Alexandre Dumont

Maternal mortality and access to obstetric services in West Africa

Summary Objectives Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa.

Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial

BACKGROUND Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali. METHODS We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658. FINDINGS 191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. INTERPRETATION Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. FUNDING Canadian Institutes of Health Research.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)

Objective To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities.

Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec

OBJECTIVE To investigate obstetricians perceptions of clinical practice guidelines targeting management of labour and vaginal birth after previous caesarean birth, and to identify the barriers to, facilitators of and obstetricians solutions for implementing these guidelines in practice. METHODS This qualitative study was conducted in three hospitals in Montreal that represent around 10% of births in Quebec. Data was collected from 10 focus groups, followed by six semi-structured interviews. Two researchers jointly analysed the verbatim transcripts according to A manual for the use of focus groups. FINDINGS The identified barriers to and facilitators of the implementation of guidelines can be classified into four categories: 1) the hospital level, including management and hospital policies; 2) the departmental level, including local policies, leadership, organizational factors, economic incentive, and availability of equipment and staff; 3) the health professionals motivations and attitudes, including medico-legal concerns, skill levels, acceptance of guidelines and strategies used to implement recommendations; and 4) patients motivations. CONCLUSION Identifying the barriers to and facilitators of the adoption of recommendations is an important way to guide the development of efficient strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals perceptions are considered to make recommendations more acceptable and useful. Our findings also support the assumption that obstetricians seek to implement best practices, but require evidence tools and support to assess their practices and enhance their performance. In addition, peer review activities championed by opinion leaders have been identified by obstetricians as the most suitable strategy to improve the use of the guidelines in their practices.

A Cluster-Randomized Trial to Reduce Cesarean Delivery Rates in Quebec

BACKGROUND In Canada, cesarean delivery rates have increased substantially over the past decade. Effective, safe strategies are needed to reduce these rates. METHODS We conducted a cluster-randomized, controlled trial of a multifaceted 1.5-year intervention at 32 hospitals in Quebec. The intervention involved audits of indications for cesarean delivery, provision of feedback to health professionals, and implementation of best practices. The primary outcome was the cesarean delivery rate in the 1-year postintervention period. RESULTS Among the 184,952 participants, 53,086 women delivered in the year before the intervention and 52,265 women delivered in the year following the intervention. There was a significant but small reduction in the rate of cesarean delivery from the preintervention period to the postintervention period in the intervention group as compared with the control group (change, 22.5% to 21.8% in the intervention group and 23.2% to 23.5% in the control group; odds ratio for incremental change over time, adjusted for hospital and patient characteristics, 0.90; 95% confidence interval [CI], 0.80 to 0.99; P=0.04; adjusted risk difference, -1.8%; 95% CI, -3.8 to -0.2). The cesarean delivery rate was significantly reduced among women with low-risk pregnancies (adjusted risk difference, -1.7%; 95% CI, -3.0 to -0.3; P=0.03) but not among those with high-risk pregnancies (P=0.35; P = 0.03 for interaction). The intervention group also had a reduction in major neonatal morbidity as compared with the control group (adjusted risk difference, -0.7%; 95% CI, -1.3 to -0.1; P=0.03) and a smaller increase in minor neonatal morbidity (adjusted risk difference, -1.7%; 95% CI, -2.6 to -0.9; P<0.001). Changes in minor and major maternal morbidity did not differ significantly between the groups. CONCLUSIONS Audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. The benefit was driven by the effect of the intervention in low-risk pregnancies. (Funded by the Canadian Institutes of Health Research; QUARISMA Current Controlled Trials number, ISRCTN95086407.).

Maternal mortality in West Africa

Background. According to estimates of maternal mortality rates from WHO/UNICEF, the West African rates appear to be among the world’s highest. The precision of these estimates from general mortality models is far from ideal and no information on the distribution of causes of death is provided. The principal objective of our study is to describe the maternal mortality, estimation of the rates and distribution of obstetric causes, from a population based survey of pregnant women carried out in West Africa. We also present the main characteristics of the deaths that occurred, including avoidable aspects.

The effects of midwives’ job satisfaction on burnout, intention to quit and turnover: a longitudinal study in Senegal

BackgroundDespite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility.MethodsA cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics.ResultsDespite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their “remuneration” and “work environment” and most satisfied with the “morale” and “job security” facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with “remuneration” and “task” satisfaction, actively job searching was associated with being dissatisfied with job “security” and voluntary quitting was associated with dissatisfaction with “continuing education”.ConclusionsThis study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education.

Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households

OBJECTIVE To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali. METHODS Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them. FINDINGS Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral systems inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits. CONCLUSION The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.

Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review

PURPOSE Low-quality obstetric care in low- and middle-income countries contributes to high in-hospital maternal mortality. Criterion-based clinical audits are increasingly used to measure and improve obstetric care in these settings. This article systematically reviews peer-reviewed literature to determine if these audits are feasible, valid and reliable measurement tools for assessing the quality of obstetric care. DATA SOURCES PUBMED, Google Scholar and Web of Science databases were searched for peer-reviewed articles published between 1995 and 2009 and which used criterion-based clinical audits to measure the quality of obstetric care in low- and middle-income countries. STUDY SELECTION Sixty-nine studies were identified by key terms and subsequently reviewed. Ten were retained based on inclusion/exclusion criteria. DATA EXTRACTION (i) General characteristics of the study; (ii) compliance with expected standards of care and on maternal/child health outcomes; (iii) selection of the study population and sampling methods; and (iv) quality control and reliability. RESULTS OF DATA SYNTHESIS Criterion-based clinical audit is increasingly used in low- and middle-income countries. Most audits were conducted in sub-Saharan Africa. Studies had cross-sectional study or before-and-after designs. Sampling methods were poorly reported and selection bias was a concern. No studies compared audit against other measures of quality of care or against patient outcomes. METHODS for quality control and assurance were generally not documented and reliability was mostly unaddressed. CONCLUSIONS Criterion-based clinical audit appears feasible. No studies have rigorously evaluated its measurement properties in low- and middle-income countries. Without such evaluation, measurement properties of the audit remain under question.

Maternal mortality in Senegal

OBJECTIVE The improvement of obstetric services is one of the key components of the Safe Motherhood Programme. Reviewing maternal deaths and complications is one method that may make pregnancy safer, but there is no evidence about the effectiveness of this strategy. The objective of our before and after study is to assess the effect of facility-based maternal deaths reviews (MDR) on maternal mortality rates in a district hospital in Senegal that provides primary and referral maternity services. METHODS We included all women who were admitted to the maternity unit for childbirth, or within 24 hours of delivery. We recorded maternal mortality during a 1-year baseline period from January to December 1997, and during a 3-year period from January 1998 to December 2000 after MDR had been implemented. Effects of MDR on organization of care were qualitatively evaluated. FINDINGS The MDR strategy led to changes in organizational structure that improved life-saving interventions with a relatively large financial contribution from the community. Overall mortality significantly decreased from 0.83 (95% CI (confidence interval) = 0.60 -1.06) in baseline period to 0.41 (95% CI = 0.25 -0.56) per 100 women 3 years later. CONCLUSION MDR had a marked effect on resources, management and maternal outcomes in this facility. However, given the design of our study and the local specific context, further research is needed to confirm the feasibility of MDR in other settings and to confirm the benefits of this approach for maternal health in developing countries.