Objective
To examine the relationship between insecurity and quality of care provided for abortion complications in high‐volume hospitals in the Democratic Republic of Congo (DRC).
Methods
Using the ...WHO Multi‐Country Survey on Abortion complications, we analyzed data for 1007 women who received care in 24 facilities in DRC. For inputs of care, we calculated the percentage of facilities in secure and insecure areas meeting 12 readiness criteria for infrastructure and capability. For process and outcomes of care, we estimated the association between security and eight indicators using generalized estimating equation models.
Results
Facilities in secure areas were more likely to report functioning electricity (93.3% vs 66.7%), availability of an obstetrician 24/7 (42.9% vs 28.6%), and the ability to offer several short‐acting contraceptives (83.3% vs 57.1%). However, a higher percentage of facilities in insecure areas reported the availability of a telephone or radio (100% vs 80.0%). Women in insecure areas appeared more likely to experience poor quality clinical care overall than women in secure areas (aOR 2.56; 95% CI, 1.13–5.82, P = 0.03). However, there was no association between security and incomplete medical records (P = 0.20), use of dilatation and curettage (D&C) (P = 0.84), women reporting poor experience of care (P = 0.22), satisfaction with care (P = 0.25), and severe maternal outcomes (P = 0.56). There was weak evidence of an association between security and nonreceipt of contraceptives (P = 0.07), with women in insecure areas 70% less likely to report no contraception (aOR 0.31, 95% CI, 0.09–1.09). Use of D&C was high in secure (43.7%) and insecure (60.4%) areas.
Conclusion
Quality of care did not seem to be very different in secure and insecure areas in DRC, except for some key infrastructure, supply, and human resources elements. The frequent use of D&C for uterine evacuation, the lack of good record keeping, and the lack of contraceptives should be urgently addressed.
Synopsis
Except for facility capability, the quality of care for abortion complications is similar in secure and insecure areas in the Democratic Republic of Congo, with frequent use of dilatation and curettage.
Objective
To assess satisfaction with care for abortion‐related complications experienced among adolescents compared to older women.
Methods
A secondary analysis of the WHO Multi‐Country Survey on ...Abortion‐related Morbidity and Mortality—a cross‐sectional study conducted in health facilities in 11 Sub‐Saharan African countries. Women with abortion‐related complications who participated in an audio computer‐assisted self‐interview were included. Two composite measures of overall satisfaction were created based on five questions: (1) study participants who were either satisfied or very satisfied across all five questions; and (2) study participants who reported being very satisfied only across all five questions. Multivariable general estimating equation analyses were conducted to assess whether there was any evidence that age (adolescents 12–19 years and older women 20+) was associated with each composite measure of satisfaction, controlling for key confounders.
Results
The study sample consisted of 2817 women (15% adolescents). Over 75% of participants reported being satisfied or very satisfied for four out of five questions. Overall, 52.9% of study participants reported being satisfied/very satisfied across all five questions and 22.4% reported being consistently very satisfied. Multivariable analyses showed no evidence of an association between age group and being either satisfied or very satisfied (OR 1.07; 95% CI, 0.82–1.41, P = 0.60), but showed strong evidence that adolescents were 50% more likely to be consistently very satisfied with their overall care than older women (OR 1.49; 95% CI, 1.13–1.96, P = 0.005).
Conclusion
Both adolescents and older women reported high levels of satisfaction with care when looking at different components of care individually, but the results of the composite measure for satisfaction showed that many study participants reported being less than satisfied with at least one element of their care. Further studies to explore the expectations, needs, and values of women's satisfaction with care for abortion‐related complications are needed.
Synopsis
This study found that patient satisfaction with care for abortion‐related complications was similar among adolescents and older women across 11 Sub‐Saharan African countries.
Abstract Objective To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities. Methods Data were obtained from all births over 2–3 months in 131 ...facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity. Results Median cesarean delivery rate was 8.8% among 83 439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity—probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths. Conclusion Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.
Objective
To characterise the current clinical practice patterns regarding the use of magnesium sulphate (MgSO4) for eclampsia prevention and treatment in a multi‐country network of health facilities ...and compare with international recommendations.
Design
Cross‐sectional survey.
Setting
A total of 147 health facilities in 15 countries across Africa, Latin America and Asia.
Population
Heads of obstetric departments or maternity units.
Methods
Anonymous online and paper‐based survey conducted in 2015.
Main outcome measures
Availability and use of MgSO4; availability of a formal clinical protocol for MgSO4 administration; and MgSO4 dosing regimens for eclampsia prevention and treatment.
Results
Magnesium sulphate and a formal protocol for its administration were reported to be always available in 87.4% and 86.4% of all facilities, respectively. MgSO4 was used for the treatment of mild pre‐eclampsia, severe pre‐eclampsia and eclampsia in 24.3%, 93.5% and 96.4% of all facilities, respectively. Regarding the treatment of severe pre‐eclampsia, 26.4% and 7.0% of all facilities reported using dosing regimens that were consistent with Zuspan and Pritchard regimens, respectively. Across regions, intramuscular maintenance regimens were more commonly used in the African region (45.7%) than in the Latin American (3.0%) and Asian (22.9%) regions, whereas intravenous maintenance regimens were more often used in the Latin American (94.0%) and Asian (60.0%) regions than in the African region (21.7%). Similar patterns were found for the treatment of eclampsia across regions.
Conclusions
The reported clinical use of MgSO4 for eclampsia prevention and treatment varied widely, and was largely inconsistent with current international recommendations.
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MgSO4 regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.
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MgSO4 regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.
IntroductionComplications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication ...severity, describe their management, and to report women’s experience of abortion care in Africa.MethodsA cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications.ResultsThere were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%).ConclusionThere is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women’s experiences of abortion care.
To set up a global system for monitoring maternal and perinatal health in 54 countries worldwide.
The WHO Global Survey for Monitoring Maternal and Perinatal Health was implemented through a network ...of health institutions, selected using a stratified multistage cluster sampling design. Focused information on maternal and perinatal health was abstracted from hospital records and entered in a specially developed online data management system. Data were collected over a two- to three-month period in each institution. The project was coordinated by WHO and supported by WHO regional offices and country coordinators in Africa and the Americas.
The initial survey was implemented between September 2004 and March 2005 in the African and American regions. A total of 125 institutions in seven African countries and 119 institutions in eight Latin American countries participated.
This project has created a technologically simple and scientifically sound system for large-scale data management, which can facilitate programme monitoring in countries.
CONTEXT For evidence-based practice to embed culturally in the workplace, teaching of evidence-based medicine (EBM) should be clinically integrated. In low-middle–income countries (LMICs) there is a ...scarcity of EBM-trained clinical tutors, lack of protected time for teaching EBM, and poor access to relevant databases in languages other than English. OBJECTIVE To evaluate the effects of a clinically integrated e-learning EBM course incorporating the World Health Organization (WHO) Reproductive Health Library (RHL) on knowledge, skills, and educational environment compared with traditional EBM teaching. DESIGN, SETTING, AND PARTICIPANTS International cluster randomized trial conducted between April 2009 and November 2010 among postgraduate trainees in obstetrics-gynecology in 7 LMICs (Argentina, Brazil, Democratic Republic of the Congo, India, Philippines, South Africa, Thailand). Each training unit was randomized to an experimental clinically integrated course consisting of e-modules using the RHL for learning activities and trainee assessments (31 clusters, 123 participants) or to a control self-directed EBM course incorporating the RHL (29 clusters, 81 participants). A facilitator with EBM teaching experience was available at all teaching units. Courses were administered for 8 weeks, with assessments at baseline and 4 weeks after course completion. The study was completed in 24 experimental clusters (98 participants) and 22 control clusters (68 participants). MAIN OUTCOME MEASURES Primary outcomes were change in EBM knowledge (score range, 0-62) and skills (score range, 0-14). Secondary outcome was educational environment (5-point Likert scale anchored between 1 strongly agree and 5 strongly disagree). RESULTS At baseline, the study groups were similar in age, year of training, and EBM-related attitudes and knowledge. After the trial, the experimental group had higher mean scores in knowledge (38.1 95% CI, 36.7 to 39.4 in the control group vs 43.1 95% CI, 42.0 to 44.1 in the experimental group; adjusted difference, 4.9 95% CI, 2.9 to 6.8; P < .001) and skills (8.3 95% CI, 7.9 to 8.7 vs 9.1 95% CI, 8.7 to 9.4; adjusted difference, 0.7 95% CI, 0.1 to 1.3; P = .02). Although there was no difference in improvement for the overall score for educational environment (6.0 95% CI, −0.1 to 12.0 vs 13.6 95% CI, 8.0 to 19.2; adjusted difference, 9.6 95% CI, −6.8 to 26.1; P = .25), there was an associated mean improvement in the domains of general relationships and support (−0.5 95% CI, −1.5 to 0.4 vs 0.3 95% CI, −0.6 to 1.1; adjusted difference, 2.3 95% CI, 0.2 to 4.3; P = .03) and EBM application opportunities (0.5 95% CI, −0.7 to 1.8 vs 2.9 95%, CI, 1.8 to 4.1; adjusted difference, 3.3 95% CI, 0.1 to 6.5; P = .04). CONCLUSION In a group of LMICs, a clinically integrated e-learning EBM curriculum in reproductive health compared with a self-directed EBM course resulted in higher knowledge and skill scores and improved educational environment. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12609000198224
Induction of labor is being increasingly used to prevent adverse outcomes in the mother and the newborn.This study assessed the prevalence of induction of labor and determinants of its use in Africa.
...We performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005. The African database was analyzed to determine the use of induction of labor at the country level and indications for induction of labor. The un-met needs for specific obstetric indications and at country level were assessed. Determinants of use of induction of labor were explored with multivariate regression analysis.
A total of 83,437 deliveries were recorded in the 7 participating countries. Average rate of induction was 4.4% with a range of 1.4 - 6.8%. Pre-labor rupture of membranes was the commonest indication for induction of labor. Two groups of women were identified: 2,776 women with indications had induction of labor while 7,996 women although had indications but labor was not induced.Induction of labor was associated with reduction of stillbirths and perinatal deaths OR - 0.34; 95% CI (0.27 - 0.43).Unmet need for induction of labor ranged between 66.0% and 80.2% across countries. Determinants of having an induction of labor were place of residence, duration of schooling, type of health facility and level of antenatal care.
Utilization of induction of labor in health facilities in Africa is very low. Improvements in social and health infrastructure are required to reverse the high unmet need for induction of labor.
Summary Background We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the ...coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23 015 (7·3%) women had potentially life-threatening disorders and 3024 (1·0%) developed an SMO. 808 (26·7%) women with an SMO had post-partum haemorrhage and 784 (25·9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0·826 95% CI 0·802–0·851). Interpretation High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. Funding UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.
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