The evidence for emergency obstetric care.

PURPOSE: We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries. METHODS: We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register. RESULTS: The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.     

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.     

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.     

Strengthening emergency obstetric care in Thanh Hoa and Quang Tri provinces in Vietnam.

OBJECTIVE: Save the Children/USA and the Ministry of Health of Vietnam undertook a project between 2001 and 2004 to improve the availability of, access to, quality and utilization of emergency obstetric care (EmOC) services at district and provincial hospitals in two provinces in Vietnam. METHODS: The project improved the functional capacity of 3 provincial and 1 district hospitals providing comprehensive EmOC services, and upgraded 1 district hospital providing basic EmOC into a comprehensive EmOC facility through training, infrastructure and quality improvement. RESULTS: Data presented in this paper focus on only the 2 district hospitals even though the UN process indicators showed increases in utilization of EmOC in all 5 hospitals. In the case of Hai Lang, the proportion of births increased from 13% at baseline to 31% at the end of 2004, and met need increased significantly from 16% to 87% largely due to increased capacity of the hospital and staff. Met need in Hoang Hoa hospital more than doubled (17% at baseline versus 54% in 2004) and the proportion of births increased slightly from 19% in 2001 to 22% in 2004. Case fatality rates for the two hospitals remarkably remained at zero. Lessons from this project have been incorporated into national policy and guidelines. CONCLUSION: Improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth can be realized in a relatively short period of time and is an essential element in reducing maternal mortality.     

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.     

Changing patterns of emergency obstetric care at a Nigerian University hospital.

OBJECTIVE: To analyze the changing patterns of critical obstetric care over two consecutive 3-year periods and identify the factors responsible for the trend through combined audits of near miss and maternal mortality at a Nigerian University hospital. METHODS: Retrospective audit and comparison of "near misses" and maternal deaths recorded in 1999-2001 and 2002-2004 at a tertiary care center in southwest Nigeria. The definition of near miss morbidity was based on validated disease-specific criteria. For each near miss and maternal death, the local audit committee compared the actual management with local treatment protocols and explored avoidable factors. Case fatality rate was calculated for "critically ill obstetric patients" (CIOP-CFR) for both periods. The cause-specific case fatality rate (CFR) was used to assess the trend in standards of care for life-threatening obstetric conditions. Data were compared using the chi(2) or Fisher's exact test. P<0.05 was considered statistically significant. RESULTS: There were 175 near misses and 27 maternal deaths in 1999-2001 and 211 near misses and 44 maternal deaths in 2002-2004. The CIOP-CFRs for the two periods showed a declining (but non-significant) trend in the standard of emergency obstetric care for life-threatening conditions (13.4% to 17.3%, P=0.250). The CIOP-CFR for postpartum hemorrhage significantly increased from 3.1% to 21.1% in the 2nd period (P=0.033), reflecting a decline in the standard of care. Lack of blood for transfusion became a more significant administrative problem in the 2nd period occurring in 17.8% of all critically ill patients managed in 2002-2004. There was a notable though statistically insignificant increase in the non-adherence to treatment protocol among cases of maternal death in 2002-2004 compared with 1999-2001. CONCLUSIONS: The standard of critical obstetric care in this center is suboptimal with no evident improvement over the 6-year period. This audit supports the feasibility of including near miss reviews in maternal death audits to provide insights into the trend in the quality of emergency services for severe maternal complications while highlighting factors associated with deficiency or improvement in care for specific maternal conditions.     

Experience from Bangladesh: implementing emergency obstetric care as part of the reproductive health agenda.

This paper describes the activities of the Ministry of Health and Family Welfare of the Government of Bangladesh and UNFPA to introduce emergency obstetric care (EmOC) services into the reproductive health care agenda. Working through the existing system of Maternal and Child Welfare Centers (MCWC), the quality and availability of comprehensive Reproductive Health and Emergency Obstetric Care services was improved. Investments in training, infrastructure, management information systems, quality assurance mechanisms and linkages between health care facilities in Bangladesh, have produced positive results in terms of increased utilization of these services. The Ministry of Health first implemented services in one division of the country and later scaled up to include all of the MCWCs nationally. While there are still obstacles to preventing obstetric deaths in Bangladesh, this experience shows that improvements in the quality and expansion of the range of services in existing health systems is an important step toward increasing the use of reproductive health care services by the women who need them most.     

Emergency obstetric care: how do we stand in Malawi?

OBJECTIVE: To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. METHODS: A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. RESULTS: Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. CONCLUSION: Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.     

Stimulating policy debate on blood transfusion services through the work of an emergency obstetric care project in Nepal.

PURPOSE: To improve the quality and accessibility of emergency obstetric care (EmOC) at district level. METHODS: As the availability of safe and reliable blood transfusion services is a critical component of EmOC, financial and management support was provided to the blood transfusion service centers in the 3 project's Phase 1 districts. EVALUATION: An evaluation after 3 years showed that, with modest financial outlays and the development of supportive district level partnerships, substantial improvements in quality and management of services had been achieved. The evaluation also identified limitations imposed by lack of legal frameworks and central support; although the Nepal Red Cross Society has a government mandate to supply the national blood needs, the operating procedures and guidelines have no legal base. The evaluation report was widely circulated, and the findings used in national policy discussions. RESULTS: Following this a task force was commissioned to develop a legal policy framework to ensure standardized quality blood services with defined management and monitoring roles and responsibilities.     

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.     

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.     

Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008

Objective

To report on the availability and quality of emergency obstetric and newborn care (EmONC) in Ethiopia.

Methods

All licensed hospitals and health centers were visited and standard questionnaires were administered. In addition, a nonrandom systematic sample was taken of recent cesarean deliveries, partographs, and maternal deaths—and these cases were systematically reviewed. Health facilities were geocoded using geographic positioning system devices.

Results

Too few facilities provided EmONC to meet the UN standards of 5 per 500 000 population, both nationally and in all but 2 regions. Only 7% of deliveries took place in institutions of any type, and only 3% in facilities that routinely provided all the signal functions. Only 6% of women with obstetric complications were treated in any health facility, half of whom were treated in fully functional EmONC facilities. Nationwide, 0.6% of expected deliveries were by cesarean. The mortality rate for women with serious obstetric complications (case fatality rate) was 2%. The cause of death was unknown in 10% of cases, and 21% were due to indirect causes (primarily malaria, anemia, and HIV-related).

Conclusion

None of the indicators met UN standards. Ethiopia faces many challenges—not least geography—with regard to improving EmONC. Nevertheless, the government places high priority on improvement and has taken (and will continue to take) action to achieve Millennium Development Goals 4 and 5. This comprehensive survey serves both as a road map for planning strategies for improvement and as a baseline for measuring the impact of interventions.     

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria

Objective

To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome.

Methods

Women were enrolled in a pre-intervention phase (n = 83) and an intervention phase (n = 86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥ 750 mL) and a clinical sign of shock (systolic blood pressure < 100 mm Hg or pulse > 100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ² tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality.

Results

Mean measured blood loss in the intervention phase was 73.5 ±93.9 mL, compared with 340.4 ± 248.2 mL pre-intervention (P < 0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14-0.72).

Conclusion

The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.     

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt

Objective

To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage.

Methods

A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss ≥ 1000 mL and/or ≥ 1 sign of shock [systolic blood pressure < 100 mm Hg or pulse > 100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO.

Results

Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P < 0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85).

Conclusion

The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.     

Program Note: Using UN process indicators to assess needs in emergency obstetric services: Gabon, Guinea-Bissau, and The Gambia.

PURPOSE: We report on assessments of the needs for emergency obstetric care in 3 West African countries. METHODS: All (or almost all) medical facilities were visited to determine whether there are sufficient facilities of adequate quality to manage the expected number of obstetric emergencies. RESULTS: Medical facilities able to provide emergency obstetric care were poorly distributed and often were unable to provide needed procedures. Too few obstetricians and other providers, lack of on-the-job training and supervision were among the challenges faced in these countries.     

Women are still deprived of access to lifesaving essential and emergency obstetric care

Two decades have passed since the global community agreed in Nairobi to the Safe Motherhood Initiative to reduce maternal deaths. However, every year 536 000 pregnant women are dying. There is no ambiguity about why most of these women are dying. These tragedies are avoidable if women have timely access to quality essential obstetric and emergency care. Rural and poor women are mostly excluded from accessing skilled and emergency care. Quality facility-based care is the best option to reduce maternal mortality. Scaling up essential interventions and services—particularly for those who are excluded—is a substantial and challenging undertaking. We need to challenge our policy makers and program managers to refocus program content; to shift focus from development of new technologies toward development of viable organizational strategies to provide access to essential and emergency obstetric care 24 hours a day 7 days a week, and account for every birth and every death.     

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.     

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.     

Improving availability of EmOC services in Rwanda--CARE's experiences and lessons learned at Kabgayi Referral Hospital.

OBJECTIVE: CARE's work in Rwanda was designed to improve the functional capacity of health facilities for the delivery of EmOC services. METHODS: The project supported a comprehensive package of focused interventions that included hospital renovations, provision of essential equipment, training of staff and improvement of management systems at the Kabgayi regional referral hospital. RESULTS: There was an increased level of preparedness for emergencies and ability to manage common obstetric complications according to evidence-based practices. These changes ultimately led to increased availability, quality and use of services as demonstrated by an increase in the demand for care of obstetric complications at the facility. The met need increased from 16% at the start of the project (2001) to 25% in 2004, while the cesarean rate remained essentially the same (1.9% and 3.2%) over the same time period. There were progressive declines in the case fatality rates from 2.2% in 2001 to 1.2% in 2004. CONCLUSION: CARE's experience indicates that progress towards reducing maternal mortality requires specific efforts that support and strengthen existing health systems to provide skilled care that can save women's lives.     

Quality of care in institutionalized deliveries: the paradox of the Dominican Republic.

OBJECTIVES: To better understand the paradox in the Dominican Republic of a relatively high maternal mortality ratio despite nearly universal institutionalized deliveries with trained attendants, a rapid assessment using an adaptation of the strategic assessment method was conducted. METHODS: A multi-disciplinary team reviewed national statistics and hospital records, inventoried facilities, and observed peripartum client-provider interactions at 14 facilities. RESULTS: The major referral hospitals, where more than 40% of births in the country occur, were overcrowded and understaffed, with inexperienced residents overseeing care provided by medical students, interns and nurses. Uncomplicated labor and deliveries were overmedicalized, while complicated ones were not managed appropriately; emergencies were not dealt with in a timely fashion. In the peripheral hospitals physicians were seldom present and clients were either turned away or delivered by unprepared nursing staff. Providers in the busiest facilities suffered from compassion fatigue, and were demoralized and overworked. In all facilities, quality of care was lacking and the delivery and birthing process was dehumanized. CONCLUSIONS: Access and availability of institutional delivery alone is not enough to decrease MMR, it is also the quality of emergency obstetric care that saves lives.