Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study

Background

Assessments of maternal near miss (MNM) are increasingly used in addition to those of maternal mortality measures. The World Health Organization (WHO) has introduced an MNM tool in 2009, but this tool was previously found to be of limited applicability in several low–resource settings. The aim of this study was to identify adaptations to enhance applicability of the WHO MNM tool in sub–Saharan Africa.

Methods

Using a Delphi consensus methodology, existing MNM tools were rated for applicability in sub-Saharan Africa over a series of three rounds. Maternal health experts from sub-Saharan Africa or with considerable knowledge of the context first rated importance of WHO MNM parameters using Likert scales, and were asked to suggest additional parameters. This was followed by two confirmation rounds. Parameters accepted by at least 70% of the panel members were accepted for use in the region.

Results

Of 58 experts who participated from study onset, 47 (81%) completed all three rounds. Out of the 25 WHO MNM parameters, all 11 clinical, four out of eight laboratory, and four out of six management–based parameters were accepted, while six parameters (PaO2/FiO2 < 200 mmHg, bilirubin >100 μmol/l or >6.0 mg/dl, pH <7.1, lactate >5 μmol/l, dialysis for acute renal failure and use of continuous vasoactive drugs) were deemed to not be applicable. An additional eight parameters (uterine rupture, sepsis/severe systemic infection, eclampsia, laparotomy other than caesarean section, pulmonary edema, severe malaria, severe complications of abortions and severe pre-eclampsia with ICU admission) were suggested for inclusion into an adapted sub-Saharan African MNM tool.

Conclusions

All WHO clinical criteria were accepted for use in the region. Only few of the laboratory- and management based were rated applicable. This study brought forward important suggestions for adaptations in the WHO MNM criteria to enhance its applicability in sub-Saharan Africa and possibly other low–resource settings.

Identifying gaps in the practices of rural health extension workers in Ethiopia: a task analysis study

Background

Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs’ pre-service education and practices. The aim of this study was to identify gaps in HEWs’ practices and recommend changes in their training and scope of practice.

Methods

A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared.

Results

A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%–57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7–97.2%) perceived themselves as competent and proficient in performing tasks in all program areas.

Conclusion

HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs’ scope of practice, update pre-service education curricula and prioritize in-service training modules.

Emergency obstetric care provision in Southern Ethiopia: a facility-based survey

OBJECTIVES

To assess the provision of basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres in Southern Ethiopia.

DESIGN

A facility-based survey, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and newborn care. Modules included infrastructure, staffing, number of deliveries, maternal and perinatal mortality, BEmONC signal functions, referral capacity and knowledge of risk factors in pregnancy.

SETTING

Primary healthcare centres providing delivery services in the Eastern Gurage Zone, a predominantly rural area in Southern Ethiopia.

PARTICIPANTS

All 20 health centres in the study area were selected for the assessment. One was excluded, as no delivery services had been provided in the 12 months prior to the study.

RESULTS

Three out of 19 health centres met the government's staffing norm. In the 12 months prior to the survey, 10 004 ([Formula: see text]) deliveries were attended to at the health centres, but none had provided all seven BEmONC signal functions in the three months prior to the survey ([Formula: see text]). Eight maternal and 32 perinatal deaths occurred. Most health centres had performed administration of parenteral uterotonics (17/89.5%), manual removal of placenta (17/89.5%) and neonatal resuscitation (17/89.5%), while few had performed assisted vaginal delivery (3/15.8%) or administration of parenteral anticonvulsants (1/5.3%). Reasons mentioned for non-performance were lack of patients with appropriate indications, lack of training and supply problems. Health workers mentioned on average 3.9±1.4 of 11 risk factors for adverse pregnancy outcomes. Five ambulances were available in the zone.

CONCLUSION

BEmONC provision is not guaranteed to women giving birth in health centres in Southern Ethiopia. Since the government aims to increase facility deliveries, investments in capacity at health centres are urgently needed.

Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a low-resource setting

Background

Postpartum haemorrhage (PPH) is a major cause of maternal mortality. Prevention and adequate treatment are therefore important. However, most births in low-resource settings are not attended by skilled providers, and knowledge and skills of healthcare workers that are available are low. Simulation-based training effectively improves knowledge and simulated skills, but the effectiveness of training on clinical behaviour and patient outcome is not yet fully understood. The aim of this study was to assess the effect of obstetric simulation-based training on the incidence of PPH and clinical performance of basic delivery skills and management of PPH.

Methods

A prospective educational intervention study was performed in a rural referral hospital in Tanzania. Sixteen research assistants observed all births with a gestational age of more than 28 weeks from May 2011 to June 2013. In March 2012 a half-day obstetric simulation-based training in management of PPH was introduced. Observations before and after training were compared. The main outcome measures were incidence of PPH (500–1000 ml and >1000 ml), use and timing of administration of uterotonic drugs, removal of placenta by controlled cord traction, uterine massage, examination of the placenta, management of PPH (>500 ml), and maternal and neonatal mortality at 24 h.

Results

Three thousand six hundred twenty two births before and 5824 births after intervention were included. The incidence of PPH (500–1000 ml) significantly reduced from 2.1% to 1.3% after training (effect size Cohen’s d = 0.07). The proportion of women that received oxytocin (87.8%), removal of placenta by controlled cord traction (96.5%), and uterine massage after birth (93.0%) significantly increased after training (to 91.7%, 98.8%, 99.0% respectively). The proportion of women who received oxytocin as part of management of PPH increased significantly (before training 43.0%, after training 61.2%). Other skills in management of PPH improved (uterine massage, examination of birth canal, bimanual uterine compression), but these were not statistically significant.

Conclusions

The introduction of obstetric simulation-based training was associated with a 38% reduction in incidence of PPH and improved clinical performance of basic delivery skills and management of PPH.

Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia

BACKGROUND

Despite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia's plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period.

METHODS

A cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests.

RESULTS

A total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training.

CONCLUSIONS

Although our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.

Trainers' perception of the learning environment and student competency: A qualitative investigation of midwifery and anesthesia training programs in Ethiopia

BACKGROUND

Ethiopia has successfully expanded training for midwives and anesthetists in public institutions. This study explored the perceptions of trainers (instructors, clinical lab assistants and preceptors) towards the adequacy of students' learning experience and implications for achieving mastery of core competencies.

METHODS

In-depth interviews with 96 trainers at 9 public universities and 17 regional health science colleges across Ethiopia were conducted to elicit their opinions about available resources, program curriculum suitability, and competence of graduating students. Using Dedoose, data were thematically analyzed using grounded theory.

RESULTS

Perceptions of anesthesia and midwifery programs were similar. Common challenges included unpreparedness and poor motivation of students, shortages of skills lab space and equipment, difficulties ensuring students' exposure to sufficient and varied enough cases to develop competence, and lack of coordination between academic training institutions and clinical attachment sites. Additional logistical barriers included lack of student transport to clinical sites. Informants recommended improved recruitment strategies, curriculum adjustments, increased time in skills labs, and better communication across academic and clinical sites.

CONCLUSIONS

An adequate learning environment ensures that graduating midwives and anesthetists are competent to provide quality services. Minimizing the human resource, infrastructural and logistical gaps identified in this study requires continued, targeted investment in health systems strengthening.

Education, Practice, and Competency Gaps of Anesthetists in Ethiopia: Task Analysis

PURPOSE

This study assessed the needs and gaps in the education, practice and competencies of anesthetists in Ethiopia.

DESIGN

A cross-sectional study design was used.

METHODS

A questionnaire consisting of 74 tasks was completed by 137 anesthetists who had been practicing for 6 months to 5 years.

FINDINGS

Over half of the respondents rated 72.9% of the tasks as being highly critical to patient outcomes, and reported that they performed 70.2% of all tasks at a high frequency. More than a quarter of respondents reported that they performed 15 of the tasks at a low frequency. Nine of the tasks rated as being highly critical were not learned during pre-service education by more than one-quarter of study participants, and over 10% of respondents reported that they were unable to perform five of the highly critical tasks.

CONCLUSIONS

Anesthetists rated themselves as being adequately prepared to perform a majority of the tasks in their scope of practice.

Respectful maternity care in Ethiopian public health facilities

Background

Disrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries. This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services.

Methods

This study had a cross sectional study design. Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists. The outcome variable, providers’ RMC performance, was measured by nine behavioral descriptors. The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment.

We present percentages of the nine RMC indicators, mean score of providers’ RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics.

Results

Women on average received 5.9 (66%) of the nine recommended RMC practices. Health centers demonstrated higher RMC performance than hospitals. At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals).

Higher likelihood of performing high level of RMC was found among male vs. female providers (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta}=0.65 $$\end{document}β^=0.65, p = 0.012), midwives vs. other cadres (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta} = 0.88 $$\end{document}β^=0.88, p = 0.002), facilities implementing a quality improvement approach, Standards-based Management and Recognition (SBM-R^©) (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta}=1.31 $$\end{document}β^=1.31, p = 0.003), and among laboring women accompanied by a companion \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta} = 0.99 $$\end{document}β^=0.99, p = 0.003). No factor was associated with observed mistreatment of women.

Conclusion

Quality improvement using SBM-R^© and having a companion during labor and delivery were associated with RMC. Policy makers need to consider the role of quality improvement approaches and accommodating companions in promoting RMC. More research is needed to identify the reason for superior RMC performance of male providers over female providers and midwives compared to other professional cadre, as are longitudinal studies of quality improvement on RMC and mistreatment of women during labor and childbirth services in public health facilities.

Using a quality improvement model to enhance providers' performance in maternal and newborn health care: a post-only intervention and comparison design

BACKGROUND

The Standards Based Management and Recognition (SBM-R^©) approach to quality improvement has been implemented in Ethiopia to strengthen routine maternal and newborn health (MNH) services. This evaluation assessed the effect of the intervention on MNH providers' performance of routine antenatal care (ANC), uncomplicated labor and delivery and immediate postnatal care (PNC) services.

METHODS

A post-only evaluation design was conducted at three hospitals and eight health centers implementing SBM-R and the same number of comparison health facilities. Structured checklists were used to observe MNH providers' performance on ANC (236 provider-client interactions), uncomplicated labor and delivery (226 provider-client interactions), and immediate PNC services in the six hours after delivery (232 provider-client interactions); observations were divided equally between intervention and comparison groups. Main outcomes were provider performance scores, calculated as the percentage of essential tasks in each service area completed by providers. Multilevel analysis was used to calculate adjusted mean percentage performance scores and standard errors to compare intervention and comparison groups.

RESULTS

There was no statistically significant difference between intervention and comparison facilities in overall mean performance scores for ANC services (63.4% at intervention facilities versus 61.0% at comparison facilities, p = 0.650) or in any specific ANC skill area. MNH providers' overall mean performance score for uncomplicated labor and delivery care was 11.9 percentage points higher in the intervention than in the comparison group (77.5% versus 65.6%; p = 0.002). Overall mean performance scores for immediate PNC were 22.2 percentage points higher at intervention than at comparison facilities (72.8% versus 50.6%; p = 0.001); and there was a significant difference of 22 percentage points between intervention and comparison facilities for each PNC skill area: care for the newborn and health check for the mother.

CONCLUSIONS

The SBM-R quality improvement intervention made a significant positive impact on MNH providers' performance during labor and delivery and immediate PNC services, but not during ANC services. Scaling up the intervention to other facilities and regions may increase the availability of good quality MNH services across Ethiopia. The findings will also guide implementation of the government's five-year (2015-2020) health sector transformation plan and health care quality strategies needed to meet the country's MNH goals.

Assessing emergency obstetric and newborn care: can performance indicators capture health system weaknesses?

Background

Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement.

Methods

Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives.

Results

Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance.

Conclusions

Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1282-z) contains supplementary material, which is available to authorized users.

Antenatal corticosteroid therapy for foetal maturation in women with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania

BACKGROUND

Preterm birth is a major cause of neonatal mortality, especially in low and middle income countries. Antenatal corticosteroid therapy for foetal maturation could have a significant impact and therefore is often referred to as an important strategy to reduce neonatal mortality. A recently conducted large multinational trial showed that antenatal corticosteroids can have adverse effects in low income countries, but this is likely to depend on the specific setting. In our hospital preterm birth is only recognized in patients with severe maternal disease, due to physician-initiated delivery. Spontaneous preterm births are rarely seen in the hospital and often take place in the community or while on the road to a health facility.

OBJECTIVE

To investigate the effects of antenatal corticosteroid therapy in a rural hospital in Tanzania.

METHODS

A secondary analysis of a retrospective medical records study of women with severe pre-eclampsia and eclampsia performed in Ndala Hospital between July 2011 and December 2012. We used data on gestational age, birth weight, Apgar score, time between admission and birth, use of corticosteroids and maternal and foetal survival. Ethical clearance was obtained from the directorate of research and publications of the University of Dodoma (ref. UDOM/DRP/346).

RESULTS

Thirty-six women with forty live foetuses were analysed. Twelve women (13 neonates) were given corticosteroids and could be compared to 24 women (27 neonates) who did not get corticosteroids. The incidence of fresh stillbirths (antenatal death) was 20 %. The 13 neonates who received corticosteroids had significantly smaller birth weight, longer interval between admission and delivery and poorer outcomes (stillbirth and neonatal death). An analysis of 24 neonates with a birth weight between 1.5 and 2.5 kg showed a trend toward better outcome in neonates who did not receive antenatal corticosteroid therapy.

CONCLUSION

Small retrospective studies as these have a low level of evidence, but this study helped to gain more knowledge of local conditions affecting the effectiveness of antenatal corticosteroid therapy in our setting of a small rural hospital. Reliability of estimating gestational age, epidemiology of preterm birth, exposure to infections, foetal monitoring and quality of neonatal care are likely to influence the effect of antenatal corticosteroid therapy. Further larger prospective studies should be conducted to determine the exact preconditions of antenatal corticosteroid therapy in low-income countries. Until that time, the WHO precautions seem reasonable and audits and small observational studies like ours can help in assessing whether a specific hospital is suited for antenatal corticosteroid therapy.

Using task analysis to generate evidence for strengthening midwifery education, practice, and regulation in Ethiopia

PURPOSE

Realizing aspirations for meeting the global reproductive, maternal, newborn, and child health goals depends not only on increasing the numbers but also on improving the capability of midwifery workforce. We conducted a task analysis study to identify the needs for strengthening the midwifery workforce in Ethiopia.

METHODS

We conducted a cross-sectional study of recently qualified midwives in Ethiopia. Purposively selected participants from representative geographic and practice settings completed a self-administered questionnaire, making judgments about the frequency of performance, criticality, competence, and location of training for a list of validated midwifery tasks. Using Statistical Package for the Social Sciences, Version 20, we computed the percentages and averages to describe participant and practice characteristics. We identified priority preservice education gaps by considering the tasks least frequently learned in preservice, most frequently mentioned for not being trained, and had the highest not capable response. Identification of top priorities for in-service training considered tasks with highest "not capable" and "never" done responses. We determined the licensing exam blueprint by weighing the composite mean scores for frequency and criticality variables and expert rating across practice categories.

RESULTS

One hundred and thirty-eight midwives participated in the study. The majority of respondents recognized the importance of midwifery tasks (89%), felt they were capable (91.8%), reported doing them frequently (63.9%), and learned them during preservice education (56.3%). We identified competence gaps in tasks related to obstetric complications, gynecology, public health, professional duties, and prevention of mother to child transmission of HIV. Moreover, our study helped to determine composition of the licensing exam for university graduates.

CONCLUSION

The task analysis indicates that midwives provide critical reproductive, maternal, newborn, and child health care services and supports continuing investment in this cadre. However, there were substantial competence gaps that limit their ability to accelerate progress toward health development goals. Moreover, basing the licensure exam on task analysis helped to ground it in national practice priorities.

Criteria-based audit of caesarean section in a referral hospital in rural Tanzania

OBJECTIVE

WHO uses the Caesarean section (CS) rate to monitor implementation of emergency obstetric care (EmOC). Although CS rates are rising in sub-Saharan Africa, maternal outcome has not improved. We audited indications for CS and related complications among women with severe maternal morbidity and mortality in a referral hospital in rural Tanzania.

METHODS

Cross-sectional study was from November 2009 to November 2011. Women with severe maternal morbidity and mortality were identified and those with CS were included in this audit. Audit criteria were developed based on the literature review and (inter)national guidelines. Tanzanian and Dutch doctors reviewed hospital notes. The main outcome measured was prevalence of substandard quality of care leading to unnecessary CS and delay in performing interventions to prevent CS.

RESULTS

A total of 216 maternal near misses and 32 pregnancy-related deaths were identified, of which 82 (33.1%) had a CS. Indication for CS was in accordance with audit criteria for 36 of 82 (44.0%) cases without delay. In 20 of 82 (24.4%) cases, the indication was correct; however, there was significant delay in providing standard obstetric care. In 16 of 82 (19.5%) cases, the indication for CS was not in accordance with audit criteria. During office hours, CS was more often correctly indicated than outside office hours (60.0% vs. 36.0%, P < 0.05).

DISCUSSION

Caesarean section rate is not an useful indicator to monitor quality of EmOC as a high rate of unnecessary and potentially preventable CS was identified in this audit.

Preparing the health workforce in Ethiopia: A Cross-sectional study of competence of anesthesia graduating students

BACKGROUND

Efforts to address shortages of health workers in low-resource settings have focused on rapidly increasing the number of higher education programs for health workers. This study examines selected competencies achieved by graduating Bachelor of Science and nurse anesthetist students in Ethiopia, a country facing a critical shortage of anesthesia professionals.

METHODS

The study, conducted in June and July 2013, assessed skills and knowledge of 122 students graduating from anesthetist training programs at six public universities and colleges in Ethiopia; these students comprise 80% of graduates from these institutions in the 2013 academic year. Data was collected from direct observations of student performance, using an objective structured clinical examination approach, and from structured interviews regarding the adequacy of the learning environment.

RESULTS

Student performance varied, with mean percentage scores highest for spinal anesthesia (80%), neonatal resuscitation (74%), endotracheal intubation (73%), and laryngeal mask airway insertion check (71%). Average scores were lowest for routine anesthesia machine check (37%) and preoperative screening assessment (48%). Male graduates outscored female graduates (63.2% versus 56.9%, P = 0.014), and university graduates outscored regional health science college graduates (64.5% versus 55.5%, P = 0.023). Multivariate linear regression found that competence was associated with being male and attending a university training program. Less than 10% of the students believed that skills labs had adequate staff and resources, and only 57.4% had performed at least 200 endotracheal intubations at clinical practicum sites, as required by national standards.

DISCUSSION

Ethiopia has successfully expanded higher education for anesthetists, but a focus on quality of training and assessment of learners is required to ensure that graduates have mastered basic skills and are able to offer safe services.

Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review

BACKGROUND

Increased preparedness for birth and complications is an essential part of antenatal care and has the potential to increase birth with a skilled attendant. We conducted a systematic review of studies to assess the effect of birth preparedness and complication readiness interventions on increasing birth with a skilled attendant.

METHODS

PubMed, Embase, CINAHL and grey literature were searched for studies from 2000 to 2012 using a broad range of search terms. Studies were included with diverse designs and intervention strategies that contained an element of birth preparedness and complication readiness. Data extracted included population, setting, study design, outcomes, intervention description, type of intervention strategy and funding sources. Quality of the studies was assessed. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings.

RESULTS

Thirty-three references encompassing 20 different intervention programmes were included, of which one programmatic element was birth preparedness and complication readiness. Implementation strategies were diverse and included facility-, community-, or home-based services. Thirteen studies resulted in an increase in birth with a skilled attendant or facility birth. The majority of authors reported an increase in knowledge on birth preparedness and complication readiness.

CONCLUSIONS

Birth Preparedness and Complication Readiness interventions can increase knowledge of preparations for birth and complications; however this does not always correspond to an increase in the use of a skilled attendant at birth.

Characteristics and outcomes of patients with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania: a retrospective medical record study

Background

Eclampsia and pre-eclampsia are well-recognized causes of maternal and neonatal mortality in low income countries, but are never studied in a district hospital. In order to get reliable data to facilitate the hospital’s obstetric audit a retrospective medical record study was performed in Ndala Hospital, Tanzania.

Methods

All patients diagnosed with severe pre-eclampsia or eclampsia between July 2011 and December 2012 were included. Medical records were searched immediately following discharge or death. General patient characteristics, medical history, obstetrical history, possible risk factors, information about the current pregnancy, antenatal clinic attendance and prescribed therapy before admission were recorded. Symptoms and complications were noted. Statistical analysis was done with Epi Info®.

Results

Of the 3398 women who gave birth in the hospital 26 cases of severe pre-eclampsia and 55 cases of eclampsia were diagnosed (0.8 and 1.6 %). Six women with eclampsia died (case fatality rate 11 %). Convulsions in patients with eclampsia were classified as antepartum (44 %), intrapartum (42 %) and postpartum (15 %). Magnesium was given in 100 % of patients with eclampsia and was effective in controlling convulsions. Intravenous antihypertensive treatment was only started in 5 % of patients. Induction of labour was done in 29 patients (78 % of women who were not yet in labour). Delivery was spontaneous in 67 %, assisted vaginal (ventouse) in 14 % and by Caesarean section in 19 % of women. Perinatal deaths occurred in 30 % of women with eclampsia and 27 % of women with severe pre-eclampsia and were associated with low birth weight and prolonged time between admission and birth.

Conclusions

2.4 % of women were diagnosed with severe pre-eclampsia or eclampsia. The case fatality rate and overall perinatal mortality were comparable to other reports. Better outcomes could be achieved by better treatment of hypertension and starting induction of labour as soon as possible.

Helping Mothers Survive Bleeding After Birth: retention of knowledge, skills, and confidence nine months after obstetric simulation-based training

Background

It is important to know the decay of knowledge, skills, and confidence over time to provide evidence-based guidance on timing of follow-up training. Studies addressing retention of simulation-based education reveal mixed results. The aim of this study was to measure the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care in order to understand the impact of training on these components.

Methods

An educational intervention study was carried out in 2012 in a rural referral hospital in Northern Tanzania. Eighty-nine healthcare workers of different cadres were trained in “Helping Mothers Survive Bleeding After Birth”, which addresses basic delivery skills including active management of third stage of labour and management of postpartum haemorrhage (PPH). Knowledge, skills, and confidence were tested before, immediately after, and nine months after training amongst 38 healthcare workers. Knowledge was tested by completing a written 26-item multiple-choice questionnaire. Skills were tested in two simulated scenarios “basic delivery” and “management of PPH”. Confidence in active management of third stage of labour, management of PPH, determination of completeness of the placenta, bimanual uterine compression, and accessing advanced care was self-assessed using a written 5-item questionnaire.

Results

Mean knowledge scores increased immediately after training from 70 % to 77 %, but decreased close to pre-training levels (72 %) at nine-month follow-up (p = 0.386) (all p-levels are compared to pre-training). The mean score in basic delivery skills increased after training from 43 % to 51 %, and was 49 % after nine months (p = 0.165). Mean scores of management of PPH increased from 39 % to 51 % and were sustained at 50 % at nine months (p = 0.003). Bimanual uterine compression skills increased from 19 % before, to 43 % immediately after, to 48 % nine months after training (p = 0.000). Confidence increased immediately after training, and was largely retained at nine-month follow-up.

Conclusions

Training resulted in an immediate increase in knowledge, skills, and confidence. While knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. These findings indicate a need for continuation of training. Future research should focus on the frequency and dosage of follow-up training.

How well does pre-service education prepare midwives for practice: competence assessment of midwifery students at the point of graduation in Ethiopia

BACKGROUND

Midwifery support and care led by midwives is the most appropriate strategy to improve maternal and newborn health. The Government of Ethiopia has recently improved the availability of midwives by scaling up pre-service education. However, the extent to which graduating students acquire core competencies for safe and effective practice is not known. The purpose of this study was to evaluate the quality of midwifery education by assessing the competence of graduating midwifery students.

METHODS

We conducted a cross-sectional study to assess the competence of students who completed basic midwifery education in Ethiopia in 2013. We interviewed students to obtain their perceptions of the sufficiency and quality of teachers and educational resources and processes. We assessed achievement of essential midwifery competencies through direct observation, using a 10-station Objective Structured Clinical Examination (OSCE). We calculated average percentage scores of performance for each station and an average summary score for all stations. Chi-square test, independent sample t test, and linear regression analysis were used to assess the statistical significance of differences and associations.

RESULTS

We assessed 484 graduating students from 25 public training institutions. Majority of students rated the learning environment unfavorably on 8 out of 10 questions. Only 32 % of students managed 20 or more births during training, and just 6 % managed 40 or more births. Students' overall average competence score was 51.8 %; scores ranged from 32.2 % for manual vacuum aspiration to 69.4 % for active management of the third stage of labor. Male gender, reporting sufficient clinical experience, and managing greater numbers of births during training were significant predictors of higher competence scores.

CONCLUSIONS

The quality of pre-service midwifery education needs to be improved, including strengthening of the learning environment and quality assurance systems. In-service training and mentoring to fill competence gaps of new graduates is also essential.

Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial

OBJECTIVE

To investigate whether uterus preserving vaginal sacrospinous hysteropexy is non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments in the surgical treatment of uterine prolapse.

DESIGN

Multicentre randomised controlled non-blinded non-inferiority trial.

SETTING

4 non-university teaching hospitals, the Netherlands.

PARTICIPANTS

208 healthy women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery.

INTERVENTIONS

Treatment with sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments. The predefined non-inferiority margin was an increase in surgical failure rate of 7%.

MAIN OUTCOME MEASURES

Primary outcome was recurrent prolapse stage 2 or higher of the uterus or vaginal vault (apical compartment) evaluated by the pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months' follow-up. Secondary outcomes were overall anatomical recurrences, including recurrent anterior compartment (bladder) and/or posterior compartment (bowel) prolapse, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning.

RESULTS

Sacrospinous hysteropexy was non-inferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n=0, 0%) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n=4, 4.0%, difference -3.9%, 95% confidence interval for difference -8.6% to 0.7%). At 12 months, overall anatomical recurrences, functional outcome, quality of life, complications, hospital stay, measures on postoperative recovery, and sexual functioning did not differ between the two groups. Five serious adverse events were reported during hospital stay. None was considered to be related to the type of surgery.

CONCLUSIONS

Uterus preservation by sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for surgical failure of the apical compartment at 12 months' follow-up.

TRIAL REGISTRATION

trialregister.nl NTR1866.

Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study

Background

Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.

Methods

A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.

Results

The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.

Conclusions

While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting

OBJECTIVE

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting.

DESIGN

Educational intervention study.

SETTING

Rural referral hospital in Northern Tanzania.

POPULATION

Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care.

METHODS

In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression.

MAIN OUTCOME MEASURES

Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training.

RESULTS

Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage).

CONCLUSIONS

The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.