Improving emergency obstetric care and reversing the underutilisation of vacuum extraction: a qualitative study of implementation in Tete Province, Mozambique.

BACKGROUND: Maternal and perinatal mortality in Mozambique were declining at a slow pace, despite progress in coverage of institutional childbirth. Implementation of quality emergency obstetric care including vacuum extraction remained inadequate. In 2015-2017, Tete Province achieved remarkable progress in improving emergency obstetric care and reversing the underutilisation of vacuum extraction, with encouraging results for maternal and perinatal outcomes, despite severe resource constraints. This paper presents the experience of Tete Province, generating a rich, contextualised understanding, which might provide generalizable insights and lessons. METHODS: This qualitative study design is used to present Tete's experience in improving emergency obstetric care and reversing the underutilisation of vacuum extraction, drawing on principles from implementation science and applying a systems thinking approach. Sources include routine data, documents, social media messages, and the lived experience of the authors, all intimately involved in the implementation process during 2014-2017. Iterative learning and analysis, involving all authors, led to the final interpretations. RESULTS: Within a context of severe resource constraints, Tete applied 4 interventions (training, accreditation, audit, monitoring and evaluation with feedback) to improve the implementation of emergency obstetric care. Considerable progress was achieved in vacuum extraction and other signal functions of emergency obstetric care and in the decision-making process for caesarean sections, contributing to important reductions in the provincial institutional maternal mortality and stillbirth rates. Facilitating factors include attributes of the vacuum extraction itself, of the structural and organisational environments in which it was introduced, of the people involved in implementation, and of the process through which the implementation was rolled-out. CONCLUSIONS: The lessons from implementation science and systems thinking can contribute to surprising results in the improvement of emergency obstetric care including the use of vacuum extraction, even in a severely resource-constrained setting. The creation of conditions for real change, with empowerment of the staff and managers at the front-line of day-to-day practice in Tete may inspire others in similar conditions and circumstances. The underutilisation of vacuum extraction in middle- and low-income countries is indeed a missed opportunity. Its reversion is possible and provides a good chance to make considerable difference in maternal and perinatal outcomes.

Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: the importance of quality surveillance.

This study compares two antivenoms used to treat Echis ocellatus snake bite patients at Mathias Hospital, Yeji, central Ghana. FAV-Afrique antivenom (Aventis Pasteur) was given to 278 patients during 2001--2003, whilst Asna Antivenom C (Bharat Serum and Vaccines Ltd) was used in 2004 to treat 66 patients. The two groups had comparable patient attributes, time from snake bite to treatment and staff adherence to the tested treatment protocol. The antivenom C group required more repeat doses and twice the amount of antivenom to treat coagulopathy. Of greater concern, the antivenom C mortality rate was 12.1%, a marked rise from the 1.8% rate in the earlier FAV-Afrique antivenom group. In this study, antivenom C was ineffective as treatment for West African E. ocellatus snake venom. This illustrates the absolute need for regional pilot tests to assess the effectiveness of a new antivenom against local snake venoms before its sole and general distribution in a region is initiated.

Gender and unwanted pregnancy: a community-based study in rural Ghana.

This study investigates attitudes concerning unwanted pregnancies in a rural district of western Ghana. Structured questionnaires were used to interview men and women between 15 and 49 years of age (n = 2179) to measure the prevalence of unwanted pregnancy, how often it led to induced abortion and to establish the reasons why a pregnancy was considered unwanted. At some time in their life at least one unwanted pregnancy was experienced by 41% of men and 43.6% of women. Men and women reported a similar proportion of pregnancies (17.3% and 16.1%, respectively) as unwanted. The proportion of unwanted pregnancies terminated by induced abortion varied with the reason why the pregnancy was undesirable. Among both men and women socio-economic problems were most commonly cited with unwanted pregnancies. Pregnancies perceived by women as unwanted ended more often in an induced abortion than those unwanted by men. Reproductive health programs need to make contraceptives available, accessible and acceptable for both women and men. More research is needed to facilitate a clear understanding of the impact of gender on unwanted pregnancy and its prevention.

Infertility in rural Ghana.

OBJECTIVES: This study measured the prevalence of self-reported infertility, as well as the level of knowledge of causes of infertility. Infertility was defined as failure to achieve conception after a minimum of 12 months of exposure. METHODS: Prevalence and knowledge of infertility were assessed in a representative community-based survey using a structured questionnaire in a rural district in Ghana among a random sample of 2,179 men and women from 15 to 49 years. RESULTS: The prevalence of infertility was 11.8% among women and 15.8% among men. The knowledge of causes of infertility was limited; only 46.5% of the respondents reported any cause. Most respondents failed to identify reproductive tract infections as causes of infertility. CONCLUSIONS: Infertility in Ghana and other sub-Saharan countries deserves more recognition as a public health problem. Prevention and treatment of infertility should be incorporated in reproductive health programs, while male participation in reproductive health programs and research needs to be encouraged. Public education about the causes of infertility is recommended.

Malaria prophylaxis and the reduction of anemia at childbirth.

OBJECTIVES: To assess the effect of introducing chloroquine prophylaxis during pregnancy on prevalence of anemia (<10.9 g/dl) at childbirth and perinatal outcome. METHODS: Observational study in a rural district hospital in Ghana, which compared 2803 women who received chloroquine prophylaxis during pregnancy with 3084 historical controls, who had not received prophylaxis during pregnancy. Main outcome measures were hemoglobin level at childbirth, perinatal mortality and birth weight. RESULTS: Mean hemoglobin level before childbirth increased from 10.7 g/dl (S.D.=1.0 g/dl) to 11.0 g/dl (S.D.=0.9 g/dl). Prevalence of anemia decreased from 29.4 to 13.3% (OR=0.4 and 95% CI=0.3-0.4). Prevalence of moderately severe anemia (<9.0 g/dl) decreased from 4.4 to 3.3% (OR=0.7, 95% CI=0.6-0.97). Perinatal mortality and low birth weight (<2500 g) remained unchanged. CONCLUSIONS: Routine chloroquine prophylaxis in pregnancy is useful in reducing anemia at childbirth in malaria-endemic regions. Fetal outcome did not improve with chloroquine prophylaxis in this study.

Contraception and induced abortion in rural Ghana.

This article describes the results of a community-based survey on birth control in a rural district in western Ghana. Structured interviews with 2179 women and men aged 15-49 years were used to study the prevalence of contraceptive methods and induced abortion. In addition, the influence of induced abortion on reported fertility in relation to residence and education was analysed. The results show that 59.8% had used a contraceptive method at some time in life, while use of induced abortion was reported by 22.6% of respondents. Prevalence of ever-use of any method to avoid childbirth, contraception and/or induced abortion was 67.1%. Urban residence and higher education were associated with more induced abortions and higher use of contraceptive methods. Differences in use of induced abortion were partly responsible for the education and residence-related changes in fertility. Induced abortion needs to be considered when discussing methods in use to avoid childbirth in developing countries.