Where there is no anesthetist - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Objective

The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs’ experience of the program, and identified factors leading to post-training performance.

Methods

The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n = 14). Data on facility preparedness and monthly case load were also collected.

Results

Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.

Conclusion

Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.     

Planning and implementing a program of renovations of emergency obstetric care facilities: experiences in Rajasthan, India.

Even though many governments and donors are now putting resources into upgrading facilities, the study of the renovation process is one of the most neglected aspects of quality improvement in emergency obstetric care (EmOC). In a previous publication, we discussed basic concepts and simple techniques to assess, plan and implement renovations. Here we focus on actual in-the-field experiences of the renovation process initiated by the health system in Rajasthan, India and the valuable lessons obtained from it. With the advice of the technical members of the Averting Maternal Death and Disability Program (AMDD) and the United Nations Population Fund (UNFPA), the facilities achieved noticeable changes in the physical infrastructure. As a result, the quality of EmOC services improved. We analyze these experiences critically and draw out lessons which may be instructive for future renovation efforts.     

The challenges of improving emergency obstetric care in two rural districts in Mali.

OBJECTIVE: We describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali. METHODS: Project planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts. RESULTS: By the end of 2004, despite many health systems' challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively. DISCUSSION: Although useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed. CONCLUSION: Save the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community.     

Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care

Objective

To assess the contribution of nonphysician clinicians (NPCs) to comprehensive emergency obstetric care (CEmOC) in Tigray, Ethiopia.

Methods

We conducted a retrospective review of the obstetric records of all women treated from January 1, 2006, to December 31, 2008, at the 11 hospitals and 2 health centers with CEmOC status in Tigray. Data were collected using 2 questionnaires, one concerning the facility and the other concerning the patient.

Results

During the studied period 25,629 deliveries and 11,059 obstetric procedures (3369 of which were major surgical interventions) were performed at these 13 institutions. Overall, NPCs performed 63.3% of these procedures, which included 1574 (55.5%) of a total of 2835 cesarean deliveries. Whereas the cesarean deliveries performed by physicians were more often elective, those performed by NPCs were more often indicated by an emergency. Maternal deaths, fetal deaths, and length of hospital stay did not statistically differ by type of attending staff.

Conclusion

Not only do NPCs perform a significant proportion of emergency obstetric procedures in Tigray, but the postoperative outcomes achieved under their care are similar to those attained by physicians. Strengthening NPC training programs in emergency obstetric surgery should further reduce maternal and fetal mortality and morbidity in Ethiopia.     

Improving emergency obstetric care in Mozambique: the story of Sofala.

OBJECTIVE: The 5-year project in the province of Sofala was designed to improve access, quality and utilization of emergency obstetric care (EmOC) by strengthening rural hospitals and health centers and ultimately the health system's capacity to respond to emergencies more quickly and effectively. METHODS: Implementation consisted of attention to infrastructure, human resource development, transportation and communication systems, and management. Specific management aspects that were targeted for improvement included: supportive supervision, logistics for supplies, equipment and drugs, record keeping, monitoring and evaluation, and quality improvement techniques such as maternal death audits. RESULTS: Access to EmOC improved with an increase in the number of fully functional EmOC facilities from 4 to 18. The number of women with obstetric complications who were admitted for treatment in participating facilities tripled, and the proportion of those women dying declined by half. CONCLUSIONS: Close collaboration and partnership with the provincial health directorate make the sustainability of many results likely while the replication of much of the Sofala model to other provinces is promising for the national strategy to reduce maternal mortality.     

One-year evaluation of the impact of an emergency obstetric and neonatal care training program in Western Kenya

Objective

To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital, Eldoret, Kenya.

Methods

A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP), and in the 3-month period (August–November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate.

Results

A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However, postpartum hemorrhage rates decreased, affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P = 0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P < 0.001). Additionally, the number of neonates with 5-minute Apgar scores of less than 5 reduced from 133 (7.7%) of 1717 to 95 (5.4%) of 1745 (P = 0.006).

Conclusion

The introduction of the AIP improved maternal outcomes. There were significant differences related to use of oxytocin and postpartum hemorrhage.     

Program note: applying the UN process indicators for emergency obstetric care to the United States.

The United Nations Process Indicators for emergency obstetric care (EmOC) have been used extensively in countries with high maternal mortality ratios (MMR) to assess the availability, utilization and quality of EmOC services. To compare the situation in high MMR countries to that of a low MMR country, data from the United States were used to determine EmOC service availability, utilization and quality. As was expected, the United States was found to have an adequate amount of good-quality EmOC services that are used by the majority of women with life-threatening obstetric complications.     

The United Nations Process Indicators for emergency obstetric care: Reflections based on a decade of experience.

OBJECTIVE: The paper reviews the experience with the EmOC process indicators, and evaluates whether the indicators serve the purposes for which they were originally created - to gather and interpret relatively accessible data to design and implement EmOC service programs. METHOD: We review experience with each of the 6 process indicators individually, and monitoring change over time, at the level of the facility and at the level of a region or country. We identify problems encountered in the field with data collection and interpretation. RESULT: While they have strengths and weaknesses, the process indicators in general serve the purposes for which they were developed. The data are easily collected, but some data problems were identified. We recommend several relatively minor modifications to improve data collection, interpretation and utility. CONCLUSIONS: The EmOC process indicators have been used successfully in a wide variety of settings. They describe vital elements of the health system and how well that system is functioning for women at risk of dying from major obstetric complications.     

The availability of life-saving obstetric services in developing countries: an in-depth look at the signal functions for emergency obstetric care.

OBJECTIVE: This paper examines the frequency with which a set of life-saving interventions or signal functions was performed to treat major obstetric complications. METHODS AND RESULTS: The basic signal functions include parenteral antibiotics, anticonvulsants and oxytocics, and the procedures of manual removal of the placenta, removal of retained uterine products, and assisted vaginal delivery. Comprehensive functions include the six basic functions, cesarean delivery, and blood transfusions. Data from 1906 health facilities in 13 countries indicate that the most likely functions to be reported are oxytocics and antibiotics. The basic function least likely to be reported is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure to perform operations or provide blood transfusions. CONCLUSIONS: These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur.     

Ethiopia's assessment of emergency obstetric and newborn care: Setting the gold standard for national facility-based assessments

Objective

To describe the methods used to implement Ethiopia's 2008 emergency obstetric and newborn care services (EmONC) assessment; highlight how the collaborative process contributed to immediate integration of results into national and subnational planning; and explain how the experience informed the development of a set of tools providing best practices and guidelines for other countries conducting similar assessments.

Methods

A team of maternal and newborn health experts from the Federal Ministry of Health (FMOH), the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA), together with representatives from the Ethiopian Society of Obstetricians and Gynecologists, provided technical guidance for the 18-month process and facilitated demand for and use of the assessment results. Eighty-four trained data collectors administered 9 data collection modules in 806 public and private facilities. Field work and data were managed by a private firm who, together with the core team, implemented a multi-layered plan for data quality. Columbia University's Averting Maternal Death and Disability Program provided technical assistance.

Results

Results were published in national and regional reports and in 1-page facility factsheets informing subnational planning activities. Assessment results—which have been published in journal articles—informed water infrastructure improvements, efforts to expand access to magnesium sulfate, and FMOH and UN planning documents. The assessment also established a permanent database for future monitoring of the health system, including geographic locations of surveyed facilities.

Conclusion

Ethiopia's assessment was successful largely because of active local leadership, a collaborative process, ample financial and technical support, and rapid integration of results into health system planning.     

Can the process indicators for emergency obstetric care assess the progress of maternal mortality reduction programs? An examination of UNFPA Projects 2000-2004.

BACKGROUND: In view of the disappointing progress made in the last 20 years in reducing maternal mortality in low-income countries and before going to scale in implementing the new evidence-based strategies, it is crucial to review and assess the progress made in pilot countries where maternal mortality reduction programs focused on emergency obstetric care. OBJECTIVE: To review the process indicators recommended for monitoring emergency obstetric care and their application in field situations, examining the conditions under which they can be used to assess the progress of maternal mortality reduction programs. METHODS: Five of the six UN recommended process indicators were monitored annually for 5 years in selected districts of Morocco, Mozambique, India and Nicaragua. Trends are presented and discussed. RESULTS: With specific variations due to different local situations in the four countries and in spite of variations in quality of data collection, all indicators showed a consistent positive trend, in response to the inputs of the programs. CONCLUSIONS: The UN process indicators for emergency obstetric care should continue to be promoted, but with two important conditions: (1) data collection is carefully checked for quality and coverage; (2) efforts are made to match process and outcome indicators (maternal and perinatal mortality, incidence of complications).     

Expected to deliver: Alignment of regulation, training, and actual performance of emergency obstetric care providers in Malawi and Tanzania

Objective

Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania.

Methods

A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities.

Results

A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery.

Conclusion

Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable.     

The evolution of a quality of care approach for improving emergency obstetric care in rural hospitals in Nepal.

We describe the iterative process of developing a locally-appropriate quality of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. We describe the context of maternal health issues in Nepal, the rationale for developing a quality of care approach within a model to improve EmOC, and outline the outcomes and catalytic effects of the process. The lessons learned during the development of this approach are detailed. The program developed and implemented a quality of care approach at three district hospitals in Nepal. This resulted in improvements in the structure, process and outcomes of EmOC in these institutions. The process also resulted in improved understanding of quality of care approaches on both local and national levels and the creation of a Nepalese quality of care evaluation framework for maternity services. While the theoretical concept of quality of care is difficult to translate into a concrete approach, we used a process in rural hospitals in Nepal that created highly motivated teams and improved the overall functioning of these hospitals.     

Emergency obstetric care in Pakistan: potential for reduced maternal mortality through improved basic EmOC facilities, services, and access.

OBJECTIVE: To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces. METHOD: Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts (n=19); were randomly selected; all public health facilities providing EmOC services (n=170) were included. RESULTS: The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab. CONCLUSION: Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality.     

Improving emergency obstetric care in a context of very high maternal mortality: the Nepal Safer Motherhood Project 1997-2004

The Nepal Safer Motherhood Project (1997-2004) was one of the first large-scale projects to focus on access to emergency obstetric care, covering 15% of Nepal. Six factors for success in reducing maternal mortality are applied to assess the project. There was an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004. Infrastructure and equipment to achieve comprehensive-level care were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia, were greater challenges. In three districts, 70% of emergency procedures were managed by nurses, with additional training. However, major shortages of skilled professionals remain. Enhancement of the weak referral system was beyond the project's scope. Instead, it worked to increase information in the community about danger signs in pregnancy and delivery and taking prompt action. A key initiative was establishing community emergency funds for obstetric complications. Efforts were also made to develop a positive shift in attitudes towards patient-centred care. Supply-side interventions are insufficient for reducing the high level of maternal deaths. In Nepal, this situation is complicated by social norms that leave women undervalued and disempowered, especially those from lower castes and certain ethnic groups, a pattern reflected in use of maternity services. Programming also needs to address the social environment.