N van den Broek

Quality of care for maternal and newborn health: the neglected agenda

The quality of care received by mothers and babies in developing countries is often reported as poor. Yet efforts to address this contributory factor to maternal and newborn mortality have received less attention compared with barriers of access to care. The current heightened concern to achieve Millennium Development Goals 4 & 5 has illuminated the neglected quality agenda. Whilst there is no universally‐accepted definition of “quality care”, it is widely acknowledged to embrace multiple levels – from patient to health system, and multiple dimensions, including safety as well as efficiency. Quality care should thus lie at the core of all strategies for accelerating progress towards MDG4 &5. Interventions to measure and improve quality need themselves to be evidence‐based. Two promising approaches are maternal and perinatal death reviews and criterion‐based audit. These and other quality improvement tools have a crucial role to play in the implementation of effective maternal and newborn care.

Skilled birth attendance-lessons learnt

To reduce the horrific maternal mortality figures that we have globally especially in resource poor countries, there was a global commitment to reduce maternal mortality by three‐quarters by 2015 using 1990 as a baseline. To measure the achievement of this goal, two indicators: maternal mortality ratio and proportion of births attended by skilled attendance were selected. To ensure skilled attendance at birth for all women, the international community set a target of 80% by 2005, 85% by 2010 and 90% coverage by 2015. However, in 2008 only 65.7% of all women were attended to by a skilled attendant during pregnancy, childbirth and immediately postpartum globally with some countries having less than 20% coverage. With the global human resource crisis, achieving this target is challenging but possible. This paper provides a narrative review of the literature on the skilled birth attendance strategy identifying key challenges and lessons learnt.

Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review

Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors.

Anaemia in Pregnancy in Southern Malawi: Prevalence and Risk Factors

Objective To determine prevalence of anaemia in pregnancy in southern Malawi, and to establish if an ‘at risk’ group can be identified for targeted intervention.

A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS TO REDUCE HEMORRHAGE DURING MYOMECTOMY FOR UTERINE FIBROIDS

To assess the effectiveness and safety of interventions to reduce blood loss during myomectomy.

Pregnancy and the erythrocyte sedimentation rate

Objectives To determine the range of erythrocyte sedimentation rate values obtained in healthy pregnant women. To examine the effect of gestational age and haemoglobin concentration on erythrocyte sedimentation rate.

Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi

BACKGROUND Facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts in Malawi in 2006. RESEARCH QUESTION Can audit and feedback improve the availability, utilisation and quality of emergency obstetric care (EmOC)? PARTICIPANTS AND METHODS Observational study in which emergency obstetric care offered to women who gave birth in 73 health facilities (13 hospitals and 60 health centres) in three districts in Malawi in 2005 (baseline, 41,637 women) was compared to 2006 (43,729 women) and 2007 (51,085 women). RESULTS The number of comprehensive and basic EmOC facilities did not change over the 3-year period (p for trend=1.000). Although institutional delivery rate decreased in 2006, overall it increased over 3 years (p for trend<0.001) - 31.8% (2005), 31.1% (2006) and 34.7% (2007), and Caesarean section rate was low and did not change (p for trend=0.257) - 1.7% (2005), 1.6% (2006) and 1.5% (2007). There was a significant increase in the met need for EmOC (p for trend<0.001) - 15.2% for 2005, 17.0% for 2006 and 18.8% for 2007. Maternal mortality decreased significantly from 250 per 100,000 women in 2005 to 222 in 2006 and 182 in 2007 (p for trend<0.001). Similarly, the case fatality rate decreased monotonically (p for trend<0.001) - 3.7% (2005), 3.0% (2006) and 1.5% (2007). DISCUSSION Audit and feedback can improve availability, utilisation and quality of emergency obstetric care in countries with limited resources. CONCLUSION There is need to increase availability of emergency obstetric care by upgrading some health centres to EmOC level through training of staff and provision of equipment and supplies.

Randomised trial of vitamin A supplementation in pregnant women in rural Malawi found to be anaemic on screening by HemoCue

Objective  To assess the effects of vitamin A supplementation in women with anaemia during pregnancy.

Ensuring effective Essential Obstetric Care in resource poor settings

Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use – What is EOC? Is it evidence‐based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi‐experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5.

Cervical cancer in Bangladesh: community perceptions of cervical cancer and cervical cancer screening

We investigated the awareness of, and the attitude towards screening for, cervical cancer in Bangladesh. We performed a qualitative study using focus group discussions (FGD). The framework approach to qualitative analysis was used. The study was performed in the catchment areas of Addin Hospital, Jessore, Southern Bangladesh (peri-urban) and LAMB hospital, Parbatipur, North West Bangladesh (rural). A total of 220 men, women and adolescents participated in 28 FGDs. Awareness of cervical cancer was widespread. Knowledge about causes was often inadequate. The perceived consequences of cervical cancer were numerous and awareness of the need for cervical cancer treatment was present. Barriers to accessing care include: low priority for seeking help for symptoms, limited availability of health services and cost. Most women were unaware of the possibility of screening via speculum examination, which was considered acceptable to women (and men), as long as the examination was done by a female healthcare provider in an environment with sufficient privacy. In conclusion, adequate gynaecological services are not available or accessible for most women in rural and peri-urban Bangladesh. However, awareness of cervical cancer is widespread. Screening for cervical cancer in these communities is acceptable if done by a female healthcare provider under conditions with sufficient privacy.