Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021.

BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records.

BACKGROUND: The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births. METHODS: We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019. RESULTS: The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days. CONCLUSIONS: The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Improving the quality of maternal and newborn health outcomes through a clinical mentorship program in the Democratic Republic of the Congo: study protocol.

BACKGROUND: The Democratic Republic of the Congo (DRC) boasts one of the highest rates of institutional deliveries in sub-Saharan Africa (80%), with eight out of every ten births also assisted by a skilled provider. However, the maternal and neonatal mortality are still among the highest in the world, which demonstrates the poor in-facility quality of maternal and newborn care. The objective of this ongoing project is to design, implement, and evaluate a clinical mentorship program in 72 health facilities in two rural provinces of Kwango and Kwilu, DRC. METHODS: This is an ongoing quasi-experimental study. In the 72 facilities, 48 facilities were assigned to the group where the clinical mentorship program is being implemented (intervention group), and 24 facilities were assigned to the group where the clinical mentorship program is not being implemented (control group). The groups were selected and assigned based on administrative criteria, taking into account the number of deliveries in each facility, the coverage of health zones, accessibility, and ease of implementation of a clinical mentorship program. The main activities are organizing and training a national team of mentors (including senior midwives, obstetricians, and pediatricians) in clinical mentoring, deploying them to mentor all health providers (mentees) performing maternal and newborn health (MNH) services, and providing in-service training in routine and Emergency Obstetrical and Newborn Care (EmONC) to the mentees in health facilities over an 18-month period. Baseline and endline assessments are carried out to evaluate the effectiveness of the clinical mentorship program on the quality of MNH care and the effective coverage of key interventions to reduce maternal and neonatal mortality. Findings will be disseminated nationwide and internationally, as scientific evidence is scarce. A national strategy, guidelines, and tools for clinical mentorship in MNH will be developed for replication in other provinces, thus benefitting the entire country. DISCUSSION: This is the largest project on clinical mentorship aimed to improving the quality of MNH care in Africa. This program is expected to generate one of the first pieces of scientific evidence on the effectiveness of a clinical mentorship program in MNH on a scientifically designed and sustainable model.

Nursing knowledge of essential maternal and newborn care in a high-mortality urban African setting: A cross-sectional study.

AIMS: To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya. BACKGROUND: The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low-resource settings. DESIGN: Cross-sectional survey. METHODS: Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015-2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed. RESULTS: Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case-load facilities had lower average knowledge scores compared with better-resourced and busier facilities. CONCLUSION: Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6). RELEVANCE TO CLINICAL PRACTICE: Focus on periodic training, ensuring retention of knowledge and skills among health workers in low-case load setting, and bridging the know-do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.

Better than nothing? maternal, newborn, and child health services and perinatal mortality, Lubumbashi, democratic republic of the Congo: a cohort study.

BACKGROUND: The Democratic Republic of Congo (DRC) has a high rate of perinatal mortality (PMR), and health measures that could reduce this high rate of mortality are not accessible to all women. Where they are in place, their quality is not optimal. This study was initiated to assess the relationship between these suboptimal maternal, newborn and child health (MNCH) services and perinatal mortality (PM) in Lubumbashi, DRC's second-largest city. METHODS: We conducted a prospective cohort study, comparing women who had no, low, moderate, or high numbers of antenatal care (ANC) visits; three different levels of delivery care; and who did or did not attend postnatal care (PNC). Women were followed for 50 days after delivery, with PM as the primary endpoint. RESULTS: Uptake of recommended prenatal interventions was between 11-43% among ANC attenders, regardless of the frequency of their visits. PM was 26 per 1000. ANC attendance was associated with PM. Newborns of mothers who had the lowest attendance had a mortality two times higher than newborns of women who had not attended ANC (low visits: adjusted odds ratio (aOR) = 2.2; 95% confidence interval (CI) = 1.4-3.8). However, moderate (aOR = 1.4; 95% CI =0.7-2.2) and high (aOR = 1.3; 95% CI 0.7-2.2) attendance were not statistically significantly associated with PM. PNC attendance was not significantly associated with lower PM (relative risk 0.4, 95% CI 0.1-2.6). Emergency obstetric and newborn care (EmONC) was significantly associated with a reduction in mortality (aOR = 0.2; 95% CI = 0.2-0.8), with an 84.4% reduction among newborns at risk, and an overall reduction in mortality of 10% for all births. CONCLUSION: Perinatal mortality was high among the infants of women in the cohort under study (26 per 1000 live births). Availability of MNCH, specifically EmONC, was associated with lower perinatal mortality, and if this association is causal, might avert 84.4% of perinatal deaths among newborns at high-risk.

[Evolution of Uterine Ruptures at the Maternity of Ignace Deen National Hospital (Chu of Conakry)]. / Évolution des Ruptures Utérines à la Maternité de L'hôpital National Ignace Deen (Chu de Conakry).

Uterine rupture is a common obstetrical drama in our delivery rooms that has become exceptional in developed countries. In developing countries including Guinea, this tragedy is one of the major concerns of the obstetrician. The objectives of this work were: to evaluate the frequency of uterine rupture in the department, to describe the socio-demographic and clinical characteristics of the patients, to identify the factors favoring the occurrence of uterine rupture, to evaluate the maternal-fetal prognosis and propose a prevention strategy to reduce maternal and fetal morbidity and mortality by uterine rupture. This was a descriptive study with data collection in two phases, one retrospective lasting 18 months from July 1, 2017 to December 31, 2018 and the other prospective, lasting 18 months also from January 1, 2019 to June 30, 2020 both carried out at the maternity ward of the Ignace Deen National Hospital. We collected 84 cases of uterine rupture out of 18,790 deliveries, i.e. a frequency of 0.44%. During the same time 10,067 cesarean sections were realized, i.e. one laparotomy for uterine rupture for 120 cesarean sections. The average age of the patients was 28.14 years with a standard deviation of 2 years and the average profile is that of a housewife (51.8%), multiparous (44.6%), evacuated from peripheral maternity (85.5%) and having an insufficient number of antenatal consultations (82.6%). In 93.1% of cases, the uterine rupture had occurred in delivery centers, peripheral maternity hospitals and on the way, the uterine ruptures were mostly spontaneous (65.1%), and occurred in a healthy uterus (59.0%). Uterine rupture was more frequently complete (83.33%). Surgical treatment was more frequently conservative with hysterorrhaphy (88.1%). We recorded 12 maternal deaths, i.e. a case fatality rate of 14.6%. On admission, almost all of the women showed no signs of fetal life. To reduce the frequency of uterine ruptures, better organization of emergency obstetric and neonatal care and better screening for risk factors for obstructed labor during prenatal consultations should be encouraged.

Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana.

INTRODUCTION: Little is known about the effect of integrating respectful maternity care into clinical training programs. We sought to examine the effectiveness of an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care on providers' knowledge and self-efficacy, and to asess providers' perceptions of the integrated training. METHODS: The project was piloted in East Mamprusi district in Northern Ghana. Forty-three maternity providers were trained, with six participants trained as Simulation Facilitators. Data are from self-administered evaluation forms (with structured and open-ended questions) from all 43 providers and in-depth interviews with 17 providers. We conducted descriptive quantitative analysis and framework qualitative analysis. RESULTS: Provider knowledge increased from an average of 61.6% at pre-test to 74.5% at post-test. Self-efficacy also increased from an average of 5.8/10 at pretest to 9.2/10 at post-test. Process evaluation data showed that providers valued the training. Over 95% of participants agreed that the training was useful to them and that they will use the tools learned in the training in their practice. Overall, providers had positive perceptions of the training. They noted improvements in their knowledge and confidence to manage obstetric and neonatal emergencies, as well as in patient-provider communication and teamwork. Many listed respectful maternity care elements as what was most impactful to them from the training. CONCLUSIONS: Simulation and team-training on emergency obstetric and neonatal care, combined with respectful maternity care content, can enable health care providers to improve both their clinical and interpersonal knowledge and skills in a training setting that reflects their complex and stressful work environments. Our findings suggest this type of training is feasible, acceptable, and effective in limited-resource settings. Uptake of such trainings could drive efforts towards providing high quality safe, responsive, and respectful obstetric and neonatal care.

Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: A cross-sectional study.

Background: Current facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care (EmONC) were assessed in the Kwango and Kwilu provinces of the Democratic Republic of the Congo (DRC). Methods: This is an analysis of the baseline survey data from an ongoing clinical mentoring program among 72 rural health facilities in the DRC. Data collectors visited each of the facilities and collected data through a pre-programmed smartphone. Frequencies of selected indicators were calculated by province and facility type-general referral hospital (GRH) and primary health centers (HC). Results: Facility conditions varied across province and facility type. Maternity wards and delivery rooms were available in the highest frequency of rooms assessed (>95% of all facilities). Drinking water was available in 25.0% of all facilities; electricity was available in 49.2% of labor rooms and 67.6% of delivery rooms in all facilities. Antenatal, delivery, and postnatal care services were available but varied across facilities. While the proportion of blood pressure measured during antenatal care was high (94.9%), the antenatal screening rate for proteinuria was low (14.7%). The use of uterotonics immediately after birth was observed in high numbers across both provinces (94.4% in Kwango and 75.6% in Kwilu) and facility type (91.3% in GRH and 81.4% in HC). The provision of immediate postnatal care to mothers every 15 minutes was provided in less than 50% of all facilities. GRH facilities generally had higher frequencies of available equipment and more services available than HC. GRH facilities provided an average of 6 EmONC signal functions (range: 2-9). Conclusions: Despite poor facility conditions and a lack of supplies, GRH and HC facilities were able to provide EmONC care in rural DRC. These findings could guide the provision of essential needs to the health facilities for better delivery of maternal and neonatal care.

Use of a geographic information system to assess accessibility to health facilities providing emergency obstetric and newborn care in Bangladesh.

OBJECTIVE: To use a geographic information system (GIS) to determine accessibility to health facilities for emergency obstetric and newborn care (EmONC) and compare coverage with that stipulated by UN guidelines (5 EmONC facilities per 500 000 individuals, ≥1 comprehensive). METHODS: A cross-sectional study was undertaken of all public facilities providing EmONC in 24 districts of Bangladesh from March to October 2012. Accessibility to each facility was assessed by applying GIS to estimate the proportion of catchment population (comprehensive 500 000; basic 100 000) able to reach the nearest facility within 2 hours and 1 hour of travel time, respectively, by existing road networks. RESULTS: The minimum number of public facilities providing comprehensive and basic EmONC services (1 and 5 per 500 000 individuals, respectively) was reached in 16 and 3 districts, respectively. However, after applying GIS, in no district did 100% of the catchment population have access to these services. A minimum of 75% and 50% of the population had accessibility to comprehensive services in 11 and 5 districts, respectively. For basic services, accessibility was much lower. CONCLUSION: Assessing only the number of EmONC facilities does not ensure universal coverage; accessibility should be assessed when planning health systems.

Emergency obstetric care provision in Southern Ethiopia: a facility-based survey.

OBJECTIVES: To assess the provision of basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres in Southern Ethiopia. DESIGN: A facility-based survey, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and newborn care. Modules included infrastructure, staffing, number of deliveries, maternal and perinatal mortality, BEmONC signal functions, referral capacity and knowledge of risk factors in pregnancy. SETTING: Primary healthcare centres providing delivery services in the Eastern Gurage Zone, a predominantly rural area in Southern Ethiopia. PARTICIPANTS: All 20 health centres in the study area were selected for the assessment. One was excluded, as no delivery services had been provided in the 12 months prior to the study. RESULTS: Three out of 19 health centres met the government's staffing norm. In the 12 months prior to the survey, 10 004 ([Formula: see text]) deliveries were attended to at the health centres, but none had provided all seven BEmONC signal functions in the three months prior to the survey ([Formula: see text]). Eight maternal and 32 perinatal deaths occurred. Most health centres had performed administration of parenteral uterotonics (17/89.5%), manual removal of placenta (17/89.5%) and neonatal resuscitation (17/89.5%), while few had performed assisted vaginal delivery (3/15.8%) or administration of parenteral anticonvulsants (1/5.3%). Reasons mentioned for non-performance were lack of patients with appropriate indications, lack of training and supply problems. Health workers mentioned on average 3.9±1.4 of 11 risk factors for adverse pregnancy outcomes. Five ambulances were available in the zone. CONCLUSION: BEmONC provision is not guaranteed to women giving birth in health centres in Southern Ethiopia. Since the government aims to increase facility deliveries, investments in capacity at health centres are urgently needed.

Local initiatives to access emergency obstetric and neonatal care in Burkina Faso.

OBJECTIVE: To describe the various local initiatives to access emergency obstetric and neonatal care in Burkina Faso. METHODS: An existing framework was used to review the three processes for local initiatives: emergence, formulation, and implementation. Multiple case studies were conducted, followed by literature review and semi-structured interviews with key informants. RESULTS: Sixteen districts had implemented local initiatives, including cost sharing, free care for women and children, and free care for delivery and cesareans. Most districts (n=10) had implemented the cost-sharing intervention. These initiatives were initiated by local actors as well as nongovernmental organizations. The profile of those involved led to different ways of handling the emergence and formulation processes. At implementation, these initiatives faced many issues including late payment of contributions, low involvement of local governments, and equity in participation. CONCLUSION: There are some issues in the implementation and sustainability of the local initiatives. Although many initiatives exist, these are unable to fully address the financial barriers to care. However, these initiatives highlight context-based financial barriers that must be taken into account to accelerate universal access to health care.

Emergency obstetric and neonatal care needs assessment: Results of the 2010 and 2014 surveys in Burkina Faso.

OBJECTIVE: To analyze and compare the availability, utilization, and quality of services for maternal and neonatal health in 2010 and 2014 in Burkina Faso. METHODS: A cross-sectional study of emergency obstetric and neonatal care services (EmONC) in all public and private health facilities in Burkina Faso in 2010 and a sample of 812 health facilities in 2014. The generic tools developed by the Averting Maternal Death and Disability (AMDD) program were used as the basic tools for evaluation. RESULTS: In 2010, 25 health facilities were considered as EmONC health facilities and there were 23 in 2014. In 2010 and 2014, the proportion of births in EmONC health facilities was low (4.5%). The cesarean delivery rate also remained very low, at 0.9% in 2010 and 1.13% in 2014. The proportion of obstetric complications supported in health facilities was 12.3% in 2010 and 17.1% in 2014. The direct complication case fatality rate in EmONC health facilities was 1.6% in 2010 and 1.3% in 2014. CONCLUSION: The two surveys did not show a significant improvement in the availability, utilization, and quality of maternal and neonatal healthcare services between 2010 and 2014.

Indicators of availability, use, and quality of emergency obstetric and neonatal care in Togo in 2012.

OBJECTIVE: To assess the availability, utilization, and quality of emergency obstetric and neonatal care (EmONC) in Togo. METHODS: A cross-sectional study of EmONC services in all public and private health facilities in the territory of Togo conducted from July to December, 2012. The generic tools developed by the Averting Maternal Death and Disability program were used as the basic tools for this evaluation. RESULTS: The survey involved 1019 health facilities including 864 potential EmONC facilities that constituted the final sample. The results showed that there was low availability of functional EmONC health facilities (8 basic EmONC and 24 comprehensive EmONC) with a large urban/rural variation. Among the 24 current CEmONC, 22 were in urban areas and half were from the private sector. The national ratio of availability was 3 EmONC health facilities per 500 000 inhabitants. Nationally, the cesarean delivery rate was 3.5%. The lethality rate of direct obstetric causes was estimated at 1.3%. CONCLUSION: Needs assessment for EmONC showed low availability of EmONC services and underutilization of the available services.

Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana.

BACKGROUND: With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011-2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. OBJECTIVE: Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. METHODS: The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. RESULTS: Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. CONCLUSION: Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders.

What is needed for taking emergency obstetric and neonatal programmes to scale?

Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation.

The state of routine and emergency obstetric and neonatal care in Southern Province, Zambia.

OBJECTIVE: To evaluate the capacity of health facilities in Southern Province, Zambia, to perform routine obstetric care and emergency obstetric and neonatal care (EmONC). METHODS: Surveys were completed at 90 health centers and 10 hospitals between September 1, 2011, and February 28, 2012. An expanded set of signal functions for routine care and EmONC was used to assess the facilities' capacity to provide obstetric and neonatal care. RESULTS: Interviews were completed with 172 health workers. Comprehensive EmONC was available in only six of 10 hospitals; the remaining four hospitals did not perform all basic EmONC signal functions. None of the 90 health centers performed the basic set of EmONC signal functions. Performance of routine obstetric care functions, health worker EmONC training, and facility infrastructure and staffing varied. CONCLUSION: Assessment of the indicators for routine care revealed that several low-cost interventions are currently underused in Southern Province. There is substantial room for improvement in emergency and routine obstetric and neonatal care at the surveyed facilities. Efforts should focus on improving infrastructure and supplies, EmONC training, and adherence to the UN guidelines for routine and emergency obstetric care.

What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana.

Abstract-Management and leadership in complex health systems have been little addressed as contributors toward improving maternal and newborn health. Widespread perceptions of weak district-level management and leadership have encouraged capacity strengthening interventions with a predominant focus on individual rather than systemic capacities. However, both types of capacities matter. Greater understanding is required about how managerial decision making and policy implementation are influenced by the systems in which managers operate. This article presents an exploratory case study to understand the balance of top-down and bottom-up dynamics influencing district manager decision making in one district in the Ghanaian health system. Our study was theory driven, drawing on concepts of decision space, power, and trust from the literature. Data collection methods included document review, participant observation, and semistructured interviews. Using analysis that drew upon complex leadership theory, we found that contexts of hierarchical authority and resource uncertainty constrained district manager decision space. These constraints also gave rise to a leadership type oriented toward serving the bureaucratic functions of the health system (more top-down than bottom-up). The analysis of this case study showed that, as a result, district-level management and leadership were less responsive to maternal and newborn health service delivery challenges.

One-year evaluation of the impact of an emergency obstetric and neonatal care training program in Western Kenya.

OBJECTIVE: To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital, Eldoret, Kenya. METHODS: A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP), and in the 3-month period (August-November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate. RESULTS: A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However, postpartum hemorrhage rates decreased, affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P=0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P<0.001). Additionally, the number of neonates with 5-minute Apgar scores of less than 5 reduced from 133 (7.7%) of 1717 to 95 (5.4%) of 1745 (P=0.006). CONCLUSION: The introduction of the AIP improved maternal outcomes. There were significant differences related to use of oxytocin and postpartum hemorrhage.

Using scorecards to achieve facility improvements for maternal and newborn health.

The Government of Sierra Leone launched the Free Health Care Initiative in 2010, which contributed to increased use of facility based maternity services. However, emergency obstetric and neonatal care (EmONC) facilities were few and were inadequately equipped to meet the increased demand. To ensure provision of EmONC in some priority facilities, the Ministry of Health and Sanitation undertook regular facility assessments. With the use of assessment tools and scorecards it is possible to make improvements to the services provided in the period after assessment. The exercise shows that evidence that is shared with providers in visually engaging formats can help decision-making for facility based improvements.

Commonly cited incentives in the community implementation of the emergency maternal and newborn care study in western Kenya.

BACKGROUND: Mortality of mothers and newborns is an important public health problem in low-income countries. In the rural setting, implementation of community based education and mobilization are strategies that have sought to reduce these mortalities. Frequently such approaches rely on volunteers within each community. OBJECTIVE: To assess the perceptions of the community volunteers in rural Kenya as they implemented the EmONC program and to identify the incentives that could result in their sustained engagement in the project. METHOD: A community-based cross sectional survey was administered to all volunteers involved in the study. Data were collected using a self-administered supervision tool from all the 881 volunteers. RESULTS: 881 surveys were completed. 769 respondents requested some form of incentive; 200 (26%) were for monetary allowance, 149 (19.4%) were for a bicycle to be used for transportation, 119 (15.5%) were for uniforms for identification, 88 (11.4%) were for provision of training materials, 81(10.5%) were for training in Home based Life Saving Skills (HBLSS), 57(7.4%) were for provision of first AID kits, and 39(5%) were for provision of training more facilitators, 36(4.7%) were for provision of free medication. CONCLUSION: Monetary allowances, improved transportation and some sort of identification are the main incentives cited by the respondents in this context.