emergency were twice as likely to deliver in a health facility (odds ratio 2.6, 95% confidence interval 2.2-3.0). Satisfaction with health-center care was moderately good (median score 77.5/100).

CONCLUSION

The stillbirth rate was reduced among women receiving prenatal care, although delivering in a health facility did not reduce the risk of stillbirth. Improving the quality of health-center care could lead to their planned use for childbirth, which might reduce stillbirth rates.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District

Background

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.

Method

A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.

Results

A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76).

Conclusions

Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

High proportions of obstetric referrals in Addis Ababa: the case of term premature rupture of membranes

Background

The Public Health Centers (HCs) provide basic obstetric and neonatal care to about 80 % of the eligible population in Addis Ababa. Hospitals provide comprehensive services and are referral centers for complications that cannot be managed at the HCs. This study assessed the proportion of obstetric referrals in general and referrals due to premature rupture of membranes (PROM) at term in particular, from the HCs in Addis Ababa and explored its appropriateness and management in hospitals.

Methods

The study used a sequential explanatory mixed methods design. Routine retrospective data were collected from ten randomly selected HCs in 2012. Key informant interviews were conducted using a guide developed following a preliminary analysis of the quantitative data. Ten head midwives, one from each health center participated in the interviews.

Results

Of the 9340 mothers who sought skilled birth care in the ten HCs in 2012, 2820 (30.3 %) were diagnosed with obstetric complications and referred to hospital. Term PROM accounted for 557 (19.7 %) of the referrals and it was widely varied across the HCs. Fifteen (7.8 %) mothers who were referred for PROM, had intact membranes upon hospital examinations. Forty-two (77.8 %) of the referred mothers who had spontaneous labour and delivery could have been misclassified as not having labour upon referral. In the interviews, variations in diagnosing and managing term PROM were identified as themes. Three HCs relayed solely on mothers’ self reports of amniotic fluid leakage to diagnose, two HCs did complementary speculum/vaginal examination, three HCs monitored sign of labour on top of confirming the leakage. Regarding management, two HCs practiced expectant management, three referred mothers after 30 min of observation while others issued referral right away. All providers reported the lack of clinical guidelines for most common obstetric problems in their HC.

Conclusions

The study reported large proportion of obstetric referrals in general and PROM referrals in particular as well as variations in diagnosing and managing term PROM. These could largely be attributed to lack of clinical guidelines for most common obstetric complications at the HCs and competency gap among providers. Addressing the identified gaps and strengthening the primary care settings could contribute to improved quality of obstetric care and outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-1852-6) contains supplementary material, which is available to authorized users.