[National survey of maternal mortality of 2010 : data of Tunisia]. / L'enquête Nationale Tunisienne sur la mortalité maternelle de 2010 : A propos des données de Tunis.

BACKGROUND: Tunisia has investigated maternal mortality in 2010 to determine maternal mortality ratio (MMR) nationally and regionally, in addition to the indentifying main causes of this mortality. OBJECTIVES: Describe methodology of this study and its principal findings in the region of Tunis and discuss the national maternal mortality strategy. METHODOLOGY: This is a Ramos study (Reproductive Ag Mortality Studies) that consists on identifying maternal deaths from reproductive age group (RAG) women deaths. We started by the a rehearsal and targeting of (RAG) women deaths , then we investigated a next of kin person of the decedent women by verbal autopsy, thereafter we identified maternal deaths to be confidentially investigated to judge the potential avoidability of the death. The study took place in 2010, it was carried out by 5 couples of investigators supervised by a coordinator doctor. RESULTS: A total of 200 deaths of (RAG) women were found in Tunis, 7 deaths among them were maternal deaths, that corresponds to an MMR of 41/100000 live births. The mean age of the deceased women was 35 years. The main causes of maternal deaths were hemorrhage (3/7), thrombo-embolic diseases (2 times for7) and HELLP syndrome (1/7). Four of a total of 4 deaths (3 deaths were not marked), were avoidable. The majority of late women had a satisfying educational level, 4 of 7 had financial autonomy. All of them had pregnancy monitoring, 5 times of 7 in university hospital. All the childbirth were medically assisted, Caesarean section was carried in 6 of 7 cases. Nationally, the MMR was estimated to 44.8/100 000 LB, that to say a decrease of 35% compared to 1993. The decrease was significant for all the regions of the country, except the great Tunis where opposite trend was recorded. This could be more likely related to quality of care rather than socio-economic conditions seeing that social determinants in Tunis are favorable. In fact, the Tunisian maternal mortality strategy had essentially focused on the monitoring system of maternal deaths rather than the quality of care improvement interventions, results were disappointing due to the lack of institutional engagement. The achievement of the OMD5 objectives is compromised, due to socio-economic constraint especially in certain regions, poor governance and lack of engagement of ministry of health in reducing maternal mortality. CONCLUSION: Tunisian maternal mortality strategy should be revised and adapted to regional context, also should includ multisectoral interventions. Priority would be given to quality of care improvement, by launching the experience of care setting accreditation in one hand, and in the other improving partnership between different levels of care.

[Monitoring of maternal and infantile care activities: experience of Tunisia basic health care services]. / Le monitoring des activites de sante maternelle et infantile. A propos de l'expérience des soins de santé de base de Tunis.

In the feamework of quality assessment, the basic service for health care of Tunis introduced in 1997 a service managing tool for prenatal activity monitoring. This paper aims to present the way this tool should be used its setting up within the basic health structures and its principal effects on the quality process. Prenatal activity monitoring is a process that allows evaluation, control and dysfunction level identification of a health program: it also permits a microplanification in order to compensate for its failings. The first step consists in calculating the 5 following covering determining factors: target population, material or, human resources availability, the service at one's disposal's use rate, the appropriate coverage rate according to a precise way in which the consultations are linked to each other concerning this program and the effective coverage rate including the required quality indicator for the care. A graph permits to visualize these different rates. The second step consists in identifying the bottleneck and the most relevant correcting actions to be conducted in relation with either the available human resources or the material resources or the process of health care by using an "intemal audit". Setting up this tool required many training sessions and supervisions for the Tunis health care services. It proved efficient enough in order to improve the actual coverage of the population especially in the responsibility area of the staff members for certain preventive programs as prenatal services or children's growth follow up. It allowed a better documentation of the consultation activity and the objective analysis of the inherent problems to the recommended program. The solutions were taken locally and dependes on the decision maker's will.