Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis

BACKGROUND

In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.

METHODS

An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA.

RESULTS

During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.

CONCLUSIONS

Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

The status of emergency obstetric and newborn care in post-conflict eastern DRC: a facility-level cross-sectional study

Background

Pregnancy-related mortality remains persistently higher in post-conflict areas. Part of the blame lies with continued disruption to vital care provision, especially emergency obstetric and newborn care (EmONC). In such settings, assessment of EmONC is essential for data-driven interventions needed to reduce preventable maternal and neonatal mortality. In the North Kivu Province (NKP), the epicentre of armed conflict in eastern Democratic Republic of the Congo (DRC) between 2006 and 2013, the post-conflict status of EmONC is unknown. We assessed the availability, use, and quality of EmONC in 3 health zones (HZs) of the NKP to contribute to informed policy and programming in improving maternal and newborn health (MNH) in the region.

Method

A cross-sectional survey of all 42 public facilities designated to provide EmONC in 3 purposively selected HZs in the NKP (Goma, Karisimbi, and Rutshuru) was conducted in 2017. Interviews, reviews of maternity ward records, and observations were used to assess the accessibility, use, and quality of EmONC against WHO standards.

Results

Only three referral facilities (two faith-based facilities in Goma and the MSF-supported referral hospital of Rutshuru) met the criteria for comprehensive EmONC. None of the health centres qualified as basic EmONC, nor could they offer EmONC services 24 h, 7 days a week (24/7). The number of functioning EmONC per 500,000 population was 1.5. Assisted vaginal delivery was the least performed signal function, followed by parenteral administration of anticonvulsants, mainly due to policy restrictions and lack of demand. The 3 HZs fell short of WHO standards for the use and quality of EmONC. The met need for EmONC was very low and the direct obstetric case fatality rate exceeded the maximum acceptable level. However, the proportion the proportion of births by caesarean section in EmONC facilities was within acceptable range in the HZs of Goma and Rutshuru. Overall, the intrapartum and very early neonatal death rate was 1.5%.

Conclusion

This study provides grounds for the development of coordinated and evidence-based programming, involving local and external stakeholders, as part of the post-conflict effort to address maternal and neonatal morbidity and mortality in the NKP. Particular attention to basic EmONC is required, focusing on strengthening human resources, equipment, supply chains, and referral capacity, on the one hand, and on tackling residual insecurity that might hinder 24/7 staff availability, on the other.

Challenges in implementing emergency obstetric care (EmOC) policies: perspectives and behaviours of frontline health workers in Uganda

Uganda is among the sub-Saharan African Countries which continue to experience high preventable maternal mortality due to obstetric emergencies. Several Emergency Obstetric Care (EmOC) policies rolled out have never achieved their intended targets to date. To explore why upstream policy expectations were not achieved at the frontline during the MDG period, we examined the implementation of EmOC policies in Uganda by; exploring the barriers frontline implementers of EmOC policies faced, their coping behaviours and the consequences for maternal health. We conducted a retrospective exploratory qualitative study between March and June 2019 in Luwero, Iganga and Masindi districts selected based on differences in maternal mortality. Data were collected using 8 in-depth interviews with doctors and 17 midwives who provided EmOC services in Uganda's public health facilities during the MDG period. We reviewed two national maternal health policy documents and interviewed two Ministry of Health Officials on referral by participants. Data analysis was guided by the theory of Street-Level Bureaucracy (SLB). Implementation of EmOC was affected by the incompatibility of policies with implementation systems. Street-level bureaucrats were expected to offer to their continuously increasing clients, sometimes presenting late, ideal EmOC services using an incomplete and unreliable package of inputs, supplies, inadequate workforce size and skills mix. To continue performing their duties and prevent services from total collapse, frontline implementers' coping behaviours oftentimes involved improvization leading to delivery of incomplete and inconsistent EmOC service packages. This resulted in unresponsive EmOC services with mothers receiving inadequate interventions sometimes after major delays across different levels of care. We suggest that SLB theory can be enriched by reflecting on the consequences of the coping behaviours of street-level bureaucrats. Future reforms should align policies to implementation contexts and resources for optimal results.

Intended Pregnancy as a Predictor of Good Knowledge on Birth Preparedness and Complication Readiness: the Case of Northern Ethiopia Pregnant Mothers

Background

Maternal mortality remains unacceptably high in developing countries. One key strategy to reduce such mortality is utilization of birth preparedness and complication readiness (BP/CR) and creating awareness of BP/CR is an important step for pregnant women, their families, and the community. However, there was limited to no evidence regarding the community's awareness on BP/CR in the study area. Therefore, this study aimed to assess knowledge on BP/CR and associated factors among pregnant women in Debremarkos town, Northwest Ethiopia, 2017.

Methods

A Community based cross-sectional study was conducted from July 1 to 30/2017. A total of 441 pregnant women were included in the study. Structured and pretested questionnaire was administered through face to face interview to collect the data. Simple random sampling technique was used to select the study participants. The data were entered in to Epinfo version 7.0 and then exported to SPSS version 20.0 for analysis. Both bivariate and multivariable logistic regression model were fitted. Crude and adjusted odds ratio with 95 % confidence interval have been computed and variables with p-value < 0.05 were considered statistically significance. Results. The proportion of pregnant women having good knowledge on birth preparedness and complication readiness was found to be 45.2 with 95%CI (40.4, 50.0). In the multivariable analysis, having history of childbirth (AOR=2.17;95%CI:1.18,4.00), having intended pregnancy (AOR=2.13;95%CI: 1.16, 3.90), being governmental employee ( AOR=6.50; 95%CI: 2.50, 16.87), and having Antenatal care visits (AOR=5.50; 95%CI:2.2,13.70) were factors which were independently and significantly associated with good knowledge on birth preparedness and complication readiness.

Conclusion

Proportion of pregnant women having good knowledge on birth preparedness and complication readiness was low. Putting emphasis on intended pregnancy and antenatal care visit was recommended.

Health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a Tanzania National Survey

OBJECTIVE

This study used a nationally representative sample from Tanzania as an example of low-resource setting with a high burden of maternal and newborn deaths, to assess the availability and readiness of health facilities to provide basic emergency obstetric and newborn care (BEmONC) and its associated factors.

DESIGN

Health facility-based cross-sectional survey.

SETTING

We analysed data for obstetric and newborn care services obtained from the 2014-2015 Tanzania Service Provision Assessment survey, using WHO-Service Availability and Readiness Assessment tool.

PRIMARY AND SECONDARY OUTCOME MEASURES

Availability of seven signal functions was measured based on the provision of 'parental administration of antibiotic', 'parental administration of oxytocic', 'parental administration of anticonvulsants', 'assisted vaginal delivery', 'manual removal of placenta', 'manual removal of retained products of conception' and 'neonatal resuscitation'. Readiness was a composite variable measured based on the availability of supportive items categorised into three domains: staff training, diagnostic equipment and basic medicines.

RESULTS

Out of 1188 facilities, 905 (76.2%) were reported to provide obstetric and newborn care services and therefore were included in the analysis of the current study. Overall availability of seven signal functions and average readiness score were consistently higher among hospitals than health centres and dispensaries (p<0.001). Furthermore, the type of facility, performing quality assurance, regular reviewing of maternal and newborn deaths, reviewing clients' opinion and number of delivery beds per facility were significantly associated with readiness to provide BEmONC.

CONCLUSION

The study findings show disparities in the availability and readiness to provide BEmONC among health facilities in Tanzania. The Tanzanian Ministry of Health should emphasise quality assurance efforts and systematic maternal and newborn death audits. Health leadership should fairly distribute clinical guidelines, essential medicines, equipment and refresher trainings to improve availability and quality BEmONC.

Estimating the met need for emergency obstetric care (EmOC) services in three payams of Torit County, South Sudan: a facility-based, retrospective cross-sectional study

OBJECTIVE

To determine the met need for emergency obstetric care (EmOC) services in three Payams of Torit County, South Sudan in 2015 and to determine the frequency of each major obstetric complication.

DESIGN

This was a retrospective cross-sectional study.

SETTING

Four primary healthcare centres (PHCCs) and one state hospital in three payams (administrative areas that form a county) in Torit County, South Sudan.

PARTICIPANTS

All admissions in the obstetrics and gynaecology wards (a total of 2466 patient admission files) in 2015 in all the facilities designated to conduct deliveries in the study area were reviewed to identify obstetric complications.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was met need for EmOC, which was defined as the proportion of all women with direct major obstetric complications in 2015 treated in health facilities providing EmOC services. The frequency of each complication and the interventions for treatment were the secondary outcomes.

RESULTS

Two hundred and fifty four major obstetric complications were admitted in 2015 out of 390 expected from 2602 pregnancies, representing 65.13% met need. The met need was highest (88%) for Nyong Payam, an urban area, compared with the other two rural payams, and 98.8% of the complications were treated from the hospital, while no complications were treated from three PHCCs. The most common obstetric complications were abortions (45.7%), prolonged obstructed labour (23.2%) and haemorrhage (16.5%). Evacuation of the uterus for retained products (42.5%), caesarean sections (32.7%) and administration of oxytocin for treatment of postpartum haemorrhage (13.3%) were the most common interventions.

CONCLUSION

The met need for EmOC in Torit County is low, with 35% of women with major obstetric complications not accessing care, and there is disparity with Nyong Payam having a higher met need. We suggest more support supervision to the PHCCs to increase access for the rural population.

Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey

AIM

The aim of this study was to assess the rural-urban differences in the prevalence and factors associated with non-utilization of healthcare facility for childbirth (home delivery) in Nigeria.

METHODS

Dataset from the Nigeria demographic and health survey, 2013, disaggregated by rural-urban residence were analyzed with appropriate adjustment for the cluster sampling design of the survey. Factors associated with home delivery were identified using multivariable logistic regression analysis.

RESULTS

In rural and urban residence, the prevalence of home delivery were 78.3% and 38.1%, respectively ( p < 0.001). The lowest prevalence of home delivery occurred in the South-East region for rural residence (18.6%) and the South-West region for urban residence (17.9%). The North-West region had the highest prevalence of home delivery, 93.6% and 70.5% in rural and urban residence, respectively. Low maternal as well as paternal education, low antenatal attendance, being less wealthy, the practice of Islam, and living in the North-East, North-West and the South-South regions increased the likelihood of home delivery in both rural and urban residences. Whether in rural or urban residence, birth order of one decreased the likelihood of home delivery. In rural residence only, living in the North-Central region increased the chances of home delivery. In urban residence only, maternal age ⩾ 36 years decreased the likelihood of home delivery, while 'Traditionalist/other' religion and maternal age < 20 years increased it.

CONCLUSION

The prevalence of home delivery was much higher in rural than urban Nigeria and the associated factors differ to varying degrees in the two residences. Future intervention efforts would need to prioritize findings in this study.