Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experience from Burundi.

OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa

The role and scope of practice of midwives in humanitarian settings:a systematic review and content analysis

Abstract Background Midwives have an essential role to play in preparing for and providing sexual and reproductive health (SRH) services in humanitarian settings due to their unique knowledge and skills, position as frontline providers and geographic and social proximity to the communities they serve. There are considerable gaps in the international guidance that defines the scope of practice of midwives in crises, particularly for the mitigation and preparedness, and recovery phases. We undertook a systematic review to provide further clarification of this scope of practice and insights to optimise midwifery performance. The review aimed to determine what SRH services midwives are involved in delivering across the emergency management cycle in humanitarian contexts, and how they are working with other professionals to deliver health care. Methods Four electronic databases and the websites of 33 organisations were searched between January and March 2017. Papers were eligible for inclusion if they were published in English between 2007 and 2017 and reported primary research pertaining to the role of midwives in delivering and performing any component of sexual and/or reproductive health in humanitarian settings. Content analysis was used to map the study findings to the Minimum Initial Service Package (MISP) for SRH across the three phases of the disaster management cycle and identify how midwives work with other members of the health care team. Results Fourteen studies from ten countries were included. Twelve studies were undertaken in conflict settings, and two were conducted in the context of the aftermath of natural disasters. We found a paucity of evidence from the research literature that examines the activities and roles undertaken by midwives across the disaster management cycle. This lack of evidence was more apparent during the mitigation and preparedness, and recovery phases than the response phase of the disaster management cycle. Conclusion Research-informed guidelines and strategies are required to better align the scope of practice of midwives with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP, to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle

What works to meet the sexual and reproductive health needs of women living with HIV/AIDS

It is critical to include a sexual and reproductive health lens in HIV programming as most HIV transmission occurs through sexual intercourse. As global attention is focusing on the sexual and reproductive health needs of women living with HIV, identifying which interventions work becomes vitally important. What evidence exists to support sexual and reproductive health programming related to HIV programmes

Female genital mutilation/cutting in Mali and Mauritania: understanding trends and evaluating policies

Despite international commitments to end female genital mutilation/cutting (FGM/C), very little is known about the effectiveness of national policies in contributing to the abandonment of this harmful practice. To help address this gap in knowledge, we apply a quasi-experimental research design to study two west African countries, Mali and Mauritania. These countries have marked similarities with respect to practices of FGM/C, but differing legal contexts. A law banning FGM/C was introduced in Mauritania in 2005; in Mali, there is no legal ban on FGM/C. We use nationally representative survey data to reconstruct trends in FGM/C prevalence in both countries, from 1997 to 2011, and then use a difference-in-difference method to evaluate the impact of the 2005 law in Mauritania. FGM/C prevalence in Mauritania began to decline slowly for girls born in the early 2000s, with the decline accelerating for girls born after 2005. However, a similar trend is observable in Mali, where no equivalent law has been passed. Additional statistical analysis confirms that the 2005 law did not have a significant impact on reducing FGM/C prevalence in Mauritania. These findings suggest that legal change alone is insufficient for behavioral change with regard to FGM/C. This study demonstrates how it is possible to evaluate national policies using readily available survey data in resource-poor settings

Compliance with focused antenatal care services: do health workers in rural Burkina Faso, Uganda and Tanzania perform all ANC procedures?

\ud \ud To assess health workers' compliance with the procedures set in the focused antenatal care (ANC) guidelines in rural Uganda, Tanzania and Burkina Faso; to compare the compliance within and among the three study sites; and to appraise the logistic and supply of the respective health facilities (HF). The cross-sectional study was conducted in the rural HF in three African countries. This descriptive observational study took place in HF in Nouna, Burkina Faso (5), Iganga, Uganda (6) and Rufiji, Tanzania (7). In total, 788 ANC sessions and service provisions were observed, the duration of each ANC service provision was calculated, and the infrastructures of the respective HF were assessed. Health workers in all HF performed most of the procedures but also omitted certain practices stipulated in the focused ANC guidelines. There was a substantial variation in provision of ANC services among HF within and among the country sites. The findings also revealed that the duration of first visits was <15 min and health workers spent even less time in subsequent visits in all three sites. Reagents for laboratory tests and drugs as outlined in the focus ANC guidelines were often out of stock in most facilities. Health workers in all three country sites failed to perform all procedures stipulated in the focused ANC guideline; this could not be always explained by the lack of supplies. It is crucial to point out the necessity of the core procedures of ANC repeatedly

Health System Support for Childbirth care in Southern Tanzania: Results from a Health Facility Census.

Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2--3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage

Building integrated health systems: lessons from HIV, sexual and reproductive health integration.

A synthetic strategy to access 2,6-disubstituted pyridines from triazolopyridines through a regioselective nickel-catalyzed alkenylation reaction of the C7–H bond is described. The N₂ fragment embedded in the resulting C–H functionalized triazolopyridine can be readily excised using acidic or oxidative conditions to unmask the pyridine

Empowering members of a rural southern community in Nigeria to plan to take action to prevent maternal mortality: a participatory action research project

Aims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioAims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioAims and objectives. To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Background. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilization. In Part One of this article presented here, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Part Two examines evaluation of the actions planned in Part One. Design. Participatory action research was utilized. Methods. Volunteers were recruited as co-researchers into the study through purposive and snowball sampling. Following orientation workshop, participatory data collection was undertaken qualitatively with consequent thematic analysis which formed basis of the plan of action. Results. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through: community education and 2 advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. Conclusion. The community is a resource which if mobilized through the process of participatory action research, can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Relevance to clinical practice. InterventioInterventions to prevent maternal deaths should include community empowerment to have better understanding of their circumstances as well as their collaboration with health professionals

Health care expenditure for hospital-based delivery care in Lao PDR

<p>Abstract</p> <p>Background</p> <p>Delivery by a skilled birth attendant (SBA) in a hospital is advocated to improve maternal health; however, hospital expenses for delivery care services are a concern for women and their families, particularly for women who pay out-of-pocket. Although health insurance is now implemented in Lao PDR, it is not universal throughout the country. The objectives of this study are to estimate the total health care expenses for vaginal delivery and caesarean section, to determine the association between health insurance and family income with health care expenditure and assess the effect of health insurance from the perspectives of the women and the skilled birth attendants (SBAs) in Lao PDR.</p> <p>Methods</p> <p>A cross-sectional study was carried out in two provincial hospitals in Lao PDR, from June to October 2010. Face to face interviews of 581 women who gave birth in hospital and 27 SBAs was carried out. Both medical and non-medical expenses were considered. A linear regression model was used to assess influencing factors on health care expenditure and trends of medical and non-medical expenditure by monthly family income stratified by mode of delivery were assessed.</p> <p>Results</p> <p>Of 581 women, 25% had health care insurance. Health care expenses for delivery care services were significantly higher for caesarean section (270 USD) than for vaginal delivery (59 USD). After adjusting for the effect of hospital, family income was significantly associated with all types of expenditure in caesarean section, while it was associated with non-medical and total expenditures in vaginal delivery. Both delivering women and health providers thought that health insurance increased the utilisation of delivery care.</p> <p>Conclusions</p> <p>Substantially higher delivery care expenses were incurred for caesarean section compared to vaginal delivery. Three-fourths of the women who were not insured needed to be responsible for their own health care payment. Women who had higher family incomes were able to pay for more non-medical care expenses. The effect of health insurance on service utilization was noted by women and SBAs. To achieve the goal of utilizing delivery care in the hospitals, coverage of health insurance needs to be expanded.</p