How does hospital organisation influence the use of caesarean sections in low- and middle-income countries? A cross-sectional survey in Argentina, Burkina Faso, Thailand and Vietnam for the QUALI-DEC project.

BACKGROUND: Improving the understanding of non-clinical factors that lead to the increasing caesarean section (CS) rates in many low- and middle-income countries is currently necessary to meet the challenge of implementing effective interventions in hospitals to reverse the trend. The objective of this study was to study the influence of organizational factors on the CS use in Argentina, Vietnam, Thailand and Burkina Faso. METHODS: A cross-sectional hospital-based postpartum survey was conducted in 32 hospitals (8 per country). We selected women with no potential medical need for CS among a random sample of women who delivered at each of the participating facilities during the data collection period. We used multilevel multivariable logistic regression to analyse the association between CS use and organizational factors, adjusted on women's characteristics. RESULTS: A total of 2,092 low-risk women who had given birth in the participating hospitals were included. The overall CS rate was 24.1%, including 4.9% of pre-labour CS and 19.3% of intra-partum CS. Pre-labour CS was significantly associated with a 24-hour anaesthetist dedicated to the delivery ward (ORa = 3.70 [1.41; 9.72]) and with the possibility to have an individual room during labour and delivery (ORa = 0.28 [0.09; 0.87]). Intra-partum CS was significantly associated with a higher bed occupancy level (ORa = 1.45 [1.09; 1.93]): intrapartum CS rate would increase of 6.3% points if the average number of births per delivery bed per day increased by 10%. CONCLUSION: Our results suggest that organisational norms and convenience associated with inadequate use of favourable resources, as well as the lack of privacy favouring women's preference for CS, and the excessive workload of healthcare providers drive the CS overuse in these hospitals. It is also crucial to enhance human and physical resources in delivery rooms and the organisation of intrapartum care to improve the birth experience and the working environment for those providing care. TRIAL REGISTRATION: The QUALI-DEC trial is registered on the Current Controlled Trials website ( https://www.isrctn.com/ ) under the number ISRCTN67214403.

How a supply-side intervention can help to increase caesarean section rates in Burkina Faso facilities-Evidence from an interrupted time-series analysis using routine health data.

OBJECTIVES: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso. METHODS: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. RESULTS: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. CONCLUSION: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption.

"Because it eases my Childbirth Plan": a qualitative study on factors contributing to preferences for caesarean section in Thailand.

BACKGROUND: Although caesarean section (CS) rates have increased rapidly in Thailand, the upward trend is not supported by significant maternal or perinatal health benefits. The appropriate use of CS through QUALIty DECision-making by women and providers (QUALI-DEC project) aims to design and implement a strategy to optimize the use of CS through non-clinical interventions. This study aimed to explore the factors influencing women's and health professionals' preferences for CS delivery in Thailand. METHODS: We conducted a formative qualitative study by using semi-structured in-depth interviews with pregnant and postpartum women, and healthcare staff. Purposive sampling was used to recruit participants from eight hospitals across four regions of Thailand. Content analysis was used to develop the main themes. RESULTS: There were 78 participants, including 27 pregnant and 25 postpartum women, 8 administrators, 13 obstetricians, and 5 interns. We identified three main themes and seven sub-themes of women and healthcare providers' perceptions on CS: (1) avoiding the negative experiences from vaginal birth (the pain of labor and childbirth, uncertainty during the labor period); (2) CS is a safer mode of birth (guarantees the baby's safety, a protective shield for doctors); and (3) CS facilitates time management (baby's destiny at an auspicious time, family's management, manage my work/time). CONCLUSIONS: Women mentioned negative experiences and beliefs about vaginal delivery, labor pain, and uncertain delivery outcomes as important factors influencing CS preferences. On the other hand, CS is safer for babies and facilitates multiple tasks in women's lives. From health professionals' perspectives, CS is the easier and safer method for patients and them. Interventions to reduce unnecessary CS, including QUALI-DEC, should be designed and implemented, taking into consideration the perceptions of both women and healthcare providers.

Women's and health providers' perceptions of companionship during labor and childbirth: a formative study for the implementation of WHO companionship model in Burkina Faso.

INTRODUCTION: A key component of achieving respectful maternal and newborn care is labor companionship. Despite important health benefits for the woman and baby, there are critical gaps in implementing labor companionship for all women globally. The paper aims to present the perceptions and experiences of pregnant women, postpartum women, and health care providers regarding companionship during labor and childbirth, and to identify barriers and facilitating factors to the implementation of labor companionship in Burkina Faso. METHODS: This is a formative study to inform the "Appropriate use of cesarean section through QUALIty DECision-making by women and providers" (QUALI-DEC) study, to design, adapt and implement a strategy to optimize the use of the cesarean section, including labor companionship. We use in-depth interviews (women, potential companions, and health workers) and health facility readiness assessments in eight hospitals across Burkina Faso. We use a thematic analysis approach for interviews, and narrative summaries to describe facility readiness assessment. RESULTS: In all, 77 qualitative interviews and eight readiness assessments are included in this analysis. The findings showed that all participants acknowledged an existing traditional companionship model, which allowed companions to support women only in the hospital waiting room and post-natal room. Despite recognizing clear benefits, participants were not familiar with companionship during labor and childbirth in the hospital as recommended by WHO. Key barriers to implementing companionship throughout labor and birth include limited space in labor and delivery wards, no private rooms for women, hospital rules preventing companionship, and social norms preventing the choice of a companion by the woman. CONCLUSION: Labor companionship was considered highly acceptable in Burkina Faso, but more work is needed to adapt to the hospital environment. Revisions to hospital policies to allow companions during labor and childbirth are needed as well as changes to provide private space for women. Training potential companions about their roles and encouraging women's rights to choose their companions may help to facilitate effective implementation.

A labor companion is a person who supports a woman throughout labor and birth, typically a woman's spouse/partner, family member, or friend. We were interested to explore if a labor companion throughout labor and birth was acceptable to women and health workers, and feasible to start doing for women in Burkina Faso. To achieve this objective, we interviewed 77 women, companions, and health workers about their beliefs and opinions about labor companions, and what might help or be a challenge to having companions. We also visited eight hospitals to understand what the labor ward looks like, and any policies about companions. We found that hospitals were allowing a 'traditional model' of companionship, allowing companions to accompany women only in the waiting and postnatal rooms (not during labor or birth). Both women and health workers believed that companionship during labor and birth would be helpful and desired, which might help to make it a reality for all women. We also identified some challenges, due to crowded labor rooms with limited privacy, and hospital rules that did not allow companionship. We found that sometimes a woman's family would choose the companion, instead of the woman herself, which may mean the woman does not want this person present. We plan to use these findings to help us to develop a program that allows any woman to have a companion present during labor and birth, in a way that ensures that she chooses the companion, and the companion can support her well.

Women's empowerment and elective cesarean section for a single pregnancy: a population-based and multivariate study in Vietnam.

BACKGROUND: Women's empowerment, and maternal and neonatal health are important targets of the Sustainable Development Goals. Our objective is to examine the relationship between women's empowerment and elective cesarean section (ECS), focusing on Vietnam, a country where the use of CS has increased rapidly in recent decades, which raises public health concerns. METHODS: We hypothesized that in the context of the developing biomedicalization of childbirth, women's empowerment increases the use of ECS due to a woman's enhanced ability to decide her mode of delivery. By using microdata from the 2013-2014 Multiple Indicator Clusters Survey, we conducted a multivariate analysis of the correlates of ECS. We studied a representative sample of 1343 institutional single birth deliveries. Due to higher ECS rates among multiparous (18.4%) than primiparous women (10.1%) and the potential interaction between parity and other correlates, we used separate models for primiparous and multiparous women. RESULTS: Among the indicators of women's external resources, which include a higher level of education, having worked during the previous 12 months, and having one's own mobile phone, only education differed between primiparous and multiparous women, with a higher level among primiparous women. Among primiparous women, no resource indicator was significantly linked to ECS. However, considering women's empowerment facilitated the identification of the negative impact of having had fewer than 3 antenatal care visits on the use of ECS. Among multiparous women, disapproval of intimate partner violence (IPV) was associated with a doubled likelihood of undergoing ECS (odds ratio = 2.415), and living in an urban area also doubled the likelihood of ECS. The positive association with living in the richest household quintile was no longer significant when attitude towards IPV was included in the model. In both groups, being aged 35 or older increased the likelihood of undergoing ECS, and this impact was stronger in primiparous women. CONCLUSIONS: These results underline the multidimensionality of empowerment, its links to other correlates and its contribution to clarifying the influence of these correlates, particularly for distinguishing between medical and sociocultural determinants. The results advocate for the integration of women's empowerment into policies aimed at reducing ECS rates.

Implementation of HPV-based screening in Burkina Faso: lessons learned from the PARACAO hybrid-effectiveness study.

BACKGROUND: Cervical cancer screening in sub-Saharan countries relies on primary visual inspection with acetic acid (VIA). Primary human papillomavirus (HPV)-based screening is considered a promising alternative. However, the implementation and real-life effectiveness of this strategy at the primary-care level in limited-resource contexts remain under explored. In Ouagadougou, Burkina Faso, free HPV-based screening was implemented in 2019 in two primary healthcare centers. We carried out a process and effectiveness evaluation of this intervention. METHODS: Effectiveness outcomes and implementation indicators were assessed through a cohort study of screened women, observations in participating centers, individual interviews with women and healthcare providers and monitoring reports. Effectiveness outcomes were screening completeness and women's satisfaction. Logistic regression models and concurrent qualitative analysis explored how implementation variability, acceptability by women and the context affected effectiveness outcomes. RESULTS: After a 3-month implementation period, of the 350 women included in the cohort, 94% completed the screening, although only 26% had their screening completed in a single visit as planned in the protocol. The proportion of highly satisfied women was higher after result disclosure (95%) than after sampling (65%). A good understanding of the screening results and recommendations increased screening completeness and women's satisfaction, while time to result disclosure decreased satisfaction. Adaptations were made to fit healthcare workers' workload. CONCLUSION: Free HPV-based screening was successfully integrated within primary care in Ouagadougou, Burkina Faso, leading to a high level of screening completeness despite the frequent use of multiple visits. Future implementation in primary healthcare centers needs to improve counseling and reduce wait times at the various steps of the screening sequence.

Créer une communauté de pratique sur la recherche interventionnelle en santé mondiale.

INTRODUCTION: In the French-speaking world, specifically in France, intervention research in global health has yet to be fully developed institutionally. The Institute of Research for Development (IRD) is one of the major public actors in global health research in France. Within this institute, researchers publish and communicate little on intervention research despite the fact that this is part of their daily work. This is why, for the past several years, the health and society department of the IRD has been working towards institutionalizing a network of IRD actors in population health intervention research (PHIR). OBJECTIVE: The objective of this article is to analyze the needs of global health actors and elements that will allow for the construction of a community of practice in order to initiate an institutional anchoring of intervention research in global health through the mobilization of IRD actors. METHOD: Qualitative research was carried out in 2017 including individual and group interviews. The results yielded several observations: 1) a definition of PHIR that differs according to the participants, 2) a need to strengthen formal and informal interactions to respond to the need for training and sharing experiences, to reinforce encounters and interpersonal bonds, to increase communication and visibility of implemented actions, 3) the participants’ desire to evolve together to overcome certain inherent challenges of global health such as interdisciplinarity, North-South partnerships, or communication with different populations. CONCLUSION: Conducting population health intervention research requires a certain amount of reflection on the ways in which research is done and implies significant changes in the daily lives and work of researchers. It is essential to have institutional support to develop this, such as a community of practice. However, the absence of this community of practice three years later illustrates the operational challenges of implementing such an initiative.

Death audits and reviews for reducing maternal, perinatal and child mortality.

BACKGROUND: The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry). OBJECTIVES: To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality. SEARCH METHODS: We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles. SELECTION CRITERIA: Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate. DATA COLLECTION AND ANALYSIS: We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful. MAIN RESULTS: We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported. We did not find any studies that evaluated child death audit and review or community-based death reviews or costs. AUTHORS' CONCLUSIONS: A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low-income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high-income setting where mortality was already very low. The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost-effective ways of implementing maternal, perinatal and paediatric death reviews in low- and middle-income countries.

Acceptability of HPV screening among HIV-infected women attending an HIV-dedicated clinic in Abidjan, Côte d'Ivoire.

BACKGROUND: Cervical cancer incidence is high among women living with HIV due to high-risk HPV persistence in the cervix. In low-income countries, cervical cancer screening is based on visual inspection with acetic acid. Implementing human papilloma virus (HPV) screening through self-sampling could increase women's participation and screening performance. Our study aims to assess the preintervention acceptability of HPV screening among HIV-infected women in Abidjan, Côte d'Ivoire. METHODS: Applying the Health Belief Model theoretical framework, we collected qualitative data through in-depth interviews with 21 HIV-infected women treated in an HIV-dedicated clinic. Maximum variation sampling was used to achieve a diverse sample of women in terms of level of health literacy. Interviews were recorded and transcribed with the participants' consent. Data analysis was performed using NVivo 12. RESULTS: Screening acceptability relies on cervical cancer representations among women. Barriers were the fear of diagnosis and the associated stigma disregard for HIV-associated health conditions, poor knowledge of screening and insufficient resources for treatment. Fees removal, higher levels of knowledge about cervical cancer and of the role of HIV status in cancer were found to facilitate screening. Healthcare providers are obstacle removers by their trusting relationship with women and help navigating through the healthcare system. Self-confidence in self-sampling is low. CONCLUSIONS: Free access to cervical screening, communication strategies increasing cervical cancer knowledge and healthcare provider involvement will foster HPV screening. Knowledge gathered through this research is crucial for designing adequate HPV-based screening interventions for women living with HIV in this setting.

DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso.

BACKGROUND: In Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries. METHODS: We conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm. RESULTS: A total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, - 17.02%; 95% CI, - 19.20 to - 13.20%). The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available. CONCLUSION: Promotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting. TRIAL REGISTRATION: The DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263 .

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.).

Do free caesarean section policies increase inequalities in Benin and Mali?

BACKGROUND: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Predictors of uterine rupture in a large sample of women in Senegal and Mali: cross-sectional analysis of QUARITE trial data.

BACKGROUND: The purpose of this study was to investigate predictors of uterine rupture in a large sample of sub-Saharan African women. Uterine rupture is rare in high-income countries, but it is more common in low-income settings where health systems are often under-resourced. However, understanding of risk factors contributing to uterine rupture in such settings is limited due to small sample sizes and research rarely considers system and individual-level factors concomitantly. METHODS: Cross-sectional data analysis from the pre-intervention period (Oct. 1, 2007- Oct. 1, 2008) of the QUARITE trial, a large-scale maternal mortality study. This research examines uterine rupture among 84,924 women who delivered in one of 46 referral hospitals in Mali and Senegal. A mixed-effects logistic regression model identified individual and geographical risk factors associated with uterine rupture, accounting for clustering by hospital. RESULTS: Five hundred sixty-nine incidences of uterine rupture (0.67% of sample) were recorded. Predictors of uterine rupture: grand multiparity defined as > 5 live births (aOR = 7.57, 95%CI; 5.19-11.03), prior cesarean (aOR = 2.02, 95%CI; 1.61-2.54), resides outside hospital region (aOR = 1.90, 95%CI: 1.28-2.81), no prenatal care visits (aOR = 1.80, 95%CI; 1.44-2.25), and birth weight of > 3600 g (aOR = 1.61, 95%CI; 1.30-1.98). Women who were referred and who had an obstructed labor had much higher odds of uterine rupture compared to those who experienced neither (aOR: 46.25, 95%CI; 32.90-65.02). CONCLUSIONS: The results of this large study confirm that the referral system, particularly for women with obstructed labor and increasing parity, is a main determinant of uterine rupture in this context. Improving labor and delivery management at each level of the health system and communication between health care facilities should be a priority to reduce uterine rupture.

DECIDE: a cluster randomized controlled trial to reduce non-medically indicated caesareans in Burkina Faso.

BACKGROUND: Since 2006, Burkina Faso has subsidized the cost of caesarean sections to increase their accessibility. Caesareans are performed by obstetricians, general practitioners, and nurses trained in emergency surgery. While the national caesarean rate is still too low (only 2 % in 2010), 12 to 24 % of caesareans performed in hospital are, in fact, not medically indicated. The objective of this study is to evaluate the effectiveness and analyze the implementation of a multi-faceted intervention to lower the rate of non-medically indicated caesareans in Burkina Faso. METHODS: This study combines a multicentre cluster randomized controlled trial with an implementation analysis in a mixed-methods approach. The evidence-based intervention will consist of three strategies to improve the competencies of maternity teams: 1) clinical audits based on objective criteria; 2) training of personnel; and 3) decision-support reminders of indications for caesareans via text messages. The unit of randomization and of intervention is the public hospital equipped with a functional operating room. Using stratified randomization on hospital type and staff qualifications, 11 hospitals have been assigned to the intervention group and 11 to the control group. The intervention will cover 1 year. Every patient who delivered by caesarean during a 6-month period in the year preceding the intervention and the 6 months following its end will be included in the trial. The change in the rate of non-medically indicated caesareans is the main criterion by which the intervention's impact will be assessed. To analyze the intervention process, a longitudinal qualitative study consisting of deliberative workshops and individual in-depth interviews will be conducted. The target outcome is a 50 % reduction in the rate of non-medically indicated caesareans. DISCUSSION: This study will provide evidence regarding the effectiveness of a multi-faceted intervention for reducing non-medically indicated caesareans in a low-income country. By combining qualitative and quantitative methods, the study's findings will allow understanding the factors that could influence the intervention process and ultimately the intended outcomes. TRIAL REGISTRATION: The DECIDE trial is registered on the Current Controlled Trials website under the number ISRCTN48510263 on January 28, 2014.

Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women's characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali. METHODS: A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death. RESULTS: Among the 3,278 women who experienced PPH, 178 (5.4%) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26-3.72]), living in Mali (adjusted OR = 1.84 [1.13-3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29-4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54-22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77-11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19-5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26-5.10]), transfusion (adjusted OR = 2.17 [1.53-3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20-28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35-0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC). CONCLUSIONS: Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.

Impact of accreditation training for residents on sonographic quality in gynecologic emergencies.

OBJECTIVES: To assess the impact of an educational intervention based on an original accreditation training program on the quality of emergency sonography performed by obstetrics and gynecology (Ob/Gyn) residents. METHODS: We conducted a prospective before-after study on residents who performed bedside standardized sonographic examinations as first-line investigations in patients seen at our gynecologic emergency department. In both periods, the residents followed a 1-hour class taught by a board-certified Ob/Gyn sonography expert (opinion leader) and received a written standardized imaging protocol. An accreditation training process was implemented for the new residents at the beginning of the second period: 5 complete sonographic examinations were required for each resident, and facilitated feedback from the opinion leader was performed using a dedicated sonographic quality score. During both periods, all consecutive sonograms were collected and stored. The primary outcome was the sonographic quality score. A mixed model for repeated measures was used to compare scores in both periods from 20 consecutive sonographic examinations performed by 5 residents who were different in each period. RESULTS: The mixed model analysis showed an increase in quality scores in the post-accreditation training compared to the pre-accreditation training period (estimated coefficient ± SD, 4.13 ± 0.51; t = 8.16). The sonographic examination order also had a significant effect in both periods (estimated coefficient ± SD, 0.11 ± 0.03; t = 3.99). CONCLUSIONS: An accreditation training process including facilitated feedback from a local opinion leader improved the quality of sonographic examinations performed by Ob/Gyn residents in women presenting to a gynecologic emergency department.

The Hidden Costs of a Free Caesarean Section Policy in West Africa (Kayes Region, Mali).

The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

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.

Development of an instrument to evaluate intrapartum care quality in Senegal: evaluation quality care.

OBJECTIVE: To evaluate the reliability of direct observation for measuring intrapartum care and compare this method with clinical audits using objective criteria based on patients' medical charts. DESIGN: Cross-sectional study, data collected by two independent evaluators. SETTING: Hospital in Dakar, Senegal. PARTICIPANTS: Thirty consecutive intrapartum care episodes provided by midwives and the corresponding medical charts. Outcome Measure The presence or absence of each of twelve criteria selected on the basis of national and international norms for monitoring of labour and delivery (six criteria) and the immediate postpartum period (six criteria). RESULTS: For direct observation, the labour and delivery mean quality scores ranged from 5.34 to 5.77. In contrast, for the chart-based method, the scores ranged from 0.32 to 0.45. For postpartum care evaluated only with direct observation, the scores were also high (5.21-5.65). For direct observation, inter-evaluator agreement was high: kappa coefficients varied from 0.78 to 0.93 depending on the criterion (total score ICC = 0.74). For the chart-based method, inter-evaluator agreement was also high: 0.66 to 1 (total score ICC = 0.72). Comparison of the two methods showed strong differences by items and subscores. CONCLUSION: Using direct observation, the quality of obstetric care was high for both the monitoring of labour and delivery and postpartum care. Both measurement instruments showed high reliability. The chart-based method underestimated the quality of care because of poor medical record documentation. Medical-record-based measurement may not be appropriate for the evaluation of the quality of obstetric care in Senegal and other low-income settings.