V. De Brouwere

The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso

Objective  To describe the implementation of facility‐based case reviews (medical audits) in a maternity unit and their effect on the staff involved.

Monitoring unmet obstetric need at district level in Morocco

Unmet obstetric need was assessed in Taounate province (Morocco) during the year 1995 by monitoring rates of major obstetric intervention for absolute maternal indications. We report results in terms of spatial distribution of the failures of the health care system to provide women with essential emergency obstetric care. An estimated 135 women with life‐threatening conditions did not benefit from the obstetric interventions they required. The paper documents the effects of the monitoring process on the way the provincial team changed their way of dealing with deliveries. Assessment of unmet obstetric need in Taounate province proved feasible and affordable without external budgetary inputs. It provided the team with information on the magnitude of a previously ignored problem. The results were so dramatic as to lead the team to look for causes and solutions. These were clearly not merely technical but systemic in nature.

Reducing financial barriers to emergency obstetric care: experience of cost‐sharing mechanism in a district hospital in Burkina Faso

Objective  To describe the implementation of a cost‐sharing system for emergency obstetric care in an urban health district of Ouagadougou, Burkina Faso and analyse its results after 1 year of activity.

Hospitals in sub-Saharan Africa : why we need more of what does not work as it should

This paper analyses the origins of todays crisis in the hospital sector in sub‐Saharan Africa. Present trends in availability of hospital services are extrapolated to the future in order to provide a low‐end estimate of the need for expansion of first referral level hospitals. This will not be possible without giving due priority to this sector, a commitment to considerable investments and reorientation of resources from tertiary to first referral level hospitals. It is to be feared that if this is not done, the backlog will increase, and, given the time lag before investments translate into operational services, there will be a major shortage of hospital services in sub‐Saharan Africa within a decade.

Quality cesarean delivery in Ouagadougou, Burkina Faso: A comprehensive approach

To assess the effects of a comprehensive intervention (staff training, equipment, internal clinical audits, cost sharing system, patients–providers meetings) in improving cesarean delivery access and quality in an urban district of Burkina Faso.

Assessment of appropriate child care at district level: how useful are mortality rates?

: Where financial resources are sharply limited, routine process and health care output data could be used to assess district level child health care system appropriateness better than mortality data. The rural district health system serving Kasongo, Zaire was studied in reaching these conclusions. Appropriate systems were defined as affordable, acceptable, flexible, and effective. Each of these four characteristics should be met where a primary health care package of techniques and activities truly meets the needs of a given sociocultural setting. The authors do not accept mortality rates as the most suitable tools needed to determine if a system meets these criteria for appropriateness. Particular attention is called to the complexity of measuring system effectiveness. A decline in mortality rate may be an implicit system objective, but not the only goal of the program recognized by its users and workers. There is also a clear need for immediate care and relief from suffering in the community. Use of mortality rates as principle indicator of system effectiveness would not fully reflect positive steps in meeting the broader objectives of the system. Moreover, mortality rates lack sensitivity and specificity, lack relevance to indicators needed by decision-makers at the district level, and are otherwise costly and complex to accurately obtain. Instead of mortality rate determination and analysis, the authors call for a comparison of hospital admission rates between regions which do and do not have properly functioning rural health units accordingly. If health unit operations are conducted as effectively and efficiently as designed, hospital admission rates for illnesses readily treated at the rural level should decline over time. this information is readily and cheaply examined, and allows local decision makers to respond quickly and accurately to local needs.

Consequences of severe obstetric complications on women's health in Morocco: please, listen to me!

In Morocco, medical care for women with severe obstetric complications (near‐miss cases) ends at discharge from the hospital. Little information exists regarding what happens after returning home. The aim of the study was to assess the physical and mental health consequences of near‐miss events on Moroccan women 8 months after childbirth.

Achievements and lessons learnt from facility-based maternal death reviews in Cameroon.

based maternal death reviews in Cameroon V De Brouwere, T Delvaux, RJ Leke a Woman & Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium b Hôpital Central Yaound e, Yaound e, Cameroon Correspondence: Dr V De Brouwere, Woman & Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155B, 2000 Antwerpen, Belgium. Email vdbrouwere@itg.be

Effectiveness of demand generation interventions on use of modern contraceptives in low- and middle-income countries.

To synthesise evidence on the implementation, costs and cost‐effectiveness of demand generation interventions and their effectiveness in improving uptake of modern contraception methods.

Les progrès du 5e objectif du millénaire pour le développement, globalement et les exemples d’application au Maghreb : quoi de neuf ?Progress of the fifth Millennium Development Goal globally and in the Maghreb: what’s new?

RésuméLa première partie de cet article examine les progrès mondiaux vers la cible A du cinquième Objectif du millénaire pour le développement OMD5). Cet objectif est de réduire de trois quarts le taux de mortalité maternelle entre 1990 et 2015. Ceci implique que la plupart des décès pourraient être évités. Les sources récentes ont été examinées et la base de données MMEIG a été utilisée pour la comparaison comme étant celle en cours d’utilisation par les Nations unies. L’accouchement demeure un processus à risque, particulièrement en Asie du Sud et en Afrique subsaharienne.Dans la deuxième partie, des données d’Algérie, de Lybie, du Maroc, de Mauritanie et de Tunisie, les cinq pays composant le Maghreb, ont été examinés. Quatre de ces pays sont en bonne voie pour atteindre l’OMD5. Au Maroc, un processus complet a été développé comprenant une amélioration de la qualité, de l’accessibilité et de la gouvernance. Ceci a inclus une procédure complète d’enquête confidentielle sur les morts maternelles, comprenant les cinq étapes recommandées du processus : identification améliorée des cas, documentation, détermination des causes, évaluation des soins sur optimaux et recommandations fondées sur les quatre premières étapes.L’hémorragie obstétricale est la première cause de décès dans cette région.AbstractThe first part of this article examines the global progress towards target A of the fifth Millennium Development Goal (MDG5). The target is to reduce by three quarters the maternal mortality ratio between 1990 and 2015. This implies that most maternal deaths could be avoided. Recent sources are examined and the MMEIG data set is used for the comparison as being the one in use by the United Nations. Giving birth remains a risk process, particularly in Souhern Asia and sub-Saharan.In the second part data from Algeria, Lybia, Mauritania, Morocco and Tunisia, the five countries composing the Maghreb are examined. Four of these countries are in good progress and possibly on track. In Morocco a full process has been developed including emproved governance, accessibility and quality. This has included a full procedure of confidential enquiry into maternal health, including the five recommended steps of the process: enhanced identification, documentation, determination of causes, assessment of substandard care and recommendations based on the results of the four first steps.Maternal haemorrhage is the leading cause of death in that region.